Practitioners' perspectives on unintended effects of illicit drug prevention public service announcements (PSAs) in Australia

doi:10.21203/rs.3.rs-4975386/v1

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Practitioners' perspectives on unintended effects of illicit drug prevention public service announcements (PSAs) in Australia

https://doi.org/10.21203/rs.3.rs-4975386/v1

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Public service announcements (PSAs) or campaigns aimed at preventing harm can inadvertently risk creating additional harms. It remains unclear whether these unintended effects are considered during campaign development, if risk mitigation strategies are implemented, or how professionals involved perceive these issues. It is in the context of illicit drug prevention PSAs that our research investigates and explores the perspectives of practitioners – health support professionals and campaign designers and creators. Semi-structured expert interviews were conducted to capture and synthesise practitioners’ perspectives which were then analysed by applying a framework to address the unintended harms of public health interventions. The results indicated that practitioners from both sectors are aware of unintended harms but place varying levels of importance on different aspects. In the case of illicit drug prevention PSAs, incorporating practitioners’ perspectives in campaign development may result in mitigating the risk of potential unintended harmful effects.

Marketing

PSA

practitioners' perspectives

illicit drug prevention

Illicit drug prevention campaigns are often deemed ineffective, and even harmful, as the messages neglect the unintended consequences on current consumers and spillover to unintended audiences.
Drug support services professionals believe that harmful unintended effects must be mitigated.
Advertising executives acknowledge there may be unintended effects but are generally more focused on message reach.
A broader range of stakeholders should be consulted prior to the design of public service campaigns with the objective of illicit drug use prevention.
A conceptual framework has been developed and tested to provide guidance when considering potential harms of illicit drug prevention PSAs.

It is widely recognised that the use of illicit substances is responsible for many forms of direct and indirect harm (Catford, 2001; United Nations Office on Drugs and Crime and World Health Organization, 2018). Illicit in this context refers to those substances that are illegal in many international jurisdictions, for example, amphetamines, ecstasy, cocaine, and heroin. The use of illicit drug prevention public service announcements (PSAs) is one common and publicly visible approach employed by public-facing organisations to attempt to address and mitigate the array of harms attributed to illicit drug use.

Advertising for commercial or social impact potentially increases an individual’s propensity towards altering their behaviour over time (Ehrenberg et al., 2002; Jones & Rossiter, 2016; Tellis, 2009). Two reported positive outcomes of such PSAs are increased efforts to seek further information and discussions with others about issues related to illicit drug use (Stancombe Research and Planning, 2018). However, previous studies indicate that illicit drug prevention PSAs may also be considered ineffective (Botvin & Griffin, 2016) and have limited impact in influencing the desired behaviour change (Werb et al., 2011). Moreover, such campaigns can also have unintended and detrimental effects which could cause harm to both the intended and unintended audiences (Botvin & Griffin, 2016; Ferri et al., 2013). Examples of these harms include substantial increases in both the actual use of illicit drugs and individuals’ intention to use them (Ferri et al., 2013). It is, therefore, important to consider the factors contributing to campaign (in)effectiveness, and, ultimately, how the process of campaign development can be improved, with the particular focus on considering possible unintended negative consequences.

Typically, illicit drug use prevention PSAs conducted by public health organisations aim to target young people aged between 10 and 24, such as the Australian National Drugs Campaign 2017 (Australian Government Department of Health and Aged Care, 2017), “Just Say No Campaign” (tru0091, 2007), and “This is your brain on drugs” (Kalamut, 2010). This target audience is considered especially vulnerable and susceptible to starting use of illicit drugs due to their propensity for risky behaviours (Australian Government Department of Health and Aged Care, 2017). To deter trial of illicit drugs practitioners commonly employ scare tactics in their PSAs (Lancaster et al., 2017). A seemingly forgotten segment of the unintended audience of illicit drug prevention PSAs are those that currently use illicit drugs, and for whom such tactics could be counter-productive, if not harmful (this is elaborated on later). Given the typical nature of mass media used to deliver most illicit drug prevention PSAs, it is very likely that both groups, intended and unintended, will receive the campaign message. This can result in a ‘spillover’ effect, something that occurs when the action of a marketer impacts the intended or unintended audience in an unintended manner (Desiraju & Van Tran, 2014). It is, therefore, critical for the creation of effective advertising to ensure campaign developers have carefully considered potential effects of the message on both audiences and that any unintended effects could be negative.

