Katz and Lazarsfeld Revisited:

Using Intermedia Theory to Enhance Health Campaigns

Randy Y. Hirokawa1 and John B. Lowe2

The decade following World War II saw the rapid rise of research on the effects

of mass communication. Most of this research focused on the persuasive influence of

mediated messages – first in print form, and later through radio and television broadcasts.

Many, in fact, feared the assumed power of the media to shape and control the ideas,

attitudes, and behaviors of societal members (Berelson, 1950).

By the mid-1950s, however, mass communication scholars were becoming aware

that the assumed ability of the media to control people’s attitudes, beliefs, and behaviors

was not being supported by media effect research. In his oft-cited book summarizing the

findings of mass communication studies to date, Klapper (1960) concluded that “mass

communication ordinarily does not serve as a necessary and sufficient cause of audience

effects, but rather functions among and through a nexus of mediating factors and

influences . . . [and] when mass communication does affect people, these effects tend to

be minor and short-lived” (p. 8).

Like their mass communication predecessors, health campaign scholars initially

assumed that the media were powerful social tools for shaping and altering the health-

related attitudes, beliefs, and behaviors of people. However, that assumption quickly

came into question as many mediated health campaigns produced either minimal or no

overall effects on various health outcomes (COMMIT, 1995; Farquhar et al., 1990;

Hornik, 2002; Lowery & DeFleur, 1995; Luepker et al.,1994; Rogers, 1998; Wallack,

1990; Winkleby et al., 1996). In short, health campaign scholars, like their mass
 2

communication counterparts, discovered that “the mass media are not the magic bullet of

health promotion and disease prevention” (Wallack, 1990, p. 370).

At the same time, health education researchers recognized that the mass media

play an important role as part of a comprehensive approach to improving health

(Wallack, 1990). As Hornik (2002) puts it:

[T]here is substantial evidence coming from observational studies showing

that there is major change in health behavior, and also that this behavior

change is credibly associated with public health communication, including

both deliberate communication programs and normal media coverage of

health issues (p. 1).

In short, contemporary health education scholars have concluded that the mass media can

influence health outcomes, but the nature of that role is poorly understood and certainly

far more complex than had once been suspected (Lowery & DeFleur, 1995; Wallack,

1990).

The complex nature of the influence of the media on health outcomes necessitates

a major change in thinking about the way researchers go about studying the effects of

mediated health campaigns on health outcomes. For one, research designs must focus

less attention on demonstrating direct effects of mediated health messages on health

outcomes, and more attention on tracing more subtle and indirect patterns of influence

(Lowery & DeFleur, 1995). More importantly, though, health education scholars need to

rethink the theoretical underpinnings of their health campaign approaches. It is this latter

concern that is the focus of attention of this paper. Specifically, this paper presents, or

more accurately, reintroduces, a theoretical perspective loosely referred to as intermedia

theory, and explicates how it can used to enhance the efficacy of mediated health

campaigns.

Katz and Lazarsfeld Revisited

In a landmark book published in 1955, Elihu Katz and Paul F. Lazarsfeld

introduced a theoretical framework of concepts and ideas for understanding media effects

that departed radically from earlier thinking about the media (Lowery & DeFleur, 1995).

At the center of their framework was the notion of a “two-step flow of communication”

(Katz & Lazarsfeld, 1955, p. 32). Unlike earlier notions that assumed a direct flow of

information (and influence) from the media to mass audiences, the “two-step flow”

concept posited a movement of information and ideas from the media to “opinion

leaders,” and from them to other people in their social network (“primary group”). In

short, Katz and Lazarsfeld theorized that mass media messages affect people’s

knowledge, attitudes, and behaviors through the stimulation of interpersonal

communication about the messages’ content among friends and colleagues who comprise

their social networks (i.e., media messages Æ interpersonal communication Æ

knowledge/attitudes /behaviors).

