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Pink Book - Making Health Communication Programs Work

Stage 1: Planning and Strategy Development

Questions to Ask and Answer
Why Planning Is Important
Planning Steps
Common Myths and Misconceptions About Planning
Selected Readings

Questions to Ask and Answer

  • What health problem are we addressing?
  • What is occurring versus what should be occurring?
  • Whom does the problem affect, and how?
  • What role can communication play in addressing the problem?
  • How and by whom is the problem being addressed? Are other communication programs being planned or implemented? (Look outside of your own organization.)
  • What approach or combination of approaches can best influence the problem? (Communication? Changes in policies, products, or services? All of these?)
  • What other organizations have similar goals and might be willing to work on this problem?
  • What measurable, reasonable objectives will we use to define success?
  • What types of partnerships would help achieve the objectives?
  • Who are our intended audiences? How will we learn about them?
  • What actions should we encourage our intended audiences to take?
  • What settings, channels, and activities are most appropriate for reaching our intended audiences and the goals of our communication objectives? (Interpersonal, organizational, mass, or computer-related media? Community? A combination?)
  • How can the channels be used most effectively?
  • How will we measure progress? What baseline information will we use to conduct our outcome evaluation?

Why Planning Is Important

The planning you do now will provide the foundation for your entire health communication program. It will enable your program to produce meaningful results instead of just boxes of materials. Effective planning will help you:

  • Understand the health issue you are addressing
  • Determine appropriate roles for health communication
  • Identify the approaches necessary to bring about or support the desired changes
  • Establish a logical program development process
  • Create a communication program that supports clearly defined objectives
  • Set priorities
  • Assign responsibilities
  • Assess progress
  • Avert disasters

Under the pressure of deadlines and demands, it is normal to think, "I don't have time to plan; I have to get started NOW." However, following a strategic planning process will save you time. Because you will define program objectives and then tailor your program's activities to meet those objectives, planning will ensure that you don't spend time doing unnecessary work. Program objectives are generally broader than communication objectives, described in step 2 on page 20, and specify the outcomes that you expect your entire program to achieve. Many of the planning activities suggested in this chapter can be completed simultaneously. Even if your program is part of a broader health promotion effort that has an overall plan, a plan specific to the communication component is necessary.

Planning Steps

This chapter is intended to help you design a program plan. The health communication planning process includes the following six steps explained in this chapter:

  1. Assess the health issue or problem and identify all the components of a possible solution (e.g., communication as well as changes in policy, products, or services).
  2. Define communication objectives.
  3. Define and learn about intended audiences.
  4. Explore settings, channels, and activities best suited to reach intended audiences.
  5. Identify potential partners and develop partnering plans.
  6. Develop a communication strategy for each intended audience; draft a communication plan.

To complete this process, use the Communication Program Plan template in Appendix A to help ensure that you don't miss any key points.

1. Assess the Health Issue/Problem and Identify All Components of a Solution

The more you understand about an issue or health problem, the better you can plan a communication program that will address it successfully. The purpose of this initial data collection is to describe the health problem or issue, who is affected, and what is occurring versus what should be occurring. Doing this will allow you to consider how communication might help address the issue or problem. In this step, review and gather data both on the problem and on what is being done about it.

Review Available Data

To collect available data, first check for sources of information in your agency or organization. Identify gaps and then seek outside sources of information. Sources and availability of information will vary by issue. The types of information you should (ideally) have at this stage include descriptions of:

  • The problem or issue
  • The incidence or prevalence of the health problem
  • Who is affected (the potential intended audience), including age, sex, ethnicity, economic situation, educational or reading level, place of work and residence, and causative or preventive behaviors. Be sure to include more information than just basic demographics
  • The effects of the health problem on individuals and communities (state, workplace, region, etc.)
  • Possible causes and preventive measures
  • Possible solutions, treatments, or remedies

To find this information, search these common data sources:

  • Libraries (for journal articles and texts)
  • Health-related resources on the Internet
  • Sources of health statistics (a local hospital, a state health department, the National Center for Health Statistics on the CDC Web site)
  • Administrative databases covering relevant populations
  • Government agencies, universities, and voluntary and health professional organizations
  • Clearinghouses
  • Community service agencies (for related service-use data)
  • Corporations, trade associations, and foundations
  • Polling companies (for intended audience knowledge and attitudes)
  • Depositories of polling information (e.g., the Roper Center)
  • Chambers of commerce
  • Advertising agencies, newspapers, and radio and television stations (for media-use data, buying and consumption patterns)

Both published and unpublished reports may be available from these sources. A number of federal health information clearinghouses and Web sites also provide information, products, materials, and sources of further assistance for specific health subjects. A helpful first step in planning may be to contact the appropriate Web sites and the health department to obtain information on the health issue your program is addressing. See Appendix C, Information Sources, for listings of additional sources of information, including Internet resources.

Identify Existing Activities and Gaps

Find out what other organizations are doing to address the problem, through communication and other approaches, such as advocating for policy or technological changes. Contact these organizations to discuss:

  • What they have learned
  • What information or advice they may have to help you plan
  • What else is needed (what gaps exist in types of change needed, media or activities available, intended audiences served to date, messages and materials directed at different stages of intended audience behavior change)
  • Opportunities for cooperative ventures

Gather New Data as Needed

You may find that the data you have gathered does not give enough insight into the health problem, its resolution, or knowledge about those who are affected in order to proceed. In other instances, you may have enough information to define the problem, know who is affected, and identify the steps that can resolve it, but other important information about the affected populations may be unavailable or outdated. To conduct primary research to gather more information, see the Communication Research Methods section.

Sometimes it is impossible to find sufficient information about the problem. This may be because the health problem has not yet been well defined. In this case, you might decide that a communication program is an inappropriate response to that particular problem until more becomes known.

Identify All Components of a Solution

Adequately addressing a health problem often requires a combination of the following approaches:

  • Communication (to the general public, patients, health care providers, policymakers—whoever needs to make or facilitate a change)
  • Policy change (e.g., new laws, regulations, or operating procedures)
  • Technological change (e.g., a new or redesigned product, drug, service, or treatment; or changing delivery of existing products, drugs, services, or treatments)

Yet all too often we rely on health communication alone and set unrealistic expectations for what it can accomplish. It is vitally important to identify all of the components necessary to bring about the desired change and then to carefully consider which of these components is being—or can be—addressed. For example, consider a woman who needs a mammogram. The mammogram graphic shows some of the problems that may occur and potential solutions for each. Solutions that communication programs can help develop are highlighted.

Communication Strategy A Case Study: Mammogram

Using Communication to Support Policy Change

The goal of a communication campaign is not always to teach or to influence behavior; it can also begin the process of changing a policy to increase health and wellness. This might mean getting community leaders excited about a new "rails to trails"project or working to bring up the issue of a lack of low-income housing. In each case, the final goal (i.e., helping people exercise by increasing the number of walking/biking trails, making sure that everyone in the community has a safe place to live by assigning more apartments in newly built housing to low-income residents) is more than a communication campaign can accomplish. However, the initial goal (gaining the support of decision-makers who can change current policy) can be met.

One of the most popular and effective ways to build support for policy change is to work with the media. Use the following questions to help plan your message:

  • What is the problem you are highlighting?
  • Is there a solution to it? If so, what is it?
  • Whose support do you need to gain to make the solution possible?
  • What do you need to do or say to get the attention of those who can make the solution happen?

Once you have developed your message, create a media list that includes organizations, such as newspapers and television stations; individuals, such as reporters, editors, and producers; and other contacts. Keep this list updated as you communicate your message and work to change policy. The following are a few methods to use:

  • News releases
  • Interviews
  • Letters to the editor
  • Media conferences

Media strategies are not the only way to build support for policy change. Also consider attending and speaking at local meetings, approaching issue decision-makers either in person or by letter, or working with and educating community members who are affected.

Note. From American Public Health Association. APHA Media Advocacy Manual 2000. Washington, DC. Adapted with permission.

Determine Whether Health Communication Is Appropriate for the Problem and Your Organization

Create a map that diagrams the components of a problem and the steps necessary to solve it (as in the mammogram graphic) to help you determine a possible role for health communication. In some cases, health communication alone may accomplish little or nothing without policy, technological, or infrastructure changes (e.g., successfully increasing physical activity of employees in the workplace might require employer policy changes to allow for longer breaks or infrastructure changes such as new walking paths). In some instances, effective solutions may not yet exist for a communication program to support. For example, no treatment may exist for an illness, or a solution may require services that are not yet available. In these cases, decide either to wait until other program elements are in place or to develop communication strategies directed to policymakers instead of consumers or patients.