Intentions and effectiveness of illicit drug prevention PSAs

Well-designed mass media advertising has the potential reach large audiences a repeatedly over extended periods (Wakefield et al., 2010). These campaigns aim to reduce drug use initiation and encourage cessation (Becker-Olsen & Briones, 2009; Lang & Yegiyan, 2008). While these objectives are often well-intentioned (Stead et al., 2019), the effectiveness of the message’s delivery mechanism requires closer examination. Despite varying evaluations of illicit drug prevention PSAs (Allara et al., 2015; Stead et al., 2019), one common theme is apparent – there is limited empirical evidence supporting their success (Ferri et al., 2013; Schoenbachler & Whittler, 1996; Werb et al., 2011). This underscores the need for enhanced evaluation practices that incorporate insights from a wider range of stakeholders. Current evaluations of illicit drug prevention campaigns largely fail to capture the perspectives of experts from two crucial areas: (1) those working in drug use support services and (2) those who design and create campaigns, leading to a lack of understanding about how to minimise unintended effects, and whether opportunities exist to address these issues during campaign development.

Unintended effects of illicit drug prevention PSAs

Illicit drug campaign messages are often designed with specific appeals to elicit certain emotions in an attempt to shock, scare, and/or threaten receivers of the messages into action (Lupton, 2014; Schoenbachler & Whittler, 1996). For example, fear tactics is a common approach employed by message creators in an effort to discourage the initial and ongoing use of methamphetamine (Lancaster et al., 2017). Consequently, those that partake in the use of methamphetamine are often portrayed as dangerous, dishonest, dirty (Erceg-Hurn, 2008), and a threat to the community (Douglass et al., 2017). These depictions can potentially intensify both internalised stigma and stigma within the broader community (Douglass et al., 2017; Treloar et al., 2021). Moreover, certain types of campaigns have been found to increase intentions to use drugs (Lang & Yegiyan, 2008), exacerbate marginalisation (Lupton, 2014), and stimulate curiosity leading to experimentation (Crano et al., 2013), particularly among specific populations.

Conceptual framework

We did not identify any existing framework specifically designed to address the unintended effects of illicit drug prevention PSAs. However, initial steps in this direction have been taken by Lorenc and Oliver (2014) and Allen-Scott et al. (2014) through their analyses of public health interventions. Our study will adopt the conceptual framework proposed by Lorenc and Oliver (2014) as the five identified harms are more aligned to illicit drug prevention PSAs. The five types of harms presented in this framework – direct, psychological, equity, group and social, and opportunity cost – will be specifically applied to illicit drug prevention PSAs.

Research questions

This study seeks to understand whether potential unintended harms of illicit drug prevention PSAs are considered by two groups of practitioners: (1) those working in drug use support and (2) those in the advertising field who design the campaigns. We will do so by collecting, analysing, and synthesising the perspectives of these two groups of professionals. The research questions guiding this study are:

What are the perspectives of drug use support practitioners on the unintended effects of illicit drug prevention PSAs?
What are the perspectives of advertising executives on the unintended effects of illicit drug prevention PSAs?
How do drug use support and advertising executive practitioner perspectives map onto the adverse effects of a public health intervention conceptual framework (Lorenc & Oliver, 2014)?

Study setting

The method employed to collect our primary data involved the conduct of semi-structured interviews guided by open-ended questions, enabling in-depth and detailed examination of extensive issues (Anderson, 2010; Neale et al., 2005). This method was also conducive to the broadening of and/or deviation from the original scope when new or unexpected information was revealed (Anderson, 2010; Bryman, 2016). Additionally, semi-structured interviews were able to underpin the discovery of patterns with reasons (Busetto et al., 2020), relevance, and importance (to the interviewee) (Bryman, 2016).

Underpinned by the authors’ use of a subjectivist interpretivist philosophical position, this research was designed to collect, understand, and interpret perspectives from participants’ viewpoints (Saunders, Lewis, and Thornhill 2019). This philosophical position acknowledges that humans create meaning, which allowed the research team (and authors) to look at and contextualise the perspectives of different individuals from distinct industry sectors. The authors adopted an empathetic position (Saunders et al., 2015), crucial for understanding the participants’ point of view, especially given the tendency for the topic to elicit contrasting perspectives. Ethics approval was granted by Flinders University Human Ethics (Project No. 5230) and the data was collected between May and September 2022.

