Why Should You Use This Book?

Introduction

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

Overview: The Health Communication Process

The Stages of the Health Communication Process

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

Stage 2: Developing and Pretesting Concepts, Messages, and Materials

Questions to Ask and Answer Why Developing and Pretesting Messages and Materials Are Important Steps in Developing and Pretesting Messages and Materials Planning for Production, Distribution, Promotion, and Process Evaluation Common Myths and Misconceptions About Materials Pretesting Selected Readings

Stage 3: Implementing the Program

Questions to Ask and Answer Preparing to Implement Your Program Maintaining Media Relations After Launch Working with the Media During a Crisis Situation Managing Implementation: Monitoring and Problem Solving Maintaining Partnerships Common Myths and Misconceptions About Program Implementation Selected Readings

Stage 4: Assessing Effectiveness and Making Refinements

Questions to Ask and Answer Why Outcome Evaluation Is Important Revising the Outcome Evaluation Plan Conducting Outcome Evaluation Refining Your Health Communication Program Common Myths and Misconceptions About Evaluation Selected Readings

Communication Research Methods

Types of Communication Research Differences Between Qualitative and Quantitative Research Methods Qualitative Research Methods Quasi-Quantitative Research Methods: Pretesting Messages and Materials Quantitative Research Methods Additional Research Methods

Appendix A: Communication Planning Forms and Samples

Appendix B: Selected Planning Frameworks, Social Science Theories, and Models of Change*

Appendix C: Information Sources

Appendix D: Selected Readings and Resources

Appendix E: Glossary

Acknowledgments

Preface

The National Cancer Institute will no longer print hard copy books or compact discs of Making Health Communication Programs Work, also known as the Pink Book. Full-length HTML and PDF versions of this publication can be printed via the Page Option tools on this page. (04/02/2008)

This book is a revision of the original Making Health Communication Programs Work, first printed in 1989, which the Office of Cancer Communications (OCC, now the Office of Communications) of the National Cancer Institute (NCI) developed to guide communication program planning. During the 25 years that NCI has been involved in health communication, ongoing evaluation of our communication programs has affirmed the value of using specific communication strategies to promote health and prevent disease. Research and practice continue to expand our understanding of the principles, theories, and techniques that provide a sound foundation for successful health communication programs. The purpose of this revision is to update communication planning guidelines to account for the advances in knowledge and technology that have occurred during the past decade.

To prepare this update, NCI solicited ideas and information from various health communication program planners and experts (see Acknowledgments). Their contributions ranged from reviewing and commenting on existing text to providing real-life examples to illustrate key concepts. In addition, the Centers for Disease Control and Prevention (CDC) provided extensive input as part of the agency’s partnership with NCI.

Although communicating effectively about health is an exacting task, those who have the earlier version of this publication know that it is possible. We hope the ideas and information in this revision will help new health communication programs start soundly and mature programs work even better.

The planning steps in this book can help make any communication program work, regardless of size, topic, geographic span, intended audience, or budget. (Intended audience is the term this book uses to convey what other publications may refer to as a target audience.) The key is reading all the steps and adapting those relevant to your program at a level of effort appropriate to the program's scope. The tips and sidebars throughout the book suggest ways to tailor the process to your various communication needs.

If you have limited funding, you might

Don’t let budget constraints keep you from setting objectives, learning about your intended audience, or pretesting. Neglecting any of these steps could limit your program's effectiveness before it starts.

This book describes a practical approach for planning and implementing health communication efforts; it offers guidelines, not hard and fast rules.Your situation may not permit or require each step outlined in the following chapters, but we hope you will consider each guideline and decide carefully whether it applies to your situation.