If you determine that health communication is appropriate, ask the following questions to consider whether your organization is best suited to carry it out:

  • Does the organization have (or can it acquire) the necessary expertise and resources?
  • Does the organization have the necessary authority or mandate?
  • Will the organization be duplicating efforts of others?
  • How much time does the organization have to address this issue?
  • What, if anything, can be accomplished in that time?


2. Define Communication Objectives

Defining communication objectives will help you set priorities among possible communication activities and determine the message and content you will use for each. Once you have defined and circulated the communication objectives, they serve as a kind of contract or agreement about the purpose of your communication, and they establish what outcomes should be measured.

It is important to create achievable objectives. Many communication efforts are said to fail only because the original objectives were wildly unreasonable. For example, it is generally impossible to achieve a change of 100 percent. If you plan to specify a numerical goal for a particular objective, an epidemiologist or statistician can help you determine recent rates of change related to the issue so that you have some guidance for deciding how much change you think your program can achieve. (Remember that commercial marketers often consider a 2 to 3 percent increase in sales to be a great success.) Fear of failure should not keep you from setting measurable objectives.Without them, there is no way to show your program has succeeded or is even making progress along the way, which could reduce support for the program among your supervisors, funding agencies, and partners.

Because objectives articulate what the communication effort is intended to do, they should be:

  • Supportive of the health program's goals
  • Reasonable and realistic (achievable)
  • Specific to the change desired, the period during which change should take place
  • Measurable, to allow you to track progress toward desired results
  • Prioritized, to direct the allocation of resources
How Communication Contributes to Complex Behavior Change

One can imagine how the process of change occurs: A woman sees some public service announcements (PSAs) and a local TV health reporter's feature telling her about the "symptomless disease"—hypertension. She checks her blood pressure in a newly accessible shopping mall machine, and the results suggest a problem. She tells her spouse, who has also seen the ads, and he encourages her to have it checked. She goes to a physician who confirms the presence of hypertension and encourages her to change her diet and return for monitoring.

The physician has become more sensitive to the issue because of a recent article in the Journal of the American Medical Association, some recommendations from a specialist society, and a conversation with a drug retailer as well as informal conversations with colleagues and exposure to television discussion of the issue. Meanwhile, the patient talks with friends at work or family members about her experience. They also become concerned and go to have their own pressure checked. She returns for another checkup and her pressure is still elevated although she has reduced her salt intake. The physician decides to treat her with medication. The patient is ready to comply because all the sources around her--personal, professional, and media--are telling her that she should.

This program is effective not because of a PSA or a specific program of physician education. It is successful because the National High Blood Pressure Education Program has changed the professional and public environment as a whole around the issue of hypertension.

Note. From "Public Health Education and Communication as Policy Instruments for Bringing About Changes in Behavior," by R. Hornik. In Social Marketing: Theoretical and Practical Perspectives (pp. 49−50), by M. E. Goldberg, M. Fishbein, and S. E. Middlestadt (Eds.), 1997, Mahwah, NJ: Lawrence Erlbaum Associates. Adapted with permission.

Be Reasonable

Objectives describe the intermediate steps that must be taken to accomplish broader goals; they describe the desired outcome, but not the steps involved in attaining it (you'll design strategies and tactics for getting there later). Develop reasonable communication objectives by looking at the health program's goal and asking, "What can communication feasibly contribute to attaining this goal, given what we know about the type of changes the intended audiences can and will make?"

Communication efforts alone cannot achieve all objectives. Appropriate purposes for communication include:

  • Creating a supportive environment for a change (societal or organizational) by influencing attitudes, beliefs, or policies
  • Contributing to a broader behavior change initiative by offering messages that motivate, persuade, or enable behavior change within a specific intended audience

Raising awareness or increasing knowledge among individuals or the organizations that reach them is also feasible; however, do not assume that accomplishing such an objective will lead to behavior change. For example, it is unreasonable to expect communication to cause a sustained change of complex behaviors or compensate for a lack of health care services, products, or resources.

The ability and willingness of the intended audience to make certain changes also affect the reasonableness of various communication objectives. Keep this in mind as you define the intended audiences in planning step 2. Your objectives will be reasonable for a particular intended audience only if audience members both can make a particular behavior change and are willing to do so.

Sample Communication Objectives

By 2005, the number of women (over age 50; Washington, DC, residents; income under $45,000) who say they get annual screening mammograms will have increased by 25 percent.

By the end of our campaign, more than 50 percent of students at South Salem High School will report having increased the number of servings of fruits and vegetables they eat (on most days) by one.

Be Realistic

Once your program has developed reasonable communication objectives, determine which of them are realistic, given your available resources, by answering these questions:

  • Which objectives cover the areas that most need to reach the program goal?
  • What communication activities will contribute the most to addressing these needs?
  • What resources are available? Include:
    • Staff and other human resources—committee members, associates from other programs, volunteers, and others who have the requisite skills and time
    • Overhead resources such as computer time, mailing costs, and printing
    • Services available from another source, such as educational materials available free or at cost and the effort by other organizations willing to help
    • Information about the issue, the intended audience, the community, and media structures, or about available educational materials
    • Budget available to fund the program
    • Time (weeks, months, or years available to complete the program)
  • What supportive factors exist (e.g., community activities, other organizations' interests, positive community attitudes)?
  • What barriers exist (e.g., obstacles to approval, absence of funding, sensitivity of an issue, intended audience constraints)?
  • Which objectives would best use the resources your program has identified and best fit within the identified constraints?

Your answers to the last question should become your priority objectives. Sometimes you may feel so constrained by a lack of funds that proceeding appears impossible. An honest assessment may lead you to conclude that a productive communication effort is not possible. However, creative use of the resources already identified may enable you to develop a communication program that can make valuable contributions.

Planning Terms

The overall health improvement that an organization or agency strives to create (e.g., more eligible cancer patients will take part in cancer clinical trials, or more Americans will avoid fatal heart attacks). A communication program should be designed to support and contribute to achieving this specific desired improvement.

Communication Objectives
The specific communication outcomes you aim to produce in support of the overall goal (e.g., by 2005, 75 percent of Americans will know that participating in cancer research studies may be an option for them; or by 2005, 50 percent of rural adults over age 40 will know the warning signs for a heart attack and what to do if they occur). Objectives should be attainable, measurable, and time specific.

The overall approaches the program takes. Strategies derive from and contribute to achieving defined goals and objectives. They should be based on knowledge about effective communication, the intended audience's needs and characteristics, and your program'fs capabilities, timelines, and resources. (See planning step 6 for more information on developing a communication strategy and evaluation plan.)

3. Define and Learn About Intended Audiences

In this step, determine whom you want to reach based on decisions made in the previous two steps.

Begin by identifying intended populations for a program based on the epidemiology of the problem (who is most affected? at risk?) and other factors contributing to the problem. Intended populations are often defined very broadly, using just a few descriptors (e.g., women over age 50). Intended audiences are carved from these broad population groups and defined more narrowly based on characteristics such as attitudes, demographics, geographic region, or patterns of behavior. Examples might include physically inactive adolescents, heavy smokers with low education and income levels who are fatalistic about health issues, or urban African-American men with hypertension who live in the South. Because the intended audience's ability and willingness to make a behavior change affects the extent to which communication objectives are reasonable and realistic, it is most efficient to select intended audiences and develop communication objectives (plaanning steps 2 and 3) in tandem.

Goals and Objectives: Healthy People 2010

Healthy People 2010, the Nation's prevention agenda for the next decade, is designed to achieve two overarching goals: 1) increase the quality and years of healthy life, and 2) eliminate health disparities. For the first time, the Health Communication chapter of Healthy People 2010 includes objectives to improve the quality of health communication interventions, the skills of health professionals, the reach and quality of interactive communication media, and the health literacy of people with inadequate or marginal literacy skills. Meeting these communication objectives will contribute to the achievement of the overarching goals. Some communication efforts that could contribute to the achievement of these goals include the following:

  • Interventions to improve the communication skills of health care providers and patients
  • Assistance for people searching for and using health information
  • Education for consumers and patients about important health topics and relevant risks, preventive measures, and ways to access the health care system

See to learn more.


Note. 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. In the public domain.

Move From Intended Population to Specific Intended Audiences

Defining subgroups of a population according to common characteristics is called segmentation. Segmentation can help you develop messages, materials, and activities that are relevant to the intended audience's current behavior and specific needs, preferences, beliefs, cultural attitudes, knowledge, and reading habits. It also helps you identify the best channels for reaching each group, because populations also differ in factors such as access to information, the information sources they find reliable, and how they prefer to learn.

