Prepared by: Wendy Burgoyne Best Start: Ontario's Maternal Newborn and Early Child Development Resource Centre 2005
The opinions expressed in this publication are those of the survey participants and the author and do not necessarily reflect the views of the Public Health Agency of Canada.
Resources and strategies mentioned in this publication are not necessarily approved or endorsed by the Public Health Agency of Canada or by the Best Start Resource Centre.
Mission:To promote and protect the health of Canadians through leadership, partnership, innovation and action in public health. Vision: Healthy Canadians and communities in a healthier world. Public Health Agency of Canada
Library and Archives Canada Cataloguing in Publication
What we have learned : Key Canadian FASD awareness campaigns.
Également disponible en français sous le titre : Ce que nous avons appris, campagnes canadiennes importantes de sensibilisation à l'ETCAF. Includes bibliographical references. ISBN 0-662-42288-0 Cat. no.: HP10-6/2006E
1. Pregnant women--Alcohol use--Canada--Prevention--Planning. 2. Fetal alcohol syndrome--Canada--Prevention-Planning. 3. Pregnant women--Alcohol use--Prevention--Planning. 4. Health promotion--Planning. 5. Social marketing. I. Public Health Agency of Canada. II. Title: Key Canadian FASD awareness campaigns.
RG629.F45W42 2006 614.5'992326861'00971 C2006-980030-8
This publication can also be made available in/on computer diskette/large print/ audio-cassette/Braille upon request.
This report is available in English electronically at: <http://www.phac-aspc.gc.ca/fasd-etcaf/index.html>
For further information or to obtain additional copies, please contact:
Publications Health Canada Ottawa, Ontario K1A 0K9 Tel.: (613) 954-5995 Fax: (613) 941-5366 E-Mail : info@hc-sc.gc.ca
© Her Majesty the Queen in Right of Canada, 2006 HC. Pub. No.: 4294
Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
1. The Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
1.1 Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
1.2 Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
1.3 Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
1.4 Respondents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
2. The Role of Awareness Campaigns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
2.1 Types of Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14
2.2 Stages of Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14
2.3 Threat and Efficacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
2.4 Reasons for Awareness Campaigns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17
3. The Issue: Prenatal Alcohol Exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19
3.1 Alcohol Use and Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20
3.2 Stigma and Judgmental Attitudes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
3.3 Raising Awareness About FASD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22
4. Geographic Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
5. Preparing for an Awareness Campaign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27
5.1 Gathering Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28
5.2 Funding Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28
5.3 Timing of Campaign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
5.4 Campaign Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
6. Partnerships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31
7. Population of Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35
8. Campaign Messages and Identity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39
8.2 Key Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41
8.3 Images . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45
9. Campaign Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51
9.2 Campaign Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54
9.3 Use of Mass Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58
9.4 Warning Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58
10. Evidence of Campaign Effectiveness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61
11. Campaign Strengths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65
12. Areas to Reconsider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69
12.1 Negative Responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70
12.1 Things to Do Differently . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70
13. Support for Local Initiatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73
14. Advice to Others . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75
15. Featured Campaign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .79
16. Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .85
17. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87
18. Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91
Appendix 1: Survey Respondents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .92 Appendix 2: Survey Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .94 Appendix 3: Helpful Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .97 Appendix 4: Insights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .99
The Best Start Resource Centre would like to acknowledge the many groups and organizations that shared information about their fetal alcohol spectrum disorder (FASD) campaigns and activities, as well as the individuals who linked the Best Start Resource Centre to others who were working in this area. Without their careful work, passion for this topic and willingness to share information, this report would not have been possible.
The Best Start Resource Centre would also like to acknowledge the contributions of the project advisors who assisted in the development and design of the national survey and resulting report:
Lois Crossman, Saskatchewan Prevention Institute
Nancy Dubois, The Health Communication Unit, Centre for Health Promotion, University of Toronto Annamaria Feltracco, Feltracco Consulting Anne George, Community Child Health Research, and H.E.L.P., University of
British Columbia
Laura Heal, Alberta Alcohol and Drug Abuse Commission
Della Maguire, Mi'kmaq First Nation Healing Society
Louise Morin, SAFERA
Karen Palmer, FASD Information and Consultation Service
Nancy Poole, BC Women's Hospital
Susan Santiago, Motherisk
Pat Spadetto, Timiskaming Brighter Futures
The Best Start Resource Centre was contracted by the Public Health Agency of Canada to review recent Canadian awareness campaigns about prenatal alcohol exposure. Phone surveys were completed with respondents who had developed large-scale campaigns, or smaller, innovative campaigns. The campaign topics ranged from preventing prenatal alcohol exposure to supports for those affected by fetal alcohol spectrum disorder (FASD).
The purpose of this review was to gather information to assist groups that are planning future awareness strategies related to FASD or alcohol use in pregnancy. Valuable information was gathered about campaign effectiveness, development, design, and sensitive and respectful approaches.
The resulting report reinforces that, when planning awareness campaigns about alcohol use in pregnancy or FASD, it is critical to:
• FASD Campaigns: Aw a reness strategies are one component of a broader strategy to a d d ress prenatal exposure to alcohol. Aw a reness campaigns have the potential to influence levels of awareness, knowledge and attitudes; encourage inform a t i o n seeking behaviour; show how to make change; indicate where to get services; and c l a r i f y, remind, re i n f o rce and encourage people who already know the facts. Wi t h s u fficient exposure, an awareness campaign can result in changes in risk behaviour.
Strategies to address FASD are mutually reinforcing and can be combined to create a comprehensive approach. FASD campaigns should be connected to other FASD strategies. Careful planning is required to avoid unnecessary repercussions for women who drink alcohol and for families affected by FASD.
• P reparing for a Campaign: The planning stages of campaign development are important and lay the groundwork for effective, sensitive approaches. It is helpful to gather information about other FASD campaigns, effective strategies and knowledge levels in the population of interest. Campaign objectives should be specific, measurable, attainable, realistic and time-specific. Campaigns are often scheduled for times of the year when others will also be addressing FASD, such as International FASday, or at times of the year when alcohol use is more prevalent.
Funding can assist in campaign development, implementation and evaluation. Funding can come from a wide variety of sources. Some groups, through teamwork and creative thinking, succeeded in implementing an awareness campaign with little or no funding.
There are many excellent FASD campaign resources. Groups with minimal budgets can make good use of existing resources. There are also benefits to developing new FASD campaign resources for specific populations and messages. All resources should be tested with the population of interest, whether they are new or existing.
The media are important in providing message exposure. Creative appro a c h e s a re needed to continue to bring this issue to their attention.
Warnings about alcohol use in pregnancy can also be used to raise awareness. There are many different ways to present warning messages, such as signs in restaurants and bars, on liquor bags and on cash register receipts.
• E v a l u a t i o n : Most respondents were able to measure the impact of their campaigns only through informal means such as qualitative feedback.
Four recent Canadian awareness campaigns had the funding for pre- and/or post-campaign surveys. These four campaigns resulted in measurable increases in awareness, and good campaign and/or message recall. Successful campaigns have common characteristics: they were carefully planned, used multiple strategies, focused on a specific problem, used carefully selected messages and images, had good reach and considered current levels of awareness. Successful campaigns focused on large populations and were designed for populations at lower risk.
Respondents recognized that some negative comments are to be expected, even when a campaign is planned carefully. These negative comments often stem from misinformation about FASD.
The Best Start Resource Centre was contracted by the FASD Team at the Public Health Agency of Canada (PHAC) in 2004 to review key fetal alcohol spectrum disorder (FASD) awareness campaigns across Canada.
influence a specific audience, through an organized set of activities that take
place in a specific time period. They may focus on use of the media, personal
contact (e.g. displays or presentations), events (e.g. launch events or FA S d a y
activities) or a combination of these three strategies.
The purpose of this review was to gather information about the development, implementation and evaluation of recent Canadian awareness campaigns about FASD in order to help groups plan future campaigns.
Until recently, people planned FASD awareness activities based on guiding values and knowledge of their communities. This report compiles valuable new information about messages, images and strategies that have been shown to be effective in increasing awareness about FASD. The information in this report will be useful to a variety of groups that are planning to increase awareness about alcohol use and pregnancy, FASD or related services. The following groups may benefit from the information in this report:
The survey results will help groups to consider approaches that are respectful, appropriate for their communities and evidence-based. It will assist in planning successful awareness activities and in considering appropriate FASD awareness messages, images and strategies.
This review is based on a phone survey of respondents involved in select Canadian FASD awareness campaigns that were implemented between 2000 and 2004. Regional FASD representatives of PHAC and individuals identified through the Canadian Centre on Substance Abuse (CCSA) Directory of FASD Services were used to identify recent, significant Canadian FASD awareness campaigns.
Campaigns were selected for this review on the basis of scale, evaluation results and geographic representation. The focus was on large-scale campaigns with pre- and post-campaign data. The review also included campaigns that were considered innovative. Campaigns were selected from every province and territory. The review includes campaigns designed for different populations, including youth, pregnant women, health care providers, the general public and families affected by FASD. It includes campaigns that focused on different areas of FASD, such as the risks of alcohol use in pregnancy, access to services, and the needs, challenges and strengths of individuals with FASD.
The review did not include isolated initiatives such as training events, displays, Web sites or production of single resources. However, these activities were often incorporated into a larger awareness strategy.
Respondents were recruited by phone and/or email. Interviews took place by phone, between October 2004 and January 2005. Interviews were conducted in either French or English, at the convenience of the respondent. The same interviewer conducted all interviews.
Prior to the interview, each respondent was sent a confirmation note by email, outlining the purpose of the survey and the topic areas for discussion. Discussions focused on what we have learned from recent Canadian awareness campaigns. Questions covered the planning process, strategies and results of FASD awareness activities (see Appendix 2 for the survey questions). Respondents were asked: how they planned for their campaign, about campaign partnerships, the population of interest, key messages, visuals, campaign resources and activities, use of media and evaluation results. There were questions about the strengths of the awareness activities, what they would do differently next time, areas of controversy and advice to others who were planning campaigns.
This survey was not intended to be a comprehensive review of all Canadian awareness campaigns about FASD, or a literature review of FASD campaigns. Instead, it focused on the development, implementation and evaluation of a select group of recent FASD campaigns.
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Only four campaigns had evaluation components that assessed changes in awareness, campaign recall or message recall. Solid evaluation data, qualitative feedback and informal assessment of effectiveness and appropriateness are shared in this report. Many campaigns had only self-reported evidence of effectiveness, based on little or no evaluation data, with a strong inherent bias.
Respondents re p o rted on activities to the best of their abilities. However, staff turn o v e r and shared responsibilities for campaign planning affected the level of detail provided in some interv i e w s .
Results are reported by interview, due to the difficulties in distinguishing between ongoing awareness strategies and distinct campaigns.
A diversity of strongly held opinions and approaches were presented concerning FASD a w a reness campaigns. Although there were few areas of universal consensus, themes emerg e d where a large proportion of respondents showed interest in the same idea or approach.