Over the years, Katz and Lazarsfeld “two-step communication” theory acquired

the label of “intermedia process” (Gumpert & Cathcart, 1986), and appeared in the work

of a variety of researchers (e.g., Boekeloo et al., 1993; Kalichman & Hunter, 1992;

Meyer et al., 1980; Miller, 1987; Rogers et al., 1997; Singhal et al., 1996; Valente, Pope,

& Merritt, 1996; Wanta & Elliott, 1995). For the most part, however, the fundamental

ideas of Katz and Lazarsfeld’s “two-step flow” (or “intermedia”) theory has remained

largely unchanged since 1955.

Intermedia Theory

Intermedia theory begins with the proposition that the individual opinions, beliefs,

attitudes, values, and behaviors that media campaigns seek to modify are anchored in

“primary groups” (Katz & Lazarsfeld, 1955, p. 44). A “primary group” is defined by

Katz and Lazarsfeld as a system of interpersonal relations among friends, co-workers,

family members, neighbors, and the like, that is characterized by regular interaction (or

communication). Katz and Lazarsfeld argue that “interacting individuals seem

collectively and continuously to generate and to maintain common ideas and behavior

patterns which they are reluctant to surrender or to modify unilaterally” (p. 44). They

point to the oft-cited “Hawthorne studies” (Rothlisberger & Dickson, 1939) as the first

major empirical study to demonstrate the influence of close interpersonal relationships on

people’s attitudes, values, and behaviors. This study found that despite the efforts of

management, workers at the Western Electric Company did not act in an individualistic

manner to maximize their own rewards, but instead self-regulated their output in

accordance with the norms and expectations of their fellow workers with whom they had

close personal ties.

Intermedia theory posits several reasons why an individual’s attitudes, beliefs,

values, and behaviors are influenced by the primary group s/he beolongs to.

1. People benefit from sharing the opinions, attitudes, and behaviors of those with

whom they wish to be identified. Early group research established that positive outcomes

like acceptance (Newcomb, 1952; Rothlisberger & Dickson, 1939), social status

(Festinger, Schachter, & Back, 1950; Homans, 1950), upward mobility (Stouffer, 1949;
 5

Warner & Lunt, 1941), and leadership (Merei, 1952) are linked to an individual’s

conformity to the norms, attitudes, beliefs, and behaviors of his/her primary group.

2. Primary groups constitute people’s social reality. Social constructionists

argue that because many aspects of everyday life are highly equivocal (i.e., subject to

multiple interpretations), we must rely on others to help us make sense of things (Weick,

1979). In short, what we believe to be true is, in large part, determined by what others

close to us likewise believe to be true (Berger & Luckman, 1966). As Festinger et al.

(1950) observed in their classic study of social pressure in groups:

. . . the “social reality” upon which an opinion or an attitude rests for its

justification is the degree to which the individual perceives that this

opinion or attitude is shared by others . . . . There are not usually

compelling facts which can unequivocally settle the question of which

attitude in wrong and which is right in connection with social opinions and

attitudes as there are in the case of what might be called “facts” . . . . The

“reality” which settles the question in the case of social attitudes and

opinions is the degree to which others with whom one is in

communication are believed to share these opinions and attitudes (p. 168).

3. People depend on their primary groups to validate their interpretations and

evaluations. Mass communication scholars have long recognized that people do not

evaluate a media message solely on the merits of the message. Rather, they compare the

advocated position against those held by people in their social network, and then decide

whether the media message should accepted. Thus, when an individual is presented with

a media message, s/he is likely to discuss the message with his/her peers to gauge their
 6

assessments of the message. Social network opinions are compared against the media

message to decide whether to accept or reject the media message. According to

intermedia theory, a media message is likely to have its greatest influence when its

arguments are supported or corroborated by an individual’s social network. Baumann et

al. (1988), for example, found that when ninth-graders were presented with media

messages that warned them about the negative consequences of smoking, they often

turned to their friends to confirm that information. The researchers found that very few

ninth-graders were concerned about death from lung cancer as a consequence of smoking

because none of their friends expressed such concerns in social interactions. However,

many teens were very concerned about such negative consequences of smoking as bad

breath, loss of friends, and trouble with adults because those consequences were validated

in conversations with their friends. In short, intermedia theory posits that media

messages are most likely to be effective when they are reinforced or validated in social

network interactions.