Increase your program's effectiveness by developing strategies that are attuned to the needs and wants of different intended audience segments. In fact, given the diversity of the general public, trying to reach everyone with one message or strategy may result in an approach that does not effectively reach those most able or ready to change. Be aware, though, that moving from a mass-market strategy to a differentiated strategy will add economic and staff resource costs for each additional segment. Segment a population into specific intended audiences using the following characteristics to define them:

  • Behavioral—health-related activities or choices, degree of readiness to change a behavior, information-seeking behavior, media use, and lifestyle characteristics
  • Cultural—language proficiency and language preferences, religion, ethnicity, generational status, family structure, degree of acculturation, and lifestyle factors (e.g., special foods, activities)
  • Demographic—occupation, income, educational attainment, family situation, and places of residence and work
  • Physical—sex, age, type and degree of exposure to health risks, medical condition, disorders and illnesses, and family health history
  • Psychographic—attitudes, outlook on life and health, self-image, opinions, beliefs, values, self-efficacy, life stage, and personality traits

The key to success is to segment the intended population on characteristics relevant to the health behavior to be changed. A logical starting point is the behavior itself: When possible, compare those who engage in the desired behavior with those who do not and identify the determinants of their behavior. Many planners simply rely on demographic, physical, or cultural segmentations. However, people who share these characteristics can be very different in terms of health behavior. For example, consider two 55-year-old African-American women. They work together in the same department. They have the same amount of schooling and comparable household incomes. They live next door to each other, attend the same church, and often invite each other's family over for meals. They enjoy the same television shows, listen to the same radio stations, and often discuss articles that they both read in the paper. Neither has a family history of breast cancer, and both had children before age 30.Yet one woman goes for annual mammograms and the other has never had one. A demographic, physical, or cultural segmentation would group these women together, yet one is a member of the intended audience for health communications about mammography and the other is not.

Databases Help NCI Identify and Communicate With Intended Audience Segments

To help identify and understand its intended audiences, NCI's Office of Communications (OC) uses a unique database that combines health behavior information with geographic, demographic, and lifestyle data. OC uses this information to create Consumer Health Profiles that give a portrait of the intended audience segments most in need of cancer prevention and detection messages. Consumer Health Profiles describe:

  • Which populations within a region most need cancer education and outreach and where these populations live, including maps (e.g., which areas of a state have the lowest cancer screening rates)
  • How to reach these populations, based on factors such as media habits and knowledge, attitudes, and beliefs about cancer

Consumer Health Profiles are useful not only in locating an intended audience but also in understanding people better. NCI's Cancer Information Service and its partners have used the profiles to plan media buys and direct mailings to increase the number of women participating in low-cost mammography screening programs. For more information, contact CIS's Partnership Program at 1-800-4-CANCER or the Office of Communications at 301-496-6667.

Select Intended Audiences

Once you have identified intended audience segments, begin to set priorities and select the intended audiences (e.g., those segments with whom you will communicate). As you select your intended audiences, distinguish among the audiences your program will address. Primary intended audiences are those you want to affect in some way; you may have one or several primary intended audiences. If you have more than one, set priorities among them to help order your planning and allocate resources. Secondary intended audiences, or gateway audiences, are those with influence on the primary intended audiences or those who must do something to help cause the change in the primary intended audiences. These intended audiences might need different kinds of messages and tools to make the desired change.

Select intended audiences by answering the following questions for each segment:

  • What is a reasonable and realistic communication objective for this intended audience? In other words, what behavior change can the intended audience make, and how willing is this group to make that change? Sometimes an intended audience can't make a behavior change—or can't make it easily—until a policy change is instituted or a new or improved product is developed. If your program cannot provide the necessary policy or technological changes, perhaps another intended audience would be a better choice. (See Appendix B for a description of relevant theories and models of behavior change that may help you answer this question.)

  • Will achieving that communication objective with this intended audience adequately contribute to attaining the health program goal? (See planning step 2.) intended audience size factors prominently in the answer to this question. It is important to choose a segment or segments large enough that changes in their behavior will make a worthwhile contribution to your program's goal. If your program's goal is population-wide improvement, asking a larger intended audience to make a small change may get you closer to the goal and require fewer resources than helping a small group make a very large change.

  • To what extent would members of this segment benefit from the communication? Some segments may already engage in the desired behavior or may be close to it (e.g., eating four servings of fruits and vegetables each day, but not five).

  • How well can available resources and channels reach this segment? If you must rely on mass communication (e.g., mass media, public events), yet one-on-one skill modeling is needed to help this segment make a behavior change, your program's resources will be wasted.

  • For secondary intended audiences, to what extent does this audience influence the primary intended audiences?

  • To what extent will we be able to measure progress? See the Communication Research Methods section for a discussion of measurement considerations.

Answering these questions will also help you determine who will not be members of an intended audience. Ruling out intended audience segments will allow you to make decisions regarding message development and dissemination more easily and will help ensure that all program resources are spent productively. Two examples of intended audiences are 1) teens who smoke, and 2) women over age 50 who are not having regular mammograms.

Learn More About the Intended Audiences

You probably need to know more about the intended audiences than you learned from the initial research. Sometimes planners conduct consumer research on all potential intended audiences to help them set objectives, complete intended audience segmentation, and set priorities. At other times, they define and set priorities among intended audiences based on initial research and then conduct more intensive research with selected intended audiences. The approach often depends upon the amount of existing secondary research and the resources available to conduct primary research.

To learn about an intended audience, find answers to the following questions:

  • What does the intended audience already know about the topic? Do intended audience members have any misconceptions?
  • What are the intended audience members'relevant attitudes, beliefs, and perceptions of barriers to change?
  • How "ready" is the intended audience to change? (Based upon the stages of change model—see Appendix B for a description.)
  • What benefit do intended audience members already associate with making the behavior change?
  • What social, cultural, and economic factors will affect program development and delivery?
  • When and where (times, places, states of mind) can the intended audience best be reached?
  • What communication channels (e.g., mass media, organization meetings, Internet sites) reach this intended audience? Which do its members prefer? Find credible? (Look to the census for this information.)
  • Do certain individuals (or gatekeepers) either have particular influence with this intended audience or control access to it? What is their degree of influence?
  • What are the intended audience's preferences in terms of learning styles, appeals, language, and tone?

See the Communication Research Methods section to learn ways to gather information about intended audiences.


4. Explore Settings, Channels, and Activities to Reach Intended Audiences

In this step, begin to think about the best ways to reach the intended audiences.

To reach intended audiences effectively and efficiently, first identify the settings (times, places, and states of mind) in which they are most receptive to and able to act upon the message. Next, identify the channels through which your program's message can be delivered and the activities that can be used to deliver it. In making these decisions, weigh what will best:

  • Reach the intended audience
  • Deliver the message

Explore Settings

To identify possible settings for reaching the intended audience, think of the following:

  • Places where your program can reach the intended audience (e.g., at home, at school or work, in the car, on the bus or train, at a community event, in the local health care provider's office or clinic)
  • Times when intended audience members may be most attentive and open to your program's communication effort
  • Places where they can act upon the message
  • Places or situations in which they will find the message most credible

Sometimes a given setting may be a good place to reach the intended audience but not a good place to deliver the message. For example, a movie theater slide might be a great way to reach the intended audience, but if the message is "call this number to sign up for this health program," people may not be receptive to (or able to act upon) the message—and they are unlikely to recall the message or the number later, when they can act on it. In contrast, if you reach people while they are preparing dinner--or in the grocery store—with a message to increase fruit and vegetable consumption, they are likely to be receptive to and able to act upon the message.

Explore Channels and Activities

Message delivery channels have changed significantly in the decade since this book first appeared. Today, channels are more numerous, are often more narrowly focused on an intended audience, and represent changes that have occurred in health care delivery, the mass media, and society. Consider the following channels:

  • Interpersonal
  • Group
  • Organizational and community
  • Mass media
  • Interactive digital media

Interpersonal Channels

Interpersonal channels (e.g., physicians, friends, family members, counselors, parents, clergy, and coaches of the intended audiences) put health messages in a familiar context. These channels are more likely to be trusted and influential than media sources. Developing messages, materials, and links into interpersonal channels may require time; however, these channels are among the most effective, especially for affecting attitudes, skills, and behavior/behavioral intent. Influence through interpersonal contacts may work best when the individual is already familiar with the message, for example, from hearing it through mass media exposure. (Similarly, mass media are most effective at changing behavior when they are supplemented with interpersonal channels.)

