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Pink Book - Making Health Communication Programs Work

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Questions to Ask and Answer
The Role of Health Communication in Disease Prevention and Control
What Health Communication Can and Cannot Do
Planning Frameworks, Theories, and Models of Change
How Market Research and Evaluation Fit Into Communication Programs
Selected Readings

Questions to Ask and Answer

  • Can communication help us achieve all or some of our aims?
  • How can health communication fit into our program?
  • What theories, models, and practices should we use to plan our communication program?
  • What types of evaluation should we include?

The Role of Health Communication in Disease Prevention and Control

There are numerous definitions of health communication. The National Cancer Institute and the Centers for Disease Control and Prevention use the following:

The study and use of communication strategies to inform and influence individual and community decisions that enhance health.

Use the principles of effective health communication to plan and create initiatives at all levels, from one brochure or Web site to a complete communication campaign. Successful health communication programs involve more than the production of messages and materials. They use research-based strategies to shape the products and determine the channels that deliver them to the right intended audiences.

Since this book first appeared in 1989, the discipline of health communication has grown and matured. As research has continued to validate and define the effectiveness of health communication, this book has become a widely accepted tool for promoting public health. Healthy People 2010, the U.S. Department of Health and Human Services’ stated health objectives for the nation, contains separate objectives for health communication for the first time. Meanwhile, the availability of new technologies is expanding access to health information and raising questions about equality of access, accuracy of information, and how to use the new tools most effectively.

What Health Communication Can and Cannot Do

Understanding what health communication can and cannot do is critical to communicating successfully. Health communication is one tool for promoting or improving health. Changes in health care services, technology, regulations, and policy are often also necessary to completely address a health problem.

Communication alone can:

  • Increase the intended audience’s knowledge and awareness of a health issue, problem, or solution
  • Influence perceptions, beliefs, and attitudes that may change social norms
  • Prompt action
  • Demonstrate or illustrate healthy skills
  • Reinforce knowledge, attitudes, or behavior
  • Show the benefit of behavior change
  • Advocate a position on a health issue or policy
  • Increase demand or support for health services
  • Refute myths and misconceptions
  • Strengthen organizational relationships

Communication combined with other strategies can:

  • Cause sustained change in which an individual adopts and maintains a new health behavior or an organization adopts and maintains a new policy direction
  • Overcome barriers/systemic problems, such as insufficient access to care

Communication cannot:

  • Compensate for inadequate health care or access to health care services
  • Produce sustained change in complex health behaviors without the support of a larger program for change, including components addressing health care services, technology, and changes in regulations and policy
  • Be equally effective in addressing all issues or relaying all messages because the topic or suggested behavior change may be complex, because the intended audience may have preconceptions about the topic or message sender, or because the topic may be controversial

Communication Can Affect Multiple Types of Change

Health communication programs can affect change among individuals and also in organizations, communities, and society as a whole:

  • Individuals—The interpersonal level is the most fundamental level of health-related communication because individual behavior affects health status. Communication can affect individuals’ awareness, knowledge, attitudes, self-efficacy, skills, and commitment to behavior change. Activities directed at other intended audiences for change may also affect individual change, such as involving patients in their own care.
  • Groups—The informal groups to which people belong and the community settings they frequent can have a significant impact on their health. Examples include relationships between customers and employees at a salon or restaurant, exercisers who go to the same gym, students and parents in a school setting, employees at a worksite, and patients and health professionals at a clinic. Activities aimed at this level can take advantage of these informal settings.
  • Organizations—Organizations are groups with defined structures, such as associations, clubs, or civic groups. This category can also include businesses, government agencies, and health insurers. Organizations can carry health messages to their constituents, provide support for health communication programs, and make policy changes that encourage individual change.
  • Communities—Community opinion leaders and policymakers can be effective allies in influencing change in policies, products, and services that can hinder or support people’s actions. By influencing communities, health communication programs can promote increased awareness of an issue, changes in attitudes and beliefs, and group or institutional support for desirable behaviors. In addition, communication can advocate policy or structural changes in the community (e.g., sidewalks) that encourage healthy behavior.
  • Society—Society as a whole influences individual behavior by affecting norms and values, attitudes and opinions, laws and policies, and by creating physical, economic, cultural, and information environments. Health communication programs aimed at the societal level can change individual attitudes or behavior and thus change social norms. Efforts to reduce drunk driving, for example, have changed individual and societal attitudes, behaviors, and policies through multiple forms of intervention, including communication.

Multistrategy health communication programs can address one or all of the above.