The final results include data from 72 phone interviews, representing a wide range of Canadian FASD awareness campaigns that took place between 2000 and 2004. Respondents represented the following geographic areas:
Most respondents had completed more than one awareness campaign on FASD, although it was often difficult to determine if activities constituted several distinct campaigns, or one ongoing, evolving campaign.
Interviews varied in length and are categorized as either full interviews (i.e. interviews from 45 to 90 minutes) or brief interviews (i.e. interviews of less than 15 minutes).
The survey included 53 full interviews. The full interviews represent the views of a range of groups concerned about FASD: health organizations, government, Aboriginal groups, FASD interest groups, FASD services, services related to substance use, corrections, education, and programs with an early childhood focus. The full interviews included in-depth questions about campaign planning, resources, strategies and evaluation (see Appendix 2 for the questionnaire).
Nineteen brief interviews were conducted. These gathered further information from liquor boards, alcohol industries, alcohol associations and government branches that had been active in the area of FASD. The brief interviews provided a quick overview of strategies, results and future plans (see Appendix 2 for the questionnaire).
The response rate for the survey was 97%, and there were two refusals. A few additional groups could not be reached due to outdated or incomplete contact information. Although the interviews involved a significant time commitment, people were eager to share their information and were proud of their work.
Awareness campaigns are one part of a broader strategy to address FASD. There are different components of prevention, and all are important. Prevention strategies work together as a whole and are mutually reinforcing.
Comprehensive prevention strategies include these main approaches:
(Basford, 2004)
FASD awareness campaigns can play a role in each of these levels of prevention (e.g. they can raise awareness in the general public, connect women with addictions to needed services, and link families affected by FASD to diagnostic or intervention services). In recognizing the continuum of services related to FASD, it is important to link awareness strategies to the other services that are needed by pregnant women and by families a ffected by FASD. Where appropriate, strategies should involve partners, family, friends and the community.
Awareness is the first step in the complex process of behaviour change. During the process of change, individuals move from being unaware to aware, to knowledgeable, interested, motivated, ready to try, leading to changed beliefs and attitudes, and a commitment to change (Prochaska and DiClemente, 1982; 1995).
The Model of Change Theory (Prochaska and DiClemente, 1982; 1995) is helpful to understand the ways that awareness campaigns can influence the process of change. Behaviour change is viewed as a process that goes through distinct stages, although change is not always linear or pro g ressive. The Model of Change Theory describes six main stages in the process of change:
The role of the service provider is to assist individuals in moving from one stage of change to the next. Different types of information and support are needed, depending on the stage of change.
Campaigns are most often planned for individuals in precontemplation, contemplation or p reparation stages and diff e rent types of messages are needed for each stage. For example:
| Sta ge of Cha ng e | Ke y Me ss a ge s |
| Precontemplation | Information about the risks of alcohol use in pregnancy |
| Contemplation | Messages about the benefits of change |
| Preparation | Information on how to get ready to change, such as where to access information about stopping drinking |
*(Hyndman, 1993; Kassire r, 1999; Aw a re and Breaking the Cycle, 2002)
The role of awareness campaigns is to provide sufficient concern about an issue and sufficient encouragement to change. Primary prevention strategies such as awareness campaigns about alcohol and pregnancy comprise two main components:
T h re a t
E ff i c a c y
(Council for To b a c c o - f ree Ontario et al., 2000; Witte and Allen, 2000)
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Relative levels of threat and efficacy are critical to campaign effectiveness. For example:
| Level of Thr eat and Ef f i c a c y | Response |
| Threat is low | No response – individuals do not feel concerned |
| T h reat is higher than eff i c a c y | Defensive response – individuals respond with avoidance, denial, anger, rationalizing (it won't happen to me) |
| E fficacy is higher than thre a t | Positive response – increases in awareness, etc. |
*(Council for To b a c c o - f ree Ontario et al., 2000; Witte and Allen, 2000)
Fear is part of any campaign, as the population needs to be concerned about an issue in order to consider making changes (Council for Tobacco-free Ontario et al., 2000; Witte and Allen, 2000). The risks of alcohol use in pregnancy need to be clearly indicated. The risks can be presented in a context that is fear-based (e.g. an image of a fetus in a wine glass), or the risks can be presented in a manner that is positive and supportive (e.g. an image of community support for a pregnant woman).
To be effective, efficacy must be higher than threat. In fact, the most effective campaigns have high efficacy and high threat (Council for Tobacco-free Ontario et al., 2000; Witte and Allen, 2000). When initial awareness strategies are not effective, it can be tempting to increase the level of threat to scare people into changing their behaviour. However, the barrier to change may not be the awareness of the risks, but may be a need for information and support to assist in the process of behaviour change. It may be more effective to increase the level of efficacy.
It is important to understand the population of interest to gauge the level of threat and e fficacy that is suitable. Decisions about appropriate levels of threat and efficacy can be made based on perceived levels of knowledge, self-esteem, social support, and underlying factors for alcohol use in the population of interest. When self-efficacy is high, a higher level of threat can be used. When self-efficacy is low, focus mainly on links to serv i c e s and support s .
Although fear-based or stronger approaches have been shown to be effective in raising awareness about other health concerns, they need to be carefully planned to avoid possible negative repercussions. In general, it is safest to avoid strong fear-based approaches in alcohol and pregnancy awareness campaigns.
When carefully planned, campaigns have the potential to influence levels of awareness, knowledge and attitudes, encourage information-seeking behaviour, show how to make change, indicate where to get services, and clarify, remind, reinforce and encourage people who already know the facts (The Health Communication Unit, 1999; National Cancer Institute, 2002). With sufficient exposure, an awareness campaign can result in changes in risk behaviour (Kaskutas and Graves, 1994; The Health Communication Unit, 1999).
Survey respondents chose to spend considerable time, energy and funding in addressing awareness about FASD, often over many years. They made a conscious decision to address awareness, rather than other aspects of FASD. Respondents gave many different reasons for their focus on awareness. Respondents felt that awareness can be used to:
“It is not about giving answers, but about helping people understand the issue.”
Respondent, British Columbia
Insights: The Role of Aw a reness Campaigns
FASD is a complex problem, with profound underlying causal factors and serious, long-term consequences. Prenatal exposure to alcohol is still a relatively new health concern for health c a reproviders and the general public. The diagnostic term of fetal alcohol syndrome (FA S ) was established in 1973 (Jones and Smith, 1973), and clear Canadian diagnostic guidelines for fetal alcohol spectrum disorder (FASD) were released in 2005 (Chudley et al., 2005). S u rveys of health care providers show a lack of skills and comfort levels in addressing both alcohol use in pregnancy and FASD (Nevin et al., 2002; Health Canada, 2005). Health
o rganizations and FASD interest groups continue to learn about strategies that are sensitive, e ffective and appropriate in raising awareness about prenatal alcohol exposure.
Healthy birth outcomes are influenced by multiple
factors, including substance use,
environmental contaminants, violence and nutrition. Alcohol use
in pregnancy is one of
many prenatal concerns. A women's ability to create an
environment conducive to a
healthy pregnancy is dependent upon her access to resources such
as information, health
care, support, counselling and healthy food. Alcohol use can be
influenced by social
factors and the broader determinants of health, including social
norms and expectations,
poverty and violence (Roberts and Nanson,
2000).
P regnancy serves as a strong
motivator to reduce or stop drinking (AADAC, 2003; 2004).
P regnant women who drink alcohol also make eff o rts to improve
their health in other ways,
such as participating in prenatal care, taking prenatal vitamins
and cutting back on smoking,
etc. (AADAC, 2004). If women drink alcohol in pre g n a n c y,
there is a reason. For example:
The actions of partners and family members also influence a woman's ability to make healthy choices in pregnancy (Environics, 2002). Partners and family members have a role to play in supporting and encouraging a pregnant woman to stop drinking.
The profile of women's use of alcohol includes varying levels of severity and risk, and different contexts of use. A range of intervention services is required to meet the diverse needs of women who use alcohol; therefore, there is a need for a variety of FASD awareness campaigns, designed for different populations of interest, as well as programs and services that address the underlying causes of alcohol use. Campaigns for women who are using alcohol to cope with difficult life circumstances, such as poverty or violence, would differ greatly from campaigns designed for women working in higher paying jobs where alcohol use is a social expectation. Some campaigns may focus on sharing important information about alcohol use in pregnancy or about FASD, while others may focus on linking women and families to critical services, such as treatment, support programs, warm lines, etc.
There are misconceptions and myths around women and alcohol use, which are compounded when alcohol use occurs within the context of pregnancy and motherhood. These misunderstandings can be translated into discriminatory practices and attitudes when dealing with women around substance use issues. Alcohol use is stigmatizing, as society places judgments on people who are unable to address their alcohol use. Pregnant women who use alcohol may find it difficult to access the services they need, due to judgmental attitudes of service providers, feelings of shame, depression, low self-esteem and fear of losing their children (Poole and Isaac, 2001). Family and friends may also discourage a pregnant woman from talking about her alcohol use, due to concerns about reprisal (Poole and Isaac, 2001). Awareness campaigns need to emphasize that alcohol use during pregnancy can cause serious harm, while being careful not to inadvertently reinforce judgmental attitudes about pregnant women who are struggling to address their alcohol use.
Society can place similar fears, judgments and consequences on individuals with FASD. FASD is an invisible disability. Individuals with FASD may be harshly judged by those who do not understand that their actions are a consequence of brain damage, not wilful misconduct. Although FASD has been linked to increased mental health concerns and contact with the legal system, early diagnosis, care and services can reduce these risks (Streissguth et al., 1996). Awareness campaigns need to reinforce the potential serious long-term consequences of prenatal alcohol exposure, without creating negative and inappropriate perceptions of individuals with FASD.
Groups need to find a balance between approaches that are strong enough to be convincing, but not so strong that they increase stigma. Groups that are planning a w a reness strategies should carefully consider any possible negative re p e rcussions to
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pregnant women, communities and families affected by FASD. Awareness campaigns can be expensive and time consuming. We want them to work, and we do not want to alienate our population of interest.
Aw a reness campaigns have been shown to increase awareness about the consequences of prenatal alcohol exposure (Casiro et al., 1994; AADAC, 2000; MLCC, 2002; Best Start Resource Centre, 2004). Cumulative exposure to prevention messages has been shown to reduce alcohol use in pregnancy (Kaskutas and Graves, 1994). Campaigns can also link families affected by FASD to important information and supports.
There are differences between raising awareness about FASD and promoting other health practices (Best Start, 2003). Alcohol use in pregnancy may be based in addiction and/or other health and social issues, and can lead to an infant with a distinct disability, rather than general poor health or injury. Women may need support and services, as well as information, to change their alcohol use. Fear-based strategies in FASD campaigns can appear to be victim blaming, or discriminatory of individuals with disabilities such as FASD. Fear-based strategies also risk producing reactions such as anger, denial, defensiveness and avoidance (Witte and Allen, 2000). Humour-based strategies can be seen as mocking or blaming pregnant women, or as insensitive to the underlying factors related to alcohol use in pregnancy.