Sampling and recruitment

Recruitment was undertaken by way of purposive sampling, a common approach in qualitative research (Anderson, 2010). Professionals with expertise in drug use support services, as well as those employed in the advertising and media fields, were intentionally approached due to their relevant expertise. The sample was recruited by a combination of methods:

drawing from a network of known contacts,
contacting specific organisations following desk research, and
contacting individuals who made submissions to an Australian Parliamentary Joint Committee on Law Enforcement Inquiry (Parliament of Australia 2020).

Participants

Participants represented two sectors – those experienced in drug use support services (support services cohort) and those situated in the advertising media sector (advertising media cohort). Nineteen participants agreed to be interviewed - 12 participants from the support services sector and seven from the advertising media industry. As data saturation (the point at which there is a reliable lack of variation and emergent themes (Bryman, 2016)) was becoming evident, this number of interviews was considered appropriate. The sample size was driven by the interviewing, ongoing analysis, and reflection processes and is supported by previous work undertaken with similar industries (e.g., Drumwright & Murphy, 2009).

Data collection and ethical considerations

Interviews were conducted by the researchers and conversations guided using semi-structured schedules to allow participants to express their own perspectives of experiences; especially eliciting unintended effects of illicit drug prevention PSAs. A choice of face-to-face in-person or video conferencing via Microsoft Teams or via telephone was offered. 19 interviews in total were conducted – 16 via video conferencing using Microsoft Teams and digitally video-recorded; two by telephone, audio-recorded; and one in-person, also audio-recorded. Participants were physically located in Australia, and the interviews lasted between 30 and 90 minutes. Field notes were taken during and after all interviews. Prior to each interview all participants received an introductory email and a letter with information about the study (i.e., that participation was voluntary, interviews would be recorded, and how their participation would contribute to knowledge etc). Participants were assured of complete confidentiality and anonymity of their responses – both in terms of their personal and organisational identities. Only generalised themes and anonymous quotes are used for this publication. Written consent was obtained before each interview commenced and all participants were given the opportunity to review and amend transcribed data and/or watch the recorded interview. One participant opted to review and edit responses.

The interview guides differed slightly for each sector as is evidenced in Appendix A. The support services participants were asked about their perceptions of the effects illicit drug prevention campaigns had on their clientele. The advertising media interviewees were asked to consider what effects of behaviour-change campaigns might entail and what was taken into consideration at the design and creation stage in relation to unintended effects. Further information was explored when deemed appropriate.

Data analysis and structure of results

An initial analysis of data was undertaken following two to three interviews from each sector to understand perspectives and appropriate analytical framework to use. As there were common categories, both within and between cohorts, thematic analysis, a common (Bryman, 2016), independent, and reliable method used for analysing interview data (Vaismoradi et al., 2013) was employed. Accordingly, the researchers followed the seven phases proposed by Lester et al. (2020), detailed in Figure 1 below. The results of the primary data collection thematic analysis are covered under the themes of the adverse effects of public health interventions conceptual framework (Lorenc and Oliver (2014).

[insert – Figure 1. Phases of thematic analysis – here].

The first two research questions are concerned with the perspectives of drug use support and advertising media sectors. To answer these questions, perspectives of practitioners from drug use support and advertising media sectors are thematically presented under each category proposed by Lorenc and Oliver’s (2014) conceptual framework.

Perspectives of support services and advertising media cohorts

Drug use support counsellors and social workers, along with representatives from drug education and support peak body organisations formed the cohort of drug use support participants (n = 12). In this context, a peak body is a representative, non-government organisation advocating for their specific community sector (Ogle & Bowling, 2011). Participants interviewed from the advertising media sector (those who design and create behaviour change campaigns) included advertising executives, intermediaries, managing directors, and general managers experienced in the design, creation, and dissemination of either illicit drug prevention and/or broader behaviour change advertising (n = 7). They represented, local, national, and international advertising media agencies.

Intentions and effectiveness of illicit drug prevention PSAs

Most support services participants perceived the goals and aims of illicit drug prevention PSAs as being to stop or deter illicit drug use by (particularly) young people, as well as increasing awareness and reducing associated harms through education. However, one participant took a rather cynical view:

“just to get them [the general community] to hyperventilate a bit about it, want to lock people up … get them out of our backyard, build up a sense of crisis around individuals that often have multiple layers of complexity in their life ... sometimes it’s just virtue-signalling that they [the government] care about the affected community.” (SS#6)

The overwhelming opinion was that the campaigns were not effective. Most support services participants believed that shock and scare tactics did not achieve the desired outcome or change behaviour and could be damaging. Further, if the target audience is not exposed to the advertisement or is marginalised, an advertising campaign could be especially ineffective.

