Health Communication Campaign Critique: Hear Her.

The US has the highest maternal mortality of any developed country, and upwards of 80% of pregnancy-related deaths are preventable. The Centers for Disease Control and Prevention (CDC) “Hear Her” Campaign is a nationwide communication campaign aiming to prevent these tragedies (CDC, 2020). The campaign outlines four goals: increase awareness of the warning signs of life-threatening pregnancy complications, empower pregnant and postpartum women to raise concerns about their health, encourage people in women’s support systems to support, and provide tools for productive conversations with doctors (CDC, 2024). As Wanda Barfield, MD, MPH, director of the CDC Division of Reproductive Health, succinctly stated, “Women know their bodies and can often tell when something is not right. We hope Hear Her will help people recognize maternal warning signs and quickly get the care women need” (CDC, 2020). I chose this campaign because, as a future OB/GYN, I am invested in ameliorating the maternal mortality crisis, and critiquing Hear Her will further prepare me to face one of the most pressing healthcare challenges today.

The Hear Her campaign has a wide breadth of audiences, as the CDC believes everyone has a role to play in preventing maternal deaths. Audiences include pregnant and postpartum women, people who support them (such as their partners, family, and friends), and healthcare professionals who treat them (CDC, 2024). Additionally, Black and American Indian/Alaskan Native (AI/AN) pregnant people are additional targeted audiences because women of these groups are two to three times more likely to die while pregnant compared to their white counterparts (Behm et al., 2024). The Hear Her campaign launched in August 2020 and is active to the present day (Kuehn, 2022). Before developing Hear Her, the CDC analyzed existing education programs, including the “Every Woman. Every Time.” campaign, and designed Hear Her to complement these programs (Behm et al., 2024). Hear Her was also created in collaboration with intended audience members (Behm et al., 2024).

Hear Her employs a variety of channels to reach its broad audience, including a website, social media, public service announcements, and news media (Behm et al., 2024). The campaign materials center around audience-specific webpages with information, testimonial videos, downloadable resources, news articles, and TV PSAs (Behm et al., 2024). The website homepage contains a brief overview of the maternal mortality crisis and a description of the campaign goals. There is an option to view information designed “For Everyone” or specific to “Healthcare Providers,” which leads to resources relevant to each audience. Most of the materials are available in Spanish.

The content for healthcare providers is directed towards obstetricians. These materials include videos of physicians describing how to support pregnant women and the need for everyone to be mindful of their unconscious biases. The site also provides handouts, posters, graphics, and clinical resources to integrate Hear Her into practice. Finally, there is a page for providers working with AIAN women, encouraging them to provide culturally appropriate care. The “For Everyone” section of the site centers around “15 Urgent Maternal Warning Signs,” depicted in an infographic with signs and symptoms indicating that a pregnant woman should seek medical attention. Viewers can assess their knowledge of this topic with an interactive quiz. There is another subsection for pregnant and postpartum women with tips for sharing their concerns with their healthcare providers, including conversation starters and questions to ask. Another section for support people details a list of how loved ones can help by knowing the warning signs and encouraging them to get help. Finally, a page is devoted to resources for AI/AN pregnant women.

Theory Justification- Social Cognitive Theory

Social Cognitive Theory (SCT) posits that there is dynamic interaction, known as reciprocal determinism, between personal and environmental factors that determine behavior (NCI, 2012). Personal factors include prior history, knowledge, attitudes, self-efficacy, and expectations. Environmental factors include feedback from others and observational learning (McKensie et al., 2016). Self-efficacy, an essential component of this model, is a person’s confidence in their ability to perform an action by overcoming barriers (NCI, 2012). Feedback from others serves as reinforcement that increases or decreases the likelihood of repeating a behavior, while observational learning, also known as modeling, occurs when someone learns to adopt a behavior by watching others (NCI, 2012).