About half of all pregnancies are unplanned in Canada. Many women drink alcohol before they know they are pregnant. When raising awareness about FASD, we do not want to raise undue fear about very small amounts of alcohol that may be consumed before women know they are pregnant. We also do not want to give any false reassurance about the safety of unintended alcohol exposure early in pregnancy.
Although we can learn from campaigns on other health topics, we must also consider the specific issues related to alcohol use in pregnancy and FASD.
Some regions of Canada have been working intensively on FASD for many years and have succeeded in implementing formal, large-scale, multi-component campaigns. Others are relatively new to the issue and have completed more basic awareness strategies. Some areas of Canada are currently very active in raising awareness, others are just starting to consider prevention strategies, and a few have moved on to other methods. Campaigns vary widely in their approaches, partnerships and strategies. Although it is important to design campaigns to meet the precise needs of the intended population of interest, there is also a need for information and guidelines to increase the effectiveness of campaigns.
In 2003, 14% of recent Canadian mothers reported that they drank alcohol during their last pregnancy (Statistics Canada, 2003). Across Canada, there are different rates of alcohol use in pregnancy and different levels of awareness. This necessitates different messages and approaches to the issue.
The western provinces and territories have been actively addressing FASD for over a decade. The western provinces have many examples of large-scale, multi-component campaigns and innovative smaller campaigns. Ontario is in an intensive period of raising awareness in the area of alcohol and pregnancy, reflected by many local activities and a provincial awareness campaign. Quebec and the Atlantic Provinces, for the most part, are just starting to address FASD prevention strategies.
Rates of alcohol use in pregnancy are decreasing in geographic areas that have been working intensively over many years to address FASD. For example, there were significant steady decreases in reported alcohol use in pregnancy in British Columbia and the Prairie Provinces between 1994 and 1999 (Health Canada, 2003). Changes in risk behaviour are influenced by many factors, including social norms, changes in awareness, comfort levels in disclosing alcohol use and availability of services.
There are similar trends in levels of awareness across Canada. In Quebec, where FASD activities have been limited, women are more likely to think alcohol use in pregnancy is safe (Environics, 2002). In Alberta, with its many provincial and local FASD strategies, women are more likely to think alcohol use in pregnancy is risky (Environics, 2002). Again, awareness campaigns are only one factor that influences perceived risk.
Although some studies have reviewed rates of diagnosis of FASD over time (Habbick et al., 1996), diagnosis is affected by many factors, such as access to diagnostic services and confirmation of maternal alcohol use. Increased rates of diagnosed FASD can be related to increased awareness of the issue or increased availability of diagnostic services, rather than increased incidence of FASD. Rates of diagnosis of FASD should be used with caution and are generally understood to be an underestimate of the incidence of FASD.
Careful preparation and conscious decisions help to ensure the effectiveness and sensitivity of FASD awareness campaigns. In campaign development, attention needs to be given to background information, funding sources, the timing of activities and the purpose or objective of the campaign.
Most groups felt it was important to gather information to guide the selection and development of their campaign. Before selecting campaign strategies, respondents talked with their part n e r s (28%), reviewed best practices (21%), reviewed information from other campaigns (15%), looked at relevant Web sites (9%) and/or researched awareness rates (11%).
concept. Spend the other 50% on developing and implementing your campaign.”
See Appendix 3 for resources that can assist in the development of awareness campaigns about alcohol and pregnancy.
Funding sources varied widely from groups with no formal funding, to projects that were well financed through government or alcohol industry funds. Some groups made creative use of multiple sources of funding.
The most common campaign funding sources included federal grants (42%), pro v i n c i a l or territorial government (26%), alcohol industry (11%), non-profit organizations (9%), community fundraising (9%), municipalities (8%), public health (8%) and FASD interest groups (8%). Some respondents (8%) implemented their campaigns with no funding.
Of the groups that received funding from the alcohol industry, some were very pleased with the partnership, while others mentioned tension over the funding source. Community members and partners felt the alcohol industry should take action in the form of social responsibility and support efforts to raise awareness about prenatal alcohol exposure. When groups did accept alcohol-industry funding, some clients or partners felt that this was a conflict of interest, or maintained that the messages and images were compromised by direction from the alcohol industry. Some groups were unable to use resources funded by the alcohol industry because of their internal sponsorship guidelines. One group described alcohol industry funding as a “catch 22,” where there are complaints whether you do or do not accept alcohol sponsorship.
Groups chose the timing of their campaigns based on availability of funding (43%), FASday (23%) or seasonal periods of higher alcohol use, such as the winter holidays or the May long weekend (10%). Other groups talked about a sense of readiness in their working group or community, based on previous work (15%). Although funding enabled the groups to proceed with a campaign, groups often qualified this by saying that the passion and ideas had been around for a while. However, they were not able to start until they had significant funding.
“The timing was just right. We felt like we were riding a wave.” Respondent, Ontario
Insights: Timing of Campaign
Ideally, campaign objectives are specific, measurable, attainable, realistic and time-specific (The Health Communication Unit, 1999). An example of a well-crafted FASD campaign objective is:
• to increase awareness of the benefits of not drinking alcohol during pregnancy in women of childbearing age, by June 2004
Although most groups chose appropriate campaign objectives, some groups used objectives that were not measurable, immediately attainable or realistic for an awareness campaign.
Most respondents (57%) indicated that their main campaign objective was to raise awareness about FASD or about alcohol and pregnancy in a specific population. These objectives are measurable and appropriate to the strategy of awareness campaigns. In contrast, only four campaigns included an evaluation component that assessed the impact on awareness.
A small number of respondents (7%) wanted to focus mainly on linking people to specific services. Hits on Web sites or calls to specific phone numbers can be used to track this type of objective. This objective is specific and measurable, and therefore appropriate for awareness campaigns.
Other groups (13%) chose to work on changing attitudes and increasing support (13%). Although this is an important part of work on FASD, it is difficult to measure changes in attitudes and levels of support.
A small number of groups defined their campaign objectives in terms of decreasing rates of alcohol use in pregnancy (2%) or decreasing rates of FASD (2%), which are commendable. However, it is difficult to link the impact of a short-term awareness campaign with measurable changes in the rates of alcohol use in pregnancy or rates of syndromes that are difficult to diagnose at birth.
In general, respondents knew what was driving them to work energetically in this area, but many had difficulty defining measurable objectives for their activities.
FASD touches people in every social and economic group and has consequences for many agencies and organizations. No specific group is entirely responsible for the breadth of this mandate. Interdisciplinary groups are needed to provide a comprehensive approach and an in-depth understanding of all aspects of FASD.
Not surprisingly, when respondents were asked about their partnerships, they replied with passion. Respondents felt strongly that many different players are needed to make a difference. Almost every respondent (93%) stressed the importance of partnerships in planning awareness campaigns about FASD. They emphasized that partners were critical and central to the development of effective campaign resources and strategies, and to the process of campaign implementation.
Many groups (32%) described the high level of commitment they saw in their partners. Partners were often given staff time to plan and implement FASD activities and made community projects part of their work. They were willing to participate, contribute and complete tasks. Partners were described as being “100% behind the campaign” and took on specific roles. Partners helped to increase the scale and the reach of projects. One respondent described their working group as very committed and action oriented, eager to raise awareness, “any way, any time.”
“The impact of partners was huge. You can't do it yourself. It would be like
Many of the respondents (38%) felt that the most important aspect of partnerships was increased collective expertise. Respondents also mentioned that partners were valuable because they increased the staff time and funding available for their campaign. Partners also contributed by providing vision, ideas, guidance, support, energy, credibility and knowledge of community and clients. More specifically, partners assisted in identifying needs, developing culturally sensitive and respectful approaches, accessing funding, developing campaign messages, distributing resources and accessing the media.
Often, partnerships evolved over time. Some groups used an initial training event or workshop about FASD as an opportunity to create interest in forming a working group to address FASD. In a new working group, the lead agency usually did most of the work at first, with input from partners. As partnerships developed, partners picked up on pieces of the work or expanded the scope of the activities. Over time, as initiatives became more comprehensive, more people were recruited to join the partnership, resulting in more formal coalitions or working groups.
“Until there is a perceived need within your
community, it is hard to get
p a rtners involved.” Respondent, Ontario
Most partnerships were described as highly successful and rewarding. There were occasional challenges with partnerships, especially in getting groups of people with diverse roles and viewpoints to work together, and in finding common ground when working with organizations that had different values and beliefs. Occasionally, respondents expressed feelings of competition and defensiveness about who should be doing awareness work or frustration because some partners wanted a strong approach to the issue and others wanted a sensitive approach.
Some groups (8%) had partnerships that they wanted to improve. Respondents were looking for active partnerships, where members each took on a role and worked together as a team. In most cases, groups were successful in achieving this goal; however, some partnership attempts did not flourish.
A few people (4%) did not involve partners. They felt they had the experience and skills to do the project in-house and wanted to retain full ownership and control of the project.
The types of partners varied, depending on the project. Some partnerships were chosen for political and strategic reasons, others for expertise and context. The most common partnerships were established with Aboriginal groups, services for parents and children, the education sector, alcohol and drug programs, public health, corrections, FASD interest groups, law enforcement, social services, health care providers, parents, child protection services, early intervention programs and justice.
Although involving the population of interest in campaign planning is seen as cru c i a l , t h e rewere very few specific mentions of including members of this population at the p a rtnership level.
The population of interest is the specific group of people you want to reach through your awareness campaign. This is also called the target group or audience of interest. When selecting the population of interest for a campaign, it is helpful to ask the following questions:
“Make sure you choose a target population or you will be all over the place very
It is critical to carefully consider the interests, needs, concerns, priorities and vocabulary of the group you want to reach. Specific populations of interest, such as women at higher risk, young women and women of specific cultural groups, each have diff e rent information needs and respond diff e rently to given approaches. They listen to diff e rent radio stations, obtain i n f o rmation from diff e rent sources, view pregnancy diff e rently and use alcohol in diff e re n t contexts. Carefully defining and learning about the intended population is an important part of planning for an awareness campaign (The Health Communications Unit, 1999).
Although some campaigns in this review focused on one population of interest, others had several. The most common populations of interest for the campaigns reviewed in this project included the community (38%), youth (30%), the general public (28%), women of childbearing age (21%), service providers (19%), partners and family members of pregnant women (15%), the Aboriginal community (13%) and pregnant women (11%). Additional populations of interest included families affected by FASD (6%), friends (4%), high-risk families (4%), working adults (2%), multicultural community (2%), male partners (2%), sex trade workers (2%), licensed establishments (2%) and women before pregnancy (2%).