4. People rely on their primary groups for instructions on how to do things.

Media messages tell people what they should do, but rarely provide instructions about

how to do it. For example, anti-smoking messages tell people to quit smoking, but do not

tell them how to go about doing so. Thus, people often do not perform what they are told

to do in a media message, not because they disagree with the message, but because they

lack the requisite knowledge or skills for doing so. In such cases, an individual will seek

the advice or guidance of those in his/her social network who the individual believes

possesses the requisite knowledge or skills to help him/her engage in the called-for

behavior. For instance, a person who is influenced by an anti-smoking commercial to

quit smoking, will ask a friend who has successfully quit smoking how s/he went about

doing so. Reliance on interpersonal communication channels to receive instructional

feedback is a reason why studies have found that the most effective media messages are

those that are supplemented with interpersonal instruction. For example, Meyer et al.

(1980) launched a three-community information campaign to effect changes in smoking,

diet, and exercise. The researchers chose three cities that were comparable in

characteristics and demographics. Two of the cities received a multimedia campaign, and

in one of those cities, high-risk individuals received both media programs and the

opportunity for interpersonal instruction. The third city served as the control city. The

study found that the multimedia campaign had a strong impact on knowledge and

behavior, with the group receiving both media and interpersonal instruction showing the

greatest improvements.

5. Primary groups provide people with normative guidelines. Media messages

typically provide us with information designed to influence our beliefs, attitudes, and

ultimately our behaviors. However, media messages seldom provide us with information

about social norms – that is, what our friends, family, and associates think we ought to

do. These social norms must usually be obtained through direct interaction with our

peers, and hence we typically talk to our friends about what they think we ought to do in

light of the suggestions of media messages. For example, researchers have found that

men who have unprotected sex prior to being presented with media messages about the

dangers of unprotected sex, often talked to their peers about whether they should go for

an HIV test prior to actually going to the clinic to receive the test (Boekeloo et al., 1993;

Kalichman & Hunter, 1992; Rao et al., 1996).

Not only do primary groups influence the attitudes, beliefs, values, and behaviors

of individuals, but they also serve as channels for mass media transmission. According

to intermedia theory, within a primary group, some members are more available to media

messages than others in the network. Referred to as “gatekeepers,” there individuals

pass on what they read, hear, or see in the media to others within their network who are

less exposed to the media. Gatekeepers are not passive relays of information in a primary

group. Rather, they often exert their own biasing effect on mediated messages by either

reinforcing or counteracting the messages they relay to others in their primary group

(Katz & Lazarsfeld, 1955, p. 45). In other words, gatekeepers have the ability to alter the

attitudinal and informational content of media messages. According to intermedia

theory, gatekeepers can have two types of biasing effects: promotive and inhibitive

influence.

Promotive influence occurs when the gatekeeper reinforces or supplements the

attitudinal and/or informational content of the media message. In a study by Kalichman

and Hunter (1992), data were gathered from men waiting for mass transportation in

downtown Chicago, before and after Earvin “Magic” Johnson’s televised press

conference on November 7, 1991, announcing his retirement from professional basketball

because he was diagnosed as having the HIV virus. The researchers found a marked

increase in perceptions of AIDS, with an increased concern about AIDS, and greater

interest in AIDS-related information. They also found that all of the men interviewed in

the study had heard, or read, about Magic Johnson’s HIV infection; most (86%) had

engaged in frequent interpersonal discussion about AIDS with their friends during the

three days following his news conference; and most reported that their interpersonal
 9

interactions with peers had reinforced their concerns about HIV and AIDS. In short,

Kalichman and Hunter’s findings suggest that gatekeepers probably enhanced or

promoted the impact of “Magic” Johnson’s news conference in terms of increasing

people’s interest in AIDS-related information.

