Health Awareness Days: Sufficient Evidence to Support the Craze?

Abstract

Health awareness initiatives are a ubiquitous intervention strategy. Nearly 200 health awareness days, weeks, and months are on the US National Health Observances calendar, and more than 145 awareness day bills have been introduced in Congress since 2005.

We contend that health awareness days are not held to appropriate scrutiny given the scale at which they have been embraced and are misaligned with research on the social determinants of health and the tenets of ecological models of health promotion. We examined health awareness days from a critical public health perspective and offer empirically supported recommendations to advance the intervention strategy.

If left unchecked, health awareness days may do little more than reinforce ideologies of individual responsibility and the false notion that adverse health outcomes are simply the product of misinformed behaviors.

Today is not like every other day, or at least it is supposed to be unique. Chances are, today is designated as one of the nearly 200 health awareness days, weeks, or months on the US Department of Health and Human Services’ (DHHS) National Health Observances (NHO) calendar.¹ The health awareness day—to our knowledge first defined by Mulvihill as a “brief exposure, high visibility program designed to stimulate thinking and discussion of certain health risks and issues by large numbers of [people]”^2(p321)—is an intervention strategy well known to public health practitioners, policymakers, and the public alike.

Although the ubiquity of awareness days might be self-evident, data suggest that health awareness days have proliferated over the past four decades (Figure 1). A legislative search revealed that 202 bills have been introduced in the US Congress with “awareness day” in the title since 1973, with 71% of them introduced after 2005.³ The awareness day has also received increasing attention in the health science literature. A November 10, 2014, PubMed search for entries with “awareness day” or “awareness days” in the title or abstract retrieved 80 results, with the trend in publication volume corresponding with the trend in bills introduced.⁴

FIGURE 1—

Trends in attention to awareness days in US Congress and health science literature (1974–2014).

Despite the frequency with which awareness days are implemented and written about, relatively little public health scholarship has critically examined the intervention strategy. For example, the 2011 Joint Committee Report on Health Education and Promotion Terminology, which contains a glossary of key terms to the work of the profession, does not provide a definition for awareness or awareness day.⁵ In addition, many widely used health promotion textbooks do not discuss the construct of awareness.^6,7 As a result, the public health literature provides little guidance concerning fundamental questions that should be considered before developing and implementing a health awareness day. These include:

• To what extent have awareness days been evaluated?

• What strategies should be used to assess their effectiveness?

• How is the construct of awareness operationalized and measured?

• Is the awareness day intervention design guided by appropriate theories of health promotion?

In this commentary, we synthesize research and scholarship to explore these questions, identify knowledge gaps, and examine the awareness day from a critical public health perspective. Although we touch upon related intervention strategies, such as the awareness week and the awareness month, we primarily focus on the awareness day because it is the smallest unit of intervention and component of which the others are comprised. We contend that the health awareness day has not been held to an appropriate level of scrutiny given the scale at which it has been embraced. It is our intention for this commentary to stimulate dialogue about awareness days—as well as the broader construct of awareness—in the public health community and offer empirically supported recommendations to ensure that the health impacts of this intervention strategy are maximized and measured.

SEARCHING FOR EVIDENCE IN AN AWARENESS DAZE

To begin to assess the state of the art of the health awareness day, we searched PubMed for entries with the phrase “awareness day” or “awareness days” in the title or abstract. This search strategy yielded 80 results, 74 of which were in English.⁴ We obtained the full text of the English language articles and reviewed their content with a focus on the contexts in which health awareness days were discussed and the extent to which they were evaluated. Although conducted according to a replicable method, our review was neither comprehensive nor intended to supplant the need for a true systematic review (which is recommended in the following). Rather our aim was to begin and map the scholarly discourse about health awareness days and to identify priorities for evaluation and intervention design.