Respondents considered many things when choosing the main population of interest for their campaign. While respondents felt that women need information to make decisions about alcohol and pregnancy, most also felt that supports from family, friends and community played an important role. Other respondents were concerned mainly with populations that demonstrate high-risk alcohol and sexual behaviours, such as youth and sex trade workers, due to their increased risk of having a child with FASD.
Health communication campaigns are strategies that are most effective with large gro u p s of people at lower risk (The Health Communication Unit, 1999). As a result, some groups planned their campaigns for women of childbearing age, rather than specific high-risk groups. Respondents were clear that, although some groups are at higher risk for having a child with FASD, this is an issue of concern for all pregnant women.
Health promotion research indicates that there are benefits to carefully defining a very specific population of interest for an awareness campaign (e.g. women aged 20 to 30 who are planning to have a baby within the next 5 years) (The Health Communication Unit, 1999). However, many groups chose to focus on the general public or the community for their campaign strategies. More than half of all respondents (66%) wanted to get information to a broad group, such as the community or the general public, in order to be inclusive and to encourage support. Groups gave the following reasons for their focus on the general public or community:
Several groups (15%) mentioned that they wanted to get information to physicians and other health care providers. Some groups designed resources or strategies specifically for health care providers, such as mail-outs of posters and patient resources. Several groups found it difficult to reach physicians, in part because they did not feel they had the skills or credibility to plan strategies for health care providers.
While some groups tailored their campaign activities to one specific cultural group, others avoided this strategy because they were concerned that people would think FASD was a concern for only one specific population. There was a range of discussions about the need for culturally specific campaigns and resources, versus the need for inclusive campaigns and materials (i.e. materials that were suitable for a broad multicultural audience).
A few groups chose to focus entirely on youth (17%) because of concerns about alcohol use and sexual activity. Rates of alcohol consumption have increased significantly between the ages of 12 and 14 years, with almost as many girls as boys reporting binge drinking (Boyce, 2004). Binge drinking is more frequent in young people (Centre for Addiction and Mental Health, 2004). In addition, only two thirds of sexually active students used condoms
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the last time they had sexual intercourse, and only half used birth control pills (Boyce, 2004). Young people are at risk of unplanned, unprotected sexual activity and of alcohol use in the early stages of an unexpected pregnancy. Youth are perceived as having low levels of awareness about alcohol and pregnancy. Until recently, few resources and awareness strategies had been designed specifically for this population.
Campaigns speak to the population of interest through the key messages, design elements and the general tone of the campaign. The wording you choose, the images you select and the overall feel of the campaign strongly influence the campaign's ability to reach, interest and affect the population of interest. If carefully planned, the population of interest will attend to, recall and be influenced by the campaign (The Health Communication Unit, 1999).
Every campaign has an identity, whether or not it is consciously defined during development. Campaign identity includes key elements such as campaign name, positioning statements, use of logos, images, etc. A consistent identity should appear in all elements of the campaign, from the materials produced, to the messages shared through presentations and to the press. Building consistency and recognition for your campaign enhances the messages and objectives, resulting in increased strength and influence of the campaign (The Health Communication Unit, 1999).
In this review, campaigns varied widely in tone, from warm, positive themes, to stronger fear-based or shock approaches. Most respondents took a respectful, supportive approach to raising awareness about FASD. These campaigns recognized the complex issues associated with prenatal alcohol exposure and linked pregnant women and families to needed supports, or talked about how to be supportive. A few campaigns used a stronger approach, reinforcing the amount of harm and level of risk that can be caused by alcohol use in pregnancy. Some groups started with stronger approaches and moved to a more supportive tone as their skills and understanding of FASD increased. There is a lack of reliable information on the effectiveness of warmer versus stronger approaches in raising awareness about FASD.
Different types of appeals work with different populations of interest. Groups may have different knowledge levels or may be at different stages of readiness-to-change behaviour. For example, uninvolved groups that do not know the risks or have not thought about changing their behaviour will generally respond to an emotional appeal, such as information about the consequences of prenatal alcohol exposure. Groups that are thinking about changing a specific risk behaviour or are planning a pregnancy will be more likely to respond to an educational or rational approach, such as clear direction on safe levels of alcohol use during pregnancy.
Although fear-based strategies have been shown to be effective in tobacco campaigns for the general public (Council for Tobacco-free Ontario et al., 2000), it is still unclear if fear-based appeals are effective and appropriate in campaigns for pregnant women, and more specifically, in raising awareness about alcohol and pregnancy. There are concerns about possible side effects of fear-based campaigns, such as increased stigma about alcohol use in pregnancy, increased stress for pregnant women, decreased access to services and increased fear of disclosure of alcohol use in pregnancy. In the case of counselling strategies, there is evidence that confrontational approaches can increase resistance to change or push people to make change before they are ready, resulting in short-term changes that are not sustainable (Miller and Rollnick, 2002). Although fear-based appeals have been successfully incorporated into tobacco and seat belt strategies, the possible repercussions for pregnant substance-using women make fear-based approaches risky for use in FASD awareness campaigns.
Many respondents reflected on their guiding values during the planning process. The guiding values of hope, respect, compassion and understanding for both women who use alcohol and for individuals with FASD were considered to be helpful in defining the tone of a campaign.
A national survey of public awareness about alcohol and pregnancy indicates that there w e re high levels of awareness that alcohol use in pregnancy leads to lifelong consequences (Environics, 2002). However, there was confusion about the safety of lower levels of alcohol use and a lack of knowledge concerning the exact consequences of p renatal alcohol exposure. This type of information is invaluable in choosing messages for campaigns. Think about what your population of interest already knows and understands, as well as any myths or misconceptions. Although the general public recognizes that alcohol use in pregnancy is not a healthy choice (Environics, 2002), sub-populations and higher risk groups may have lower levels of awareness. Ideally, messages should be designed for specific populations and be tested with that population (The Health Communication Unit, 1999).
The following formula is useful in defining campaign messages:
• Include important information, such as “It is safest not to drink alcohol during pregnancy.”
• Present relevant reasons for change, such as brain damage or birth defects in the baby.
• Define an easy action, such as calling a helpline or talking to a health care provider.
Campaigns that were reviewed in this survey often had two or more key messages. The most common messages were:
“It was hard to choose messages, there was a lot we wanted to share . ”
Respondent, Manitoba
Respondents discussed messages that were controversial. The chart below presents concerns about certain messages:
| C o n t roversial Message | C o n c e rns with Message |
| FASD is 100% preventable. | FASD is not entirely preventable. Alcohol use often happens before a woman recognizes that she is pregnant and is related to unintended pregnancies, p o v e rt y, violence, addictions and mental health issues. |
| If you are pregnant, drink less or not at all. | Including harm reduction messages is necessary for some sub-populations. With the general public, it can confuse the issue. Harm reduction approaches may be most appropriate in the context of individual counselling sessions with a health professional, instead of an awareness campaign. |
| Simply don't drink alcohol for nine months. | For some women, stopping drinking is not simple. It can be a struggle. Depicting this as simple is misleading and can alienate the population of intere s t . |
| Choose not to drink alcohol during pregnancy. | For some women alcohol use is not about choice, it is about addiction. |
| It takes only one drink. | Many women have a small amount of alcohol before they know they are pregnant. While we want to be clear that there is no known safe limit, we also do not want to instil undue fear about the risks of unknowingly drinking a very small amount of alcohol in pregnancy. |
| Pregnant women never drink alone. | This can be seen as use of shame and blame, making it more difficult for women to disclose alcohol use, and to access appropriate services. |
“Unless we address violence, poverty and other things that happen to women, we will never be able to stop FASD.” Respondent, Yu k o n
Respondents were asked how they chose their key messages. They used various strategies: committee discussions, focus groups, resources from other campaigns, input from women in recovery, information about planning campaigns, feedback from staff, community partners and FASD experts, as well as research about awareness levels in the intended audience. One group used a values clarification exercise, which helped them to consider their personal beliefs about alcohol and pregnancy, their values related to pregnancy and children, and the impact they had on the selection of sensitive and respectful FASD awareness strategies. The key messages for two campaigns were selected based on questions that were often asked in FASD workshops. In a few cases, someone from the population of interest developed the campaign messages. One group used a message contest followed by a committee vote and focus testing to select the key messages for its campaign. For some campaigns, message selection was based on passion, rather than evidence of effectiveness with the population of interest.
When choosing campaign messages, there were many considerations. Respondents mentioned that they wanted to avoid alarmist messages and lecturing people. Almost half of the respondents (42%) talked about the need to avoid shame and blame in messages about alcohol and pregnancy. Respondents wanted to be non-judgmental, show respect, compassion and hope to reduce stigma and to share positive messages. They did not want to imply that it was only a woman's issue; they wanted to show support. Groups wanted their messages to appeal to their population of interest. Some respondents felt that cultural beliefs and practices were in themselves health promotion tools. Others wanted to recognize that alcohol use can be an addiction and to focus on underlying causes and strategies for support.
There was a lot of interest in clear, simple, straightforward messages. Many chose to avoid using terms such as FAS, FAE, FASD, etc., as it was easier to talk about alcohol use or brain damage, rather than to define complex, evolving terminology.
Some groups started out with basic messages about the risks of alcohol use in pregnancy, and then moved on in subsequent campaigns to messages about community support for pregnant women and where pregnant women can access help.
“People need to know that FASD is permanent, and brain damage is one of the consequences.” Respondent, Nunavut
When planning campaigns that included print resources, most respondents (87%) included a specific call to action or a simple first step for the population of interest. The calls to action included calling a specific phone number (66%), visiting a specific Web site (19%) or talking to a health care provider (8%). The calls to action included contact information for local, provincial or national services. Some campaigns provided more than one call to action (e.g. a phone number and a Web site). A few respondents (13%) did not include a call to action in their campaigns; however, most of these indicated that this was an oversight.
Images are powerful and are as much a part of the message as the chosen words. They a re often the campaign component that determines whether or not people will stop to read a poster or pick up and review a brochure. Images can have unexpected positive or negative repercussions for pregnant women who use alcohol and for individuals and families affected by FASD. Images should be chosen with care. If poorly selected, images can ridicule pregnant women, indicate that women who drink in pregnancy do not love their children, make it more difficult for women to reach out for help, or imply that there is no hope for individuals who have FASD.
One common mistake in developing awareness campaigns is to choose the image first. Ideally, the population of interest should be selected first, followed by the key messages, and finally the images (The Health Communication Unit, 1999). The images should speak to the population of interest and should support the key messages. When images are chosen first, campaigns may inadvertently be insensitive to the needs of pregnant women and families affected by FASD.
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Respondents talked about how difficult it was to choose the “right” visual for a campaign. One person said that, on the subject of FASD, she had “image phobia,” because alcohol use in pregnancy is such a complex and sensitive issue.