Communication Programs Can Include Multiple Methods of Influence

Health communicators can use a wide range of methods to design programs to fit specific circumstances. These methods include:

  • Media literacy—teaches intended audiences (often youth) to deconstruct media messages so they can identify the sponsor’s motives; also teaches communicators how to compose messages attuned to the intended audience’s point of view
  • Media advocacy—seeks to change the social and political environment in which decisions that affect health and health resources are made by influencing the mass media's selection of topics and by shaping the debate about those topics
  • Public relations—promotes the inclusion of messages about a health issue or behavior in the mass media
  • Advertising—places paid or public service messages in the media or in public spaces to increase awareness of and support for a product, service, or behavior
  • Education entertainment—seeks to embed health-promoting messages and storylines into entertainment and news programs or to eliminate messages that counter health messages; can also include seeking entertainment industry support for a health issue
  • Individual and group instruction—influences, counsels, and provides skills to support desirable behaviors
  • Partnership development—increases support for a program or issue by harnessing the influence, credibility, and resources of profit, nonprofit, or governmental organizations

Characteristics of Effective Health Communication Campaigns

Certain attributes can make health communication campaigns more effective. Use the guidelines in this section to plan your campaign. Define the communication campaign goal effectively:
  • Identify the larger goal
  • Determine which part of the larger goal could be met by a communication campaign
  • Describe the specific objectives of the campaign; integrate these into a campaign plan
Define the intended audience effectively:
  • Identify the group to whom you want to communicate your message
  • Consider identifying subgroups to whom you could tailor your message
  • Learn as much as possible about the intended audience; add information about beliefs, current actions, and social and physical environment to demographic information

Create messages effectively:

  • Brainstorm messages that fit with the communication campaign goal and the intended audience(s)
  • Identify channels and sources that are considered credible and influential by the intended audience(s)
  • Consider the best times to reach the audience(s) and prepare messages accordingly
  • Select a few messages and plan to pretest them

Pretest and revise messages and materials effectively:

  • Select pretesting methods that fit the campaign’s budget and timeline
  • Pretest messages and materials with people who share the attributes of the intended audience(s)
  • Take the time to revise messages and materials based upon pretesting findings

Implement the campaign effectively:

  • Follow the plans you developed at the beginning of the campaign
  • Communicate with partners and the media as necessary to ensure the campaign runs smoothly
  • Begin evaluating the campaign plan and processes as soon as the campaign is implemented
Note. Adapted from the University of Kansas Community Toolbox, Community Workstation, available at Accessed March 7, 2002.


Theories Guide Action to Increase Mammography Use

Fox Chase Cancer Center, in cooperation with area managed care organizations, designed a program that was based on key elements of the health belief model to encourage women to have regular mammograms. Selected women received educational materials explaining that virtually all women are at risk for breast cancer, regardless of the absence of symptoms, and that risk increases with age (susceptibility). The materials stressed that early detection brings not only the best chance of cure but also the widest range of treatment choices (benefit). Women received a letter stating their physician#8217;s support (cue to action) and a coupon for a free mammogram (to overcome the cost barrier). Those who did not have a mammogram within 90 days received different forms of reminders (cues to action). In the most intensive reminder, a telephone counselor called selected women to review their perceptions about susceptibility, benefits, and barriers. Program evaluation showed that mammography use increased substantially.

The Fox Chase program also applied social learning theory in developing interventions to encourage physician support of mammography and to improve clinical breast examinations (CBEs). The planners examined the environmental and situational factors that might affect physician behavior and tried to change the low expectations of physicians about the benefits of breast screening. The interventions included observational learning by watching an expert perform a CBE, an opportunity to increase self-efficacy by practicing CBE with the instructor, and the use of a feedback report and CME credits to reinforce physician skills.

In taking a community approach to change, a UCLA mammography program used a diffusion of innovations model. Community analysis showed that women who were early adopters (leaders) already had a heightened awareness of the value of mammography. To reach middle adopters, the program mobilized the social influence of the early adopters by using volunteers who had breast cancer to provide mammography information. The program also provided highly individualized educational strategies linked to social interaction approaches to reach late adopters. A social marketing framework influenced the program’s planning approach, and media materials incorporated the health belief model to promote individual behavior change.

Note. From "Audiences and Messages for Breast and Cervical Cancer Screenings," by B. K. Rimer, 1995, Wellness Perspectives: Research, Theory, and Practice, 11(2), pp. 13−39. Copyright by University of Alabama. Adapted with permission

Communication programs can take advantage of the strengths of each of the above by using multiple methods. A program to decrease tobacco use among youth, for example, could include:

  • Paid advertising to ensure that youth are exposed to on-target, unfiltered motivational messages
  • Media advocacy to support regulatory or policy changes to limit access to tobacco
  • Public relations to support anti-tobacco attitudes
  • Media literacy instruction in schools to reduce the influence of the tobacco industry
  • Entertainment education and advocacy to decrease the depiction of tobacco use in movies
  • Partnerships with commercial enterprises (such as retail chains popular among youth) to spread the anti-smoking message

Using multiple methods increases the need for careful planning and program management to ensure that all efforts are integrated and consistently support program goals and objectives.