We found three distinct types of articles. The majority of articles were editorials and commentaries that announced, and functioned to raise awareness about, an awareness day (e.g., World Elder Abuse Awareness Day).⁸ These articles did not present empirical data and rarely identified the aims of the day. They did, however, highlight the wide range of health-related topics that awareness days addressed, spanning from hepatitis⁹ to the prudent use of hospital linens.¹⁰

A second category of articles had a Methods section and presented empirical data, but did not evaluate the impact of the awareness days. These articles included instances in which an awareness day event was used to collect cross-sectional data about a population,^11,12 when hosting a health awareness day was named as a recommendation based on a study’s findings,^13,14 and when data about participants of an awareness day were presented.^15,16

The third category of articles included both a Methods section and evaluation data. Five articles fell into this category (Table 1).^17–21 Despite the attention awareness days received over the past four decades, particularly in the United States, the first evaluation article was not published until 2006, and none of the articles evaluated a US-based health awareness day. This finding suggests that the craze of awareness days observed in the United States has not been driven by evidence of their effectiveness, which highlights the need for guidance about evaluation strategies and raises questions about the extent to which awareness days reflect a theoretically sound model of public health practice.

TABLE 1—

Studies Evaluating the Impacts of Health Awareness Days

Article	Awareness Topic	Awareness Day Location	Target Population	Evaluation Design	Outcomes Assessed	Results
Owen et al.17	Smoking	United Kingdom	Residents of the United Kingdom	Longitudinal (1986–2005) Pre–post Interrupted time series	Knowledge of the awareness day Attempt to stop smoking on the awareness day UK news coverage of the awareness day Number of visitors to awareness day web site Number of calls to smoking helpline	Knowledge of the awareness day among smokers ranged from 70% to 96%
						The proportion of smokers who reported attempting to stop smoking on the awareness day ranged from 7% to 18%
						The number of news stories ranged from 934 to 1633 annually
						The average number of web site visits during the month of the awareness day was 3.5 times higher than the annual average
						The average number of calls to the smoking helpline was approximately 5 times higher on the awareness day than the annual daily average
Tibazarwa et al.18	Cardiovascular risk	South Africa	Residents of Soweto, South Africa	Cross-sectional Pre–post	Perceptions of personal cardiovascular risk	Of the 969 awareness day attendees who were screened and did not perceive themselves as having any cardiovascular risk factors, 73.6% learned that they had at least one risk factor following a clinical risk assessment that was conducted at the awareness day
MacCarthy et al.19	Mouth cancer	Ireland	Residents of Ireland	Cross-sectional Post only	Identification of previously unknown cases of mouth cancer	Of the 1661 awareness day attendees who were screened, 5 (0.3%) were identified as having biopsy-confirmed mouth cancer
Jones et al.20	Hexamethylen- ediisocyanate-based paints	United Kingdom	Employees of motor vehicle repair shops	Cross-sectional Pre–post	Hexamethylene diamine (HDA) levels in urine	The proportion of participants with unhealthy levels of HDA in their urine decreased from 14.0% to 6.5% between the pretest and posttest
Al-Dorzi et al.21	Venous thromboembolism	Saudi Arabia	Health care providers at a tertiary care hospital	Cross-sectional Pre–post	Knowledge of evidence-based thromboprophylaxis guidelines	The average knowledge test score increased from 7.7 to 8.8 between the pretest and posttest

SEEING THROUGH THE HAZE

Although outcomes research about awareness days appeared to be limited, strategies to inform their evaluation are embedded in the literature. At the individual level, awareness days were assessed according to their impacts on knowledge, perceptions, and, to a lesser extent, behaviors. For example, evaluations assessed baseline perceptions of health risk among event participants, conducted a clinical risk assessment, provided the participants with information about the results, and attributed changes in risk perception to the awareness day.^18,19

At the population level, Internet usage and media coverage were used as indicators of the impact of awareness days. An evaluation of No Smoking Day, for instance, tracked visits to a designated Web site and inventoried print media coverage about the day.¹⁷ A number of studies have used Internet search data to evaluate the related intervention of awareness months. Internet search volume was used to assess the impacts of Autism, Breast Cancer, Colorectal Cancer, and Prostate Cancer Awareness Months and was shown to increase significantly.^22–24 Internet search data are publicly available and are capable of identifying proximal impacts of awareness initiatives through interrupted time series designs. Increased awareness, however, is not necessarily a meaningful public health outcome in and of itself. Awareness is often described as the first step in the change process²⁵; therefore, additional action is required to produce meaningful public health outcomes (e.g., behavior change).