The role of professional communicators, as defined by the advertising media cohort, is to take complex information and distil it. This is achieved by understanding the problem, working out what they need people to know, and what they want people to do as a result. Some of the main aims and goals of illicit drug prevention PSAs were perceived as increasing target group awareness, decreasing use, preventing and discouraging initial uptake, educating, facilitating long-term behaviour change, and increasing people’s understanding of drug addiction. These campaigns should be able to convey details of valuable tools available:

“…all about tapping into the sense that there is actually a way to claw your way back, if you find yourself spiralling and losing control. It was all about how you can find your way back. There is help and there are tools to help you.” (AD#4)

Most of the advertising media cohort indicated that effectiveness was either measured in conjunction with, or entirely by, the commissioning agency (typically a government body). Effectiveness was simply measured on whether the message reached the intended audience and if it was value for money for the campaign investment. Another participant perceived most illicit drug prevention advertising was evaluated as having neutral or negative effects. There was, notably, a strong focus on reaching the target or intended audience with the message, as the main measure of campaign effectiveness.

“…So how do we get it to the right audience with the right message … from our point of view, we’re looking at this through a lens of advertising effectiveness … did it reach the intended target?” (AD#3)

Unintended indirect effects

All support services practitioners identified the existence of unintended effects that can potentially create real and serious direct and indirect harms. The advertising media participants acknowledged their awareness of unintended consequences and indicated that care was needed to connect with an audience in an authentic way. However, one agency had a slightly nuanced perspective:

“We’ve been doing this for a really long time, so I think in terms of unintended consequences, we usually know pretty early on what those pain points are likely to be … then it’s, I guess, a matter of in the development of the campaign, how you address it, or if you choose not to.” (AD#2)

In general, the advertising media cohort rely on their client (typically a commissioning arm of a government agency) to let them know what messaging might be problematic and then decide how or whether to mitigate any negative effects. Another aspect raised was that the consideration of unintended effects was outside their scope:

“…our role is to make sure whatever the message the department wants to deliver, just reaches that audience.” (AD#3)

Further perspectives of both cohorts are reported in themes under the categories of harms identified by Lorence and Oliver (2014).

Direct harms

Normalisation, increased interest and increased drug use

Of concern to the support services participants were the effects the advertising may have on increasing (even initiating) use of illicit drugs. Some of the benefits of drug use may be unintentionally portrayed, or the fact that a particular drug is mentioned at all can result in increased or initial use:

“…there's some evidence to say that there are individuals who never would have thought about using any drug who potentially it now brings it to the forefront of their mind. So… merely the mentioning of it may actually… in an unintended, an indirect way… result in maybe some people using those drugs.” (SS#4)

For the advertising media cohort, despite the existence of literature suggesting that the normalisation of drug use behaviour increases interest in drug use, only two participants alluded to this. One participant found it intolerable, while for the other, it was just a consideration.

“…a risk might be it increases interest in illicit drug use where it normalises the drug use…now that, obviously, is a key risk…we couldn’t tolerate. So, if that was thought to happen, we’re not going to…be participating in that.” (AD#7)

One advertising media participant touched on the need to be careful if showing the product in the advertising as it may trigger use, confirmed by other perceptions that if something new is mentioned in the media, young people will want to try it; it prompts interest in use and…

“you’ve done the absolute opposite of what you intended to do … so that would be probably the most awful public health outcome.” (AD#7)

Lack of credibility

Most support services participants agreed that advertisements exampling the extreme behaviours of the minority do not resonate with the target audience and are readily dismissed (e.g., portraying someone under the influence of methamphetamine exhibiting violent behaviour will be disregarded as most people who take this drug don’t become violent). Similarly, if messages are unrecognisable as the target audience’s own experiences, they are disregarded.

