Celebrities often use their popularity to champion causes and endorse products.[2-4] They play multiple roles as spokespersons for health issues including advocate, educator, social change agent, and fundraiser. The December 2, 1991, issue of People magazine focused on 12 celebrities who developed off-camera roles providing services for people or causes. Actor Steve Guttenberg distributes food to the homeless. Actress Kate Capshaw works for immunization of children. Television star Jill Eikenberry narrated a documentary about breast cancer and testified before a Senate subcommittee on breast cancer. School administrators often use celebrities in anti-drug programs. Celebrities also serve as role models, particularly for children.
Mass media are primary sources of health information for many Americans. In the absence of other means for making health decisions, people often rely on intuitive judgments of probabilities known as heuristic strategies. One common strategy involves the availability heuristic in which individuals judge the likelihood of developing a health problem or disease based on how readily they can imagine or recall the condition. For example, individuals often overestimate the probability of developing a serious disease because the disease has become vivid or emotionally intense. Testimonials by prominent public figures or celebrities who disclose their personal health concerns potentially create emotionally intense and vivid images.
Consequently, celebrities represent a potentially salient source of health information for the general public with the power to stimulate and frame public discussions about health problems. Yet, a study of endorsements in national magazine advertising from 1980 to 1986 revealed that while endorsements by celebrities are widely used, less product information was provided in endorsement advertising than in other types of advertising. The role of celebrities as media advocates for health education warrants analysis.
The Magic Johnson Case
The situation created by Magic Johnson's desire to become a spokesperson for AIDS illustrates the need to understand the dynamics of celebrities as health educators. While many consider Johnson an ideal spokesperson for AIDS, others note that his public disclosure raised important questions.[9,10]
In his first public disclosure about the illness, Johnson sent intended as well as unintended messages. Initially, Johnson revealed that, having tested positive for HIV, he would retire from basketball to devote his attention to battling AIDS as a spokesperson. He emphasized heterosexual transmission of the HIV in his case and prevention of AIDS with safe sex. In doing so, Johnson simultaneously admitted and demonstrated a naivete about AIDS, its implications, and his own vulnerability. AIDS educators and public school health teachers questioned the appropriateness and effectiveness of Johnson's safe sex message. Since his disclosure, Johnson has begun promoting abstinence.
Johnson has broad appeal, to young and old, black and white, men and women, due to rare athletic talent and a charismatic personality. As an African-American sports idol, Johnson may be a highly credible spokesperson with inner city youth. Johnson lends a new image to AIDS, a disease previously associated with politically sensitive issues such as homosexuality, drug use, poverty, and limited access to health care. Noting the media's tactful treatment of Johnson's admitted heterosexual promiscuity, tennis star Martina Navrati-lova and others suggest a double standard:
The Magic Johnson story tells us that AIDS is an equal opportunity disease crossing all lines of sex, sexual orientation, race, and class. However, the role model is flawed, because in the portrayal of Johnson as a virile, heterosexual sports star, women, lesbians and gay men are again cast as less valuable, and perhaps even disposable parts of the human family.
While it may take years before researchers assess the impact of Johnson's disclosure, the immediate response has been significant. As a result of Johnson's disclosure and subsequent public sympathy for the plight of HIV positive people, President Bush admitted that his administration may not have done enough about AIDS. Bush also invited Johnson to serve on the President's Commission on AIDS. Many of Johnson's corporate sponsors expressed immediate support for his efforts.
Interest in information about AIDS increased dramatically in the wake of Johnson's disclosure. The National AIDS Hotline reported 10 times the usual number of inquiries the day of Johnson's announcement. The Centers for Disease Control had 10,000 calls per hour in contrast to their typical 200 calls per hour. As appointments for HIV testing increase, so do questions about adequacy of the health care delivery system to meet the challenge. More long-term outcomes anticipated by some include legislation requiring sexuality education in more states and increased funding for AIDS prevention.
The overwhelmingly positive public reaction to Johnson's decision to become a spokesperson for AIDS demonstrates the tremendous potential for use of celebrities as health educators. Johnson's announcement increased public interest in AIDS prevention, addressed the myths surrounding AIDS, and stimulated discussion about access to health care in the African-American community. Yet, given the controversy over Johnson's message, the cause may have been better served by a more systematic strategy for serving as an AIDS spokesperson.
