Does "raising awareness" have a meaningful impact?

Question

People often talk about the indirect value of "raising awareness" or "consciousness raising".

For issues that most people already know about (like cancer), is there value to raising awareness?

Answer 1

The paper BAKER, S. B., SWISHER, J. D., NADENICHEK, P. E. and POPOWICZ, C. L. (1984), Measured Effects of Primary Prevention Strategies conducted a meta-analysis on 40 primary prevention studies in the context of education.

For evaluating the effectiveness they defined the Effect Size to be:

where ES is the Effective Size - means the benchmark how well prevention helped, X_t the "posttest mean of the treatment condition", X_c the "posttest mean of control condition" and SD_c the posttest standard deviation of the control condition.

Their benchmark ist defined after Smith, Mary Lee, Gene V. Glass, and Thomas I. Miller. The benefits of psychotherapy. Baltimore: Johns Hopkins University Press, 1980:

Based on the interpretation format in Smith, Glass and Miller (1980), the combined primary prevention ES (without outlayer) of .55 means that a hypothetical person not having received a primary prevention treatment but being at the mean of the control group on dependant measures will improve on those dependant measures to a position .55 standard deviations above the mean after experiencing primary prevention treatmeant. In terms of percentile ranks, this represents an increase from the 50th to approximately the 73rd percentile. In other words, persons not previously exposed to primary prevention strategies similar to those listed in Table 1 should improve 23 percentile points after having received such a treatment. Different figures are appropriate when making estimates for the the specific subcategories of primary prevention strategies listed in Table 2 (e.g. moral education, values clarification).

After explaining their benchmark, they define the performance indices:

Cohen (1996) suggested that the criteria for judging effect size magnitude should be: .20 to .49 = small, .50 to .79 = medium, and above .80 = large. Therefor, based on Cohen's (1969) criteria, the overall primary prevention strategy effect size (.91; with outlayer) and the effect size for career maturity enhancement (1.33), communication skills training (3.90 and .93; with and without the outlayer, repsectively), deliberate psychological education programs (1.43), and deliberate psychological education and moral education programs combined (.83) may be classified as large. Furthermore, the overall effective siize for primary prevention programs (:55; without outlayer) and those for values clarification programs (.69) and all values clarification programs combined (.51) may be classified as medium. Finally, the effective size for cognitive coping skills training programs (.26), moral education programs (.42), substance abuse preventions programs (.34) and programs blending values clarification with other strategies (.37) are viewd as low according to Cohen's (1969) standards. Readers should note that the number of studies in several categories is relatively small, which suggests caution in intepreting the comparison of strategies.

(Permanent link, in case imgur is down)

Disclaimer: I ain't no social science scholar, so take my interpretation with care.

Summary:

• prevention helps on a general scale in the context of this meta-study.
• it fails in moral education
• it fails in "coping skills training founded on cognitive-behaviour modification principles"
• it's excellent in "communication skills programs"
• it fails in "moral education programs"
• it also fails in "substance abuse programs"

You have to keep in mind that this meta-study is from 1984. Anecdotal evidence and personal expericen tell me that the "substance abuse programs" improved quite a lot in the last 30 years, and I bet that there are improvements in other areas as well.

P.S.: Needs copyediting, I had to manually type in all the quotes. Also, since I ain't no expert in that field it'd be helpful if someone familiar with the topic could review this posting.

Answer 2

Yes it can have an impact; but that isn't necessarily a good thing

There are plenty of issues in the world that people ought to know more about and raising awareness of them should not be a problem; unfortunately there are many things that feel as though people ought to be more aware of, but that awareness just causes harm.

I'm going to point out some of the second kind.

The sorts of issues that make us feel good are issues where we think awareness will save lives. There are several good examples in the field of cancer screening. The argument that raising awareness is good comes because the conventional belief is that screening can only save lives by catching cancer early and achieves this miracle at no cost to the patient. So we should encourage people's awareness of screening programmes and other ways to catch early signs of the disease.

There are several problems here. The first is that no screening programme is costless. Some pretty certainly cause more harm than good (see Does screening for prostate cancer save lives?); others are still the subject of much debate (see Is routine screening for breast cancer for asymptomatic women worthwhile?). When the trio of benefit to harm is not clear then improving awareness of the programme is itself of dubious benefit.

The second problem comes because of the way awareness is raised. If you (mistakenly) believe that medical screening is all upside, then your goal in raising awareness is to propagandise the uptake of screening. What you are unlikely to do is to give the patient a balanced view of the issues so they can make their mind up. This isn't just me being cynical but has been demonstrated. See the comments on patient advice on breast screening in the BMJ in 2008 and in the BMJ in 2006. As the 2008 article reports:

No mention is made of the major harm of screening—that is, unnecessary treatment of harmless lesions that would not have been identified without screening. This harm is well known and acknowledged, even among screening enthusiasts. It is in violation of guidelines and laws for informed consent not to mention this common harm, especially when screening is aimed at healthy people.

We do know, in some cases, that patients who are given carefully structured and unbiased advice are far less likley to choose screening and medical intervention (see example here).

The third problem is related to the second. It is about what sort of organisations are attempting to increase our awareness of things. This is fairly obvious, but worth stating explicitly: they are often, effectively, lobbyists for a cause. This is one of the causes of problem two: lobbyists don't obey an oath of impartiality; they want your attention on their campaign, not someone else's. Medical charities, for all the good they can do, are not exempt from this. One question that should be asked when they are trying to raise awareness is: are they just redistributing our awareness away from their competitors? I have no particular objection to charities raising money for their cause. But they may end up sending unbalanced views of the benefits of screening or, perhaps worse, unbalanced views about the health issues faced by the average person and the steps they should take to minimise that risk. AS Margaret McCartney, a british GP points out in her recent book, The Patient Paradox (the quote is p275 in my paperback edition):

All healthcare charities wish for more attention than they currently get...We have become so inured to the 'need' for awareness that most people never bother questioning whether it is a good idea to receive information about our health this way. Most people who hear the call to awareness will never have the disease or disorder in question, and the evidence-based messages about what can improve your quality and quantity of life ... are drowned out in the clamour.

Another problem with charity lobbying is that is tends to distort health spending towards sentimental or sensational headlines and away from boring, but more effective, ways of allocating resources on healthcare. Margaret McCartney has a whole chapter "The problem with PR" on this.

So raising awareness to raise money for the charity looks OK; raising awareness to encourage screening may well cause harm; and raising awareness to grab a bigger share of other people's spending for your cause is at best distorting and a worst very harmful if the money flows to the sensational headline not the real need.

The bottom line is that, even in the area of medical charities where "raising awareness" feels like it ought to be all good, there are plenty of ways for it to actually do harm