A study that used Twitter data to evaluate Breast Cancer Awareness Month found that the volume of breast cancer tweets increased when the month began, but that the content of most tweets focused on awareness-raising behaviors (e.g., wearing pink) and was not focused on preventive behaviors (e.g., cancer screening).²⁶ A systematic review of public awareness campaigns about suicide and depression concluded that these initiatives produced short-term changes in knowledge and attitudes, but that there was little evidence that these changes were sustained over time, and there was no evidence of increased treatment-seeking or reduced suicidal behavior.²⁷ The limited evidence of awareness initiatives’ health impacts could be a reflection of their conceptual models not sufficiently accounting for the complex and multilevel interplay of factors that influence health behavior.

Conceptual and Theoretical Foundations

We did not identify any articles that explicitly defined the conceptual model or theory of health promotion upon which an awareness day was designed. Health awareness day protocols and intervention toolkits, however, provided indication of the theories that implicitly guide them. Dissemination of information about health risk is a core component of awareness strategies. For example, the DHHS National Childhood Obesity Awareness Month toolkit provides resources to disseminate messages such as “eat healthy,” “exercise,” and “walk to the school bus.”²⁸ Similar strategies are prominent in other awareness toolkits on the NHO Web site.²⁹ Such individually focused and information-based strategies are consistent with an intrapersonal model of behavior change. One of the more widely researched models is the Health Belief Model, which holds that a person’s health behaviors are a product of their perceptions of susceptibility, disease severity, and benefits or barriers to the recommended behavior change.^6,30

By relying on an intrapersonal theory of health promotion, health awareness days do not sufficiently account for research about the social determinants of health and tenets of social ecological models of health promotion that have been encouraged by leading public health authorities for more than 20 years.³¹ The impact of intrapersonal focused awareness days will be limited if they do not account for interpersonal, community, and socioeconomic factors that influence health behavior (e.g., the built environment and food access in the case of obesity).^32,33 Furthermore, in addition to being ineffective, short-sighted health awareness initiatives could produce adverse effects.

Considering Unintended Consequences

Health communication campaigns can have unintended effects,³⁴ and those resulting from awareness days have not yet been systematically investigated. Given the ubiquity of health awareness days and ambiguity of their messages, it is possible that they bombard the public with information to the point where individuals conflate being knowledgeable about a health issue with taking action to address it. Lazarsfeld and Merton coined the term “narcotizing dysfunction” to describe this phenomenon.³⁵ As they discuss, “Exposure to this flood of information may serve to narcotize rather than to energize” and is

dysfunction[al] because it is not in the interest of modern complex society to have large masses of the population politically apathetic and inert.^35(p239)

Narcotizing dysfunction has been empirically documented in the social problems literature,³⁶ peripherally explored in the context of breast cancer awareness and “pink fatigue,”³⁷ and should be considered when designing health awareness days and evaluating their impacts.

GAZING AHEAD: RECOMMENDATIONS

Our appraisal of research and scholarship about health awareness days suggests that evidence of their effectiveness is, at best, equivocal, and that the intervention strategy is guided by an overly simplistic theory of health promotion. We offer the following recommendations to help align a widely utilized health promotion strategy with standards of contemporary public health practice.

Systematic Review

Given the frequency with which health awareness days are implemented, there is a significant need for a systematic review of their effectiveness. This will involve a complex search protocol to identify articles about health awareness–raising interventions across disciplines.