“Under the influence of methamphetamine that [smashing windows in a hospital] can happen, but at the same time, most, a lot of people on methamphetamine don’t get violent.” (SS#2)

“I think most people would say, ‘well that’s not me’ … The ads tend to show the extreme, the minority.” (SS#2)

Some young people have a distrust in government, therefore governmental messaging is hard for them to accept. Additionally, some government advertising has been so far off the mark that it has been ridiculed and considered a joke, therefore lacking any credibility and again, disregarded (the Stoner Sloth (aa4398743873, 2015) campaign was exampled more than once):

“…if I was a teenager in high school, I would just be laughing … I’d be smoking weed with my friends, ‘oh, I’m a sloth.’ You know, it would become a joke.” (SS#5)

Younger audiences were identified by some advertising media participants as being sceptical of illicit drug prevention advertising. If the portrayals and stereotyping of certain populations are not realistic, the communication won’t resonate with the target audience, and they may disconnect from and disregard the message; they don’t think it applies to them as they don’t know anyone who has experienced it and/or it never happens:

“One of the most important things is that everything must feel credible. Stereotyping can be a trap that allows people to exclude themselves from thinking the message has relevance for them personally.” (AD#4)

“…it’s true in relation to behaviour change marketing that, the more you do something without negative consequence, the less likely you are to believe that anything bad will happen to you.” (AD#4)

Psychological, equity, and group and social harms

Stigma and marginalisation

Stigma implied through illicit drug prevention PSAs was a major concern to the support services cohort of participants. In their view, those that use illicit drugs are labelled, judged, blamed, and isolated by wider society with the resultant stigma reducing likelihood of seeking help.

“…if you stigmatise a particular group, then they get resistant to the objective of what you're seeking to pursue … you stigmatise drug users because of the drug seeking habits, you will definitely fail to get them into health seeking behaviours.” (SS#6)

“And what a barrier that then becomes to that person getting better and getting treatment and helping themselves and being able to ask for the help they need.” (SS#5)

The support services cohort also identified that younger people may avoid attending their local general practitioner (GP) out of fear of details of their drug use being passed on to a family member. Attending an alternative GP, combined with the absence of a full medical history, can result in the appropriate care not being received. Those living in smaller communities may be especially susceptible, e.g., the attendance at an emergency department of a local hospital with a history of drug use may prevent them receiving appropriate (non-related) future healthcare.

“So the stigma…attached to go into a family GP is a big one.” (SS#2)

“the healthcare system, I think, unfortunately, the medical profession, by and large, is quite stigmatising towards illicit substance use, I think.” (SS#5)

The support services cohort wanted to see people educated about the language around drug use and people who use drugs as a starting point. They believed some of the language used in advertising is stigmatising, such as the words ‘addict’ and ‘ice’, (as in the Australian government’s media campaign Ice Destroys Lives) (BCM Group, 2016). Such language is taken on by drug users and is immensely damaging, perpetuating internal stigma.

“And the word addict comes to mind, which is stigmatising and labelling. It’s not person-centred, it’s really about … society looks down upon you. You are something that we are not…a lot of shame attached to it – shame and blame and labelling.” (SS#1)

Three key support services informants had a concern that ineffective advertising resulted in further marginalisation of groups of drug users that were already disconnected from society, effectively driving them further away:

“If you’re someone … living, rough-sleeping, using heroin every day, you look around to the rest of the world and you think ‘I’m not a part of this, I don’t belong to any of this…there is a world over there, and there’s me over here.” (SS#5)

Stigma was recognised by all advertising media participants, however, only one noted that they actively refrain from using fear and scare tactics as they are less effective with a stigmatised audience. Others recognised that stigma was one of the challenges and a part of the consideration, and importantly, one participant acknowledged that stigma may also affect the unintended audience.

“They’re so focused on their target audience, which is preventing usage in that group, they’re not thinking about all the other people here who are like, ‘Oh, hang on, but what about me? I already use this so do you not care? I’m feeling worse.’” (AD#1)

Interestingly, one participant commented that stigma was not necessarily a bad thing as the intention is for people to realise drug addiction is a serious issue:

“It sounds brutal, but you know, our intention was that we want people to realise that this is a serious issue, and to go and talk to somebody about it. So if that means that there's a stigma about [ ], then I think that would be a good thing. Whether or not that I mean, that is good for the individual, I don't know, but as a culture, and … part of the attraction of this campaign was that you want people to go, ‘No, I don't want to take [ ].’ … So I think that stigma around the drug use, I think, is a is a good thing.” (AD#2)

Some participants in the advertising media cohort also believe that stigmatising the target audience can create further damage by the generation of help- and support-seeking barriers.