Group Channels

Group channels (e.g., brown bag lunches at work, classroom activities, Sunday school discussions, neighborhood gatherings, and club meetings) can help your program more easily reach more of the intended audience, retaining some of the influence of interpersonal channels. Health messages can be designed for groups with specific things in common, such as workplace, school, church, club affiliations, or favorite activities, and these channels add the benefits of group discussion and affirmation of the messages. As with interpersonal channels, working through group channels can require significant levels of effort. Influence through group channels is more effective when groups are already familiar with the message through interpersonal channels or the others described here.

Doctor to Patient: The Interpersonal Channeldoctor and her patient

Interpersonal channels have shown great success in delivering credible messages that produce desired results. When the one-to-one message comes from the doctor, people are especially likely to listen. Good communication between health care providers and individuals is so important to achieving positive health outcomes that the Health Communication chapter of Healthy People 2010 includes an objective to "increase the proportion of persons who report that their health care providers have satisfactory communication skills" (objective 11-6). In addition, the chapter on cancer includes an objective to "increase the proportion of physicians and dentists who counsel their at-risk patients about tobacco-use cessation, physical activity, and cancer screening" (objective 3-10).

Examples of the results of physician-patient communication include:

  • Doctor-patient communication has been associated with improved recovery from surgery, shortened hospital stays, lower blood pressure and blood sugar, and better health status.
  • People who quit smoking in response to physician advice are more likely to make repeated attempts to quit and are more likely to remain off cigarettes.
  • Women in a national survey said a major reason they never had a mammogram was, "My doctor never recommended one." When a Massachusetts program increased the number of physicians who recommended mammography, screening rates also rose.
  • Most people in a national survey said their preferred source of information about prescription medicines is their physician. When patients and physicians communicate, compliance improves.

Organizational and Community Channels

Organizations and community groups, such as advocacy groups, can disseminate materials, include your program's messages in their newsletters and other materials, hold events, and offer instruction related to the message. Their involvement also can lend their credibility to your program's efforts. Organizational/community channels can offer support for action and are two-way, allowing discussion and clarification, enhancing motivation, and reinforcing action.

Mass Media Channels

Mass media channels (e.g., radio, network and cable television, magazines, direct mail, billboards, transit cards, newspapers) offer many opportunities for message dissemination, including mentions in news programs, entertainment programming ("entertainment education"), public affairs programs, "magazine" and talk shows (including radio audience call-ins), live remote broadcasts, editorials (television, radio, newspapers, magazines), health and political columns in newspapers and magazines, posters, brochures, advertising, and public service campaigns.You may decide to use a variety of formats and media channels, always choosing from among those most likely to reach the intended audiences.

Mass media campaigns are a tried-and-true communication approach. They have been conducted on topics ranging from general health to specific diseases, from prevention to treatment. Overall, research has demonstrated the effectiveness of mass media approaches in:

  • Raising awareness
  • Stimulating the intended audience to seek information and services
  • Increasing knowledge
  • Changing attitudes and even achieving some change (usually) in self-reported behavioral intentions and behaviors

However, behavior change is usually associated with long-term, multiple−intervention campaigns rather than with one-time communication−only programs.

Interactive Digital Media Channels

Interactive digital media channels (e.g., Internet Web sites, bulletin boards, newsgroups, chat rooms, CD-ROMs, kiosks) are an evolving phenomenon and are useful channels that should have even greater reach in the future. These media allow communicators to deliver highly tailored messages to and receive feedback from the intended audience. These channels are capable of producing both mass communication and interpersonal interaction. Use these media to:

  • Send individual messages via electronic mail
  • Post program messages (such as information about health-related campaigns) on Internet sites that large numbers of computer users access
  • Create and display advertisements
  • Survey and gather information from computer users
  • Engage intended audiences in personalized, interactive activities
  • Exchange ideas with peers and partners

Using interactive digital media is not without challenges. If you choose to do so, consider credibility and access issues.

Internet and Multimedia Channels

CD-ROMs—Computer disks that can contain an enormous amount of information, including sound and video clips and interactive devices.

Chat rooms—Places on the Internet where users hold live typed conversations. The "chats" typically involve a general topic. To begin chatting, users need chat software, most of which can be downloaded from the Internet for free.

Electronic mail (e-mail)—A technology that allows users to send and receive messages to one or more individuals on a computer via the Internet.

Interactive television—Technologies that allow television viewers to access new dimensions of information (e.g., link to Web sites, order materials, view additional background information, play interactive games) through their television during related TV programming.

Intranets—Electronic information sources with limited access (e.g., Web sites available only to members of an organization or employees of a company). Intranets can be used to send an online newsletter with instant distribution or provide instant messages or links to sources of information within an organization.

Kiosks—Displays containing a computer programmed with related information. Users can follow simple instructions to access personally tailored information of interest and, in some cases, print out what they find. A relatively common health application is placing kiosks in pharmacies to provide information about medicines.

Mailing lists (listservs)—E-mail−based discussions on a specific topic. All the subscribers to a list can elect to receive a copy of every message sent to the list, or they may receive a regular "digest" disseminated via e-mail.

Newsgroups—Collections of e-mail messages on related topics. The major difference between newsgroups and listservs is that the newsgroup host does not disseminate all the messages the host sends or receives to all subscribers. In addition, subscribers need special software to read the messages. Many Web browsers, such as Internet Explorer, contain this software. Some newsgroups are regulated (the messages are screened for appropriateness to the topic before they are posted).

Web sites—Documents on the World Wide Web that provide information from an organization (or individual) and provide links to other sources of Internet information. Web sites give users access to text, graphics, sound, video, and databases. A Web site can consist of one Web page or thousands of Web pages. Many health-related organizations have their own Web sites.

Credibility. Anyone can put information on the Internet, and it may or may not be accurate. Thus it is important to demonstrate the credibility of your organization when you use this channel to disseminate health information. This will help ensure that users trust the information they receive.

To improve the quality of health information on the Internet, Healthy People 2010 includes an objective to increase the proportion of health-related Web sites that disclose information that can be used to assess the site's quality (objective 11-4). To improve quality, health Web sites should disclose the following information:

  • The identity of the developers and sponsors of the site, how to contact them, and information about any potential conflicts of interest or biases
  • The explicit purpose of the site, including any commercial purposes and advertising
  • The original sources of the content on the site
  • How the privacy and confidentiality of any personal information collected from users is protected
  • How the site is evaluated
  • How content is updated

Access. The average computer user is affluent and well educated. Although access to this medium is increasing, it is definitely not universal; television and radio are better choices to reach a larger intended audience. The U.S. Department of Commerce issues reports on the "digital divide," the gap between those with access to computers and the Internet and those without. Healthy People 2010 includes an objective to increase from 26 to 80 the percentage of households with access to the Internet so that individuals will be able to get the information and services they need to address their health concerns (objective 11-1).