Planning Frameworks, Theories, and Models of Change

Sound health communication development should draw upon theories and models that offer different perspectives on the intended audiences and on the steps that can influence their change. No single theory dominates health communication because health problems, populations, cultures, and contexts vary. Many programs achieve the greatest impact by combining theories to address a problem. The approach to health communication we use in this book is based on the social marketing framework. (See Appendix B for an overview of some other relevant theoretical models.) Social marketing concentrates on tailoring programs to serve a defined group and is most successful when it is implemented as a systematic, continuous process that is driven at every step by decision-based research, which is used as feedback to adjust the program.*

National Objectives for Research and Evaluation

The Health Communication chapter of Healthy People 2010, the nationwide health promotion and disease prevention agenda, identifies increasing the proportion of health communication activities that include research and evaluation as one of six objectives for the field for the next decade (objective 11-3). This objective focuses attention on the need to make research and evaluation integral parts of initial program design. Research and evaluation are used to systematically obtain the information needed to refine the design, development, implementation, adoption, redesign, and overall quality of a communication intervention.

Healthy People 2010

Why Use Theories and Models?

Although theories cannot substitute for effective planning and research, they offer many benefits for the design of health communication programs. At each stage of the process outlined in this book, theories and models can help answer key questions, such as:

  • Why a problem exists
  • Whom to select
  • What you need to know about the population/intended audience before taking action
  • How to reach people and make an impact
  • Which strategies are most likely to cause change

Reviewing theories and models can suggest factors to consider as you formulate your objectives and approach, and can help you determine whether specific ideas are likely to work. Theories and models can guide message and materials development, and are also useful when you decide what to evaluate and how to design evaluation tools.

How Market Research and Evaluation Fit Into Communication Programs

Conducting market research is vital to identifying and understanding intended audiences and developing messages and strategies that will motivate action. Evaluations conducted before, throughout, and after implementation provide data on which to base conclusions about success or failure and help to improve current and future communication programs.

Evaluation should be built in from the start, not tacked on to the end of a program. Integrating evaluation throughout planning and implementation ensures that you:

  • Tailor messages, materials, and activities to your intended audience
  • Include evaluation mechanisms (e.g., include feedback forms with a community guide)
  • Define appropriate, meaningful, achievable, and time-specific program objectives

Evaluating your program’s communication efforts enables you to:

  • Understand what is and is not working, and why
  • Improve the effort while it is under way and improve future efforts
  • Demonstrate the value of the program to interested parties such as partners, funding agencies, and the public
  • Help program staff see how its work affects the intended audiences

In this book, we address appropriate evaluation activities for each stage; see the Communication Research Methods section for a description of the different types of research and evaluation that support each stage of the health communication process. See Appendix A for sample forms and instruments.

* From Theory at a Glance: A Guide for Health Promotion Practice (NIH Publication No. 97-3896), by the National Cancer Institute, 1995. Bethesda, MD. In the public domain.

Selected Readings

  • Andreasen, A. (1995). Marketing social change: Changing behavior to promote health, social development, and the environment. San Francisco: Jossey-Bass.
  • Backer, T. E., Rogers, E. M., & Sopory, P. (1992). Designing health communication campaigns: What works. Thousand Oaks, CA: Sage.
  • Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice-Hall.
  • Centers for Disease Control and Prevention. (2001). CDCynergy 2001 [CD-ROM]. Atlanta.
  • Glanz, K., Lewis, F. M., & Rimer, B. K. (Eds.). (1997). Health behavior and health education: Theory, research, and practice (2nd ed.). San Francisco: Jossey-Bass.
  • Glanz, K., & Rimer, B. K. (1995). Theory at a glance: A guide for health promotion practice (NIH Publication No. 97-3896). Bethesda, MD: National Cancer Institute.
  • Goldberg, M. E., Fishbein, M. F., & Middlestadt, S. E. (Eds.). (1997). Social marketing: Theoretical and practical perspectives. Mahwah, NJ: Erlbaum.
  • Green, L.W., & Kreuter, M.W. (1999). Health promotion planning: An educational and ecological approach (3rd ed.). Mountain View, CA: Mayfield.
  • Maibach, E., & Parrott, R. L. (Eds.). (1995). Designing health messages: Approaches from communication theory and public health practice. Thousand Oaks, CA: Sage.
  • National Cancer Institute. (1993). A picture of health (NIH Publication No. 94-3604). Rockville, MD: U.S. Department of Health and Human Services.
  • Rimer, B. K. (1995). Audiences and messages for breast and cervical cancer screenings. Wellness Perspectives: Research, Theory, and Practice, 11(2), 13−39.
  • Siegel, M., & Doner, L. (1998). Marketing public health: Strategies to promote social change. Gaithersburg, MD: Aspen.
  • U.S. Department of Health and Human Services. (2000). Healthy people 2010 (2nd Ed.; in two volumes: Understanding and improving health and Objectives for improving health.). Washington, DC: U.S. Government Printing Office.