“…that can be very difficult for already vulnerable groups seeing greater differences between those groups and social exclusion, and then a lack of people feeling comfortable to be able to speak to other people to seek help. Whether that might be in a professional sense, or to speak to family and friends about these things.” (AD#1)

Opportunity cost harms

Opportunity cost harms arise when funds used to employ a particular intervention that may be ineffective could have been used to make a material difference in another area (Lorenc & Oliver, 2014). Although most support services participants identified barriers to help- and treatment-seeking (e.g., waitlists, capacity, lack of facilities), it was not linked to consideration of redirecting advertising funds towards such resources.

The third research question delved into how practitioners’ viewpoints aligned with a conceptual framework proposed by Lorenc and Oliver (2014) regarding the adverse effects of public health interventions. The perspectives obtained from the practitioners perceived these adverse effects similarly to how they are outlined in the framework in four out of the five categories – direct, psychological, equity, and group and social harms. While the concept of opportunity cost harms wasn’t explicitly addressed, there were observations that support services professionals were keenly aware of the scarcity of treatment facilities. This concept was not mentioned by the advertising media cohort.

This study aimed to gather and integrate perspectives from practitioners in two distinct industry sectors: professionals experienced in supporting individuals using illicit substances, and professionals involved in designing drug prevention PSAs. For the first time, these perspectives were then applied to a conceptual framework designed to examine the adverse effects of public health interventions. The findings indicate that the cohort of support services practitioners appeared to be well-informed about the potential unintended effects of illicit drug prevention PSAs. Although some advertising media professionals were broadly aware of potential unintended effects of illicit drug prevention PSAs, this was not front-of-mind for most (with the responsibility for such considerations often put on the departments commissioning the campaign). Accordingly, this study makes two key contributions to theory and the literature. The consolidation of the identified literature and qualitative data surrounding the unintended and harmful consequences of illicit drug prevention PSAs can both be applied to the five concepts proposed by Lorenc and Oliver (2014).

Direct harms

Public health interventions can potentially increase the risk of physical injury or harm (Lorenc & Oliver, 2014). When illicit drug prevention PSAs are ineffective in influencing desired behaviours such as cessation, reduction, or prevention of use, the result can be the initiation (Strickland & Stoops, 2018) or continuation (Becker-Olsen & Briones, 2009) of illicit drug use. As these damaging consequences are borne from the PSA, they are considered a direct harm. The unintended effects categorised under this heading include normalisation of illicit drug use behaviour, increased interest in and use of illicit drugs, and lack of PSA credibility. Stigmatisation and marginalisation are also very much aligned with this category, however, as these harms span multiple categories, they will be discussed separately.

Normalisation and increased interest and use

Portraying drug use, or its effects, could result in normalisation of drug use behaviour; that is, such a behaviour becomes acceptable as a norm and the perceived danger decreases (Erceg-Hurn, 2008). While illicit drug prevention PSAs have the positive effect of raising awareness about the dangers of illicit drug use, this can result in piquing the interest among those at risk, potentially resulting in a desire to try or use drugs, or accept the forbidden as an attraction or challenge (Crano et al., 2013; Strickland & Stoops, 2018). For example, while a small study conducted on an anti-methamphetamine use campaign resulted in 36.1% of participants wanting help to stop using, it was arguably overshadowed by 11.9% of the participants wanting to either start or increase methamphetamine use (Nanin et al., 2006). Although only a minority of both cohorts of participants in our study recognised the existence of normalisation and increased interest and use as unintended effects of PSAs, they acknowledged these as unacceptable outcomes.

Lack of credibility

If the consequences of drug use depicted are overly exaggerated or lack credibility, the message may be disregarded, rendering it ineffective (Becker-Olsen & Briones, 2009; Cao & Xu, 2021). As far back as 1972 (and before), for example, it was identified that governmental messages and strategies were rejected by drug users due to exaggeration and patronisation (McEwen & Hanneman, 1972). The perspectives of practitioners from both sectors strongly align with the evidence that governmental advertising, lacking credibility, can lead to ridicule from the target audience. This ridicule extends to the rejection of the message, as it fails to resonate with the audience. Coupled with a general distrust in government, this leads to the overall dismissal of the message (Scheier & Grenard, 2010).