Communication Channels and Activities: Pros and Cons
Type of ChannelActivitiesProsCons
Interpersonal Channels
  • Hotline counseling
  • Patient counseling
  • Instruction
  • Informal discussion
  • Can be credible
  • Permit two-way discussion
  • Can be motivational, influential, supportive
  • Most effective for teaching and helping/caring
  • Can be expensive
  • Can be time-consuming
  • Can have limited intended audience reach
  • Can be difficult to link into interpersonal channels; sources need to be convinced and taught about the message themselves
Organizational and Community Channels
  • Town hall meetings and other events
  • Organizational meetings and conferences
  • Workplace campaigns
  • May be familiar, trusted, and influential
  • May provide more motivation/support than media alone
  • Can sometimes be inexpensive
  • Can offer shared experiences
  • Can reach larger intended audience in one place
  • Can be costly, time consuming to establish
  • May not provide personalized attention
  • Organizational constraints may require message approval
  • May lose control of message if adapted to fit organizational needs
Mass Media Channels
  • Ads
  • Inserted sections on a health topic (paid)
  • News
  • Feature stories
  • Letters to the editor
  • Op/ed pieces
  • Can reach broad intended audiences rapidly
  • Can convey health news/breakthroughs more thoroughly than TV or radio and faster than magazines
  • Intended audience has chance to clip, reread, contemplate, and pass along material
  • Small circulation papers may take PSAs
  • Coverage demands a newsworthy item
  • Larger circulation papers may take only paid ads and inserts
  • Exposure usually limited to one day
  • Article placement requires contacts and may be time-consuming
  • Ads (paid or public service placement)
  • News
  • Public affairs/talk shows
  • Dramatic programming (entertainment education)
  • Range of formats available to intended audiences with known listening preferences
  • Opportunity for direct intended audience involvement (through callin shows)
  • Can distribute ad scripts (termed "live-copy ads"), which are flexible and inexpensive
  • Paid ads or specific programming can reach intended audience when they are most receptive
  • Paid ads can be relatively inexpensive
  • Ad production costs are low relative to TV
  • Ads allow message and its execution to be controlled
  • Reaches smaller intended audiences than TV
  • Public service ads run infrequently and at low listening times
  • Many stations have limited formats that may not be conducive to health messages
  • Difficult for intended audiences to retain or pass on material
  • Ads (paid or public service placement)
  • News
  • Public affairs/talk shows
  • Dramatic programming (entertainment education)
  • Reaches potentially the largest and widest range of intended audiences
  • Visual combined with audio good for emotional appeals and demonstrating behaviors
  • Can reach low income intended audiences
  • Paid ads or specific programming can reach intended audience when most receptive
  • Ads allow message and its execution to be controlled
  • Opportunity for direct intended audience involvement (through call-in shows)
  • Ads are expensive to produce
  • Paid advertising is expensive
  • PSAs run infrequently and at low viewing times
  • Message may be obscured by commercial clutter
  • Some stations reach very small intended audiences
  • Promotion can result in huge demand
  • Can be difficult for intended audiences to retain or pass on material
  • Web sites
  • E-mail mailing lists
  • Chat rooms
  • Newsgroups
  • Ads (paid or public service placement)
  • Can reach large numbers of people rapidly
  • Can instantaneously update and disseminate information
  • Can control information provided
  • Can tailor information specifically for intended audiences
  • Can be interactive
  • Can provide health information in a graphically appealing way
  • Can combine the audio/visual benefits of TV or radio with the self-paced benefits of print media
  • Can use banner ads to direct intended audience to your program's Web site
  • Can be expensive
  • Many intended audiences do not have access to Internet
  • Intended audience must be proactive--must search or sign up for information
  • Newsgroups and chat rooms may require monitoring
  • Can require maintenance over time

Weigh Pros and Cons

As illustrated in the table Communication Channels and Activities: Pros and Cons, each type of channel—and activity used within that channel—has benefits and drawbacks.Weigh the pros and cons by considering the following factors:

  • Intended audiences you want to reach:
    • Will the channel and activity reach and influence the intended audiences (e.g., individuals, informal social groups, organizations, society)?
    • Are the channel and activity acceptable to and trusted by the intended audiences, and can they influence attitudes?
  • Your message:
    • Is the channel appropriate for conveying information at the desired level of simplicity or complexity?
    • If skills need to be modeled, can the channel model and demonstrate specific behaviors?
  • Channel reach:
    • How many people will be exposed to the message?
    • Can the channel meet intended audience interaction needs?
    • Can the channel allow the intended audience to control the pace of information delivery?
  • Cost and accessibility:
    • Does your program have the resources to use the channel and the activity?
  • Activities and materials:
    • Is the channel appropriate for the activity or material you plan to produce? (Decisions about activities and channels are interrelated and should be made in tandem. See Stage 2 for a list of possible materials for health programs and a discussion of decision factors.)
    • Will the channel and activity reinforce messages and activities you plan through other routes to increase overall exposure among the intended audiences?

Best Choice: Using Multiple Channels to Reach Intended Audiences

Using several different channels increases the likelihood of reaching more of the intended audiences. It also can increase repetition of the message, improving the chance that intended audiences will be exposed to it often enough to absorb and act upon it. For these reasons, a combination of channels has been found most effective in producing desired results, including behavior change.

For example, Center for Substance Abuse Prevention (CSAP) communication grantees have combined channels in unique ways that reflect their communities. One grantee used posters in community facilities, placed radio spots, and distributed brochures through community sites and requests by radio listeners. Another used a satellite network to show videos, made small group presentations through organizations, and worked with schools to promote at-home activities. Yet another promoted its message through a music and visual arts training program that resulted in a live performance and television broadcast of the program's art and musical creations.

Note. Center for Substance Abuse Prevention Communications Cooperative Agreements. (1996). Bridging the Gap for People with Disabilities. Rockville, MD: U.S. Department of Health and Human Services. In the public domain.Content goes here


5. Identify Potential Partners

Working with other organizations can be a cost-effective way to enhance the credibility and reach of your program's messages. Many public health institutions seek out partner organizations to reach particular intended audiences.

The benefits to your program of forming partnerships can include:

  • Access to an intended audience
  • More credibility for your message or program because the intended audiences consider the potential partner to be a trusted source
  • An increase in the number of messages your program will be able to share with intended audiences
  • Additional resources, either tangible or intangible (e.g., volunteers)
  • Added expertise (e.g., training capabilities)
  • Expanded support for your organization's priority activities
  • Cosponsorship of events and activities

You may partner with one or a few organizations to accomplish specific projects. Some communication initiatives may call for tapping into or assembling a coalition of organizations with a shared goal. In some cases, you may need to assemble many organizations that support particular recommendations or policies. At other times, you may want the organizations to play an active role in developing and implementing communication activities.

To encourage selected groups to partner with your organization, consider the benefits you can offer, such as:

  • Added credibility
  • Access to your organization's data
  • Assurance of message accuracy
  • Liaison with other partners

Decide Whether You Want Partners

Although working with partners can be essential to achieving communication objectives, there are also drawbacks that you should recognize and prepare to address.Working with other organizations can:

  • Be time consuming—Identifying potential partners, persuading them to work with your program, gaining internal approvals, and coordinating planning and training all take time.
  • Require altering the program—Every organization has different priorities and perspectives, and partners may want to make minor or major program changes to accommodate their own structure or needs.
  • Result in loss of ownership and control of the program—Other organizations may change the time schedule, functions, or even the messages, and take credit for the program.

Decide how much flexibility you would be willing to allow a partner in the program without violating the integrity of your program, its direction, and your own agency's procedures. If you decide to partner with other organizations, consider which:

  • Would best reach the intended audiences
  • Might have the greatest influence and credibility with the intended audiences
  • Will be easiest to persuade to work with you (e.g., organizations in which you know a contact person)
  • Would require less support from you (e.g., fewer resources)

Develop Partnering Plans

Think about the roles potential partners might play in your program and use the suggestions below to help identify specific roles for partners:

  • Supplemental printing, promotion, and distribution of materials
  • Sponsorship of publicity and promotion
  • Purchase of advertising space/time
  • Creation of advertising about your organization's priority themes and messages
  • Underwriting of communication materials or program development with your organization

See Appendix A for a partnership plan form.


Working With For-Profit Partners

The National Cancer Institute uses these guidelines when considering commercial partners.


  • The National Cancer Institute will not consider any collaboration that endorses a specific commercial product, service, or enterprise.
  • The National Cancer Institute name and logo may be used only in conjunction with approved projects and only with the written permission of NCI. NCI retains the right to review all copy (e.g., advertising, publicity, or for any other intended use) prior to approval of the use of the NCI name and logo.
  • The National Cancer Institute will formally review each proposal for partnership.
  • No company will have an exclusive right to use the NCI name and logo, messages, or materials.
  • Confidentiality cannot be guaranteed for any collaboration with a federal program.

Criteria for Reviewing Corporations Prior to Partnership Negotiations

  • Company is not directly owned by a tobacco company and is not involved in producing, marketing, or promoting tobacco products.
  • Company does not have any products, services, or promotional messages that conflict with NCI policies or programs (e.g., the company does not market known carcinogens or market some other product that NCI would not consider medically or scientifically acceptable).
  • Company is not currently in negotiation for a grant or contract with NCI.
  • Company does not have any unresolved conflicts or disputes with NCI or NIH.
  • Establishing a partnership with this company will not create tensions/conflicts with another NCI partner or federal program.
  • Company or institution satisfactorily conforms with standards of health or medical care.
  • There is evidence that the company would be interested in becoming a partner with NCI.

Working With Partners

The staff person responsible for working with partners should be:

  • A good manager who is able to balance all program components
  • A team player who is able to work with other organizations
  • Diplomatic and willing to negotiate
  • Willing to share credit for success

Developing and Maintaining Coalitions

Community coalitions have become an important force in health promotion. Coalitions have all of the advantages of partnerships plus another benefit. Because they harness the resources and commitment of multiple organizations, the attention those organizations pay to an issue is institutionalized for long-term action. The strongest potential partners may be interested in joining coalitions.

Coalitions often grow from informal partnerships or advisory bodies created around special projects. Experience in working together lays the groundwork for a long-term association.