Respondents also talked about the difficulty in reaching consensus on images because of differences of opinion over supportive versus stronger images. Most respondents indicated a preference for positive images that showed happy, healthy people. Some groups chose “safer” neutral images, such as a picture of a phone or a butterfly.
Respondents were interested in choosing a campaign image that provided a clear visual message about not drinking during pregnancy. However, most respondents also had a preference for positive images that showed health and support. This was one of the main conflicts in the process of planning for campaigns. Most groups made a conscious choice not to include images of alcohol, especially images that associated pregnant women, babies and children with alcohol. A minority of respondents (21%) used images of alcohol in their campaigns. There were many variations on the theme of a pregnant woman holding a drink with a red slashed circle over the woman or over the alcohol.
In campaigns that were funded by the alcohol industry, the funder often stipulated that if images of alcohol were shown, there should be several different types of alcohol. Showing a range of alcohol products indicates that all alcohol is harmful to pregnant women, and also does not implicate a specific sector of the alcohol industry.
The most common images chosen by respondents were pregnant women (38%), babies (13%), pregnant bellies (8%) and community groups (8%). There were also images of pregnant women with a partner, women in a bar, fathers, young women drinking alcohol, friends, family groupings, a fetus inside a pregnant woman, etc.
There is no perfect answer. Many respondents talked about the compromises they made in choosing their campaign visuals and about the benefits and concerns related to images that have been used in campaigns about alcohol and pregnancy:
| I m a g e | B e n e f i t s | C o n c e r n s |
|---|---|---|
| Pregnant woman | Clearly indicates that the issue is related to pregnancy | May imply that this is only the pregnant woman's problem |
| Pregnant woman and a male partner | Indicates the role of the father | Not inclusive of single women or women with a female partner |
| Pregnant woman drinking alcohol | Clear visual message | Negative approach to the issue |
| Women at higher risk | Can help link women at higher risk to specific services | May reinforce the myth that FASD is only a concern for “high-risk” women |
| Brain of a baby with FASD | Shows serious consequences on the developing brain | Not representative of the common problems seen in brains of individuals with FASD |
| Headless pregnant women | Focuses on pregnancy | Can be seen as objectifying women |
| Undressed pregnant women | Clearly indicates pregnancy | May be viewed as culturally inappropriate or objectifying pregnant women |
| Fetus floating in alcohol | Strong image | May alienate the population of interest |
| Babies drinking alcohol | Strong image | May alienate the population of interest |
| Individuals in jail | Portrays the higher risk for encounters with the law | Does not show hope and can create misconceptions about the future expectations for individuals with FASD |
| Individuals with FASD | Positive images of people with FASD can provide role models and can show the quality of life that can come when appropriate supports are in place | Images of individuals with serious physical disabilities can create confusion about FASD since only a small proportion of people with FASD have serious evident physical challenges |
Most respondents wanted to avoid the following images: headless women, pregnant women drinking alcohol, children with serious physical signs of FAS, women alone, undressed women, children in jail, fetus floating in alcohol, and babies drinking alcohol. There were also concerns over the use of images that might indicate that alcohol use in pregnancy is primarily the concern of one social or cultural group.
Respondents who had worked on several FASD campaigns often talked about how their use of images changed over time. As education about FASD progressed, staff, community and the political climate called for more supportive and positive approaches. Groups frequently started with hard-hitting, blaming images and moved toward images that showed that the community had a role to play in prevention of FASD.
Images should be selected or designed to attract the attention of a specific population of interest. Inappropriate images may alienate a population of interest or trigger avoidance, denial, anger or rationalization (Witte and Allen, 2000). Visuals need to be engaging, interesting and believable to a population of interest.
Groups used various methods to help select their campaign images. They brainstormed ideas, showed the images to health care providers or considered the needs and intere s t s of the population of interest. Some groups found their guiding principles to be helpful in narrowing down the choice of images. A few groups looked at resources from other campaigns and thought about how they would affect individuals with FASD and women who drink. Only about a third of the respondents (32%) tested the images with the population of interest before proceeding with resource development. Testing was done either through formal focus groups, informally or by asking for feedback from families, program participants, etc.
Overall, respondents found that image selection was a challenging and sensitive part of campaign planning. No matter which image was chosen, there were some negative comments.
Research evidence supports the use of carefully planned awareness campaigns as one part of a broader strategy to prevent and address alcohol use in pregnancy. Research into single approaches to alcohol use in pregnancy, such as warning signs in licensed establishments or warning labels on alcohol containers, has shown mixed results and limited impact on awareness and behaviour (Roberts and Nanson, 2000). It is clear that multifaceted approaches that combine media, interpersonal communication and events are more effective (The Health Communication Unit, 1999), especially those that link people to additional services.
There are benefits to planning carefully, making conscious decisions and involving others when developing campaign strategies. Respondents were asked about the strategies or the main methods used to promote awareness, such as resource development and distribution, use of media and other activities.
When choosing the main strategies for campaigns, respondents relied on their own knowledge, information they learned from training, discussions with committees, information on the Internet and other resources. The most common ways to make decisions around campaign strategies were to get input from partners (70%), and feedback from co-workers (25%) and the population of interest (19%). Respondents also used other methods to define their campaign strategies, such as input from FASD experts, health communication experts and birth mothers, or by reviewing the approaches used in other campaigns. Some campaigns were planned to meet identified needs or gaps in services. Government direction and funding requirements provided frameworks for some campaigns. In 9% of cases, campaigns were planned with no input from others.
One group provided training to its working group before the members worked on any new issue. Before developing its awareness campaign, the group held a training session for the working group on social marketing strategies. After the training session, the working group applied the concepts in planning its campaign. Skills were transferable to other work areas as well. Partners found this to be useful in helping them to reach consensus on strategies.
All campaigns included some level of resource development and distribution. Other common campaign activities included print media (43%), radio (42%), workshops (34%), displays (32%), television (28%), speeches (21%), Internet (17%) and transit ads (13%).
Some interesting and popular campaign components are listed below:
Other interesting activities that were part of FASD campaigns included tours of facilities, Father's Day declarations, messages in grocery stores, poster contests, a youth karaoke event, presentations to the town council, plays and stories about FASD.
even if they are small. Start with baby steps, and build from there . ”
Respondent, Saskatchewan
When raising awareness, exposure and reach are important to increase the likelihood that messages will be heard and remembered. People need to see messages many times in many places, from reliable sources. While this is often done through expensive strategies such as purchased print, radio and television ads, many groups made creative use of media and face-to-face and other strategies to provide reach and message exposure. Partnerships, contributions and passionate pleas, use of earned media, newsworthy stories, displays, posters, mail-outs, presentations and feature stories all provided reach and exposure with little or no funding.
Although FASD is still a relatively new health concern, it is a resource-rich topic. There is no shortage of FASD campaign resources, and respondents discussed their challenges in selecting and designing resources to meet the needs of their population of interest.
Resource development takes time and is expensive, but is not always necessary when there are excellent resources available that meet the needs of your population of interest. One third of groups (36%) made use of existing resources in their campaigns. The decision to use existing resources in a campaign was based on budget limitations and/or the availability of suitable resources.
“ You don't need money, but you do need passion.” Respondent, Nova Scotia
There are benefits to developing new resources, rather than using existing resources. The process of resource development can foster community involvement, increasing ownership, skills and commitment to the issue. Resources can be designed to focus on specific or new information and tailored to meet the needs of a well-defined population. Resources can have a common look and message, supporting a specific campaign identity.
New resources were designed for all campaigns in this review. The most common resources developed were:
Many other creative resources were also developed. Promotional items included stickers, water bottles, pens, aprons, bags, cups, notebooks, magnets, mouse pads, yo-yo's, T-shirts and cloth bags. Some groups developed tools for sharing information, such as kits for people planning FASday, presentation folders, binders of resources, community action kits for shifting norms, information kits, PowerPoint presentations, totes of FASD resources, flipcharts, a DVD of flipchart images and overheads. Others developed tools specifically for use with young people, including computer games, curricula, music, temporary tattoos, education kits, resource kits and children's books. There were tools designed for places that serve or sell alcohol, including aprons, recipe booklets or cards, static clings, coasters, table toppers, messages on liquor bags and till tapes. Additional resources included handouts, service directories, tip sheets, fact sheets, newsletters, true and false tests, videos, Web sites, outreach kits, prenatal packages, support cards and postcards.
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There were differing opinions on poster size, the usefulness of brochures and the role of promotional items. Some liked large posters, as they were more likely to draw attention; others liked small posters because costs were significantly lowered and they fit easily on community and health centre bulletin boards. Some felt that brochures are usually thrown out unread; others felt that brochures are important tools in providing answers to common questions. While some were strongly opposed to promotional items such as magnets and pens and thought they were a waste of money, others thought the message would be reinforced if it was visible on resources that were used on a daily basis by the population of interest. There is a need for further research into the role and effectiveness of promotional items.
Many people talked about the value of visual resources, such as videos and flipcharts. In communities where learning is more likely to occur in a visual format, these tools can be very useful.
Ultimately, it is important to know the types of resources that will be effective in reaching a specific population of interest. We need to think about the way information will be shared
(e.g. through health clinics, media or presentations) and the types of resources that will engage the interest of a specific population.
“ R e s o u rces are not right or wrong, but need to fit with where you stand.”
Respondent, British Columbia
For most people, testing draft resources was an important part of developing effective tools. Respondents felt that testing helped to make their drafts more sensitive and informative. Respondents often commented on the value and depth of the input they received, especially the insights from the population of interest. Respondents who tested their draft resources during development said that they learned important things, even if they had been working on the topic for a long time. Reviewers saw things they had not noticed before and provided valuable advice, although it was not possible to develop a resource that pleased all reviewers.
Some groups (26%) did not test their draft resources. For a few it was an issue of time, but most thought that committee members knew the population of interest well and did not think testing was necessary.
Different methods were used to test the draft resources. Most commonly, respondents sought out individual input from partners (43%), the population of interest (32%) and staff (26%). Some groups set up focus groups (19%) in either formal or informal settings to discuss the draft resources. To keep the review process simple, respondents sometimes sought input by taking draft resources to existing meetings with partners or to programs for pregnant women, etc. This saved the costs and challenges involved in setting up formal focus groups. Of the community groups that tested their resources, most used more than one method.
Draft resources were tested with a variety of groups, including FASD experts, health communication experts, the alcohol industry, people on the street, literacy groups, youth and adults in corrections, adult education workers, frontline workers, sex trade workers, participants in programs for pregnant women who use substances, youth, males, young parents, service providers, detox clients, and people in northern, urban or rural communities. Some respondents mentioned that the best input came from pregnant women who used substances. People who had struggled with alcohol use had insights into the types of resources that would influence pregnant women and the small changes that would make the resources more effective.
“It is a big mistake to think you know what the target audience likes.”
