Cancer Prevention Billboards Evaluation in American Samoa, Sara Krosch

Cancer Prevention Billboards Evaluation Report December 2008 Sara Krosch, amsamccn@gmail.com

American Samoa Community Cancer Network

Contents Introduction .............................................................................................................................................. 3 Billboard Aims ........................................................................................................................................... 3 Billboard Message & Target Audience ...................................................................................................... 4 Billboard Evaluation Criteria ..................................................................................................................... 4 Billboard Evaluation Methods ................................................................................................................... 5 Billboard Observations .............................................................................................................................. 5 Community Survey .................................................................................................................................... 5 Evaluation Criteria ..................................................................................................................................... 6 Billboard Locations .................................................................................................................................... 6 Billboard Observation Results ................................................................................................................... 7 Community Survey Results ..................................................................................................................... 12 Respondent Demographics ..................................................................................................................... 12 Billboard Recall Results ........................................................................................................................... 17 Billboard Opinion Results ........................................................................................................................ 20 Billboard Behavior Change Results ......................................................................................................... 21 Billboard Design Evaluation .................................................................................................................... 22 Billboard Recommendations ................................................................................................................... 23 Survey Respondent Recommendations .................................................................................................. 23 Evaluator Recommendations .................................................................................................................. 23

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Introduction During 2007‐08, the American Samoa Community Cancer Network (ASCCN) erected 13 cancer prevention billboards on the main island of Tutuila in the Territory. Four (4) billboards encouraged screening for breast and cervical cancer; 3 billboards encouraged smoking cessation and Quitline calling; and 6 billboards encouraged screening for cancer in general. All billboards listed the ASCCN as sponsor but other office phone numbers were usually given.

The lumber and nails for each billboard were donated by ACE Hardware, $37.00 per billboard. The front messages were produced by Local Graphix but they could not recall the exact price of the billboards.

Currently, they are creating billboards of similar size for about $200.00 each. So, to construct or replace a billboard would cost about $240.00 each.

By November 2008, 2 breast and cervical cancer screening billboards had been removed and one general cancer screening billboard had been vandalized. This evaluation report does not assess billboards encouraging breast and cervical cancer screening, initiatives covered by the Breast and Cervical Cancer Early Detection and Prevention program under the American Samoa Department of Health.

In an effort to assess the impact of the 3 smoking cessation and 6 general cancer screening billboards, evaluation activities were implemented September – November 2008: a convenience sample survey of 200 community members and observations of billboard traffic. This report documents the results of these evaluation activities.

Billboard Aims The mission of the ASCCN is to reduce cancer health disparities—incidence, morbidity and mortality—in American Samoa via research and the support of education and service partners.

The cancer prevention billboards specifically aimed to 1) Increase utilization of screening services offered at the Lyndon B. Johnson Tropical Medical Center (LBJ) and the Tobacco Quitline managed by the AS Department of Health; and 2) Stimulate interpersonal dialogue about cancer screening and smoking cessation.

While the billboards have been standing, the ASCCN sponsored or supported screening clinics/events for breast, cervical and prostate cancers and billboard messages were reiterated on local radio, television media and elaborated on regularly in a local newspaper. Therefore, the billboards were a part of a lager social marketing campaign. Social marketing is the use of commercial marketing techniques to promote the adoption of a healthy behavior. This approach is best used to increase service use, but it may be ineffective when the health issue is beyond individual control. Billboards are only one method of conveying social marketing messages. They are great for reaching commuters, allow for repetition, and are a relatively inexpensive way to reach many people. On the downside, billboards cannot provide much information, their message must be understood within seconds, and they can become unnoticeable after time especially if they are near other outdoor advertisements (Kline Weinreich, 1999).

Kline Weinreich, Kendra. (1999) Hands‐on Social Marketing: a Step‐by‐Step Approach. Sage:Thousand Oaks, CA. 4, 85.

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Billboard Message & Target Audience Billboards are meant to convey a single action‐oriented message. There is no evidence of prior research or stakeholder involvement in the development of the cancer screening or smoking cessation billboard messages or designs. No specific target audiences were defined for the billboards. Nor were the messages and designs pre‐tested with any target audiences before billboards were erected.

The billboard messages were as follows with the targeted behavior underlined: General Cancer Screening Billboards Screen for your life!

Screen for cancer Find the cancer Beat the cancer It's best to be sure.

Smoking Cessation/Quitline Billboards Stop Smoking: Do you wish to quit smoking?

We can help you quit.