Use the following guidelines to create a successful coalition:

  • Formalize the relationship to create greater commitment. Formal arrangements include written memoranda of understanding, by-laws, mission statements, or regular reminders of the coalition's purpose and progress.
  • Make sure that the responsibilities of each organization and its staff are clear. In particular, staff members need to know whether to take direction from the coalition chairperson or from the agency that pays their salary.
  • Structure aspects of the coalition's operation. Elect officers. Form standing committees. Have regularly scheduled meetings with written agenda and minutes. Expect and support action, not just discussion, at these meetings. Circulate action items resulting from meetings among coalition members. Establish communication channels and use them frequently.
  • Ensure the involvement of representatives who show leadership characteristics, such as the ability to obtain resources, problem−solve, and promote collaboration and equality among members. Members with political knowledge, administrative or communication skills, or access to the media and decision-makers are also valuable.
  • Create and reinforce positive expectations by providing information on the coalition's progress. Optimism and success sustain member interest.
  • Formalize accountability and develop criteria for judging whether coalition members are honoring their commitments.
  • Be flexible. Losing prospective partners can limit a program's effectiveness.
  • Provide training to help members complete their tasks. For example, coalition members may need training in how to be effective advocates for your program's issues.
  • Give members a stake in the coalition and an active role in decision-making.
  • Seek external resources to augment member resources.
  • Evaluate the effectiveness of the coalition periodically and make necessary changes. This should include process evaluation of the coalition's functioning and assessment of the coalition's impact on the health problem being addressed.

Steps for Involving Partners in the Program

  1. Choose organizations, agencies, or individuals (e.g., physicians) that can bring the resources, expertise, or credibility your program needs.
  2. Consider which roles partners might play to best support the program.
  3. Involve representatives of the organizations you want to work with as early as appropriate in program planning.
  4. Give partners the program rationale, strategies, and messages (in ready-to-use form). Remember that strategic planning, creative messages, and quality production are the most difficult aspects of a communication program to develop and may be the most valuable product you can offer to a community organization.
  5. Give partners advance notice so that they can build their part of the program into their schedule, and negotiate what will be expected of them.
  6. Allow partners to personalize and adapt program materials to fit their circumstances and give them a feeling of ownership, but don't let them stray from the strategy.
  7. Ask partners what they need to implement their part of the program. Beyond the question of funding, consider other assistance, training, information, or tools that would enable them to function successfully.
  8. Provide partners with new local/regional/national contacts or linkages that they will perceive as valuable for their ongoing activities.
  9. Give partners an appropriate amount of work. Give them a series of small, tangible, short-term responsibilities, as well as a feedback/tracking mechanism.
  10. Gently remind partners that they are responsible for their activities; help them complete tasks, but don't complete tasks for them.
  11. Assess progress through the feedback/tracking mechanism and help make adjustments to respond to the organization's needs and to keep the program on track.
  12. Provide moral support by frequently saying "thank you" and by providing other rewards (e.g., letters or certificates of appreciation).
  13. Give partners a final report of what was accomplished and meet to discuss follow-up activities and resources they might find useful. Make sure that they feel they are a part of the program's success.
  14. Share one final, tremendous "Thank you for a job well done."


6. Develop a Communication Strategy; Draft Communication and Evaluation Plans

At this point your program has:

  • Defined intended audiences and the actions you want their members to take (communication objectives)
  • Explored the settings, channels, and activities that can be used to reach them
  • Identified potential partners
  • Developed partnering plans

In this step, you will use this information as the basis for developing a communication strategy and drafting communication and evaluation plans.

Develop a Communication Strategy Statement (Creative Brief)

In this context, a strategy is a communication approach your program plans to take with a specific intended audience; while you may develop many different communication materials and use a variety of activities, the strategies are guiding principles for all program products and activities. A communication strategy includes everything you need to know to communicate with the intended audience. It defines the intended audience, describes the action its members should take, tells how they will benefit (from their perspective, not necessarily from a public health perspective), and how you can reach them. A communication strategy is:

  • Based on knowledge of the intended audience's wants, needs, values, and accessibility
  • Guided by general communication research as well as theories and models of behavior
  • Tempered by the realities of available resources and deadlines

Developing the strategy statement provides a good test of whether your program has enough information to begin developing messages. It also gives you an opportunity to obtain management and partner buy-in for the approach.You may be tempted to skip this step, but do not. Having an approved strategy statement will save time and effort later. The statement provides both a foundation and boundaries for all the materials you produce and all the activities you conduct.

The communication strategy statement is sometimes called a creative brief because it is used to brief the creative team. In addition, sharing the strategy statement with management and partners allows you to make sure there is support for your program's approach before resources are expended and makes easier the approvals and cooperation you may need later.

For each of the intended audiences, write a creative brief (see Appendix A for a template to use) that includes the following:

  • A definition and description of the intended audience (intended-audience profile). Think of one person in the intended audience and describe him or her, rather than describing the group. The information you gathered in planning step 3 should provide the basis for this section.
  • A description of the action the intended audience members should take as a result of exposure to the communication. The action is the change the communication objective specifies (planning step 2). If you haven't already done so, now is the time to find out if intended audience members are willing and able to take the action—and to identify the current behavior that you want to change. Knowing what an intended audience currently does—and why it does it—will provide important insights into the behavior change process and can be used to develop communications that demonstrate replacing the old behavior with the new one.
  • A list of any obstacles to taking action. Common obstacles include intended audience beliefs, social norms, time or peer pressures, costs, ingrained habits, misinformation, and product inaccessibility. The "map" you created in planning step 1 should identify many of the obstacles, particularly those related to product inaccessibility (e.g., a woman can't get to a mammography location, a worker has no access to fruits or vegetables at break times, a condom isn't available at the time of intercourse). The additional information you gathered about the intended audience in planning step 3 should also help you identify obstacles.
  • The consumer-perceived benefit of taking the action. Many theories and models of behavior change include the idea that people change their behavior because they expect to receive some benefit (e.g., gain in time, money, enjoyment, potential gain in stature among peers) that outweighs the personal cost of the behavior change. Short-term, high-probability personal benefits generally are more effective than long-term population benefits (e.g., "stop smoking to smell better and be more attractive" rather than "stop smoking to reduce your risk of developing lung cancer").
  • A description of the support that will make the benefit, and its ability to attain it, credible to the intended audience. Support can be provided through hard data, peer testimonials about success or satisfaction, demonstrations of how to perform the action, or statements from organizations the intended audience finds credible. Tailor the particular supports you use to the concerns intended audience members have about the action. For example, if they are worried they can't do it, a demonstration may be warranted; if they question why they should take the action or whether it will have the promised health benefit, hard data or statements from credible organizations may be in order; if they don't believe they need to take the action (e.g., they deny being in the intended audience), a peer testimonial can be compelling.
  • The settings, channels, and activities that will reach intended audience members—particularly when they will be receptive to or able to act upon the message. This information should come from the work you did in planning step 4.
  • The image your program plans to convey through the tone, look, and feel of messages and materials. The goal should be to convey an image that 1) convinces intended audience members that the communication is for them, and 2) is culturally appropriate. Image is conveyed largely through executional details. Printed materials convey image through typeface, layout, visuals, color, language, and paper stock used.Web materials convey image through design, typeface, color, layout, and ease of use. Audio materials convey image through voices, language, and music; in addition to these details, video materials convey image through visuals, characteristics of the actors (including their clothing and accessories), camera angles, and editing.Work with the creative team to develop the image you select.

Sample Strategy Statement

Draft Creative Brief Used for NCI 5 A Day for Better Health Program Concept Development and Testing (June 2001)

Intended Audiences—African-American and Latino adults (men and women) with primary responsibility for shopping and food preparation who have children under the age of 13 and have household incomes of $25,000 to $50,000 who believe they and their families should eat more fruits and vegetables.

Objective(s)—1) to believe that increasing their fruit and vegetable (f/v) intake is possible (provides a "can do" self-efficacy element), and 2) to increase their f/v intake (gets at the behavioral element, which is the ultimate goal; provides the "do it" element).