Respondent, Ontario
Distribution methods varied, depending on funding and campaign strategies. Brochures were most commonly distributed to the intended population by mail or by hand, through displays, workshops and conferences. Planned distribution to key sectors was sometimes included in campaigns. Distribution strategies such as mass mail-outs were planned for health care providers, other service providers, liquor stores, restaurants and bars, schools, community centres, programs for pregnant women, community partners, pharmacies, prenatal health fairs and grocery stores.
Campaign resources were promoted through Web sites, email, list serves and newsletters. Some groups talked about the importance of personal contact in distribution. In communities where FASD was a relatively new or sensitive issue, respondents had to “chat it up” with service providers and community members to share important information and resources.
The media were a big part of most awareness campaigns. People wanted to spread the word widely. For groups with funding and even for those without, the media were a useful tool. Two thirds of all respondents (64%) included mass media in their campaigns, focusing mainly on the following areas:
Campaigns included a range of newspaper and print ads, articles and stories. Radio strategies included interviews, radio plays, ads, call-in shows and talk shows. Television opportunities were used for interviews, ads, news clips, call-in shows and stories. Videos were shown on cable television. Groups also accessed other mass media to provide reach, including mall ads, bus and subway ads, transit platform ads, bus shelter ads, newsletters, mailbox stuffers, restaurant/bar ads, movie theatre ads and billboards. Some groups developed media kits that included fact sheets and Q&As.
Respondents stressed the importance of television in providing reach and impact. Radio and print advertising were also seen as priority areas for media involvement. Although it is expensive to produce and purchase air time for radio and television ads, groups found many opportunities to make this issue sufficiently newswort h y. New information, angles and compelling stories are needed to continue to bring FASD to the attention of the media.
Insights: Use of Mass Media
About one quarter of respondents (28%) had developed some form of warnings for use in licensed establishments. Warnings included signs, posters, stickers, coasters, static clings, messages on cash register receipts or on liquor bags. Most groups found that licensed establishments were already concerned about alcohol use in pregnancy and were happy to act as caring members of their community.
Most of these respondents felt strongly that warning strategies are effective prevention approaches for prenatal exposure to alcohol. They indicated that many strategies are needed to influence this issue, and that warnings are another way to get this important message out. The respondents felt that women need to see these messages many times, in situations related to alcohol use, and that partners, friends, family, bar staff and the community need to see the messages as well.
“ P revention messages need to come from many sources.”
Women need information to make informed choices, although, for some, awareness is not enough. Respondents stated that, alone, the warnings in licensed establishments would not likely be enough to change behaviour. However, they felt that warnings are an important part of a larger strategy. Warnings in establishments such as liquor stores or bars can help to make the issue official and to create social norms around alcohol use in pregnancy.
Respondents realized that it is important to track the impact of awareness campaigns. However, their ability to assess the impact of their activities was limited and evaluation was performed on different levels. Only four campaigns were able to measure campaign recall, message recall or levels of awareness.
Although most groups did not have the funding to complete a formal evaluation, they looked at media reach, number of resources distributed, requests for resources, participation in events, requests for displays or presentations, number of partners, number of events, and calls for information and qualitative feedback at events and activities. Basic evaluation methods also included workshop evaluation forms, mini surveys and feedback forms in videos or kits. After campaigns wrapped up, committees often discussed the process of the campaign, reviewing the things that went well and areas that could be improved.
Signs of success included increased demand for resources, increased number of events held each year, positive feedback from the community and from partners, additional partners, increased hits on Web sites, increased requests for information or services, awards for campaigns and requests to present information about the campaigns at workshops and conferences. One community called physicians' offices after a mass distribution and found that 95% of the offices had put up the posters.
Regardless of the type of objectives, population of interest, key strategies and level of funding, all groups interviewed felt their activities were very successful and that they had met or exceeded their objectives. However, for most groups, the ability to measure their success objectively was limited.
The four groups that were able to measure the impact of their activities felt that it was important to verify the effectiveness of their work, to share important information with funders and to assist in planning future campaigns. This level of evaluation required substantial financial resources. All these groups had positive evaluation results, such as increases in awareness about alcohol and pregnancy in the population of interest or good campaign and message recall. These campaigns had common characteristics, which are associated with successful campaigns. The campaigns were carefully planned, used multiple strategies, focused on a specific problem, used carefully selected messages and images, had good reach and considered current levels of awareness. These campaigns all focused on large populations (i.e. they were provincial in scope), were designed for populations at lower risk (i.e. they were not designed for women who were alcohol dependent), and all addressed the topic of alcohol use in pregnancy rather than individuals with FASD.
The following campaigns used evaluation strategies that examined awareness levels, campaign or message recall:
Pre- and post-campaign phone survey of the general population in Alberta showed:
Post-campaign survey of women of childbearing age in Manitoba showed:
Post-campaign survey of the impact of the radio messages in this campaign showed:
• 40% recall of radio spots
Pre- and post-campaign phone survey of women of childbearing age in Ontario showed:
Respondents talked about the highlights and strengths of their campaign, the positive feedback they had received and what went well. The most common and heartfelt comments were about the invaluable contributions from partners.
• P a rtners: When asked what went well, respondents (51%) overwhelmingly indicated that partnerships made their activities strong. They were pleased with the diversity and number of partners and the way they worked together, with everyone pitching in. Partnerships sometimes developed into roles that went beyond the campaigns. Working groups were described as energetic, committed, strong, supportive, enthusiastic, determined, collaborative and passionate. Committees were proud of their work. People wanted to be involved, and committees were growing in size.
“ S t o rytelling reaches the heart of women.” Respondent, Prince Edward Island
Best Start: Ontario's Maternal Newborn and Early Child Development Resource Centre 2 0 0 5 6 7
Respondents were asked if there were things they would do differently in their next campaign. Respondents learned from negative responses, areas of controversy and from issues that came up in campaign development and implementation. They gained a better sense of community needs and of the process of campaign development.
About half of all respondents had received negative comments about their work. Negative responses were usually isolated and not easy to address directly. These comments often stemmed from a misunderstanding of the issue of FASD. For example, some people said they did not have sympathy for pregnant women who use substances, as this is a choice they make.
There was a range of negative comments from service providers and community members about the type of images, such as discomfort with images of nudity, images that indicated it was only an issue for high-risk women and images that were exclusive of high-risk women. Some community members thought that FASD was not a concern in their area. Some negative comments had to do with the general tone of the campaign, indicating that the campaign was not hard hitting enough, or that it needed to be more supportive.
In general, negative responses indicated the need to tailor information to specific audiences, to increase sensitivity and understanding about the issues, to choose images and the tone of the campaign with care, to decrease stigma and blame, to show hope, to increase understanding of the role that partners, friends, families and communities play in preventing FASD, and to increase access to services.
The most common “negative comment” from community members was that more strategies were needed, which in a sense, is also strongly supportive of their work.
Many respondents wished they had more time to plan, be creative, consider the level of readiness of the community, gather information, review existing resources, collect input from the population of interest and develop higher quality resources.
Groups wanted to build stronger partnerships and involve more partners. They wanted better relationships with the medical community, media, schools, restaurants and bars, the alcohol industry and non-traditional partners such as grocery stores. Groups wanted to develop volunteer strategies and to find ways to share the work more equally.
They wanted to build on the work that they had already completed by updating their resources, developing additional resources, reassessing their use of visuals, distributing resources more broadly, working with new populations of interest, including new messages, translating their materials into different languages and increasing their reach. Respondents wanted to find ways to reach a range of audiences, especially women who are drinking large amounts of alcohol. They wanted to include messages about the role of the partner, family and friends. Groups were interested in developing comprehensive plans, including all levels of prevention, so that awareness campaigns were clearly linked to access to services.
Groups were interested in evaluating more effectively, by building in evaluation strategies from the start and gathering baseline data. They wanted to develop follow-up activities, so the campaigns were not one-time efforts. Groups wanted to look into additional funding sources, to build on or sustain their work.
Groups also talked about the need for patience, as well as strategies to prevent burnout in staff and partners.
“Go slowly, it is a tough topic, a big re s p o n s i b i l i t y, and lots of people want to
be involved.” Respondent, Prince Edward Island
Because this is a new, sensitive and complex health issue, it is not unexpected that there are areas of controversy. Although, overall, respondents were very pleased with their work, they mentioned several areas where there was disagreement or debate. Sometimes this was a source of friction within a working group; sometimes it was a reaction from the community. The most common area of controversy was:
• the relative benefits of warm, supportive campaigns, versus stronger approaches
Additional areas of controversy or debate included:
Best Start: Ontario's Maternal Newborn and Early Child Development Resource Centre 2 0 0 5 7 1
Disagreements can make it difficult for groups to proceed with their work. Controversy can be avoided or minimized by discussing guiding principles, carefully selecting a population of interest, involving the population of interest and by testing materials with the population of interest. It is clear that there is no single universally effective approach. Materials and strategies need to be selected or designed with specific groups in mind.
To support local or regional efforts to raise awareness, respondents indicated that there was a need for additional information that was specific to the development of FASD awareness campaigns.
Although people who work on FASD are knowledgeable about the causes and consequences of prenatal alcohol exposure, this survey indicates that many do not have skills specific to the development of awareness campaigns. Respondents were interested in a step-by-step manual about how to implement an effective campaign, including content about resource development, health promotion, social marketing and considerations specific to FASD, how to involve media, talk to municipal councils, and work with physicians and licensed establishments. More specifically, there was interest in learning about principles and practices, issues, visuals, messages and activities. They wanted to l e a rn how to build, maintain and strengthen partnerships. They also wanted to know how to assess the effectiveness of awareness activities through simple evaluation tools and templates. They wanted to know about the relative benefits of different resources and approaches, and about the value of promotional items.
Respondents mentioned that they wanted to know about best practices for effective FASD campaigns and about related health promotion topics such as tobacco use. Respondents wanted to learn from the process, products and outcomes from other campaigns and to share information through a newsletter or list serve. They wanted to know about messages, images and strategies that are effective with women at risk and with youth. Since funding was often minimal or non-existent, many respondents wanted to know where they could access free print resources or electronic files for existing resources. They felt they needed access to well-designed resources for a range of populations.
Research into hard-hitting versus warmer campaigns and their impact on other levels of prevention would help people maximize the effectiveness of their campaigns and minimize any unfortunate consequences.
Local statistics on alcohol use in pregnancy, levels of awareness and incidence of FASD would also be useful to people planning awareness strategies on FASD. Respondents wanted more information about who needs this message most and the populations most amenable to a communication campaign.
Respondents provided advice about planning an FASD awareness campaign. The most common advice was:
This section features a selection of innovative and/or large-scale awareness campaigns about FASD from across Canada. The featured campaigns were designed for diff e rent populations and show an interesting range of strategies, key messages and images.
