Summary of findings
The results presented in this paper illustrate that, in addition to improving attitudes towards appropriate ambulance use, as reported previously [5], the Save 000 for Emergencies campaign also influenced health-seeking behaviours among the Victorian community. Specifically, there was an increase in intentions to call NURSE-ON-CALL and ‘Visit your local pharmacist’ for non-emergency healthcare needs after Meet the Team commenced. The trend in daily Triple Zero calls also changed from increasing before Will’s Story commenced to decreasing after it started. We attribute a significant part of this decrease to the launch of Meet the Team as level effects were identified 3 and 9 months after it went to market. There was an increase in calls to NURSE-ON-CALL, which coincided with a decrease in calls to Triple Zero during the 3 months after Meet the Team commenced, compared to the same time in previous years. However, this short-term change did not translate into a decrease in behavioural trends for any of the services included in the current study. Rather than shifting from Triple Zero to another specific healthcare service, it is likely that those who would have previously called Triple Zero in a non-emergency sought advice or treatment from a number of different healthcare services, essentially dispersing among the Victorian healthcare system.
This study is the most comprehensive known evaluation of a community-wide mass-media behaviour change campaign in this sector. Similar campaign approaches have been adopted in Australia and other countries, but evaluation has been limited. For example, following a campaign about appropriate ambulance use in Japan, the number of ambulance transports was the only measure [9]. Similarly, a previous evaluation of an Australian Triple Zero community awareness campaign assessed ambulance usage, clinical urgency and illness severity of patients attending an emergency department at a hospital in Brisbane [10]. However, neither the Japanese nor the Australian study measured behavioural intentions, attitudes, and campaign awareness.
If Triple Zero calls had been the only measure used in the current evaluation, this may have misled evaluators into thinking the campaign had not been effective in the short-term. However, our results demonstrate that attitude and awareness were precursors of behaviour. Additionally, comprehensive monitoring and evaluation enabled us to identify the unintended consequences of this behaviour change strategy. For example, all emergency ambulance services experience a small number of cases where patients should have called for an ambulance but did not. It was therefore critical to identify if the campaign reduced the number of time-critical, life-threatening emergency calls. Our results indicate that this campaign did not influence the number of calls in the highest priority emergency category.
Limitations of this project include a lack of a control group; while the study design was appropriate for evaluating the effectiveness of a mass media campaign, we cannot be certain that the changes observed in the study were the direct result of the campaign (attribution). For example, the severe influenza season in Victoria in 2017 may explain the increase in calls to Triple Zero and NURSE-ON-CALL during this period. There were 12,348 laboratory-confirmed cases of influenza in Victoria by the start of September 2017 [11] – more than double the comparable period in 2016 (6666) [12]. This likely led to an increase in both emergency and non-emergency health-seeking behaviours like influenza vaccinations [13].
A further limitation is the limited consistency and availability of some administrative data, which meant that certain analyses could not be performed uniformly across data sets. For example, NURSE-ON-CALL did not have enough benchmark data available for seasonal adjustments. Similarly, due to significant changes to the Triple Zero dispatch model in 2016 (where a large number of calls were redirected to non-emergency services), it was not possible to consistently identify non-emergency calls to Triple Zero throughout the benchmark and campaign periods. Finally, the lack of standard data collection for pharmacy presentations in Victoria meant that administrative data for pharmacies, which were promoted in Meet the Team, could not be included in this study.
The final limitation relates to the behavioural intentions survey measure. Respondents were asked about their likelihood of engaging in a series of behaviours specifically in a non-emergency situation, which could be interpreted as a leading question where calling the Triple Zero emergency service is assumed to be an erroneous response. The question also did not capture behavioural intentions, which are the result of genuine misconceptions about what constitutes an emergency healthcare need. While we recognise these limitations, we also note that designing a measure of the behavioural intentions in a non-emergency situation is quite complex. As found in the formative research phase of this research, definitions of ‘emergency’ and ‘non-emergency’ are not definitive in research literature or practice, and even members of the medical field often have contrasting perspectives on what constitutes a medical emergency [5]. Therefore, specific symptoms were avoided throughout the entire campaign and evaluation so that the focus was on individual’s responses to situations that they perceived to be a non-emergency (e.g. the primary attitude measures from the initial evaluation were ‘Ambulances are for All’ and ‘Ambulances are for Emergencies’).