  • Low salience/competition with everyday concerns and priorities
  • Storage
  • Low self-efficacy
  • Children's reaction/sensory
  • Cost, convenience, freshness (cost, both out of pocket and perishability, is a top barrier among African Americans)
  • Not filling and don't taste good (Latino issues)
  • Safety (safety/pesticide issues are top barriers for eating vegetables for Latinos)
  • Lack of planning time
  • Preparation time (preparation time is a "top" barrier for eating vegetables among African Americans)
  • Lack of familiarity with certain fruits and vegetables
  • Competition with other food products; i.e., fast foods
  • Nutritional concerns about frozen/canned; e.g., canned are high in sodium; and for Latinos, "not as healthy" misconception
  • Lack of confidence in ability to get fruits and vegetables outside the home (survey data, Latinos)

Key Promise

  • If we eat more fruits and vegetables every day, I'll feel good knowing we're setting a good example for our children and investing in a healthy future.
  • If my family members eat more fruits and vegetables, they will function at their best and protect their health as well as feel more energetic, help control their weight, and cleanse their system.
  • If we eat more fruits and vegetables every day, my family will stay healthy while reducing its risk of cancer or heart disease in the future.
  • If we have plenty of fruits and vegetables available for our family, we will be setting a good example and teaching our children good, lifelong eating habits.

Support Statements

  • Fruit and vegetable consumption helps people feel good, look good, and maintain their weight.
  • Fruit and vegetable consumption provides generous amounts of fiber and promotes digestive health.
  • Obesity and childhood diabetes are epidemic.
  • Fruit and vegetable consumption reduces the risk of heart disease/cancer.

Tone—Urgency without fear; positive...


  • TV PSAs
  • Radio PSAs/Live announcer scripts
  • Posters
  • Newspaper ads
  • Billboard and Metro Transit ads
  • Earned Media ("Do Yourself a Flavor"')—African-American/Latino women can send Graham Kerr recipes that he can select and feature
  • Web site
  • Articles in women's magazines

Other Channels/Intermediaries

  • Produce for Better Health
  • State coordinators


  • Traveling home from work
  • Mother's Day
  • Community outreach (health fairs, in-store events such as taste tests or demonstrations), grassroots programs

Creative Considerations

  • Adaptable to local needs (state health profiles)
  • Focus on more than one fruit or vegetable (equal opportunity)
  • Appetite appeal, culturally appropriate, cross-cultural concepts that can be tailored in execution
  • Focus groups that include men and women and low-income ($25,000 or less in San Antonio) participants at each site, which may drive creative to accommodate low literacy; this is a good thing if we have both English- and Spanish-speaking people in the intended audience. (Note: Creative executions should be intended audience specific, while the concepts will cross over and work for both ethnic groups.)

    The information in Appendix B and the information you learned about your intended audience in planning step 3 are the foundation for strategy development. Use this information to prepare a document similar to the NCI sample strategy statement provided here. At first, you may have question marks next to some items, or lists of possibilities for actions, benefits, support, or image.You can fill in the answers, narrow down the list, and get overall reactions to the strategy by conducting research with the intended audience. (See the Communication Research Methods section for suggestions on how to obtain this input.) Developing the communication strategy is usually an iterative process; as you learn more about one element, other elements will likely need to be adjusted.

    The communication strategy provides all program staff—including writers, creative staff, and evaluators—with the same direction for developing all messages and materials. In a cooperative program with partner organizations, the strategy statement can also help all players communicate consistent themes and take similar action. Some organizations choose to produce report-length strategy statements that contain additional information, such as background on the health problem being addressed, extensive intended audience profiles, and situation analyses.

    Once your program has decided on a communication strategy, all program elements should be compatible with it. This means every program task should contribute to reaching the established objectives and be designed to reach the identified intended audiences; all messages and materials should incorporate the benefits and other information from the strategy statement.

    As you learn more about the intended audiences and their perceptions, you may need to alter or refine the strategy statement. However, it should be changed only to reflect information that will strengthen your program's ability to reach the communication objectives. Do not alter your strategy simply to accommodate a great idea that doesn't match the objectives.

    Draft Communication Plan

    All of the elements of your planning should be recorded in a communication plan that will become your "blueprint." It should be used to:

    • Explain the plans within your agency and with others
    • Support and justify budget requests
    • Provide a record of where your program began
    • Show the program's planned evolution over time

    Include the following sections in the plan:

    • Communication strategy
    • Partnering plans
    • Message and materials development and testing plans
    • Implementation plans, including plans for distribution, promotion, and process evaluation
    • Outcome evaluation plans
    • Tasks and timeline

    A template for a communication plan that includes all of these sections is in Appendix A. During Stage 1, prepare initial drafts of all plan sections except distribution and promotion. Realize that some of the sections, such as implementation and process evaluation (see Stage 3), may not be as detailed as others at this point.

    Draft Outcome Evaluation Plans

    Outcome evaluation is used to assess the degree to which the communication objectives are achieved. Conducting useful outcome evaluation can be challenging because of the following constraints:

    • Many standard evaluation approaches assume a direct cause-and-effect relationship between the stimulus (your program's communication) and the intended audience's response to it. However, it can be impossible to isolate the effects of a particular communication activity, or even the effect of a communication program on a specific intended audience, because change does not often occur as a result of just one specific activity.
    • Communication programs generally occur in a real-world setting, where there are many other influences on the intended audiences. Other activities (and often other organizations) may be addressing the same problem. Attributing change to program activities may be very difficult.
    • Communication objectives can be reasonable but not measurable because of reasons such as:
      • The change is too small for available methodologies to detect (e.g., a 2 percent increase over the course of a year in the number of women age 50 or over who get a mammogram would have important public health benefits, but would not be detectable by a survey with a typical 3.1 percent margin of error).
      • The change is difficult to measure validly or reliably (e.g., self-reports of behavior are often unreliable).

    Plan Outcome Evaluation Activities

    Before you begin to plan for outcome evaluation, review Stage 4 for descriptions of common methodologies. As you plan, keep the following tips in mind:

    • Ensure that the evaluation design is appropriate for the particular communication activity. Experimental designs, in which a treatment group (people exposed to the communication) is compared to a control group (people not exposed to the communication), are the gold standard of outcome evaluation. However, they often cannot be used to assess communication activities, largely because untreated control groups may not exist, particularly for national-, state-, or community-based efforts. Even if people are not exposed to your program's communication, they are likely to be exposed to some communication on the same topic. In these situations, appropriate designs include comparisons between cross-sectional studies (such as independent surveys taken at different points in time), panel studies (the same people are interviewed or observed multiple times), and time series analyses (comparisons between projections of what would have happened without the intervention versus what did happen). However, each is appropriate in different situations; seek the advice of an evaluation expert before selecting a design.
    • Consider how the communication activity is expected to work and the time period in which it is expected to work. Then make sure it is evaluated in accordance with those expectations. For example, if you expect people to need at least five to eight exposures to the message before they will take action, make sure that you allow sufficient implementation time to achieve the intended level of exposure. If you expect people to take action immediately after exposure, then the outcome measurement should take place soon after that. Conversely, if you don't expect to see effects for at least a year, outcomes shouldn't be measured until then. Communication programs are often deemed "failures" because they don't reach people with sufficient repetition to work—either because they are inadequately funded or because everything runs late and they are not in place long enough before outcomes are measured. (Use process evaluation to track the level of intensity and the duration of message exposure to learn why expected outcomes did or did not occur.)
    • Consider what level of evidence is acceptable for your outcome evaluation purpose (e.g., to report back to management or funding agencies).
    • Consider what baseline measures you have available or can collect and how to track changes related to desired outcomes (e.g., how, and how often, data will be collected).
    • Ensure that you measure change against the communication objectives and not against your program's goal. For example, if the communication objective is to increase the percentage of women age 50 or older who ask their doctor about a mammogram, you would measure how many women asked their doctor about a mammogram, not how many women got a mammogram.
    • Ensure that progress toward outcomes is captured. For example, if you expect people to think about changing a behavior, and perhaps try changing it a few times before making and sustaining the change, make sure the evaluation can capture these intermediate outcomes. If the objective is to increase the percent of people engaging in moderate exercise on most days of the week, it would be important to determine 1) people's current behavior, and 2) whether they have thought about increasing their amount of activity, taken steps to increase it, or increased it some weeks but not consistently.

    Appendix A contains an outcome evaluation form. Although you may not be ready to complete final evaluation planning now, it is important to put together a general plan so that your program can collect any necessary baseline data before implementation begins, build any needed evaluation mechanisms into the program, and ensure that evaluation resources are allocated. To get started, do the following:

    1. Read Stage 4 (Assessing Effectiveness and Making Refinements) and look at the table at the beginning of the Communication Research Methods chapter.What you learn about evaluation may affect what you choose to do with the program.
    2. Take another look at these sections after your initial communication plan is complete to be sure the evaluation activities will be appropriate and valuable.
    3. Involve an evaluation expert familiar with evaluating communication programs during initial planning. His or her advice can help prevent time-consuming fixes later by ensuring you develop a program that can be validly evaluated (e.g., making sure data collection mechanisms are in place, making sure baseline data are collected for comparison later).