*www.calgaryfasd.com
The Calgary Fetal Alcohol Network, in partnership with the Calgary Health Region, planned a unique campaign for the Calgary area about helping friends avoid alcohol. This cheerful, positive campaign started in 2003 and new initiatives were still being added in 2004-05, with expansion to rural and Aboriginal communities. The main population of interest was youth aged 16 to 24, and resources showed groups of happy young people. The main messages were, “Help a pregnant friend avoid alcohol. Support your pregnant friends. Friends caring for pregnant friends.” A wide range of strategies was used, including presentations, posters, pamphlets, info packs, media kits, PowerPoint presentations, print public service announcements (PSAs), transit ads, theatre ads, articles in magazines, newspapers and newsletters. The central activity for the campaign was a youth event with music, painting, discussion, videos, presentations by people with FASD, etc. Youth were carefully involved in all stages of campaign planning and implementation. The supportive, positive, empowering tone and the focus on both young women and young men made this a lively and fresh approach.
www.beststart.org
The Best Start Resource Centre implemented Ontario's first province-wide campaign about alcohol and pregnancy in 2004. This campaign was designed for women of childbearing age and focused on messages about no safe amount of alcohol and no safe time in pregnancy for alcohol. The main visual was a pregnant couple. There were three main strategies. One was a provincial media strategy, including transit ads, theatre ads, mall ads and links to provincial print, radio and television media. The second level was a mail-out of patient and health care resources to all Ontario family physicians and midwives. The last level was linking community groups and organizations to resources and tools to develop local campaigns, in support of the provincial strategies. “How to” resources were provided through a Web site and groups and organizations were provided with free posters, brochures and static clings, as well as electronic files for additional resources.
The North Shore Tribal Council, in nort h e rn Ontario, found that it was difficult for communities to talk about FASD. Alcohol use in pregnancy was a very sensitive issue, and it was difficult to initiate prevention activities. In 2003, a member of the Whitefish Lake First Nation was given tobacco and a small wooden staff to design and decorate. Nine eagle fluffs were added to re p resent the nine months of pregnancy and two additional eagle fluffs symbolize balance during p re g n a n c y. The FAS Knot was included to honour those who have been aff e c t e d by alcohol during pre g n a n c y, for they too have a purpose to fulfill. This became the FAS staff, now known as the Wo m a n 's Eagle Staff. In honour of the nine months of pre g n a n c y, the little staff took part in nine days of celebration thro u g h a journey to the seven First Nation's communities, the Indian Friendship Centre and the North Shore Tribal Council's FAS Program. To send it off in a good way, beginning in the eastern community, a pipe ceremony was held. From there , each community presented a gift to the FAS staff, such as tobacco, moccasins, posters, etc. Activities included cultural ceremonies, speakers, pre s e n t a t i o n s , displays, a poker walk, barbecue, distribution of bro c h u res and presentations for c h i l d ren at each of the sites. On the ninth day, the FAS staff was taken to an E l d e r's Gathering where the elders “activated” the staff and gave acknowledgement for the work it was about to do with individuals throughout the life cycle. Following this, the FAS staff was given a Grand Entry with a song, followed by its helpers, at North Shore Tribal Council's Celebration of I n t e rnational FA S d a y. This staff will help people remember those affected by FASD and think about future generations to come. It has already begun to do its work in the promotion and prevention of prenatal alcohol exposure. The staff makes it easier to talk to people about FASD in a kind and gentle manner and has helped the communities start planning FASD activities.
www.withchildwithoutalcohol.com
In 2001, the Manitoba Liquor Control Board's “With Child – Without Alcohol” campaign was launched across Manitoba, and was still ongoing in 2005. This prevention campaign was planned in partnership by Healthy Child Manitoba, the Addictions Foundation of Manitoba and the Manitoba Liquor Control Board. Two main images were used, a silhouette of a pregnant woman and a photo of a woman who drank during pregnancy, who acts as a spokesperson for the
Best Start: Ontario's Maternal Newborn and Early Child Development Resource Centre 2 0 0 5 8 1
campaign. This campaign intends to raise public awareness and link pregnant women and their supports with important information about alcohol and pregnancy through a Web site and through the FAS Information Manitoba warm line. Strategies included booklets at liquor marts or through the warm line, stickers in licensed establishments, messages on cash register receipts and liquor bags, information in the responsible server training program, television and radio ads, billboards and bus shelter ads, information kits and a Web site.
*S A F E R A
www.safera.qc.ca
This FASD campaign is one of the few campaigns designed primarily for Francophones. The campaign was developed by SAFERA in 2003. Campaign materials were used across Quebec as well as in other regions of Canada. The image of a yo-yo was used to re p resent risk and pre g n a n c y. The messages were , “ D o n 't play yo-yo with your baby. Pregnant, no alcohol.” This campaign focused mainly on resource distribution, including posters and leaflets, bookmarks, yo-yo's and newsletter articles. The campaign was intended for the general public and also shared messages about the need for community support. The campaign visuals portrayed the consequences of alcohol use in pregnancy and images of y o - y o 's. This is an example of a campaign that uses stronger messages and i m a g e s .
Keep Families Strong Campaign, D e p a rtment of Health and Social Services, Government of the NWT, the NWT Status of Wo m e n 's Council and NWT Native Wo m e n 's Association
*This warm, supportive campaign takes an inclusive look at issues around alcohol use and pregnancy. Using a water colour painting of fireweed and images of families, this campaign shares messages about the need to support recovery from abuse and addiction and emphasizes the need for respect, health, family, love and nurturing. The 2000 campaign, which was a partnership initiative by the NWT Status of Women Council, the NWT Native Women's Association and Health Promotion, Department of Health and Social Services, Government of the NWT, included two television advertisements, mega-posters, presentation folders, newspaper inserts, computer mouse pads, T- s h i rts, bookmarks and a series of six “Keep Families Strong” magnets. An Archie Beaulieu print was used for a subsequent campaign implemented in 2004 by the NWT Native Women's Association and its partners for communities in the Northwest Territories. Campaign resources included posters, presentation folders, note books, T-shirts and mouse pads.
In 2003, Prince Edward Island developed an awareness strategy about alcohol and pregnancy based on the message, ”No time is the right time to drink when you are pregnant.” The image of a pregnant woman and the hands of a clock reinforced this key message. The campaign was implemented through radio ads, brochures, posters, bookmarks and a Web site. The languages used were English, French and Mi'kmaq. Feedback from communities indicated that people
liked hearing the Mi'kmaq and the clear visual message.
This Is Our Baby Campaign, Yukon Govern m e n t
The Yukon government implemented an awareness campaign in 2004 to coincide with the Super Bowl. The campaign used positive images and focused on linking women to support from family, friends, community and services. There was a series of posters, reflecting happy, healthy people, including pregnant women, fathers, couples, babies and young parents. The campaign made use of print, radio, television ads and interior bus ads. This group felt their campaign was successful because of its gentle, supportive, invitational nature and the focus on the positive.
Feeling Pretty Good Campaign,
*The Asante Centre for Fetal Alcohol Syndro m e
The Asante Centre for Fetal Alcohol Syndrome in British Columbia felt that youth needed information about alcohol and pregnancy due to their high levels of alcohol use and sexual activity. They wanted to design resources that appealed to this group, but could not show a pregnant woman on the cover, as this image would not connect with young people. Instead they used an image of women partying and focused on messages about supporting friends, the consequences of alcohol use in pregnancy, and what to do if you were pregnant or needed help to stop drinking. The materials were tested with youth to ensure that they would be effective, and the planning committee frequently referred to their guiding principles to develop messaging that respected the unique circumstances of young women in today's society.
www.child.gov.ab.ca
* A l b e rta Childre n 's Services implemented a series of provincial aware n e s s campaigns about alcohol use in pre g n a n c y, starting with the Born Fre e campaign in 2000. In 2003, it implemented a campaign called Your Decision – B a b y 's Future in partnership with the Alberta Medical Association, the College of Physicians and Surgeons and AADAC. This campaign shared inform a t i o n about the risk of alcohol use during pregnancy with women of childbearing age and the general public. Campaign images included a pregnant woman with dice in her alcoholic drink and a roulette wheel with an alcohol bottle as the p o i n t e r. A range of re s o u rces and approaches was used, including posters, post c a rds, a newsletter, re s t room ads for restaurants and bars, print, television and radio ads. Bro c h u res and posters were distributed to Alberta doctors' off i c e s and medical students.
This report can be used to assist in program planning for future FASD campaigns. The main area of consensus was a high level of concern about FASD and passion for prevention approaches.
The principal implications are:
Awareness campaigns:
Most people believed strongly in the value of:
AADAC. (2004). Windows of opportunity: A statistical profile of substance use among women in their childbearing years in Albert a. Edmonton: Author.
AADAC. (2003). The help guide for professionals working with women who use substances. Edmonton, Author.
AADAC. (2000). FAS Aw a reness Campaign Assessment Study. Edmonton: Angus Reid Group, Inc.
Aware, & Breaking the Cycle. (2002). The SMART guide: Motivational approaches within the stages of change for pregnant women who use alcohol. Kingston, Ont.: Authors.
Basford D.L. et al. (2004). State of the evidence: Fetal alcohol spectrum disorder (FA S D ) p re v e n t i o n. Edmonton, Alta.: Alberta Centre for Child, Family and Community Research, University of Lethbridge.
Best Start Resource Centre. (2004). O n t a r i o 's provincial alcohol and pregnancy aware n e s s campaign. Be safe: Have an alcohol-free pre g n a n c y. Evaluation re s u l t s. Toronto: Best Start. Available from http://www.beststart.org/apcampaign/evaluation.html
Best Start Resource Centre. (2003). Keys to a successful alcohol and pre g n a n c y communication campaign. Toronto: Author.
Boyce, W. (2004). Young people in Canada: Their health and well-being. Ottawa: Health Canada. Available from http://www.phac-aspc.gc.ca/dca-dea/7-18yrs-ans/index_e.html
C a s i ro, O.G. et al. (1994). Public awareness of the risks of drinking alcohol during pre g n a n c y : The effects of a television campaign. Canadian Journal of Public Health, 85(1), 23–27.
Centre for Addiction and Mental Health. (2004). 2003 Ontario Student Drug Use Surv e y. Toronto: Author. Available from http://www.camh.net/publications/ontarioyouthuse_crcuspring2004.html
Chudley, A.E. et al. (2005). Fetal alcohol spectrum disorder: Canadian guidelines for diagnosis. Canadian Medical Association Journ a l, 172(Suppl), S1–S21.
Council for Tobacco-Free Ontario et al. (2000). Understanding and using fear appeals for tobacco contro l. Available from http://www.ptcc.on.ca/pubs/fa-web.pdf
Environics Research Group Limited. (2002). Aw a reness of the effects of alcohol use during p regnancy and fetal alcohol syndrome: Results of a national surv e y. Ottawa: Health Canada.
Habbick, B.F. et al. (1996). Foetal alcohol syndrome in Saskatchewan: Unchanged incidence in a 20-year period. Canadian Journal of Public Health, 87(3), 204–207.