Before impact evaluation activities commenced, the following primary and secondary target audiences (TA) were defined: General Cancer Screening Billboards Primary TA‐ Adults age 40+, females and males Secondary TA‐ All females and males, ages 13+

Smoking Cessation/Quitline Billboards Primary TA‐ current smokers, females and males Secondary TA‐ All females and males, ages 13+

The Primary TAs are more likely to be diagnosed with cancer while the secondary TAs may be influential in encouraging uptake of target behaviors.

Billboard Evaluation Criteria Marketing experts offer these criteria for planning and assessing billboard design: 1) Visibility

2) Color 3) Copy 4) Images 5) Layout 6) Message 7) Intrigue

Can the message be read easily? Are the fonts easy to read and large enough (from a moving vehicle at 500‐1,000 feet in less than 5 seconds)? Are the words properly spaced?

Are contrasting colors used? Does the billboard stand out from the surroundings?

Do the colors appeal to the TA? Are short and simple words used? Are the words memorable and culturally appropriate?

Are images attention‐getting? Does the TA relate to pictures? Do images reinforce the message?

Is there are balance between copy and images? Are contrasting colors balanced? Is the design simple and not cluttered?

Is a single, behavior‐oriented message conveyed? Is enough information given to adopt the behavior?

Does the billboard message and image grab the TA’s attention? Does the billboard prompt informal and formal discussion about the target behavior?

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Billboard Evaluation Methods Three methods were used to evaluate the cancer prevention billboards: • • •

Observations of billboard traffic on site Convenience sample survey of 200 American Samoa residents Application of billboard evaluation criteria

Billboard Observations The author conducted 10 minute observations on site at all Screen for Your Life! And Stop Smoking billboards on sunny weekdays October 22‐27 between 10am and 12noon. An observation checklist was used to note the infrastructure immediately surrounding the billboard (within 100 yards) and the number of female and male adults, youth, and children who passed by. Adults were considered 25 years and older, youth 12 – 24 years and children anyone appearing to be under age 12. Observations were noted only if the person could feasibly see the billboard as most billboards were only visible from particular directions or angles. After noting the 10 minute tally of passerbys, this number was multiplied by 6 to estimate the amount of possible traffic per hour on a typical day per billboard.

Community Survey A convenience sample survey of 200 American Samoa residents was conducted September – November 2008. The sample was stratified by gender and age group such that 100 males and 100 females responded, 40 from each age group: under age 20; 20 – 29 years; 30 – 39 years; 40 – 49 years; and age 50 and older. The self‐administered survey was distributed at the 2008 Annual ASCCN Cancer Symposium (September), at workshops sponsored by the ASCCN (September – November), at an American Samoa Community Cancer Coalition Policy Skills Training Workshop (October), at the LBJ Billing Office (October), and in the villages of ASCCN staff and partners. On most occasions respondents were given the opportunity to win a prize (computer flashdrive or calling card) and all respondents were offered a free pencil.

The survey asked questions about respondent demographics, cancer billboard opinions, and uptake of behaviors related to the aims of the initiative. More than 200 residents responded to the billboard evaluation survey. One hundred (100) female and 100 male surveys, 20 per age group were analyzed.

Incomplete surveys (*billboard evaluation, health beliefs and demographics) were not included. If more than 20 surveys were completed for a gender’s age group, surveys were randomly selected for inclusion.

Three (3) survey respondents identified their gender as “Other” (neither male nor female). Given the small, unrepresentative proportion of this demographic, the 3 surveys were not included in the analysis.

Survey data was analyzed for differences between genders, age groups and education groups.

Education groups were defined as Lower Education (highest attainment being elementary, secondary or 2 year college) and Higher Education (highest attainment being 4 year college degree or more than a 4 year college degree).

5 *The billboard evaluation survey was part of a larger survey pack that included media habits and health beliefs, results from which will be shared in future reports.

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Evaluation Criteria After analyzing survey and observation results, the author assessed the cancer prevention billboards using these well‐establish (social) marketing criteria, assigning a score of high, medium or low achievement. Final recommendations were then made.

Billboard Locations

Nine (9) billboards were assessed, numbers 3‐11 on the map below. All billboards were along main roads on Tutuila Island and all but one (#10) were in large to mid‐sized populated villages. Three (3) billboards (# 3‐5) were in the business canter and most populated village on the island, Tafuna.