    Create a Timetable

    Finally, produce a time schedule for development, implementation, and evaluation. The schedule should include every task you can think of from the time you write the plan until the time you intend to complete the program. The more tasks you build into the timetable now, the more likel you will remember to assign the work and keep on schedule. Also, detailing the tasks will make it easier to decide what resources will be required. If you forget important intermediate steps, your program's costs and schedule might change.

    The timetable should be considered a flexible management tool. Review and update it regularly (e.g., once a month) so that it can function dually to manage and track progress. Many managers believe computer-based tools are especially useful for this task. Project management computer software contains schedule forms that you can fill in and monitor on the computer and print out for staff and others involved.

    Common Myths and Misconceptions About Planning

    Myth: Our program can't afford to conduct intended audience research.

    Fact: Your program can't afford not to conduct intended audience research. Without it, you do not know for sure whom to select, where to reach them, what to ask them to do, or how to ask it. The information you need to develop effective communication may be relatively inexpensive or free. Resources include literature searches, information available free from government health agencies, and advisory groups and representatives of the intended audience. For example, the National Cancer Institute's 5 A Day for Better Health Program media campaign used primary research to identify its intended audiences, actions they would be willing to take, and benefits they would find compelling, but used existing marketing databases to obtain a great deal of information about their lifestyles, interests, outlook, and media habits. The cost for analyzing the databases was substantially less than it would have been to conduct and analyze additional primary research.

    Myth: Market research isn't relevant for a health program.

    Fact: Health program planners can use the methodologies and types of information normally associated with market research in many ways, including:

    • Understanding why individuals would choose or not choose to undertake a new behavior, other preferences regarding the behavior, how communicators should talk about the behavior (tone and language), and where individuals seek out or receive information
    • Creating a multidimensional portrait of the intended audience for communication planning; knowing only health-related factors limits understanding of the whole person your program is trying to influence and does not provide guidance on when and where to reach the person or what to say to persuade the intended audience
    • Supporting strategy development for policy initiatives by helping to describe opinion leaders, policymakers, and their constituents

    Myth: We don't have time for planning. Our boss (or funding agency or partner organization) wants us to get started right away.

    Fact: Making health communication programs work requires planning, but planning need not be a long-term, time-consuming activity. Nor should all the activities suggested in this section be conducted en masse, before any other actions are taken. Planning is easiest and best done bit by bit—related to and just in time for the programmatic tasks it governs. For example, you need certain kinds of information about the intended audiences in order to define them, select them, and set objectives.You need different information to guide message development; gather each type as you need it.

    One person should not be doing all planning tasks. Divide responsibilities for individual tasks such as managing market research or drafting the strategic plan and have the whole planning team (or manager) reconcile and revise to create the final plan.

    Myth: If we work with partner organizations that represent the intended audience, we'll have access to all the channels we need.

    Fact: Channels you access through a partner organization may be very useful, but they may miss intended audience segments the organization does not represent, and they may not be the most credible or effective way to influence the intended audience. Using additional channels will help reinforce your program's messages and enhance the likelihood that the intended audience will recall them.

    Myth: It's best to use the channels we're comfortable with and have used before.

    Fact: Selecting the right channels is as important to success as developing effective materials or having a sound strategy. If the intended audience never sees/hears the message, doesn't believe it because it comes from an unrespected source, or doesn't attend to it because it comes from a noninfluential source, the time and money your program spends developing the message will be wasted. While you may well make good use of channels where you have previous contacts, determine whether these channels alone will reach and influence intended audiences before relying solely on them.

    Myth: If we use only one channel, we should use mass media.

    Fact: In the past, many programs may have concentrated on mass media, particularly public service announcements. Today, however, many other effective channels exist and relying on mass media alone may not achieve some communication program goals. Although it may take time, effort, and possibly outside expertise to learn about and use new channels, the potential rewards make this a good investment in your program's future and in your organization's long-term skill/knowledge base.

    Myth: Using interactive digital media requires major technical capabilities we don't have, and we can't keep up.

    Fact: Using interactive digital media effectively does require professional expertise in product design--just as professional expertise is needed to create other types of communication vehicles and develop effective evaluations. Consultants from other branches of your organization, universities, a volunteer pool, or commercial firms can help. Some advertising/creative firms are beginning to develop expertise in these media, or you can use experts to advise you on the electronic end while you take care of the communication aspects.

    These media are changing rapidly, just as the computer field as a whole. However, if you determine that interactive digital channels will be very effective in reaching the intended audience, networking with peers, and conducting program research, the investment may pay off.

    Myth: If you don't have interactive digital media in your program, you are missing out on today's hottest communication opportunity and will look very out of date and low tech to your peers.

    Fact: Remember, interactive digital media are just other channels. The same steps discussed in this guide still apply, and good communication principles and skills are still paramount. The key selection factor is how well these media will reach the intended audience and how suited they are to carrying the message. The intended audience may not have sufficient access to computers or have the skills or attitudes/interest to seek information through them. And, despite their potential, much remains to be learned about their best uses and how intended audiences respond to and interact with them.

    Selected Readings

    American Cancer Society. (2001). Cancer facts and figures. Atlanta.

    American Public Health Association. (2000). APHA media advocacy manual 2000. Washington, DC.

    Andreasen, A. (1988). Cheap but good marketing research. Homewood, IL: Dow Jones-Irvin.

    Andreasen, A. (1995). Marketing social change: Changing behavior to promote health, social development, and the environment. San Francisco: Jossey-Bass.

    Calvert, P. (Ed.). (1996). The communicator's handbook: Tools, techniques, and technology (3rd ed.). Gainesville, FL: Maupin House.

    Center for Substance Abuse Prevention. (1994). Following specific guidelines will help you assess cultural competence in program design, application, and management [Technical Assistance Bulletin].Washington, DC: U.S. Government Printing Office.

    Center for Substance Abuse Prevention. (1998). Evaluating the results of communication programs [Technical Assistance Bulletin].Washington, DC: U.S. Government Printing Office.

    Center for Substance Abuse Prevention Communications Cooperative Agreements. (1996). Bridging the gap for people with disabilities. Rockville, MD: U.S. Department of Health and Human Services.

    Centers for Disease Control and Prevention. (1996). The prevention marketing initiative: Applying prevention marketing (CDC Publication No. D905). Atlanta.

    Centers for Disease Control and Prevention. (2000). Beyond the brochure (CDC Publication No. PDF-821K). Atlanta.

    Davis, J. (Ed.). (2001). Health and medicine on the Internet: An annual guide to the World Wide Web for health care professionals. Los Angeles: Practice Management Information Corporation.

    The Dialog Corporation. (2001). Packaged facts. Available:

    Eng, T. R., & Gustafson, D. H. (Eds.). (1999). Wired for health and well-being: The emergence of interactive health communication. Washington, DC: U.S. Department of Health and Human Services, U.S. Government Printing Office.

    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.

    Jernigan, D. H., & Wright, P. A. (1996). Media advocacy: Lessons from community experiences. Journal of Public Health Policy, 17, 306–330.

    Maibach, E., Maxfield, A., Ladin, K., & Slater, M. (1996). Translating health psychology into effective health communication. Journal of Health Psychology, 1, 261–277.

    Matiella, A. C. (Ed.). (1990). Getting the word out: A practical guide to AIDS materials development. Santa Cruz, CA: Network Publications.

    Miller, J., & Pifer, L. K. (1993). Public understanding of biomedical science in the United States, 1993: A report to the National Institutes of Health. Chicago: Chicago Academy of Science.

    National Cancer Institute. (1996). Cancer rates and risks (4th ed.; NIH Publication No. 96-691). Bethesda, MD: Surveillance, Epidemiology, and End Results (SEER) Program.

    Schooler, C., Chaffee, S. H., Flora, J. A., & Roser, C. (1998). Health campaign channels: Tradeoffs among reach, specificity, and impact. Human Communication Research, 24, 410–432.

    Slater, M. D. (1996). Theory and method in health audience segmentation. Journal of Health Communication, 1, 267–283.

    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.

    University of Toronto. (1999). Overview of health communication campaigns. Toronto, Canada: Health Communication Unit, Centre for Health Promotion, University of Toronto.

    Wallach, L., & Dorfman, L. (1996). Media advocacy: A strategy for advancing policy and promoting health. Health Education Quarterly, 23(3), 293–317.

    Wallach, L., Dorfman, L., Jernigan, D., & Themba, M. (1993). Media advocacy and public health: Power of prevention. Thousand Oaks, CA: Sage.