Health Canada. (2005). Knowledge and attitudes of health professionals about fetal alcohol syndrome: Results of a national surv e y. Ottawa: Health Canada. Available from www.phac-aspc.gc.ca/hp-ps/index.html
Health Canada. (2003). Canadian perinatal health re p o rt 2003. Ottawa: Author.
Hyndman, B. et al. (1993). The use of social science theory to develop health pro m o t i o n p ro g r a m s. Toronto: Centre for Health Promotion, University of Toronto.
Jones, K.L., & Smith, D.W. (1973). Recognition of fetal alcohol syndrome in early infancy. L a n c e t. Nov., 999–1001.
Kaskutas, L.A., & Graves, K. (1994). Relationship between cumulative exposure to health messages and awareness and behavior-related drinking during pregnancy. A m e r i c a n J o u rnal of Health Pro m o t i o n, 9(2), 115–124.
Kassirer, J. (1999). Tools of change: Proven methods for promoting health, safety and e n v i ronmental citizenship. Available from http://www.toolsofchange.com
Miller, W.R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York: The Guilford Press.
MLCC. (2002). Su m m a ry of Advertising Aw a reness Study. Direct Focus.
National Cancer Institute. (2002). Making health communication programs work – A p l a n n e r's guide. Available from http://oc.nci.nih.gov/services/HCPW/HOME.HTM
Nevin, A.C., Parshuram, C.C., Nulman, I.I., Koren, G.G., & Einarson, A.A. (2002). A survey of physicians' knowledge regarding awareness of maternal alcohol use and the diagnosis of FAS. BMC Family Practice, 3(1), 2.
Poole, N., & Isacc, B. (2001). A p p rehensions: Barriers to treatment for substance using m o t h e r s. Vancouver: British Columbia Centre of Excellence for Women's Health. Available from www.bccewh.bc.ca
Prochaska, J.O., & DiClemente, C.C. (1985). Common processes of self-change in smoking, weight control, and psychological distress. In: S. Shiffman & T. Wills (Eds.), Coping with Substance Use, pp. 345–364. Orlando, Fla.: Academic Press.
Prochaska, J.O., & DiClemente, C.C. (1982). Transtheoretical theory: Towards a more integrative model of change. Psychotherapy Theory, Research and Practice, 19(3), 276–287.
Roberts, G., & Nanson, J. (2000). Best practices: Fetal alcohol syndrome/Fetal alcohol e ffects and the effects of other substance use during pre g n a n c y. Ottawa: Health Canada.
Best Start: Ontario's Maternal Newborn and Early Child Development Resource Centre 2 0 0 5 8 9
Statistics Canada. (2003). Canadian community health surveys. Ottawa: Government of Canada. In: Public Health Agency of Canada. (2005). Make every mother and child. Ottawa: Author.
Streissguth, A.P. et al. (1996). Understanding the occurrence of secondary disabilities in clients with fetal alcohol syndrome (FAS) and fetal alcohol effects (FAE). Seattle: University of Washington School of Medicine.
The Health Communication Unit. (1999). O v e rview of health communication campaigns. Toronto: Author. Available from http://www.thcu.ca/infoandresources/general_communication.htm#tp
Witte, K., & Allen, M. (2000). A meta-analysis of fear-appeals: Implications for effective public health campaigns. Health Educator and Behaviour, 27, 591–615.
Appendix 1: Survey Respondents
The following organizations were interviewed during this national environmental scan of key awareness campaigns about alcohol and pregnancy.
The Brewers of Canada, Ottawa, Ontario FASworld Canada, Toronto, Ontario Friends of Motherisk, Toronto, Ontario Labatt Canada, Toronto, Ontario Molson Pauktuutit Inuit Women's Association, Ottawa, Ontario Prostitutes Empowerment Education Resources Society (PEERS), Victoria, BC
Alberta Alcohol and Drug Abuse Commission (AADAC), Edmonton Alberta Children's Services, Edmonton Alberta Liquor and Gaming Commission, St. Albert Alberta Liquor Store Association, Edmonton Calgary Fetal Alcohol Network, Calgary Edmonton Success by Six, Edmonton Lakeland Centre for FASD, Cold Lake
The Asante Centre for Fetal Alcohol Syndrome, Maple Ridge BC Liquor Stores, Vancouver BC Ministry of Children and Family Development, Victoria Campbell River FASD Community Action Network, Campbell River Community Healing and Intervention Program (CHIP), Cranbrook Northern Family Health Centre, Prince George BC Women's Hospital, Vancouver SNAP Promotions, Vancouver
Healthy Child Manitoba, Winnipeg Interagency FASD, Winnipeg Manitoba Health Living, Winnipeg Manitoba Liquor Control Commission, Winnipeg
Alcool NB Liquor, Fredericton Family & Community Services, FAS Committee, Saint John Moncton Headstart Inc., Saint John Union of New Brunswick Indians Training Institute, Fredericton
Aboriginal Family Centre, Happy Valley, Labrador Health and Community Services – Central, Gander, Newfoundland Newfoundland Liquor Corporation, St. John's, Newfoundland
Department of Health and Social Services, Yellowknife FASD Working Group, Fort Simpson NWT Liquor Commission, Hay River NWT Native Women's Association, Yellowknife Status of Women Council, Yellowknife
Dorchester Penitentiary, Southampton Mi'ikmaq First Nation Healing Society, Hantsport The Nova Scotia Liquor Corporation, Halifax VON, Sackville
FASD Pilot Project, Department of Health and Social Services, Kuglutkuk Nunavut Liquor Management, Rankin Inlet
Association of Iroquois and Allied Indians, London Best Start Resource Centre, Toronto Breaking the Cycle, Toronto City of Hamilton, Hamilton East York East Toronto Family Resources, Toronto FASD North, North Bay Kingston, Frontenac, Lennox and Addington Health Unit, Kingston Liquor Control Board of Ontario, Toronto Mamaweswen, North Shore Tribal Council, Cutler Ontario Ministry of Consumer and Business Services, Toronto Rural Response for Healthy Children, Clinton Timiskaming Brighter Futures, Kirkland Lake Upper Canada District School Board, Brockville
Best Start: Ontario's Maternal Newborn and Early Child Development Resource Centre 2 0 0 5 9 3
Aboriginal Women's Association of Prince Edward Island, Lennox Island Department of Health and Social Services, Charlottetown
P.E.I. Liquor Control Commission, Charlottetown
Educ'alcool, Montréal SAFERA, St-Henri-de-Lévis Société des alcools du Québec
Battlefords FASD Committee, North Battleford La Ronge Area FASD Prevention Team, La Ronge Regina FASD Community Network, Regina Saskatchewan Liquor and Gaming Authority, Regina Saskatchewan Prevention Institute, Saskatoon Yorkton and Area FASD Committee, Yorkton
Fetal Alcohol Syndrome Society of Yukon (FASSY), Whitehorse Government of Yukon, Whitehorse Yukon Liquor Corporation, Whitehorse
Appendix 2: Survey Instru m e n t s
Geographic
Area for the Campaign:
Responsible Organization/Committee/Group:
Key Partners/Committee Members:
Funding Source:
Appendix 3: Helpful Resourc e s
The following resources may be helpful to groups that are planning an awareness campaign about alcohol and pregnancy.
| O R G A N I Z AT I O N | R E S O U R C E S |
| Best Start: Ontario's Maternal, Newborn and Early Child Development Resource C e n t re c/o OPC 180 Dundas Street West, Suite 1900 Toronto, ON M5G 1Z8 Phone: 1-416-408-2249 Fax: 1-416-408-2122 Email: beststart@beststart.org www.beststart.org | • Keys to a successful alcohol and pregnancy communication campaign • Tip sheet on working with the media • Tip sheet on working with licensed establishments • How to work with coalitions • How to work with physicians • How to work with youth |
| FASD Information and Consultation S e rv i c e Canadian Centre on Substance Abuse 75 Albert Street, Suite 300 Ottawa, ON K1P 5E7 Phone: 1-613-235-4048 x 223 or 1-800-559-4514 Fax: 1-613-235-8101 Email: fas@ccsa.ca www.ccsa.ca | • Reference Library on FASD • National Database of FAS and Substance Use During Pregnancy • Resources FAS Toolkit |
| FA S w o r l d 1509 Danforth Avenue Toronto, ON M4J 5C3 Tel: 1-416-465-7766 Fax: 1-416-465-8890 Email: fasworldcanada@rogers.com www.fasworld.com | • Ideas for FASday |
| Public Health Agency of Canada Publications Ottawa, ON K1A 0K9 Phone: 1-613-954-5995 Fax: 1-613-941-5366 www.phac-aspc.gc.ca | • FAS/FAE Best Practices • Awareness of the Effects of Alcohol Use • During Pregnancy and FAS • Knowledge and Attitudes of Health Professionals About FAS • It Takes a Community • FASD: A Framework for Action |
| O R G A N I Z AT I O N | R E S O U R C E S |
| M o t h e r i s k The Hospital for Sick Children 555 University Avenue Toronto, ON M5G 1X8 Phone: 1-877-327-4636 Fax: 1-416-813-7562 www.motherisk.org | • Alcohol and Substance Use in Pre g n a n c y Help Line (1-877-FAS-INFO) • On-line Journal about FASD (JFAS) |
| Ontario's North for the Children and Timiskaming Brighter Future s 6 Hudson Bay Avenue Kirkland Lake, ON P2N 2H7 Phone: 1-705-676-2104 Fax: 1-705-676-2121 Email: mandr@ntl.sympatico.ca | • Different Directions video • Different Directions Training Manual |
| Program Training and Consultation Centre c/o City of Ottawa Public Health and Long-Term Care Branch 495 Richmond Road Ottawa, ON K2A 4A4 Phone: 1-613-722-2242 or 1-800-363-7822 Fax: 1-613-724-4116 www.ptcc-cfc.on.ca | • Understanding and Using Fear Appeals for Tobacco Control |
| The Health Communication Unit at The Centre for Health Promotion 100 College Street - Room 213 The Banting Institute University of To ro n t o Toronto, Ontario M5G 1L5 Phone: 1-416-978-0522 Fax: 1-416-971-2443 Email: hc.unit@utoronto.ca www.thcu.ca | • Overview of Health Communications Campaigns Workbook • Overview of Health Communication Campaigns Toolkit • Evaluating Health Promotion Programs • I n t roduction to Health Promotion Planning • Developing Exceptional Ads and Other Communication Materials • Case Studies of Health Communication Campaigns |
Appendix 4: Insights
This appendix is a summary of the main insights from this review and can be used as a reference sheet when planning campaigns, or as a handout at workshops about designing FASD awareness campaigns.
Best Start: Ontario's Maternal Newborn and Early Child Development Resource Centre 2 0 0 5 9 9
Best Start: Ontario's Maternal Newborn and Early Child Development Resource Centre 2 0 0 5 1 0 1