Gatekeepers can also inhibit the effects of media messages. People do not simply

buy into what the media sources say, and often they openly express their disagreement or

disbelief in interpersonal communication with others. As such, gatekeepers can serve as

a source of counter-attitudinal advocacy to neutralize or negative the content of the media

message. In the study by Baumann et al. (1988), media messages purporting a causal

relationship between smoking and lung cancer deaths were rejected by ninth-graders

because peer interactions failed to validate that information. Similarly, in a study of

Rogers et al. (1997), it was found that people rejected family-planning information

presented in media messages when interpersonal communication among friends and

family debunked the information presented in the messages. In both these cases, it is

possible that gatekeepers exerted inhibitive influence on media messages.

In addition to gatekeepers, intermedia posits that certain individuals in a primary

group exert disproportinately greater influence on the attitudes, beliefs, values, and

behaviors of others in the group. Katz and Lazarsfeld (1955) refer to these individuals as

“opinion leaders” (p. 32) . In some primary groups, the same individual plays the roles of

gatekeeper and opinion leader. However, it is often the case that the gatekeeper and

opinion leader are two different people (p. 119). Opinion leaders, according to Katz and

Lazarsfeld, are “distributed in all occupational groups, and on every social and economic

level” (p. 32). They are “an integral part of the give-and-take of everyday personal
 10

relationships” and can be thought of as individuals whose opinions and views are highly

regarded by members of the primary group. Because opinion leaders are highly respected

in the group, individuals often look to confirm and validate their own views and opinions

by comparing them to those held by the opinion leader(s). Opinion leaders thus play a

key role in shaping the attitudes, values, beliefs, and behavioral patterns of the entire

primary group (p. 33). More importantly, according to intermedia theory, they are the

individuals who essentially intervene between mass media messages and resultant

opinions, decisions, and actions by recipients of those messages. Opinion leaders, like

gatekeepers, then, can also promote or negate media messages circulating within the

group.

Intermedia theory posits that media messages have the best chance of making a

difference if gatekeepers and opinion leaders exert promotive influence within their

primary groups. If the gatekeepers and opinion leaders exert an inhibitive influence, the

media message has little chance of producing its desired effect. The key, then, is to

design media messages that lead to promotive communication within primary groups.

Intermedia theory identifies several message characteristics that are known to

facilitate supportive interpersonal communication within social networks and primary

groups. The first of those is the extent to which the message content corresponds with

the prevailing opinions or views of the group. When media messages are inconsistent

with the prevailing opinions, attitudes, or behavioral patterns/habits of the group,

gatekeepers are unlikely to relay the messages, or if they do, are likely to put a negative

spin on them. Similarly, opinion leaders are likely to counteract media messages that

assail prevailing attitudes, opinions, or habits (Katz & Lazarsfeld, 1955, p. 74).
 11

A second message characteristic that encourages supportive interpersonal

communication within primary groups the extent to which the message is identified with

a valued group norm. If a message advocates a normative behavior in the group, it is

more likely to enlist the support of gatekeepers and opinion leaders. However, if the

message advocates a behavior that goes against established group norms, gatekeepers are

likely to prevent it from reaching the group, or opinion leaders are likely to advocate

against the proposed behaviors (Katz & Lazarsfeld, 1955, p. 131).

A third message characteristic that affects in reception in social networks is the

quality of evidence contained in the message. Studies have shown that a media message

is more likely to be discussed in a positive light if it contains evidence that is believable

to people (Reinard, 1988). There are two aspects to evidence that make it believable to

people. The first is its credibility; in general, we are more likely to believe evidence from

a trustworthy source than one we are skeptical about. A second is its plausibility; that is,

evidence is more believable if it resonates and is consistent with our own experiences and

those of our friends and acquaintances.

