Systematic reviews have confirmed that telephone-based interventions [4,5] are effective in increasing physical activity, improving nutrition and reducing weight. Within this context, in 2009 the state of New South Wales (NSW) launched the Get Healthy Information and Coaching Service® (GHS), a free Government-funded, population-based telephone service aimed at helping adults achieve and maintain lifestyle based changes ( http://www.gethealthynsw.com.au). The GHS targets the 52.2% of NSW adults who are overweight or obese; the 45.4% of NSW adults who do not undertake the recommended levels of physical activity; and the proportion of adults who do not eat the recommended levels of fruit and vegetables (49.6% and 91.3% respectively) [6]. Callers to the GHS can receive detailed information on physical activity, nutrition and healthy weight and/or enrol in the intensive and evidence-based 6-month coaching (counselling) program that provides ongoing support to assist them in setting and achieving their health related goals.

The GHS was launched and promoted using both state-level GHS specific mass-reach campaigns (February 2009 – June 2009) and indirectly through a national healthy weight mass-media campaign ( http://www.measureup.gov.au) that included the GHS phone number as a call to action. From July 2010 to June 2011, the GHS was promoted again using the GHS-specific campaign and using the GHS tag line nested within the next phase of the national healthy weight campaign ( http://www.swapit.gov.au). The GHS-specific campaign included television advertising (two 30-second advertisements and a 15-second advertisement) encouraging people to think about healthier lifestyles and directed people to call the GHS. Supportive marketing activities included radio, print, online advertising and pamphlets being distributed in household letterboxes and home delivered magazines specifically targeted to disadvantaged locations (based on geography and unhealthy lifestyle behaviours). The national healthy weight campaign encouraged the swapping of unhealthy behaviours for healthy ones and prompted viewers to call the GHS phone number.

The use of public education campaigns to catalyse people to think about behaviour change is well understood [7-9]. The effectiveness of mass-media campaigns in increasing health service utilisation is also recognized [10] and can be effective at promoting awareness and use of a new service or program [11-13]. Such a relationship is well established with mass-media being widely used to promote calls to telephone-based smoking cessation services such as Tobacco Quitlines [14-17]. However, the differential effects of mass-media on accessing Quitlines service levels (eg., quitting information via the mail vs. comprehensive, proactive multi-session behaviour modification programs [18]) are largely unknown. With respect to lifestyle-change programs, limited evidence exists on the relative impact of mass-media campaigns on driving people to different program components, although a previous study has reported that continuous advertising of the GHS state-wide prevention initiative achieves good reach and recall among socio-economically disadvantaged groups [19].

The increase in the levels of awareness (prompted and unprompted) associated with the GHS following the periods of mass-media advertising are in line with other public health related mass-media campaigns [29-31]. Interestingly there was higher unprompted awareness at time period 2 (31.8%) compared to time period 3 (5.9%) which could be accounted for by national healthy weight campaign airing prior to time period 2, whilst only aired in NSW for four weeks, it had a high level of media exposure. Those participants who lived in locations other than Sydney were more likely to report prompted awareness of the GHS advertising, whereas those from the lowest two quintiles of socio-economic advantage were less likely to report prompted awareness. This indicates the success of the mass-media advertising at promoting GHS to those outside of Sydney but not being as successful at reaching those in the lowest quintiles of socio-economic advantage; confirming the important role that mass-media advertising has in facilitating rural accessibility [19].

It is well reported that raising awareness may be a mediator of taking action and that those who are more aware are also more amenable to engaging in behaviour change or health-care seeking behaviours [32-36]. Respondents to the tracking survey reported having undertaken some behavioural lifestyle changes as a result of seeing the GHS mass-media advertising, including choosing to be more active and eating more healthy foods; the magnitude of change was small (2.5%), but still significant. This is good news for both promoting healthy lifestyle behaviours and GHS service utilisation. With the significant increases in awareness brought about by the implementation of the GHS advertising campaign, the results clearly show that GHS mass-media advertising has a substantial impact on the call volume to the GHS as well as influencing positive changes towards increasing physical activity and choosing to eat healthier foods, effects similar to the “tip of the iceberg” of quitting activity experienced as a greater proportion of calls to the Quitline [37].