The SCT concept of modeling, or observational learning, is integral to the Hear Her Campaign. Social modeling is employed through patient testimonials, actor portrayals, and the campaign spokesperson (Behm et al., 2022). For instance, Hear Her features videos of five women describing their experiences with pregnancy-related conditions and emphasize the importance of seeking care. In other videos, actors model talking to their healthcare providers about worrisome pregnancy-related symptoms. Finally, the campaign’s celebrity spokesperson, Olympic athlete Allyson Felix, who survived preeclampsia, now serves as an advocate for maternal health, especially Black maternal health (Behm et al., 2022). These videos of women affected by maternal health conditions and modeling the desired behavior change of talking to a healthcare provider about worrisome symptoms may motivate the audience towards behavior change. Pregnant women may identify with these spokespeople and learn from them how to build their self-efficacy in bringing concerns to their doctors. Hear Her also offers specific tips, including a guide for initiating a conversation about worrisome symptoms with a healthcare provider. By providing this and similar tools, the campaign empowers pregnant women with self-advocacy skills, increasing their self-efficacy and the likelihood that they will talk to their doctor.

Theory Justification- Health Belief Model

The Health Belief Model (HBM) is an individual-level theory containing six constructs influencing the likelihood of someone adopting a health behavior (NCI, 2012). At the individual level, perceived susceptibility, one’s beliefs about the chances of getting a disease, and perceived severity, one’s beliefs about the seriousness of a disease, comprise an individual’s threat perception (McKensie et al., 2016). Demographic, social, psychological, and structural factors also affect threat perception (McKensie et al., 2016). When deciding whether to act, the HBM posits that an individual weighs the perceived benefits of a behavior against the perceived barriers of performing that behavior (NCI, 2012). Finally, cues to action that prepare or remind a person to perform a behavior, and self-efficacy, one’s confidence in their ability to perform an action, influence the likelihood of performing an action.

The Hear Her campaign employs several strategies that align with the HBM. First, the campaign helps pregnant women develop an accurate perception of their susceptibility to pregnancy-related complications through the testimonial videos in which regular women discuss their experiences with pregnancy-related complications. Viewers of these videos may identify with the diverse women they see in these videos and reflect on their susceptibility to the complications. Thus, the Hear Her Campaign increases women’s perception of the threat of pregnancy-related complications. Additionally, through promoting strategies for initiating a conversation with a healthcare professional, the Hear Her campaign also employs the HBM concepts of perceived barriers and self-efficacy. A woman’s lack of self-efficacy in advocating for herself in the doctor’s office may be a barrier to her bringing up her concerns, but the campaign seeks to help women overcome this by providing sample questions and actionable steps to have a more productive conversation with their doctor. Finally, the creators of the Hear Her campaign recognize that cues to action are essential to encouraging women to bring their concerns to their doctors. Thus, the campaign is also promoted to loved ones of pregnant people, who can encourage pregnant women to seek medical help.

Combining the Health Belief Model and Social Cognitive Theory

The HBM and SCT, while operating at the individual and interpersonal levels, respectively, have similar characteristics; the two theories share a few variables. Both emphasize the importance of self-efficacy in determining if a behavior will be performed (NCI, 2012). This is vital because even if someone thinks a behavior will be beneficial, they will likely forgo that behavior if they do not have confidence in their ability to perform it. Additionally, self-efficacy is the target of many communication campaigns and has been demonstrated to be a powerful determinant of behavior in studies (NCI, 2012). The concepts of history, knowledge, and attitudes of SCT could be considered modifying factors in the HBM framework as they influence perceived threat (McKensie et al., 2016). Finally, the HBM’s concept of cues to action, the factors that activate an individual’s readiness for change, such as reminders, are examples of environmental factors that influence behavior in SCT (NCI, 2012). As a whole, the individual factors of the HBM can be situated within the personal factors domain of the SCT, combining these theories to create a more comprehensive explanation of behavior.

Evaluation and Recommendations

Overall, Hear Her is a strong campaign as it effectively employs a variety of health communication strategies grounded in theory. Many HBM and SCT constructs, such as perceived susceptibility, perceived severity, modeling, and self-efficacy, are used to strengthen the Hear Her campaign materials. The use of digital media as the primary channel is a strength of this campaign because this is an efficient way of educating large numbers of people and was a feasible means of reaching women at home during the COVID pandemic (Nielsen, 2020). The campaign materials are also very engaging; the pages include embedded videos, graphics, and photos throughout. Using these elements rather than plain text helps to engage the audience. The website is also interactive, with a quiz on pregnancy warning signs and activities encouraging women to think of questions they might ask their doctor. The website is also very detailed, with hundreds of resources. In some ways, this variety of materials is a strength because many forms are suited to different learning styles. However, at the same time, the website can be a bit overwhelming to navigate with its many pages.

The use of Allyson Felix as the celebrity spokesperson for the Hear Her campaign is another strength. Seeing a celebrity with a vested interest in the issue of maternal mortality is an effective way of increasing publicity for a campaign on social media. Research demonstrates that celebrity endorsements create greater public interest in a topic (Huffman & Tan, 2015). The timing of this campaign and Felix’s accomplishments in the Tokyo Olympics in 2021 contributed to the success of Hear Her on Facebook and Twitter (Behm et al., 2022).

Based on the evaluation of the first year of the Hear Her campaign, the program was successful in its reach; Hear Her garnered >179 million impressions and >407,000 engagements with posts on Facebook and Twitter, and the English website received 584,928 page views, with 400,000 visitors viewing content beyond the homepage (Behm et al., 2022). While this data demonstrates the success of the campaigns’ reach, it also reveals that engagement was considerably lower. There was a disconnect between gaining viewers' attention and keeping it long enough to promote active engagement with the Hear Her content. The CDC could conduct focus groups to evaluate why most viewers did not navigate past the home page of the Hear Her website, and then make improvements to keep the audience engaged for longer.

Another recommendation for improving this campaign would be to decrease the reading level of the materials. The average Flesch Kincaid reading level of the Hear Her website is 8th to 9th grade, while the average reading level in the US is 7^th grade. Furthermore, organizations advise creating health education materials at no greater than a 6th-grade reading level (US Department of Education, 2023). Adjusting the reading level of the Hear Her website would make it accessible to a larger percentage of the population. In general, some of the text could be trimmed on the website and replaced with even more graphics and photos depicting the information in a way that is accessible to even those without adequate literacy.

The Hear Her campaign could also add actionable steps for women if they find a doctor dismissing them. While the campaign outlines techniques for patients to initiate conversations with their doctors, it does not mention what women can do if their doctor dismisses them during their conversation. We know that patients, especially women and racial/ethnic minorities, are commonly dismissed by doctors, but there are steps they can take to advocate for the care they need (Chen et al., 2008). The Hear Her Campaign could incorporate instruction on using assertive statements to empower women with the self-efficacy to combat medical dismissal (AHRQ, 2023).

The Hear Her Campaign should also add a page of resources specifically targeted for Black women, similar to the page it has for resources for American Indian and Alaska Native (AI/AN) Women who are pregnant. The campaign highlights that Black women are disproportionately affected by maternal mortality, yet it neglects to customize its content to Black women. Finally, the dissemination of the provider-focused materials could be improved by partnering with the American College of Obstetricians and Gynecologists to allow doctors to get Continuing Medical Education (CME) credit for reviewing the Hear Her materials.

Conclusion

In sum, the Hear Her campaign attempts to raise awareness of maternal mortality and empower women with the knowledge and skills they need to advocate for their health while pregnant. This ongoing program is grounded in theory, but some elements of its execution could be improved for better reach and engagement. The materials can be modified to be more accessible to a low-literacy audience, and additional modifications could help increase meaningful engagement with the website.

References

Agency for Healthcare Research and Quality. (2023, May). Tool: Advocacy and assertion. AHRQ. https://www.ahrq.gov/teamstepps-program/curriculum/mutual/tools/advocacy.html

Behm, B., Tevendale, H., Carrigan, S., Stone, C., Morris, K., & Rosenthal, J. (2022). A national communication effort addressing maternal mortality in the United States: Implementation of the Hear Her campaign. Journal of Women’s Health, 31(12), 1677–1685. https://doi.org/10.1089/jwh.2022.0428

CDC. (2020, August 10). Hear Her: CDC Campaign Highlights Warning Signs of Pregnancy-Related Deaths. Centers for Disease Control and Prevention. https://archive.cdc.gov/#/details?url=https://www.cdc.gov/media/releases/2020/p0810-warning-signs-pregnancy-deaths.html

CDC. (2024, May 15). Hear Her Campaign: An Overview. Centers for Disease Control and Prevention. https://www.cdc.gov/hearher/about/index.html

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Kuehn, B. M. (2022). A new resource in CDC’s campaign to reduce maternal deaths. JAMA: The Journal of the American Medical Association, 327(12), 1119. https://doi.org/10.1001/jama.2022.2804

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U.S. Department of Education, National Center for Education Statistics. (2024). Highlights of the 2023 U.S. PIAAC Results Web Report. Washington, DC. https://nces.ed.gov/surveys/piaac/2023/national_results.asp.