The review should explore how outcomes vary across settings (e.g., workplaces, college campuses), populations (e.g., high vs low risk), and health issues (e.g., acute vs chronic conditions). In addition to synthesizing outcomes research, a systematic review could provide the foundation for common definitions of constructs related to awareness in health promotion. A shared nomenclature would help facilitate the transportability and standardization of awareness interventions.

Clear Aims and Key Constructs

Health awareness days should conform to fundamental principles of health promotion practice. The individuals or organizations that designate or implement awareness days should explicitly define their aims (in greater detail than raising awareness), the theory or conceptual model through which they expect health benefits to be produced, and how core constructs (e.g., knowledge) will be operationalized and measured.

Recognizing that many people who conceptualize, champion, and participate in awareness days are community members without formal public health training, we believe that a resource should be developed to provide guidelines about the intervention strategy. The resource would include a logic model depicting how outcomes could be achieved and standards for appropriate aims, evidence-supported program components, and evaluation activities. The National Cancer Institute’s Making Health Communication Programs Work,³⁸ for example, could serve as a model for such a document. These standards could be enforced by funding agencies that support awareness activities. By holding awareness days to the same level of scrutiny as other public health interventions, their rigor will be enhanced and quality improved.

Evaluating Impacts Across Multiple Levels and Domains

Although it appears that most health awareness days focus on producing changes at the intrapersonal level, it is possible that they produce benefits at multiple levels of the social ecology. For example, walk and run events are a component of many health awareness days.³⁹ These events are often attended by people who have lived experiences of the health issue (e.g., cancer survivors). Although these events are unlikely to substantially increase knowledge among this segment of the event’s population, because these attendees are already intimately aware of the health issue, they could produce benefits at the interpersonal level, such as by fostering social support and feelings of collective efficacy. Similarly, an awareness day could increase media coverage about a health issue and foster a social milieu that cultivates political will for policy changes to address the issue.⁴⁰ Legislation that designates a health awareness day may not increase knowledge about the health issue among the public, but it likely will increase awareness among policymakers as the bill crosses their desks and is presented for vote. Introducing health awareness day legislation could be an effective political strategy to frame a health issue as a public policy problem and secure its place on the policy agenda.⁴¹ Awareness day outcomes across these multiple levels and domains can, and should be, evaluated.

Furthermore, because health awareness initiatives are numerous and have overlapping intervention periods and topics, consideration should be given to interaction effects between health awareness days and related campaigns that are implemented concurrently. For example, the following awareness initiatives all took place in fall 2014: World Suicide Prevention Day (September 10), National Suicide Prevention Week (September 8–14), and Mental Illness Awareness Week (October 5–11).

Economic Evaluation

The benefits of awareness days should be weighed against their costs. Information about cost inputs related to awareness days should be shared to enable program planners and evaluators to conduct cost-benefit and cost-effectiveness analyses. If fundraising is an aim of an awareness day, the developers should utilize a conceptual model to demonstrate how funds will be reinvested to improve the health of populations and not just the fiscal health of the organization.

CONCLUSIONS

The provision of health information is the core component of health awareness days. The magnitude of health awareness days’ public health impact likely depends upon the level at which this information is disseminated and invokes change. Interventions that aim to increase awareness about health-promoting behaviors at the intrapersonal level alone are unlikely to have substantial impacts. As Frieden noted, the provision of health information to urge behavioral change is the least impactful type of public health intervention and “symptomatic of failure to establish contexts in which healthy choices are default actions.”^42(p592) That said, health awareness campaigns have the potential to increase knowledge about the root causes of public health problems and foster a social and political environment that supports changes at the policy level. The onus is on public health professionals to ensure that health awareness days convey that improving population health means a social responsibility to promote healthy contexts. Otherwise, health awareness days might do little more than reinforce ideologies of individual responsibility and the false notion that adverse health outcomes are simply the product of misinformed behaviors.