Questions to Ask and Answer

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

The Role of Health Communication in Disease Prevention and Control

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

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

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

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

What Health Communication Can and Cannot Do

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

Communication alone can:

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

Communication combined with other strategies can:

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

Communication cannot:

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

Communication Can Affect Multiple Types of Change

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

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

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

Communication Programs Can Include Multiple Methods of Influence

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

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

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

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

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

Planning Frameworks, Theories, and Models of Change

Sound health communication development should draw upon theories and models that offer different perspectives on the intended audiences and on the steps that can influence their change. No single theory dominates health communication because health problems, populations, cultures, and contexts vary. Many programs achieve the greatest impact by combining theories to address a problem. The approach to health communication we use in this book is based on the social marketing framework. (See Appendix B ² for an overview of some other relevant theoretical models.) Social marketing concentrates on tailoring programs to serve a defined group and is most successful when it is implemented as a systematic, continuous process that is driven at every step by decision-based research, which is used as feedback to adjust the program.*

National Objectives for Research and Evaluation

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

Why Use Theories and Models?

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

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

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

How Market Research and Evaluation Fit Into Communication Programs

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

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

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

Evaluating your program’s communication efforts enables you to:

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

In this book, we address appropriate evaluation activities for each stage; see the Communication Research Methods ³ section for a description of the different types of research and evaluation that support each stage of the health communication process. See Appendix A ⁴ for sample forms and instruments.

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

Selected Readings

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

Backer, T. E., Rogers, E. M., & Sopory, P. (1992). Designing health communication campaigns: What works. Thousand Oaks, CA: Sage.

Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice-Hall.

Centers for Disease Control and Prevention. (2001). CDCynergy 2001 [CD-ROM]. Atlanta.

Glanz, K., Lewis, F. M., & Rimer, B. K. (Eds.). (1997). Health behavior and health education: Theory, research, and practice (2nd ed.). San Francisco: Jossey-Bass.

Glanz, K., & Rimer, B. K. (1995). Theory at a glance: A guide for health promotion practice (NIH Publication No. 97-3896). Bethesda, MD: National Cancer Institute.

Goldberg, M. E., Fishbein, M. F., & Middlestadt, S. E. (Eds.). (1997). Social marketing: Theoretical and practical perspectives. Mahwah, NJ: Erlbaum.

Green, L.W., & Kreuter, M.W. (1999). Health promotion planning: An educational and ecological approach (3rd ed.). Mountain View, CA: Mayfield.

Maibach, E., & Parrott, R. L. (Eds.). (1995). Designing health messages: Approaches from communication theory and public health practice. Thousand Oaks, CA: Sage.

National Cancer Institute. (1993). A picture of health (NIH Publication No. 94-3604). Rockville, MD: U.S. Department of Health and Human Services.

Rimer, B. K. (1995). Audiences and messages for breast and cervical cancer screenings. Wellness Perspectives: Research, Theory, and Practice, 11(2), 13−39.

Siegel, M., & Doner, L. (1998). Marketing public health: Strategies to promote social change. Gaithersburg, MD: Aspen.

U.S. Department of Health and Human Services. (2000). Healthy people 2010 (2nd Ed.; in two volumes: Understanding and improving health and Objectives for improving health.). Washington, DC: U.S. Government Printing Office.

Overview: The Health Communication Process

The Stages of the Health Communication Process

For a communication program to be successful, it must be based on an understanding of the needs and perceptions of the intended audience. In this book, we incorporate tips on how to learn about the intended audience’s needs and perceptions in each of the program stages. Remember, these needs and perceptions may change as the project progresses, so be prepared to make changes to the communication program as you proceed. To help with planning and developing a health communication program, we have divided the process into four stages: Planning and Strategy Development; Developing and Pretesting Concepts, Messages, and Materials; Implementing the Program; and Assessing Effectiveness and Making Refinements. The stages constitute a circular process in which the last stage feeds back into the first as you work through a continuous loop of planning, implementation, and improvement.

Use this book to produce and implement a plan for a communication program. The final plan will include the following components:

• General description of the program, including intended audiences, goals, and objectives
• Market research plans
• Message and materials development and pretesting plans
• Materials production, distribution, and promotion plans
• Partnership plans
• Process evaluation plan
• Outcome evaluation plan
• Task and time table
• