Topics in Clinical Practice
Fostering change in back pain beliefs and behaviors: when public
education is not enough
Douglas P. Gross, PhDa,*, Sameer Deshpande, PhDb, Erik L. Werner, PhDc,
Michiel F. Reneman, PhDd, Maxi A. Miciak, BScPTe, Rachelle Buchbinder, PhDf,g
aDepartment of Physical Therapy, University of Alberta, 2-50 Corbett Hall, 8205 114 St. Edmonton, Alberta T6G 2G4, Canada
bFaculty of Management, University of Lethbridge, 4401 University Drive, Lethbridge, Alberta T1K 3M4, Canada
cResearch Unit for General Practice, Uni Health, Kalfarveien 31, 5018 Bergen, Norway
dDepartment of Rehabilitation Medicine, Center for Rehabilitation & Rehabilitation Medicine, University Medical Center Groningen, University of
Groningen, P.O. Box 30002, 9750 RA Hare, The Netherlands
eFaculty of Rehabilitation Medicine, University of Alberta, 3-48 Corbett Hall, 8205 114 St. Edmonton, Alberta T6G 2G4, Canada
fMonash Department of Clinical Epidemiology, Cabrini Hospital, Suite 41, Cabrini Medical Centre, 183 Wattletree Rd, Malvern, VIC, Australia
gDepartment of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Australia
Received 9 June 2011; revised 27 February 2012; accepted 1 September 2012
Abstract Mass media campaigns designed to alter societal views and individual behaviors about back pain
have been undertaken and evaluated in multiple countries. In contrast to the original Australian
campaign, subsequent campaigns have been less successful, with improvements observed in beliefs
without the corresponding changes in related behaviors. This article summarizes the results of a lit-
erature review, expert panel, and workshop held at the Melbourne International Forum XI: Primary
Care Research on Low Back Pain in March 2011 on the role and interplay of various social behavior
change strategies, including public education, law and legislation, healthy public policy, and social
marketing in achieving a sustained reduction in the societal burden of back pain. Given the com-
plexities inherent to health-related behaviors change, the Rothschild framework is applied in which
behavior change strategies are viewed on a continuum from public education at one end through law
and health policy at the other. Educational endeavors should likely be augmented with social mar-
keting endeavors and supportive laws and health policy to foster sustained change in outcomes such
as work disability and health utilization. Practical suggestions are provided for future interventions
aimed at changing back pain-related behaviors. Evaluation of previous back pain mass media cam-
paigns reveals that education alone is unlikely to foster positive and persisting behavioral change
without concomitant strategies. ? 2012 Elsevier Inc. All rights reserved.
Keywords: Mass media; Social marketing; Back pain; Behavior change, public policy; Public education
The clinical problem
Mass media campaigns designed to alter beliefs about
back pain have been undertaken and evaluated in Australia,
addressed widely held misconceptions about back pain that
view it as a serious disabling condition requiring rest. Key
messaging in the campaigns has included advice to stay ac-
tive, and at least three of the campaigns had the similar
FDA device/drug status: Not applicable.
Author disclosures: DPG: Nothing to disclose. SD: Nothing to dis-
close. ELW: Nothing to disclose. MFR: Nothing to disclose. MAM: Noth-
ing to disclose. RB: Speaking/Teaching Arrangements: Abbott Pty Ltd (C),
Roche Annual Symposium on Rheumatology (B, Paid directly to institu-
tion/employer), Pfizer (B), Wyeth (B); Trips/Travel: Abbott Pty Ltd
(None); Grants: ANZ Trustees Medical Research & Technology in Victoria
Program—The Appel Family Bequest (C, Paid directly to institution/
employer), Arthritis Australia (B, Paid directly to institution/employer),
Monash University (B, Paid directly to institution/employer), Australian
Government, Department of Health & Aging (E, Paid directly to institu-
tion/employer), NHMRC (F, Paid directly to institution/employer); Fellow-
ship Support: NHMRC (F, Paid directly to institution/employer).
The disclosure key can be found on the Table of Contents and at www.
* Corresponding author. 2-50 Corbett Hall, University of Alberta, 116
St. and 85 Ave., Edmonton, Alberta T6G 2G4, Canada. Tel.: (1) 780-492-
2690; fax: (1) 780-492-4429.
E-mail address: firstname.lastname@example.org (D.P. Gross)
1529-9430/$ - see front matter ? 2012 Elsevier Inc. All rights reserved.
The Spine Journal 12 (2012) 979–988
theme of ‘‘Back Pain: Don’t Take It Lying Down.’’ These
campaigns were previously compared and contrasted from
a content as well as methodological perspective to identify
how best to design and evaluate such interventions .
Important differences exist across mass media cam-
paigns in terms of their scope, amount of funding, and me-
dia used. The most successful in demonstrating a sustained
change in beliefs about back pain as well as behaviors, such
as health care utilization and disability, appears to have
been the campaign conducted in the state of Victoria, Aus-
tralia [6,7]. This campaign was very well funded (~US$8
million over 3 years), predominantly used television com-
mercials, featured recognizable spokespeople, comedians
and a wide variety of clinical experts, and contained prac-
tical information about how to stay active and stay at work
(ie, exercise, modified work demands, and so forth). Also,
the messages were endorsed by all relevant clinical organi-
zations with a stake in treating back pain and this was
prominently noted in the television commercials. The cam-
paign had the approval of employer and employee organi-
zations ensuring that stakeholders were ‘‘on side’’ ,
and in conjunction with the campaign, Victorian doctors
were mailed evidence-based guidelines for the management
of compensable back pain. Evaluation of the Australian
campaign involved surveying beliefs of the general popula-
tion of Victoria and an adjacent demographically similar
state that did not receive the campaign. Surveys were com-
pleted at four times; before, during, immediately after, and
3 years after the intervention. Surveys of general practi-
tioners in Victoria and the adjacent control state were also
performed before, immediately after, and 4.5 years after the
Victorian campaign. Behavioral outcomes were evaluated
through an analysis of the Victorian WorkCover Authority
claims database (proportion of time loss claims for back
pain and health utilization for back pain). The evaluation
indicated that the population exposed to the intervention
showed sustained improvements in back pain beliefs (ie,
were less likely to think back pain needed to be rested)
and dramatic reductions in work-related disability (15% re-
duction in compensation claims) and health care visits
(20% reduction in medical costs per claim) for the condi-
Subsequent campaigns in Scotland, Norway, and Canada
also seem to have resulted in population belief changes but
did not measurably impact health use or disability behav-
iors, such as work loss. An explanation for this is likely to
be multifactorial. For example, these campaigns were un-
dertaken on a much more limited budget, relied on other
media besides television (eg, radio advertisements, bill-
boards, and online messaging) and did not have the capacity
to present the breadth of specific advice about how to stay
active (ie, the Australian campaign featured messages on
why and how to stay active from a variety of recognized
international and national medical experts from a wide
variety of disciplines, as well as sporting celebrities and lo-
cal television personalities, some of whom had successfully
managed their own back pain). The cost of the Australian
campaign was approximately US$1.8 per resident, whereas
the cost of the other campaigns ranged from approximately
US$0.2 per resident in Scotland and Norway to US$0.3 per
resident in Norway and Canada (amounts are not adjusted
for inflation) . Some did not provide explicit advice about
staying at work. These important differences may partially
explain why subsequent campaigns have not proven as suc-
cessful as the original Australian campaign. However, fac-
tors unrelated to the campaigns, such as legislation and
health policy, also likely played an important role.
This article summarizes results of a literature review, ex-
pert panel, and workshop held at the Melbourne Interna-
tional Forum XI: Primary Care Research on Low Back
Pain in March 2011 on the role and interplay of various so-
cial behavior change strategies including public education,
law and legislation, healthy public policy, and social mar-
keting in achieving a sustained reduction in the societal
burden of back pain.
Initially, a group of researchers and practitioners from
multiple fields and disciplines involved in changing
health-related behavior were brought together to discuss
the issue of changing societal back pain behaviors. This
group included researchers who had previously evaluated
the various international back pain mass media campaigns.
The group also included academics with content expertise
and experience in conducting research in the areas of social
marketing, law and legislation, and healthy public policy.
Next, this group reviewed and discussed general theories
and techniques of health-related social behavior change
from the perspective of the different disciplines repre-
sented. An article was drafted summarizing results of the
previous back pain mass media campaigns and the broader
literature related to social behavior change.
The draft article was then presented as a basis for discus-
sion at a workshop held at the Melbourne International
Forum XI: Primary Care Research on Low Back Pain
(March 2011). One key theme of the Melbourne Forum
was informing the public and examining the role of social
marketing, advertising authorities, public health, and jour-
nalists. Plenary talks and a roundtable discussion were held
at the Forum focused on this issue. Additionally, our mul-
tidisciplinary group hosted a workshop at the conference
focused on key strategies for achieving health behavior
change. Attendees at the workshop were identified in ad-
vance. They were given the draft article to review and asked
to come to the workshop ready to discuss the main issues
identified and provide feedback on the article. Discussion
at the conference and comments from the workshop partic-
ipants were synthesized and incorporated into the manu-
script. A summary of the workshop and the revised
article were then sent back to the workshop participants
980D.P. Gross et al. / The Spine Journal 12 (2012) 979–988
for comments. They were asked whether the summary and
revisions accurately captured the discussion and were spe-
cifically asked to contact us if they identified inaccuracies.
After this verification step, the article was finalized.
Areas of uncertainty/critique of established
Strategies for achieving social change
When considering health at the population level, the dis-
tinction between health beliefs and associated behaviors is
critical and complex . Although people may believe
a certain activity or product is healthy, whether they actu-
ally modify their behavior to undertake the activity or use
the product is a separate issue and is dependent on many
factors other than health beliefs, such as ability, addiction,
habit, and choice, among others . The transition from
a healthy belief to a corresponding change of behavior de-
pends not only partially on a perception that the positive
health outcomes outweigh the burdens of changing behav-
ior but also on a supportive social, environmental, and po-
litical context [9,10]. One well-known example is smoking
cessation. A sizeable proportion of people believe that
smoking is bad for health, yet they continue to smoke
. For this reason, most public health interventions
aimed at helping people to stop smoking do not rely solely
on providing education regarding the health detriments of
smoking but combined the messaging with other tobacco
control strategies such as legislation changes involving
laws against smoking in public areas or increased taxation
on tobacco products [12,13].
Given the complexities inherent to health-related behav-
ior change, Rothschild  has proposed a framework for
themanagement ofpublic health andrelatedsocial behavior.
In this framework, behavior change strategies are viewed on
a continuum from public education at one end through law
and health policy at the other (see Table 1). Social marketing
resides somewhere between education and law on the con-
tinuum, incorporating both education as well as contextual
modifications to facilitate change. Each of these strategies
will be discussed in the context of nonspecific back pain,
although many of the messages also apply to individuals
with specific back pain (ie, stay as active as possible).
One of the most basic assumptions about human behav-
ior is that what people believe guides what they do .
This assumption implies that detrimental health behavior
is caused by a lack of awareness or knowledge on the part
of the individual. If an individual holds the belief that back
pain is because of serious structural pathology that requires
rest to heal, they will be more likely to rest when experienc-
ing an episode of pain [16,17]. Changing this belief should
change the resulting behavior, and this has been the focus
of previous back pain mass media campaigns [3,5]. Other
examples of public education strategies in addition to mass
media campaigns include classes or ‘‘schools’’ where mul-
tiple people with the health condition receive education
about their condition, distribution of booklets or educa-
tional pamphlets to patients, or direct education by health
care providers. Each of these has been tested in populations
of patients with back pain, and the results are modestly pos-
Social determinants of health have been found to influ-
ence knowledge and beliefs about back pain. Male gender,
lower household income, lower educational attainment, sub-
optimal health literacy, and blue-collar occupation have all
been associated with back pain beliefs that are not in accor-
dance with the best available scientific evidence [4,22–24].
dia campaigns, education is typically effective to change be-
liefs irrespective of social determinants but may have less
ability to alter behavior for a variety of reasons, including
other factors besides beliefs influencing health behaviors
[25,26]. Attitudes about the health condition play an impor-
tant role, as does the broader context in which the individual
resides. For example, if a worker experiencing back pain be-
lieves staying active is important but is unable to continue
work at a heavy level, that worker is unlikely to stay active
Rothschild model of social behavior change
Public educationSocial marketing Law/policy interventions
Libertarian approachIntermediate approach (Incorporates
components of education and contextual
Use of commercial marketing techniques to
change health behaviors
Assumes behavior is explained by a lack of
opportunity and strives to provide both
motivation and opportunity
Provision of information Legislation changes to limit or facilitate access
to a behavior
Assumes the public is unwilling to change
health behavior and requires forced
Assumes the public will act on health
information provided to appropriately change
981 D.P. Gross et al. / The Spine Journal 12 (2012) 979–988
within the context of work if modified work duties are not
provided by the employer or if financial compensation is
only available if they take time off work. There are also sit-
uations when the person’s environment plays a critical role
in influencing whetherthe person remains activeornot, such
as the presence of a solicitous spouse or family member who
takes over required home and personal care activities. The
message-only approach is unlikely to work in these situa-
tions. Additionally, people are often exposed to conflicting
educational messages in the media . For example,
people may be less likely to self-manage back pain through
activity when they hear media advertisements from health
professionals offering ‘‘curative’’ treatments as the quickest
way to recover .
Clearly, education has a role in changing behavior; how-
ever, its effects may vary depending on the context in which
it is given. Recent research is showing that initial experi-
ences with back pain occur early in the lifespan, at times
within the teenage years [29,30]. Perhaps educational ini-
tiatives need to target individuals earlier in the lifespan,
during key formative years when maladaptive beliefs and
attitudes about the condition are being shaped. Such
a change in audience would require dramatic changes in
the messaging and media used in future public educational
campaigns. Strategies such as comics, children’s books, or
using cartoon celebrity spokespeople could be useful tech-
niques for disseminating advice. From a research and eval-
uation point of view, the outcome of such a strategy would
take many years to be measurable. Although this has not
been evaluated for back pain, some promising pilot re-
search has been conducted on the use of comic books for
smoking cessation and prevention of sexually transmitted
In the case of previous back pain mass media cam-
paigns, it is important to consider the key differences be-
tween campaigns in terms of scope, timing, and key
messaging. It may be the case that a larger campaign with
more expansive messaging, as was done in Australia, is
needed to obtain behavior change. Not only was higher
penetration of the campaign observed (86% awareness in
Australia vs. 60% in Scotland, 39% in Norway, and 49%
in Canada) but also back pain beliefs improved across the
population to the same extent irrespective of demographic,
clinical, socioeconomic, and occupational factors. How-
ever, it is important to recognize that there were other
favorable features of the Australian campaign that aug-
mented the overall educational messages and may have
contributed to behavior change. These will be discussed
within the context of law or public policy, the opposite
end of the Rothschild framework.
Law and public policy
As noted above, smoking cessation educational activities
have been augmented with legal or public policy interven-
tions such as increased taxation on tobacco products 
and bylaws against smoking in public places, such as
restaurants, bars, or airplanes . Restricting access to
the activity combined with ongoing messaging related to
adverse health effects has been proven to be successful
for reducing smoking rates at the population level.
Such strategies assume that behavior is explained not on-
ly by knowledge or beliefs but also by a lack of motivation.
Incorporating societal rules to prohibit undesirable behav-
iors may create the necessary incentive for people to act
on what they already know to be healthy. In this section,
law and healthy public policy will be considered together al-
though it is recognized that healthy public policy can often
be developed and implemented without formal legislation.
In the case of back pain and other painful musculoskel-
etal conditions, public policy has been observed to dramat-
ically influence behaviors such as work disability and
health care utilization [34,35]. Public policy includes eco-
nomic factors such as willingness to pay for health care
for back pain as well as availability and level of financial
compensation or payments. For example, availability of
workers’ compensation payments or ability to sue for pain
and suffering have both been found associated with delayed
recovery [35–37]. Because of this, legal or health policy
interventions have the potential to play a major role in
improving back pain-related health behaviors. Such inter-
ventions could include restrictions on the amount of adver-
tising allowed by providers or companies offering unproven
curative interventions or system changes to alter access to
health services, wage replacement benefits, or reimburse-
ments for unproven treatments. For example, during the
Canadian campaign, the workers’ compensation board
mandated that injured workers visit a physician or health
provider every 2 weeks for follow-up. If claimants with
back pain did not visit their physician at 2-week intervals,
they were at risk of having their case closed as noncompli-
ant with care. It is unlikely that an educational campaign
focused on self-management via activity would impact
the number of visits to physicians when such a policy is
in place. Other examples of how changes in laws or health
policies have led to altered disability or health utilization
behaviors for people with musculoskeletal conditions have
been discussed elsewhere [38–40].
During the Australian campaign, some information was
presented about policies or laws that supported the cam-
paign’s key messaging. In addition to educational messages
explicitly encouraging people with back pain to remain at
or return to work, several advertisements featured an em-
ployer discussing the possibility of being fined if the com-
pany did not help a worker with back pain return to work
(see Table 2) . Other advertisements provided advice
to employers about the importance of having modified
work policies to enable workers to return to work early
and despite back pain, along with the potential reductions
in claim costs this provides (Table 2). It is important to note
that these policies and financial incentives were already in
place in the jurisdiction, and campaign messaging only
highlighted them. However, highlighting the supportive
982D.P. Gross et al. / The Spine Journal 12 (2012) 979–988
policies may have been a major reason for the changes ob-
served in the associated behaviors. Not only did subsequent
campaigns fail to explicitly provide advice regarding work
but also failed to feature messaging of this type. Also, the
Australian mass media campaign had the support and par-
ticipation of all major stakeholders, including not only
the various health care professionals with a stake in treating
back pain but also employer groups and workers’ unions.
Stakeholder endorsement and participation has been
deemed critical for successful back pain interventions .
Of note, the only subgroup that the Australian mass me-
dia campaign failed to influence were general practitioners
with a special interest in back pain . Before the cam-
paign, these doctors also had significantly poorer beliefs
(nonevidence based) about low back pain compared with
their colleagues without a special interest in low back pain.
This suggests that special interests may be an important
barrier to behavior change toward evidence-based care
and additional policy initiatives directed at health care pro-
viders may also be necessary.
In locations where supportive law or policy already ex-
ists, future mass media campaigns are likely to be more
successful if they build on this and highlight the policy
and laws as part of the messaging strategy. Where support-
ive laws and health policy are not in place, this could be
an effective avenue for fostering behavioral change. Alter-
natively, detrimental laws or health policies related to com-
pensation for back pain could be changed. However, policy
makers meet conflicting interests. In most industrialized
countries, compensation for work loss due to illness or in-
jury is a gained right for workers, with back pain consid-
ered a compensable condition. If back pain were to be
withdrawn from this right, it would implicate a view of
back pain as a natural condition. This may be true but still
difficult to implement as it would likely be considered as
a loss of a gained right among workers. However, as early
as 1995, an International Association for the Study of Pain
task force proposed the radical alteration of limiting wage
replacement funding for back pain to 6 weeks, unless cred-
ible diagnostic evidence (ie, diagnosis other than nonspe-
disability . Implementing such a restrictive policy in
societies in which being off work is perceived as a right
might not be perceived as a public gain and could have
clear implications for leaders proposing the legislation. Ad-
ditionally, individuals holding such views are unlikely to
agree wholeheartedly with messages regarding the impor-
tance of staying active and staying at work. Such restric-
tions of eligibility for sick listing and wage replacement
benefits have recently been put in place in Sweden with
mixed response , but this initiative has not yet been for-
mally evaluated. Although law and health policy changes
may be needed in some jurisdictions more than others
, deciding what policies should be put in place to ben-
efit the health of the population is controversial and cur-
rently a matter of debate with several conflicting interests.
In Australia, it has been suggested that back pain be-
come one of the several national health priority areas
. The national health priority areas initiative seeks to
focus public attention and health policy not only on areas
of health that impose a significant national burden but also
where improved health outcomes are attainable to reduce
that burden . This could provide a more cohesive focus
for policy, legislation and public awareness of back pain,
and opportunities for appropriate public health and work-
place initiatives. This type of policy window of opportunity
is critical to placing issues such as back pain prevention and
management on the agenda [47,48].
Although education attempts to change the individual
whereas law and policy attempts to change the broader so-
cial context, social marketing typically strives to do both.
Social marketing has been defined as ‘‘the use of marketing
Scripts of two Australian television advertisements
Policy-focused (upstream) advertisement
Employer: ‘‘Do you know that I can be fined $25,000 if I don’t take Joe back to work? How the hell am I supposed to get him back? He’s done his back in.’’
Secretary: ‘‘Are you asking me?’’
Employer: ‘‘Ah . yes, go on.’’
Secretary: ‘‘You could change the job a bit. Get some bench-height trolleys. That way Joe wouldn’t have to lift the parts on and off after he’s
Employer: ‘‘He wouldn’t have to twist or bend.’’
Secretary: ‘‘You’d get Joe back and you’d save yourself $25,000 in fines.’’
Employer: ‘‘Why didn’t I think of that?’’
Secretary: ‘‘Because you’re the boss . and I’m just a secretary.’’
Behavior-focused (downstream) advertisement
Employer: ‘‘You know, I want Joe back but it is just too hard.’’
Secretary: ‘‘Joe’s been with us a long time. You owe it to him.’’
Employer: ‘‘Oh I know, I know. He did his back in here. But what can I get him to do?’’
Secretary: ‘‘Is this a serious inquiry?’’
Employer: ‘‘Yes, it is.’’
Secretary: ‘‘Well maybe think about changing the way Joe does his job. Talk to the occupational rehab person. They deal with this thing all the time.’’
Employer: ‘‘Good idea. I should have thought of that earlier.’’
Secretary: ‘‘Yes, you should have. Maybe Joe wouldn’t have hurt his back in the first place.’’
983 D.P. Gross et al. / The Spine Journal 12 (2012) 979–988
principles and techniques to influence a target audience to
voluntarily accept, reject, or abandon a behavior for the
benefit of individuals, groups, or society as a whole.’’
 It is based on the assumption that behavior is explained
by a lack of opportunity as opposed to a lack of motivation
. In addition to providing education about the health
condition, social marketers attempt to change the social
context to provide a legitimate and attractive alternative
to the status quo. For example, social marketing aimed at
reducing drunk driving have combined education about
the risks of the behavior along with advice about and pro-
vision of feasible alternatives to the activity (ie, inexpensive
rides home from pubs or bars) . As such, social market-
ing goes beyond education about health conditions and in-
cludes attempts to ‘‘nudge’’ and ‘‘hug’’ individuals toward
positive health behaviors without imposing penalties or se-
rious consequences [51,52]. In this manner, individual au-
tonomy and responsibility for health is maintained.
Social marketing may consist of efforts to influence the
behaviors of individuals within a society (ie, downstream
marketing) or the behavior of governments or health policy
makers (ie, upstream marketing). Marketing efforts aimed
at governments or policy makers attempt to influence the
creation of laws and supportive policy when these are not
already in place. The choice of the target audience
(upstream or downstream) governs what messages and mar-
keting approaches are used. Detailed benchmarking criteria
have been outlined to assist in planning social marketing in-
terventions (see Table 3) [53,54]. This includes detailed
planning, segmentation analysis of the target audience,
consideration of the four P’s of traditional marketing (Pro-
motion, Product, Price, and Place), strategic planning for
how to engage all relevant stakeholders, as well as formal
In terms of promotion, social marketing considers a vari-
ety of techniques to spread information including advertis-
ing, public relations, sales promotion, and direct marketing
(see Table 4). Although many of these are done separately,
recent recommendations include striving to integrate these
techniques because of the high volume of marketing mes-
sages and ‘‘noise’’ the public is exposed to daily . Be-
cause of the exposure to thousands of messages, marketers
have to create messages that cut through the clutter. Ensur-
ing consistency in messaging is one way to do this and im-
prove message recognition. As a result, integrating various
communication elements becomes critical and could occur
on several fronts. First, the promotion strategy should be
consistent with the marketing strategy (ie, with the behavior
being promoted, brand positioning, and so forth). Second,
the audience should be exposed to consistent messaging
across the advertising campaign, publicity from journalists,
incentivizing attempts of sales promotion, and so on. These
strategies result in less confusion of the audience members
and higher intervention effectiveness. Such integrated mes-
saging should be considered for the case of back pain to
outline the most appropriate means of disseminating infor-
mation to the target audience.
Given the huge expense associated with traditional means
of advertising in the mass media, it may be that future cam-
paigns spread messaging predominantly via less expensive
Social marketing benchmark criteria
Customer orientation (know the audience): The intervention uses formative research based on primary or secondary data sources to identify audience
characteristics and needs, or the intervention elements are pretested with a sample of the target audience.
Behavior: The intervention seeks to influence the behavior of individuals or groups and has specific measurable goals.
Theory-based design: The development of the intervention and/or understanding of the audience explicitly relies on behavioral or social theories or models.
Insight: What moves and motivates
Exchange of value: The intervention motivates people to adopt or sustain behavior by offering benefits (tangible or intangible) and/or reducing costs (barriers)
related to the behavior. The exchange concept is actualized through the design and implementation of the marketing mix.
Competition: Considers competing behaviors or messages that may influence the target audience to not perform the desired behavior. What competes for the
time and attention of the audience?
Segmentation and targeting: The intervention’s audience is divided into subgroups called ‘‘segments’’ that share something in common (eg, job type,
demographic characteristics, desires, or readiness to change) that make them more likely to respond similarly to the intervention. The intervention strategy
targets or is customized for the selected segment(s). Propose segmenting the market if it is appropriate for the health context/behavior.
Methods mix: Four primary domains:
3. Designing/adjusting the environment
The intervention attempts to use all four ‘‘Ps’’ of traditional marketing:
Promotion: Communication with the audience to make a product or service familiar, acceptable, and desirable.
Product: A product (or service) is a bundle of benefits that satisfies a need for the audience. The product augments the desired health behavior.
Price: Identification and reduction of the monetary and nonmonetary costs of performing a behavior.
Place: Reduction of the location cost of a product or service as well as carrying out the behavior achieved through enhancing convenience and accessibility.
Partnership and stakeholder engagement: The intervention builds, enhances, and retains good relationships with the target audience; for example, by
ensuring service quality or audience satisfaction or by audience participation in the design of the intervention.
Review and evaluation: Research aimed at evaluating the effectiveness of the intervention.
Adapted from Mah et al. . University of Chicago Press. ? 2007 by The Society for Healthcare Epidemiology of America. All rights reserved.
984 D.P. Gross et al. / The Spine Journal 12 (2012) 979–988
methods, such as the internet or web-based communication.
For example, if well-known celebrities or sporting figures
are enrolled as spokespeople then social networking sites
such as Facebook or Twitter could be used to widely and
inexpensively disseminate advice to followers. How best to
incorporate ‘‘direct to consumer’’ marketing should also be
considered. Traditionally, health care providers have pro-
vided one-on-one education for individuals with back pain.
This has proven to be successful in smoking cessation but de-
pends highly on the knowledge, beliefs, and interests of the
health care providers [56,57]. In the case of back pain, be-
causeknowledge, beliefs, and interests vary across providers,
this may not be the ideal venue for providing advice to stay
active [58,59]. Back pain sufferers typically seek care when
pain is severe, and recent qualitative research has indicated
that advice to stay active is not well received during acute
bouts of severe pain . Education could take the form of
mailed pamphlets or email messages from public health
agencies, employers, or insurance companies. Messaging
provided at the location of the desired behavior (ie, work-
places) may also be more effective than via the mass media,
paign . For example, employers could be targeted to pro-
vide rewards or incentives to workers who demonstrate
desirable behaviors such as participation in worksite exercise
sessions or modified work programs. Messaging by ‘‘low
back pain–peers’’ who are able to remain working although
experiencing low back pain may be considered . Peers
could highlight strategies for and the benefits of staying at
work. Financial incentives are currently offered to companies
via reduced compensation or insurance premiums because
of the participation in modified work programs; however,
these incentives are rarely passed on to front-line workers
participating in the programs. Sales promotion (ie, providing
monetary/nonmonetary incentives) is another strategy that
has not been used in back pain messaging, yet is worthy of
exploration. Giventhe emphasison behaviorchange insocial
marketing, sales promotion strategies are warranted.
In the case of back pain, the issue of sustainability of
behavior change is important because it is a recurring phe-
nomenon. Ideally, individuals would have their beliefs
changed regarding the importance of activity via education,
and this would be combined with long-term changes in
their context to allow the integration of the desired behav-
iors. Provision of education alone may be less likely to lead
to long-term, sustained changes without modifications to
the social context. For this reason, when compared with ed-
ucation and law and policy changes, social marketing may
be more effective for changing back pain-related behavior.
Indeed, the Australian campaign appears to have moved
beyond education to include components of social market-
ing both in how it was conceived and what the messages
were. Besides just talking about back pain and how to man-
age it through exercise and activity, the campaign provided
explicit advice about implementing changes and modified
work programs at worksites (see Table 2). The combination
of education and advice about the condition, combined with
attempts to foster more supportive work contexts move this
campaign more into the realm of social marketing.
Lastly, considering the expense of public education or
social marketing interventions and the frequent exposure
to advertising messaging in modern society, it may be
worthwhile merging back pain campaigns with other public
health campaigns addressing different conditions but simi-
lar target behaviors. Staying or becoming active and partici-
pating in exercise is not only beneficial for back pain but
also a key message of other health condition campaigns,
such as obesity, diabetes, heart disease, and arthritis, among
others. All these campaigns include advice to stay active as
a key message, and perhaps, there is opportunity to build on
each other. For example, the successful ‘‘10,000 steps’’
campaigns focusing on increasing physical activity via pe-
dometer use share many similar goals as the ‘‘Stay Active’’
back pain campaigns [62,63]. Perhaps synergies and effi-
ciencies could be obtained if campaign organizers worked
together to target this common behavioral goal.
When to choose education versus law, policy, or social
Evidence in the field of back pain research supports that
education, law, policy, and social marketing may each be
effective for changing behaviors, but what should be the
prime focus of future public health initiatives? This will de-
pend largely on the nature of the target audience as well as
the social context in which they reside. Rothschild has pro-
posed a categorization system whereby audiences can be
analyzed for the purpose of selecting the most appropriate
strategy (see Figure) . This system indicates that the
most effective strategy for obtaining behavior change
depends on the characteristics of the target audience, in-
cluding motivation and readiness to change, opportunity
to change, and ability to change. If a population is deemed
motivated to change, has appropriate opportunity to change,
and is prone to behave, education alone is likely to be effec-
tive. If they are motivated but do not have the opportunity
or ability to change, social marketing may be effective. If
an audience is not motivated to change yet has the opportu-
nity and ability, legal or policy interventions are required.
Other combinations of the factors will require a combina-
tion of education, social marketing, and law (see Figure).
Integrated social marketing communication
1) Advertising: Paid, sponsor-identified, nonpersonal media communications
2) Marketing public relations: Publicity, events, advocacy (structural
changes, pass laws), fundraising, and sponsorship
3) Sales promotion: Special incentive to encourage immediate ‘‘sale,’’
uptake or use (ie, samples, coupons, gifts, contests)
4) Direct marketing: Direct contact with target via personal ‘‘selling,’’
direct mail, direct response ads
Based on the study by Glanz et al. .
985 D.P. Gross et al. / The Spine Journal 12 (2012) 979–988
This categorization system is conceptual but some valid-
ity evidence has been presented from the studies of work-
injury prevention initiatives . Developers of future back
pain public health initiatives should carefully consider the
nature of their audience and the context before deciding
what behavioral intervention strategies to use. However,
recognizing that most populations are not entirely homoge-
neous in the areas of motivation, opportunity, and ability to
change, it is likely that a combination of the three will be
required for most impact. As mentioned, this appears to
have been the strategy taken by the organizers of the Aus-
tralian campaign. Given that all subsequent campaigns have
been substantially different, replicating the initial Austra-
lian campaign as closely as possible with careful and rigor-
ous evaluation of effectiveness is required.
Another important issue that must be considered by de-
velopers of future campaigns is how the effectiveness of
a specific change strategy can be optimized, given the var-
ious factors that could potentially influence results. This
includes broad societal factors such as characteristics of
the prevailing culture, ethnicities, and religious beliefs,
among other factors. As discussed previously, the change
strategy chosen, whether it be education, social marketing,
or law and healthy public policy will need to be tailored to
the meet the specific needs of the target population.
Conclusions and recommendations
Evaluations of previous back pain mass media cam-
paigns highlight that education alone is unlikely to be
sufficient to foster positive and persisting societal
behavioral change. Four mass media campaigns have
been undertaken and evaluated in separate countries
(Australia, Scotland, Norway, and Canada) and only the
Australian campaign resulted in changes to both work
disability and beliefs. The Australian campaign was not
only larger in magnitude but also accompanied by sup-
portive laws and policies in the jurisdiction. The other
three campaigns were much smaller in scope, had more
limited messaging, and were not always as supported by
institutional policies and legislation. Educational en-
deavors should likely be augmented with supportive laws,
healthy public policy, and social marketing endeavors to
foster sustained change in outcomes such as work disabil-
ity and health utilization.
This manuscript was reviewed and informed by partici-
pants of the Melbourne International Forum XI Workshop:
Back Pain Mass Media Campaigns: Next Steps? No funds
were received in support of this research. Shelley Bowen
from the Population Health Strategic Research Centre, Dea-
kin University, provided input on this manuscript.
 Buchbinder R, Jolley D, Wyatt M. Population based intervention to
change back pain beliefs and disability: three part evaluation. BMJ
 Waddell G, O’Connor M, Boorman S, Torsney B. Working Backs
Scotland: a public and professional health education campaign for
back pain. Spine 2007;32:2139–43.
Figure. Applications of education, marketing, and law. Reprinted with permission from Journal of Marketing, published by the American Marketing Asso-
ciation, Rothschild ML, 1999, vol. 69, pp. 24–37 .
986 D.P. Gross et al. / The Spine Journal 12 (2012) 979–988
no effect on sickness behaviour. Patient Educ Couns 2008;71:198–203.
 Gross DP, Russell AS, Ferrari R, et al. Evaluation of a Canadian back
pain mass media campaign. Spine 2010;35:906–13.
 Buchbinder R, Gross DP, Werner EL, Hayden JA. Understanding the
characteristics of effective mass media campaigns for back pain and
methodological challenges in evaluating their effects. Spine 2008;33:
 Buchbinder R, Jolley D, Wyatt M. 2001 Volvo Award winner in clin-
ical studies: effects of a media campaign on back pain beliefs and its
potential influence on management of low back pain in general prac-
tice. Spine 2001;26:2535–42.
 Buchbinder R, Jolley D. Effects of a media campaign on back beliefs
is sustained 3 years after its cessation. Spine 2005;30:1323–30.
 Frank J, Sinclair S, Hogg-Johnson S, et al. Preventing disability from
work-related low-back pain. New evidence gives new hope—if we
can just get all the players onside. CMAJ 1998;158:1625–31.
 Glanz K, Rimer B, Lewis F. Health behaviour and health education:
theory, research and practice. 3rd edition. San Francisco, CA: Jossey-
 Bandura A. Health promotion from the perspective of social cogni-
tive theory. In: Norman P, Abraham C, Conner M, eds. Understanding
and changing health behaviour. Reading, UK: Harwood, 2000:
 Finney Rutten LJ, Augustson EM, Moser RP, et al. Smoking knowl-
edge and behavior in the United States: sociodemographic, smoking
status, and geographic patterns. Nicotine Tob Res 2008;10:1559–70.
 Bala M, Strzeszynski L, Cahill K. Mass media interventions for
smoking cessation in adults. Cochrane Database Syst Rev 2008;1:
 Wakefield MA, Loken B, Hornik RC. Use of mass media campaigns
to change health behaviour. Lancet 2010;376:1261–71.
 Rothschild ML. Carrots, sticks and promises: a conceptual frame-
work for the management of public health and social issue behaviors.
J Market 1999;63:24–37.
 Rosenstock IM, Strecher VJ, Becker MH. Social learning theory and
the Health Belief Model. Health Educ Q 1988;15:175–83.
 Gross DP, Ferrari R, Russell AS, et al. A population-based survey of
back pain beliefs in Canada. Spine 2006;31:2142–5.
 Werner EL, Ihlebaek C, Skouen JS, Laerum E. Beliefs about low
back pain in the Norwegian general population: are they related to
pain experiences and health professionals? Spine 2005;30:1770–6.
 Heymans MW, van Tulder MW, Esmail R, et al. Back schools for
nonspecific low back pain: a systematic review within the framework
of the Cochrane Collaboration Back Review Group. Spine 2005;30:
 Brox JI, Storheim K, Grotle M, et al. Systematic review of back
schools, brief education, and fear-avoidance training for chronic
low back pain. Spine J 2008;8:948–58.
 Coudeyre E, Tubach F, Rannou F, et al. Effect of a simple informa-
tion booklet on pain persistence after an acute episode of low back
pain: a non-randomized trial in a primary care setting. PLoS One
 Sorensen PH, Bendix T, Manniche C, et al. An educational approach
based on a non-injury model compared with individual symptom-
based physical training in chronic LBP. A pragmatic, randomised
trial with a one-year follow-up. BMC Musculoskelet Disord 2010;
 Halligan PW, Aylward M. The power of belief: psychosocial influ-
ence on illness, disability and medicine. Oxford, UK: Oxford Univer-
sity Press, 2006.
 Briggs AM, Jordan JE, Buchbinder R, et al. Health literacy and be-
liefs among a community cohort with and without chronic low back
pain. Pain 2010;150:275–83.
 Bowey-Morris J, Davis S, Purcell-Jones G, Watson PJ. Beliefs about
back pain: results of a population survey of working age adults. Clin J
 Armitage CJ, Conner M. Efficacy of the theory of planned behavior:
a meta-analytic review. Br J Soc Psychol 2001;40:471–99.
 Hornik R, Yanovitzky I. Using theory to design evaluations of com-
munication campaigns: the case of the National Youth Anti-Drug Me-
dia Campaign. Comm Theor 2003;13:204–24.
 Freedhoff Y. Controversy surrounds new treatment for discogenic
back pain. CMAJ 2010;182:E409–10.
November 30, 2010.
 Dunn KM, Jordan KP, Mancl L, et al. Trajectories of pain in adoles-
cents: a prospective cohort study. Pain 2011;152:66–73.
 Roth-Isigkeit A, Thyen U, Stoven H, et al. Pain among children and
adolescents: restrictions in daily living and triggering factors. Pediat-
 Munro GB, Munro BE, Burke P. The development of a smoking ces-
sation intervention for hard-to-reach multiple substance abusing
males: a comic book as the central component. Int J Divers Organ
Communities Nations 2007;7:231–8.
 Halpern J, Finger WR. Prevention of STDs—the challenge of chang-
ing behaviors. Network 1992;12:16–8.
 Ross H, Blecher E, Yan L, Hyland A. Do cigarette prices motivate
smokers to quit? New evidence from the ITC survey. Addiction
in return-to-work after chronic occupational back pain be explained?
J Occup Rehabil 2009;19:419–26.