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Billboard Observation Results

This evaluation report does not assess billboards encouraging breast and cervical cancer screening, initiatives covered by the Breast and Cervical Cancer Early Detection and Prevention program under the American Samoa Department of Health. The Community Cancer Network is the stated sponsor on these billboards, but the phone numbers provided are to other offices.

Surroundings • On far wall of Veteran’s Memorial Stadium • Walled‐in compound with half of seating facing billboard

Observers (10min) • 0 adults • 0 youth • 0 children • *potentially 150 at stadium events • Potentially 0 /hour

Evaluator Comments • Poor location • Only visible at stadium events • Writing too small for anyone to read unless walk up close to billboard • Message appears to target athletes who do not practice at the stadium • Phone number very small

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Surroundings Observers (10min) • 9 female & 5 male • In front of Tafuna adults Family Clinic • Behind a chain‐link • 0 youth fence making • 2 female & 2 male difficult to see from children the road • Potentially • Clinic, bus stop, 108/hour businesses nearby

Evaluator Comments • Poor location, only visible within gated parking lot • Screening location not provided • Phone number no longer valid • Phone number of hospital should be provided rather than ASCCN

Surroundings • Major intersection, bus route • Sometimes obscured by tree branches • 3 Bus stops, businesses, homes nearby

Observers (10min) • 51 female & 68 male adults • 37 female & 26 male youth • 3 female & 1 male children • Potentially 1,116/hour

Evaluator Comments • Poor location, drivers may be distracted by sign or ignore it due to busy traffic • Best visible from two directions • Mostly bus passengers as potential observers • Message font good size, simple message • Phone numbers no longer valid • Phone number of hospital should be provided rather than ASCCN

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Surroundings Observers (10min) • 30 female & 38 male • In front of adults Department of Health offices • 5 female & 8 male youth • Across from hospital emergency • 0 female & 1 male room children • 2 Bus stops, offices, • Potentially businesses, parking 492/hour lots, homes nearby

Evaluator Comments • Poor location, most drivers do not appear to look this direction • Best visible from 1 bus stop • Message font good size, simple message • Location of screening services should be provided • Phone numbers no longer valid • Phone number of hospital should be provided rather than ASCCN

Surroundings • Intersection in front of government offices • 2 Bus stops, offices, parking lots, businesses, park, school nearby

Observers (10min) • 54 female & 83 male adults • 10 female & 9 male youth • 7 female & 0 male children • Potentially 978/hour

Evaluator Comments • Poor location, only bus stop and traffic leaving government office have clear view • Aesthetic of park scenery degraded • Message font good size, phone number font too small

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Surroundings Observers (10min) • 25 female & 50 male • Main road in Pago adults Pago, on corner in family yard • 7 female & 10 male youth • houses, businesses, market, park • 0 female & 2 male nearby children

• Potentially 564/hour

Evaluator Comments • Visible from one direction, going east towards cannery along main bus route • Message font good size • Phone number font too small • Sometimes temporarily covered with other signs

Surroundings Observers (10min) • 16 female & 46 male • Intersection at adults cross‐island road to national park • 5 female & 6 male youth • houses, businesses, church, school • 1 female & 1 male nearby children

• Potentially 450/hour

Evaluator Comments • Best visible from one direction, at intersection facing ocean, mostly bus traffic • Aesthetic of coastal scenery degraded • Message font good size • Other billboards nearby

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Surroundings Observers (10min) • 9 female & 13 male • Intersection at adults cross‐island road • houses, businesses, • 0 female & 0 male youth church, school nearby • 0 female & 0 male

children • Potentially 132/hour

Evaluator Comments • Only visible from one direction, heading east rather than to urban center, mostly bus traffic • Along main walking route to school, church and store • Message font good size • Other billboards nearby

Surroundings • Coastal road, corner of family yard • Houses, water taxi to Aunu’u island nearby

Observers (10min) • 13 female & 12 male adults • 0 female & 3 male youth • 1 female & 2 male children • Potentially 186/hour

Evaluator Comments • Only visible from one direction, heading east rather than to urban center, mostly bus traffic • Graffiti damaged • Other billboards nearby • Phone numbers too small to read

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Billboard Passerbys ‐ 10 Minute Observation 200 180 160 140 120 100 80 60 40 20 0

All Females Males

BB 3 BB 4

BB5

BB 6 BB 7 BB 8 BB 9 BB 10 BB 11

Based on 10 minute observations on a typical sunny weekday morning, it can be estimated that during such times as many as 4,026 people per hour could potentially be observing at least one cancer prevention billboard.

Community Survey Results

Respondent Demographics

Females (n=100)

Under 20 years (n=20) 20‐29 years (n=20) 30‐39 years (n=20) 40‐49 years (n=20) 50 and older (n=20)

Males (n=100)

Under 20 years (n=20) 20‐29 years (n=20) 30‐39 years (n=20) 40‐49 years (n=20) 50 and older (n=20)

Ninety‐four percent (94%) of females and 91% of males claimed a religious affiliation.

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Birthplace by Gender 100 80 60 male

40

female

20 0 Am Samoa

Samoa

USA

Other Pacifc Island

No Response

The majority of respondents were born in American Samoa. More respondents were born in the United States (USA) than in Samoa. There was no significant difference in birthplace between genders.

Respondents came from 38 of the 65 villages on Tutuila Island. Residents were surveyed from each village containing a billboard with forty‐six (46) respondents from the largest village with the most billboards.

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Ethnicity by Gender 180 160 140 120 100 80 60 40 20 0

male female

Samoan

Other Pacific Islander

Asian

White

No Response

Nearly all survey participants were of full or partial Samoan ethnicity. There was no significant difference in ethnicity between females and males.

Marital Status by Gender 100 80 60 male 40

female

20 0 Single

Married

Divorced Widowed

No Response

About half of respondents were married and about half were single/never married. This is largely due to two age groups being in their 20’s or younger. Slightly more females than males were married.

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Employment Status by Gender 120 100 80 male

60

female

40 20 0 Employed

Unemployed

Retired

No response

Most surveyed were currently employed. The majority of the unemployed were age 29 or under. There was no significant difference in employment status between genders.

Education Attainment by Gender 50 40 30 20

female

10

male

0

Most respondents had attained a secondary diploma or a 2‐year college degree. More males than females had only a secondary education while more females had either a 2 year college degree or more than a 4‐year college education.

For data analysis, respondents were divided into 2 educational attainment groups: Lower Education (highest attainment being elementary, secondary or 2‐year college) and Higher Education (highest attainment being 4‐year college degree or more than a 4‐year college degree). Most surveyed fell into the Lower Education group.

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Education Groups by Gender

No Response

All Females

Higher Ed

All Males Lower Ed

0

20

40

60

80

Personal Cancer Status

Yes Female 9 Male 1 Total % 5%

No 86 95 90%

No Response 5 4 5%

Frequency Personal Cancer Site Breast Stomach Lung Skin Unknown/ No Response

5 1 1 1 2

Family Cancer Status

Yes Female 53 Male 26 Total % 40%

No 41 70 55%

No Response 6 4 5%

Frequency Family Cancer Site Breast Stomach Lung Skin Brain Liver Lymph Unknown/

38 3 9 1 5 2 1 13

Cervix Leukemia Ovarian Prostate Pancreas Throat Uterus Colon

6 7 3 2 5 2 2 3

No Response

Ten (10) survey respondents were cancer survivors, 5% of the sample. The majority had been diagnosed with breast cancer. More than twice as many females than males cited a family history of cancer possibly reflecting males’ lower awareness of the disease. Again, breast cancer was most prevalent in blood relatives, followed by lung cancer. However, 13 respondents did not recall what type of cancer a family member was diagnosed with.

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Billboard Recall Results

Recalled Seeing Billboards by Gender

80

76

60

71

65

51

40

55

50

20

All Males All Females

0 Any BB Screening BB

Smoking BB

More females than males recalled seeing any cancer prevention billboard. Logically, more remembered seeing a Screen for Your Life! billboard as there are twice as many of these than Stop Smoking billboards. Half of all respondents had seen one of the three Stop Smoking, possibly proving they are in superior locations or have a more striking design.

Recalled Seeing Billboards by Education Group (% of total in group) 50

66%

73%

40 30

48% Any BB

68%

20

Screening BB

10

Smoking BB

0 Male Female Lower Ed Lower Ed

Male Higher Ed

Female Higher Ed

There were more lower education than higher education respondents. Overall, a large percentage of lower education males, lower education females, and higher education males recalled seeing a billboard. Less than half of higher education females remembered observing a billboard so this target audience may be best reach via other means.

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Billboard Recall by Age Group & Gender 20 18 16

19

18 16

15

14

15 13

14 12

10

11

10 Any BB

10 8

Screening BB

6

Smoking BB

4 2 0

Nearly all females ages 20‐29 and 40‐49 recalled seeing a billboard. Lowest recall percentage was amongst males ages 20‐29 and both males and females ages 50 and older. The latter group is concerning because they are the primary target audience for the Screen for Your Life! billboards.

Recall of Billboard Locations (Female n= 74, Male n=65) In my village Near my workplace Near my school Near my church While driving or riding Other place

All Females #,% 19, 26% 9, 12% 18, 24% 10, 14% 67, 91% 5, 7%

All Males #,% 18, 28% 12, 18% 10, 15% 5, 8% 54, 83% 6, 9%

Most females and males recall seeing a billboard while driving or riding. One quarter of billboards were observed in home villages or near schools so complementary outreach activities could be happening in these locations to strengthen message impact.

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Perceived Billboard Target Groups (Female n= 74, Male n=65) Females Males Children Youth/Students Seniors/Elders Leaders People like me People different from me

All Females #,% 64, 86% 58, 78% 51, 70% 57, 77% 56, 76% 53, 72% 60, 81% 48, 65%

All Males #,% 41, 63% 40, 62% 32, 49% 36, 55% 38, 58% 34, 52% 40, 61% 32, 49%

When asked who the cancer prevention billboards were for, most females felt they were being targeted and that the billboards were for “people like them”. Males also related to the billboards. Unlike the females, males felt the billboards were targeting males and females equally. Two thirds of females and half of males felt the billboards were not targeting them personally, but were for “people different from me.” Amongst the primary target audience, two thirds of males 40‐49 and females 50 and older related to the billboards. Nearly all of males 50 and older related to the billboards.

Gender/ Age Group Females 40‐49 Males 40‐49 Females 50+ Males 50+

BB are for People Like Me 84% 67% 67% 90%

One goal of social marketing messages is to motivate interpersonal discussion about health issues. Most survey respondents said they saw the billboards but they did not discuss them with others. This presents an opportunity for follow‐up initiatives to elevate the importance of cancer prevention and screening via informal and formal dialogue.

Discussed Billboards with Others (n saw any billboard) All Females(n=75) All Males(n=65) All <20 (n=30) All 20‐29 (n=28) All 30‐39 (n=30) All 40‐49 (n=32) All 50+ (n=21) All Lower Education (n=87) All Higher Education (n=47)

Yes #,% 36, 48% 20, 31% 10, 33% 8, 29% 12, 40% 15, 47% 11, 52% 42, 48% 13, 28%

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About half of all females, all respondents 50 years and older, and all with lower education levels talked to others about the billboards. Most of these respondents discussed the billboards with family and friends. Family and friends may prove to be influential in helping others adopt healthy behaviors and can also be targeted more specifically.

Discussed Billboards With Others 45 40 35 30 25 20 15 10 5 0

All Females All Males

Billboard Opinion Results The majority of survey participants had positive opinions about the cancer prevention billboards.

However, the billboards no longer seem to be attracting the attention of nearly one third of respondents after being up for over a year. Interestingly, people felt the billboards were easy to read, although “difficult to read” and “font too small” was a frequent area of improvement listed as well. Similarly, most males and females “think there should be more billboards” which was contrary to several written recommendations and anecdotal evidence against the use of any billboards. (See Survey Respondent Recommendations for Billboard Improvements.)

Statements I like the cancer billboards I have seen.

The cancer billboards look nice.

The cancer billboards attract my attention.

The cancer billboards are easy to read.

The cancer billboards give me useful information.

The cancer billboards make me think about my health.

I think there should be more cancer billboards.

Number Respondents

F=74 M=64 F= 72 M=65 F=74 M=65 F= 74 M=64 F= 73 M=64 F= 74 M=65 F= 74 M=65

Agreement (#,%) Females Males 57, 77% 51, 80% 54, 75% 47, 72% 50, 68% 43, 66% 62, 84% 53, 83% 59, 81% 47, 73% 58, 78% 46, 71% 60, 81% 47, 72%

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Billboard Behavior Change Results The best measure of target behavior uptake—cancer screening and smoking Quitline calling—would be data showing an increase in service utilization after the billboards were erected. Unfortunately, this information is not available for assessing the potential impact of the billboards, so self‐reporting was used.

Survey respondents were asked if they had ever smoked and if so did the Stop Smoking billboards motivate them to quit. This may be an inadequate question because people could have quit smoking long before the billboards were put up. Yet, about one fourth of male and female smokers claim the Stop Smoking billboards helped them do just that. Similarly, one fourth of males and one fifth of females ever screened for cancer claim they did so partly due to seeing a Screen for Your Life! billboard.

More than five times more females have been screened for cancer (mammogram, pap smear) than males. Interestingly, some men stated they have had a mammogram or pap smear and some women claim to have had a PSA test.

Behavior Change Motivation 44

44 41

50 40 30 20 10 0

12 10

8

9 2

All Males All Females

Ever Smoked

BB Ever BB Motivated Cancer Motivated Me to Quit Screened Me to Screen

Self‐reported Cancer Screening History 40 35 30 25 20 15 10 5 0

All Females All Males

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Billboard Design Evaluation Overall, the Screen for your Life! billboards scored low on the criteria for effective design while the Stop Smoking billboards reached a medium level of achievement.

1) Visibility

2) Color

3) Copy

4) Images

5) Layout

6) Message

7) Intrigue

Can the message be read easily? Are the fonts easy to read and large enough (from moving vehicle at 500‐1,000 feet in less than 5 seconds)? Are the words properly spaced?

Screen For Your Life! BBs Stop Smoking BBs High High Medium Medium Low Low Are contrasting colors used? Does the billboard stand out from the surroundings? Do the colors appeal to the TA? Screen For Your Life! BBs Stop Smoking BBs High High Medium Medium Low Low Are short and simple words used? Are the words memorable and culturally appropriate?

Screen For Your Life! BBs Stop Smoking BBs High High Medium Medium Low Low Are images attention getting? Does the TA relate to pictures? Do images reinforce the message?

Screen For Your Life! BBs Stop Smoking BBs High High Medium Medium Low Low Is there are balance between copy and images? Are contrasting colors balanced? Is the design simple and not cluttered?

Screen For Your Life! BBs Stop Smoking BBs High High Medium Medium Low Low Is a single, behavior‐oriented message conveyed? Is enough information given to adopt the behavior?

Screen For Your Life! BBs Stop Smoking BBs High High Medium Medium Low Low Does the billboard message and image grab the TA’s attention? Does the billboard prompt informal discussion of the target behavior?

Screen For Your Life! BBs Stop Smoking BBs High High Medium Medium Low Low

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Billboard Recommendations Survey Respondent Recommendations for Billboard Improvements Design Message Location Bright colors

Include local cases, statistics

Bigger size

New message yearly, catchy and memorable mottos Provide easy to read phone numbers, update numbers and contact information

Target to specific groups, ages, genders

State screening location clearly

Single message, motivate action and behavior change Provide more useful information (what diseases result from smoking)

More graphics and pictures: Polynesians, before and after smoking Make visible at night Fewer and simpler words, don’t waste space on sponsor advertisement Decorate Change designs often

Pictures of survivors and age groups most affected More community involvement in design, message Larger fonts

Dispel myths and describe symptoms Messages about risk factors and prevention: diet, exercise What is screening? Rephrase or explain why screening would help

Put in all villages, near schools, churches and workplaces Do not place in busy intersections where people can’t see them Put in Bingo Hall, malls, and where people walk

Other Need more billboards Need less billboards/none, they make the island look messy Use other forms of media: posters or signs that can be put on lawns, in businesses, churches, schools Protect them from vandalism and damage Don’t rely only on billboards, have events and outreach to back up message and get people’s attention Avoid addressing cancer as a “battle”, “fight” or that it can be “beat” so as to not stigmatize people who do not reach a cure as “failing” or “losing”

Evaluator Recommendations •

•

• • •

• • •

Include billboards as part of larger social marketing/outreach and service provision programming and do not rely on them solely to prompt behavior change. Or, replace billboards with smaller communications such as posters and signs in new locations of high traffic such as at bus stops or in workplaces. Fully develop a social marketing campaign: product, price, placement and promotion Develop billboard messages and designs in cooperation with the target audience(s) and always pre‐test before construction. Make sure messages encourage to realistic actions taking into account known barriers to behavior change.

Establish measureable goals for billboards. If the aim is to increase service utilization, ensure means to measure uptake of this behavior other than self‐reporting.

Billboards should have specific target audiences. Research the needs and preferences of specific audiences to craft the most appealing and motivating messages and designs.

Change current billboards as soon as possible as they have outlived their attention‐grabbing lifespans. Change billboards at least every six months with new messages and designs and updated contact information.

Provide phone numbers and locations of services in large fonts.

Billboards need relevant pictures to attract attention.

Do not place billboards in busy intersections or in scenic areas (parks, coastal drives). Instead use billboards to beautify public spaces/buildings.

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