A fourth aspect of a media message that influences the valence of interpersonal

communication in social networks is whether it is a one-sided or two-sided message. In

general, two-sided messages (those that present arguments for both sides of a

controversial issues) tend to be received and discussed in a more favorable light than one-

sided messages – especially when the one-sided message presents arguments in favor of

an unpopular position. But even when the one-sided message is consonant with the

views of the audience, people tend to see a two-sided message as less biased, and more

respectful of the receiver’s intelligence, than a one-sided message (Perloff, 1993).

Implications for Health Campaign Research

To summarize, intermedia theory calls into question the traditional media effects

model which assumes that media messages directly influence the opinions, attitudes,

beliefs, and behaviors of audience members (i.e., media messages Æ

opinions/attitudes/beliefs/behaviors). Instead, it posits an indirect influence of mass

media messages through the intervention of interpersonal interactions (i.e., media

messages Æ interpersonal interaction Æ opinions/attitudes/beliefs/behaviors).

The implications of intermedia theory for future health campaign research are

numerous:

1. If the influence of mass media health messages is dependent on interpersonal

relations, then health campaigns must focus on sociometric connections among targeted

audience members. That is, we need to discover whom audience members talk to on a

regular basis. More importantly, we need to discover whom the gatekeepers and opinion

leaders of those social networks are.

2. Mass media health messages depend on the support of both gatekeepers and

opinion leaders in order to influence the rest of the members of a social network. As

such, health campaign designers need to produce messages whose characteristics appeal

to those individuals, or at least are likely to be supported by them. Since the preferences

of gatekeepers and opinion leaders are likely to vary across different social networks, it

stands to reason that health campaigns need to utilize multiple messages – each message

being targeted for particular types of gatekeepers and opinion leaders. Marketing

researchers have long utilized segmentation techniques to produce media messages

targeted for specific segments of the target population. Health campaign designers need
 13

to utilize similar techniques in designing their messages. This, of course, necessitates

that in addition to identifying gatekeepers and opinion leaders, health campaign designers

need to gather as much information as they can about the gatekeepers and opinion leaders

in their target audience so segmentation techniques can be used to design multiple

messages.

3. Since the effectiveness of mass media health messages also depend on their fit

with valued group norms, or an endorsed new group norm, health campaign designers

need to also pay close attention to the normative components of their messages. This is

not an easy mandate since certain group norms are deeply embedded in culture norms

(e.g., alcohol or tobacco consumption in some cultures). It may be necessary, therefore,

for health campaigns to be multi-staged – with initial stages aimed at shaping valued

group norms to make them more favorable to subsequent mass media messages. For

example, recent health campaigns like as “JEL” (Just Eliminate Lies) designed to

eliminate tobacco use gain their effectiveness from changes in social norms toward

tobacco use in the U.S. Conversely, health campaigns designed to eliminate alcohol

consumption are less effective because current social norms in the U.S. still make

moderate consumption of alcohol acceptable in most social groups. The logical

conclusion is that until health campaigns can alter social norms so that any amount of

alcohol consumption is seen as socially unacceptable (like cigarette smoking), health

campaigns designed to reduce or eliminate alcohol consumption will continue to

experience limited effectiveness.

Conclusions

To conclude this paper, we again turn to the wisdom of Elihu Katz and Paul F.

Lazarsfeld. In the conclusion to their landmark book (1955), they write:

The whole moral of these chapters is that knowledge of an individual’s

interpersonal environment is basic to an understanding of his exposure and

reactions to the mass media. Thus, planning for future research of the

short-run influencing effects of the mass media must build, first, on the

systematic investigation of the everyday processes which influence people

and, secondly, on the study of the points of contact between these

everyday influences and the mass media. The aim of these chapters has

been to spell out some of the implications which arise from a

consideration of what is known about one such source of everyday

influence: interpersonal relations (p. 133).

Katz and Lazarsfeld’s conclusions speak volumes for future health campaign research.

Unless and until we find ways of effectively merging mass media messages with

interpersonal and group communication, no amount of sophisticated technology or glitzy

media presentations, will do much to enhance the efficacy of health campaigns.

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