Theoretical, practical and policy implications
The findings of this project are consistent with the Theory of Planned Behaviour, which posits that behavioural intentions are influenced by attitudes (toward the behaviour), subjective norms (perceived social pressure to engage in the behaviour) and perceived behavioural control (apparent ease or difficulty of engaging in the behaviour) [6]. Mass media campaigns can ostensibly create a sense of social pressure because the messages are delivered on a large-scale and in a public manner so audiences not only receive the message but they know that the message is being received by many others [14]. The Save 000 for Emergencies campaign further harnessed the Theory of Planned Behaviour by first addressing attitudes towards the behaviour via Will’s Story. This promoted Victorian ambulance paramedics as a highly skilled workforce for saving lives, which should be reserved for life-threatening emergencies. The campaign then maintained this attitudinal message while adding a perceived behavioural control message via Meet the Team, which introduced alternative and easily accessible services for non-emergency conditions (GPs, pharmacists and NURSE-ON-CALL).
The findings from this research demonstrate the merits of sensitising the market (Will’s Story) before moving to a specific call to action (Meet the Team). They are also consistent with results of other major behaviour change campaigns (e.g. smoking cessation, workplace safety and safe driving [15,16,17]), which indicate that continued exposure to carefully constructed mass media campaigns can play an integral role in population-level behaviour change. To sustain this change, like these previous campaigns, ongoing exposure to the campaign message should be considered.
We cannot overstate the importance of multi-sector engagement in the planning and execution of this project – that is, bringing together AV, DHHS, relevant telecommunications authorities, media strategy and communications organisations, and behavioural researchers. For example, a key lesson from the formative research was that any attempt to define an emergency should be avoided for two reasons. First, there are hundreds of emergency response codes and conditions that could not be comprehensively communicated in a public campaign. Second, attempts to classify emergencies into simplified categories, for example, red (emergency), orange (urgent and potential emergency) and green (non-emergency) are fraught and potentially dangerous because symptoms can be indicative of a range of conditions that could be classified across different categories. For example, a headache could be mild dehydration (orange) or it could be symptomatic of a stroke (red); back pain could be a pulled muscle (green) or a sign of an abdominal aortic aneurysm (red). Such ambiguity was considered too risky in the context of this Triple Zero campaign.
Collectively, the formative research, multiple phases of campaign development and ongoing evaluation required considerable investment. However, from the perspective of the project partners (particularly AV and DHHS) such an investment was considered worthwhile to manage service demand. This underscores the challenge of shifting behaviour at a community level and reinforces the need to secure a shared understanding between collaborating and funding partners of the complexity of the task and the time taken to yield results. Specifically, in deciding to undertake a state-wide public campaign, it was important to emphasise to policy-makers within DHHS that such an approach would not likely change Triple Zero calls in the short term, as attitudes needed to shift in advance of behaviour.
It is also important to consider the unintended consequences of not using behavioural theory to guide public health campaigns. For example, we know from both behavioural literature and the experiences of other state-based campaigns in Australia, that advertisements that tell viewers what not to do can unintentionally promote the highlighted behaviour through social norming. That is, once people become aware that Triple Zero has been used by others for trivial health matters, calls to Triple Zero can actually increase. Such messaging was specifically avoided for this reason, instead focusing on what to do – save ambulances for emergencies.
From a policy and practice perspective, the results of the evaluations illustrate the utility of taking an evidence-based approach to designing a state-wide campaign, along with implementing a robust monitoring and evaluation framework. In an era of rapid policy response demands, driven by a desire for instant results, this research demonstrates how a holistic model of campaign development can effectively contribute to changing such an ingrained community behaviour as calling Triple Zero for an ambulance. Based on the outcomes of this project, consideration will be given to applying this model to future applicable behaviour change campaigns within DHHS.
Future directions
For continuity and in order to build cumulative awareness, any future campaign executions should continue to use existing campaign assets, such as the four members of the healthcare team and the campaign tagline, ‘Save lives. Save 000 for Emergencies’. The next phase of the campaign could also provide more detail on specific services provided by alternative health services; for example, the ability of pharmacists in Victoria to treat, advise and refer for certain conditions. Ongoing monitoring and evaluation of any future iterations of the campaign will be critical to further building understanding of the ongoing exposure effect of variations in campaign intensity on community-level behaviour. Ongoing evaluations could also examine whether cessation of the campaign is associated with the volume of Triple Zero calls returning to previous trends – noting that other public health campaigns, such as road safety, have been in place in some form for decades [18].