 Cassidy JD, Carroll L, Cote P, et al. Low back pain after traffic
collisions: a population-based cohort study. Spine 2003;28:1002–9.
 Rasmussen C, Leboeuf-Yde C, Hestbaek L, Manniche C. Poor out-
come in patients with spine-related leg or arm pain who are involved
in compensation claims: a prospective study of patients in the second-
ary care sector. Scand J Rheumatol 2008;37:462–8.
 Hadler NM, Carey TS, Garrett J. The influence of indemnification by
workers’ compensation insurance on recovery from acute backache.
North Carolina Back Pain Project. Spine 1995;20:2710–5.
 Cassidy JD, Carroll LJ, Cote P, et al. Effect of eliminating compen-
sation for pain and suffering on the outcome of insurance claims for
whiplash injury. N Engl J Med 2000;342:1179–86.
 Stephens B, Gross DP. The influence of a continuum of care model on
the rehabilitation of compensation claimants with soft tissue disor-
ders. Spine 2007;32:2898–904.
 Quintner JL. The Australian RSI debate: stereotyping and medicine.
Disabil Rehabil 1995;17:256–62.
 Buchbinder R, Jolley D, Wyatt M. Role of the media in disability
management. In: Sullivan T, Frank J, eds. Preventing and managing
disabling injury at work. Boca Raton, Florida: CRC Press Taylor &
Francis Group, 2003.
 Buchbinder R, Staples M, Jolley D. Doctors with a special interest in
back pain have poorer knowledge about how to treat back pain. Spine
2009;34:1218–26; discussion 27.
 Fordyce WE, International Association for the Study of Pain. Task
Force on Pain in the Workplace. Back pain in the workplace: manage-
ment of disability in nonspecific conditions: a report of the Task
Force on Pain in the Workplace of the International Association for
the Study of Pain. Seattle, WA: IASP Press, 1995.
 Gomes A, Llena-Nozal A, Prinz C. Sickness, disability and work:
Sweden: will the recent reforms make it? Paris, France: Organisation
for Economic Co-operation and Development, 2009.
 Briggs AM, Buchbinder R. Back pain: a National Health Priority
Area in Australia? Med J Aust 2009;190:499–502.
 Australian Institute of Health and Welfare and Commonwealth De-
partment of Health and Family Services. First report on National
Health Priority Areas 1996. AIHW Cat. No. PHE 1. Canberra, Aus-
tralia: AIHWand DHFS, 1997. Available at: http://www.aihw.gov.au/
publications/index.cfm/title/121. Accessed Sept 24, 2012.
987 D.P. Gross et al. / The Spine Journal 12 (2012) 979–988
 Beland D. Policy change and health care research. J Health Polit Pol- Download full-text
icy Law 2010;35:615–41.
 Ritter A, Bammer G. Models of policy-making and their relevance
for drug research. Drug Alcohol Rev 2010;29:352–7.
 Kotler P, Roberto N, Lee N. Social marketing: improving the quality
of life. 2nd ed. Thousand Oaks, CA: Sage Publications, 2002.
 Deshpande S, Rothschild ML, Brooks RS. New product development
in social marketing. Soc Market Q 2004;X:39–49.
 Thaler RH, Sunstein CR. Nudge: improving decisions about health,
wealth, and happiness. New York, NY: Penguin Books, 2009.
 French J. Why nudging is not enough. J Soc Market 2011;1:154–62.
 Social Marketing National Benchmark Criteria. National Social Mar-
keting Centre, 2010. Available at: http://thensmc.com/sites/default/
files/benchmark-criteria-090910.pdf. Accessed October 3, 2012.
 Mah MW, Tam YC, Deshpande S. Social marketing analysis of
2 years of hand hygiene promotion. Infect Control Hosp Epidemiol
 Alden D, Basil M, Deshpande S. Communications in social market-
ing. In: Hastings G, Bryant C, Angus K, eds. The Sage handbook on
social marketing. Thousand Oaks, CA: Sage Publications, 2011:
 Raupach T, Merker J, Hasenfuss G, et al. Knowledge gaps about
smoking cessation in hospitalized patients and their doctors. Eur J
Cardiovasc Prev Rehabil 2011;18:334–41.
 Pipe A, Sorensen M, Reid R. Physician smoking status, attitudes to-
ward smoking, and cessation advice to patients: an international
survey. Patient Educ Couns 2009;74:118–23.
 Linton SJ, Vlaeyen J, Ostelo R. The back pain beliefs of health
care providers: are we fear-avoidant? J Occup Rehabil 2002;12:
 Werner EL, Gross DP, Lie SA, Ihlebaek C. Healthcare provider back
pain beliefs unaffected by a media campaign. Scand J Prim Health
 Young AE, Wasiak R, Phillips L, Gross DP. Workers’ perspectives on
low back pain recurrence: ‘‘It comes and goes and comes and goes,
but it’s always there’’. Pain 2011;152:204–11.
 Werner EL, Laerum E, Wormgoor ME, et al. Peer support in an
occupational setting preventing LBP-related sick leave. Occup Med
 De Cocker KA, De Bourdeaudhuij IM, Brown WJ, Cardon GM.
Effects of ‘‘10,000 steps Ghent’’: a whole-community intervention.
Am J Prev Med 2007;33:455–63.
 Harvey JT, Eime RM, Payne WR. Effectiveness of the 2006 Com-
monwealth Games 10,000 Steps Walking Challenge. Med Sci Sports
 Lavack AM, Magnuson SL, Deshpande S, et al. Enhancing occupa-
tional health and safety in young workers: the role of social market-
ing. Int J Nonprofit Voluntary Sector Market 2008;13:193–204.
988 D.P. Gross et al. / The Spine Journal 12 (2012) 979–988