Psychological, equity, group and social, and opportunity cost harms

Lorenc and Oliver (2014) propose several examples of psychological harms, one of which is the generation of feelings of guilt, produced when prescribed behaviours are unable to be adopted (Guttman & Salmon, 2004). These feelings are psychologically damaging and can have negative effects on the behaviour targeted by the advertising campaign (Lorenc & Oliver, 2014). Similarly, illicit drug prevention campaigns can use message appeals to invoke feelings of guilt, which can consequently exacerbate stigma in the target population, leading to further marginalisation, less treatment-seeking, and increased use of illicit substances (Meehan, 2017).

Interventions targeted at specific groups or behaviours may contribute to further stigmatisation (Lorenc & Oliver, 2014). This creates a barrier to the seeking of help for those using illicit drugs (Douglass et al., 2017; Lancaster et al., 2017). Additionally, if the stereotypical portrayals of those who use illicit substances are associated with “marginal status” (Lorenc & Oliver, 2014, p. 289), the public health message will be rejected.

Something not always considered as part of the unintended effects is the fact that funds spent on public communications, that provide seemingly little in the way of measurable effectiveness, could be redirected into more effective interventions (Lorenc & Oliver, 2014). In the illicit drug use space, this is a missed opportunity to direct these funds towards services such as rehabilitation, treatment, counselling, support, etc.

Stigma and marginalisation

Stigma, arguably one of the most harmful effects of illicit drug prevention PSAs, encompasses four of the five harms (direct, psychological, equity, and group and social) proposed by Lorenc and Oliver (2014); perpetuated using exaggerated and graphic portrayals of drug users. Stigmatising messages are intended to create fear, to convey the social unacceptability of drug use (Lancaster et al., 2017; Marsh et al., 2017). However, stigmatising messages could have the opposite and detrimental effect on the minorities who already use illicit drugs, further contributing to their isolation and social exclusion.

Both groups of practitioners devoted most of their discussion time to the topics of stigma and marginalisation. Initially, our interpretation was that these unintended effects were of equal importance to each sector. However, this was not the case. Support services practitioners were firm in their belief that unintended effects of stigma contribute to creating and worsening barriers to seeking help for drug use as well as general healthcare. This phenomenon further marginalises already vulnerable groups. Conversely, the advertising media cohort described stigma as a challenge and a consideration – something not discussed in the literature. One participant mentioned refraining from the use of fear and scare tactics, not because they might stigmatise, but because these tactics are less effective when the audience is already stigmatised. Furthermore, another participant from the advertising sector perceived the use of stigma as beneficial in the context of illicit drug prevention PSAs. These differences may well be explained by the fact that the advertising media cohort are looking through a lens of advertising effectiveness such as if the message reached the intended target, whereas the support services cohort’s view is through a lens of behavioural change.

Although the two sectors of support services and advertising practitioners are unrelated, they both identified harms applicable to four of the five categories proposed by Lorenc and Oliver (2014) – direct, psychological, equity, and group and social harms. The alignment of practitioners’ perspectives with the conceptual framework of these typologies indicates the importance of the application of theory in the field of unintended consequences of illicit drug prevention PSAs.

Four implications for practice for campaign development and implementation are drawn from this study. Firstly, to mitigate the most harmful risk identified, stigma, cross-disciplinary, multi-sector perspectives should be included and considered (Allara et al., 2015; Wakefield et al., 2010) as much as practicable and as early as possible in the process of campaign conceptualisation. This will likely involve consultation with stakeholders from all relevant disciplines, including the two cohorts identified in this research. All perspectives should be considered, as the messaging might need to be fine-tuned to minimise possible negative effects on unintended audiences, i.e., depending on the medium used, there is difficulty ensuring only the intended audience sees the campaign, resulting in a spillover effect.

Secondly, during campaign development, it should be carefully considered who the unintended audience might be and what the potential effects might be, especially surrounding stigma (Douglass et al., 2017; Stead et al., 2019). During media planning, care should be taken to minimise the unintended audience receiving the message if that message could be potentially harmful for them, or alter the message to minimise the potential harm.

Thirdly, conducting thorough pretesting is a crucial process to be undertaken prior to the release of any illicit drug prevention campaign material. Pretesting can provide indications of things such as: whether the campaign will be understood and interpreted correctly by the intended audience, the identification of any potentially distracting elements or errors, and advice if any messages are offensive (Weinreich 2010). Consideration should be given to extending this pretesting to include broader stakeholders (e.g., support services, police etc), and the likely unintended audiences who might be harmed by the campaign.

The fourth implication involves improving integration between the campaign development team and other support services in the community to ensure the campaign does not deliver the message in isolation (Wakefield et al., 2010). An illicit drug prevention PSA will have further reach than just the designated target audience. As the unintended audience and wider population may include individuals who are already using illicit substances, consideration should be given to running a complementary campaign for this population around how to access more support.

Naturally, there are limitations to be taken into consideration. Firstly, both advertising and commissioning agencies have documents (i.e., risk matrices, detailed instructions etc.) they are unable to share for document analysis due to commercial-in-confidence status, which would have been informative to analyse. To better understand the commissioning decisions that impact on included content of illicit drug prevention PSAs, we suggest that future research is conducted to include perspectives of practitioners who are responsible for commissioning campaigns and creating policy in this arena. These perspectives could: provide insights into details of these sectors’ contributions, add to the understanding of the driving forces, enable identification of campaign development processes that may be improved, and further address literature and knowledge gaps.

A further limitation surrounds the smaller sample size for this qualitative work. While quantitative surveys are an alternative which can address the issue of generalisability (as many respondents can complete a survey providing results potentially generalisable to a broader population), semi-structured interviews are able to elicit in-depth, rich information in a way that quantitative surveys cannot, which is necessary to answer the research questions (Bryman, 2016). Although data saturation for both cohorts was reached after only a relatively small number of interviews when the absence of new or additional themes were forthcoming, this allowed the themes to be discussed in more detail.

Missing from the literature are the perspectives of support services and advertising media practitioners on the unintended effects of illicit drug prevention PSAs in health promotion advertising. Interviews were conducted with cohorts from these two industry sectors and their perspectives have been analysed. Consolidated data from these sources suggests that practitioners are largely aware of the existence of unintended effects of illicit drug prevention PSAs, yet their focus is often limited to their immediate task at hand. There is a lack of systemic understanding and purposeful consideration in the development of illicit drug prevention PSAs that may be created at the campaign commissioning level.

This research has identified several practical recommendations for minimising potential unintended campaign harms. As unintended harms are often borne from non-intended audiences receiving the campaign message, it is recommended that campaign pretesting includes broader populations to provide more opportunity to identify and mitigate the potential for harmful effects. Additionally, consultation with, and consideration of, the views of all stakeholders involved, not just in campaign development, but also wider campaign support (e.g., from support services, police etc) is needed. Consideration should be given to running a complementary campaign for the population that are already using illicit drugs on how to access support.

ACKNOWLEDGEMENTS

The authors thank the organisations, practitioners, and professionals who participated in the study.

DECLARATION OF INTEREST

The authors declare that they have no competing interests.

AUTHORS AND INSTITUTIONAL AFFILIATIONS

Kirsteen Munro, Centre for Social Impact, College of Business, Government and Law, Flinders University, Bedford Park, South Australia.

Svetlana Bogomolova, Centre for Social Impact, College of Business, Government and Law, Flinders University, Bedford Park, South Australia.

Lucy Simmonds, Centre for Social Impact, College of Business, Government and Law, Flinders University, Bedford Park, South Australia.

AUTHOR CONTRIBUTIONS

KM undertook background research. KM, LS and SB collected primary data. KM transcribed and analysed the data. KM wrote the manuscript with substantive contributions by LS and SB. LS and SB supervised the study to ensure overall quality. All authors critically reviewed the manuscript and agreed with final version.

FUNDING

No funding was received to conduct this study.

ETHICS APPROVAL

Ethical approval was granted by the Flinders University Human Ethics Low Risk Panel (Project No. 5230).

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Practitioners' perspectives on unintended effects of illicit drug prevention public service announcements (PSAs) in Australia

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Abstract

Figures

Contribution statement

Background

Intentions and effectiveness of illicit drug prevention PSAs

Unintended effects of illicit drug prevention PSAs

Conceptual framework

Methods

Results

Perspectives of support services and advertising media cohorts

Intentions and effectiveness of illicit drug prevention PSAs

Unintended indirect effects

Direct harms

Normalisation, increased interest and increased drug use

Lack of credibility

Psychological, equity, and group and social harms

Stigma and marginalisation

Opportunity cost harms

Discussion

Direct harms

Normalisation and increased interest and use

Lack of credibility

Psychological, equity, group and social, and opportunity cost harms

Stigma and marginalisation

Conclusion

Declarations

References

Appendix

Additional Declarations

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