The inclusion of GHS service utilisation data in this study recognises the importance of campaign related process evaluation, including collecting information pertaining to a call to action by any social marketing campaign [32]. Moreover, the mass-media campaign was particularly effective at reaching males, 18–49year olds and those in the lowest two quintiles of advantage. However, mass-media was also cited as the main referral source for those who opted for information-only package, whereas those who registered in the coaching program were more likely to have identified another source of referral such as family or friends, workplaces, general practitioner and health professional referrals. This is similar to the experience of telephone-based smoking cessation Quitlines where greater recruitment to counselling occurs when the advertising investment was lower [37] and other referral mechanisms are relied upon.

The findings of this study also provide important evidence in relation to the effectiveness of specific components of the mass-media campaign. The information from service usage data lends support to the general effectiveness of the television advertising across all socio-demographic segments at recruiting GHS participants in general. Second to television advertising, press advertising was also particularly effective at recruiting those aged 50+years, those in the 4th and 5th quintile and those who identified as being from Aboriginal communities and those who speak a language other than English at home. This provides valuable support to the need to ensure the integration of campaign messages aimed at vulnerable communities using culturally specific mechanisms. In early 2010 GHS press advertisements were adapted to be more appropriate to Aboriginal communities and culturally and linguistically diverse communities and placed in Aboriginal and other community specific publications. The results from service usage data support the effectiveness of these initiatives at promoting participant engagement from these communities. The distribution of GHS information in specifically targeted households was also particularly effective at recruiting participants over the age of 50years, those who were not employed, in the lowest two quintiles of advantage and those who lived outside of major cities, reflecting the targeted placement of this promotion.

The question of which types of mass-media are most effective at recruiting coaching participants is also of importance; as it is the evidence-based coaching program that is more likely to change the long term chronic disease risk factor profile of adults, compared to those registered as information-only participants. In this regard, when compared to other types of mass-media referral sources, mail out was most effective at recruiting individuals to the coaching program (in the presence of mass-media exposure). This study also notes that it is sources other than mass-media that are most effective at recruiting coaching participants. That is, recommendations from family and friends, and even the employer or workplace, as well as direct referrals by general practitioners and other health professionals are critical in “introducing” a potential participant to the GHS. These referral mechanisms, like the information provided in the letter box, provide an opportunity to explain the GHS in further detail and result in a greater likelihood of a participant registering for the coaching program.

The current findings provide opportunities for improving the ways in which mass-media and GHS itself can work to increase GHS coaching participation rates. In particular, the authors draw on the experience of Quitline promotion as a tobacco cessation support service with varying service levels, which are undertaken within a comprehensive approach to tobacco control mass-media that include both “push” and “pull” style campaigns. The “push” style campaigns tend to promote the health consequences of smoking and are supported by “pull” campaigns that offer advice/counselling or suggest a call to action [37,38]. Within this context, a study has shown that the “pull” style advertising is successful at recruiting participants to the ongoing support offered by the Quitline, rather than just opting for the information component [37]. The GHS as a support service is primarily being promoted in isolation of any public health education about the health consequences of physical inactivity, unhealthy eating and overweight/obesity. Thus, recruitment of coaching participants through mass-media may be more successful when positioned within a wider campaign. The promotion of the GHS within the national healthy weight campaign for four weeks during the study period did not allow for adequate exploration of this hypothesis. Further, the success of the letterbox and magazine pamphlet insert was as effective as other secondary referral sources at recruiting coaching participants. This, alongside the broader mass-media campaign advertising is a low cost promotion that can be targeted to particular populations and warrants repeat use. Specifically-developed print advertising was successful at recruiting Aboriginal and culturally and linguistically diverse communities to GHS and if further refined to include more detail about the availability of coaching support may be successful at increasing the number of registrants to coaching program.

The results of this study also have practical implications for the design of the GHS and the opportunity to facilitate greater recruitment into coaching among those who contact GHS. The current introductory script to all callers promotes the information kit as the first option, followed by the health coaching program. The coaching program could be promoted as the default service option and for those that are reluctant to join, the information kit could be provided with the addition of a follow up phone call persuading coaching program involvement. Currently 5% of information participants re-contact the GHS and opt to join the coaching program, opportunities to maximise this conversion rate would be beneficial.