The Media Advocacy Approach
Research indicates mass media provides a powerful influence in shaping attitudes which can be used to influence public policy regarding health. To make best use of mass media to promote health, Wallack and Sciandra and Arkin suggest a media advocacy approach that entails strategic use of mass media for framing public debate about a health issue. Media advocacy seeks to change public debate and attention on health issues from individual risk behavior to the underlying social, economic, and political causes to stimulate public participation in health policy development. Wallack and Sciandra describe three functions of mass media in setting norms:
First, mass media is often able to set the public agenda. It is often said that the media may not tell people what to think but do tell people what to think about. Second, the media confer status and legitimacy on various topics or points of view which are selected for our attention. The presence of a topic in the media helps to establish its importance. Third, the mass media can activate and stimulate public discussion. It also provides the framework for the discussion by roughly establishing the boundaries of legitimate discourse.
An example of a successful media advocacy approach involves the campaign by anti-smoking advocates to counter the tobacco industry's advertising to women and minorities. As an emerging technique, media advocacy lacks clear definition and principles. Yet, the approach presents health information in new media formats, reaches wide audiences with credible spokespersons, and can "create a dynamic context in which to convey the information." In addition, media advocacy provides the media with feedback, systematic monitoring, and accountability. Application of the media advocacy approach may improve the effectiveness of celebrities as advocates for health education. Yet, celebrities have not used the media advocacy approach systematically to maximize their effectiveness in promoting health causes.
The process of implementing a media advocacy approach with celebrity spokespersons involves several steps. First, professional preparation in media advocacy must be developed and provided for health educators. Professional preparation can be provided through professional development workshops at national conferences and courses at colleges and universities. Second, a major professional organization such as the American School Health Association, the Society for Public Education, or the American Public Health Association must adopt a leadership role. The organization would take responsibility for developing generic and topic-specific media advocacy guidelines for dissemination to celebrity spokespersons as need arises along with ongoing technical support. Third, the organization must market and disseminate the media advocacy guidelines to appropriate celebrity spokespersons. Media advocacy guidelines for celebrity spokespersons should include strategies for developing and nurturing access to the media, gaining knowledge of the subject matter, using creative epidemiology, and framing of issues.
Access to the Media. Media access constitutes a celebrity's greatest asset as a media advocate. Yet, overreliance on testimonials and anecdotal information by celebrities undermines their credibility and ignores the policy issues involved in the health problem. Celebrities gain media access by virtue of their celebrity status. Drawing on the public's desire for information about celebrities, media advocates can augment or enhance health news stories by announcing reactions of celebrities. Descriptions of celebrities' personal health regimens can evoke interest in health promotion strategies. [17,18]
Knowledge of Subject Matter. In a study on the impact of celebrity endorsement on consumer choices, Ohanian found that perceived celebrity expertise explained consumer intentions to purchase products. To serve as reliable and credible media advocates, celebrities need to be familiar with current research and controversy on their health issues as well as appropriate media outlets. As Magic Johnson discovered, celebrities must be well versed in the health topic before fielding questions from the public and the media. For example, a celebrity promoting increased funding for AIDS research can improve effectiveness by selecting interview opportunities conducted by an informed, unbiased, and well-respected media outlet.
Creative Epidemiology. Celebrity spokespersons for health issues can use creative epidemiology to their advantage in delivering messages. Creative epidemiology refers to presentation of health data and research in a palatable and provocative manner to the media and the general public. For example, the celebrity spokesperson can use vivid images to convey vital statistics by comparing the number of deaths from AIDS occurring in a year to the number of people who died in Vietnam over a certain period of time.
Issue Framing. The most complex skill to be mastered by the celebrity spokesperson involves issue framing. Purposes of issue framing are twofold: 1) to shift focus from individual health behavior to underlying societal practices and attitudes that influence health, and 2) to identify and publicize exploitive and unethical practices that affect health."  In one example of issue framing, media advocates from the Community Intervention Trial for Smoking Cessation (COMMIT) publicized efforts of the tobacco and alcohol industry to gain public acceptance for their products by funding sports and cultural events. Condemnation by anti-smoking groups of the tobacco industry's use of the Bill of Rights in advertising provides another example of issue framing. A celebrity spokesperson for AIDS could use issue framing to shift public debate from individual sexual practices to public policy regarding sexuality education.
Research demonstrates the utility and limitations of celebrity endorsement in gaining public attention and compliance to recommended health behavior. While celebrity spokespersons serve as popular and positive representatives for promoting causes and products, their credibility and effectiveness have limits. The media advocacy approach offers a systematic means to maximize effectiveness of celebrity spokespersons and stimulate health policy improvements.
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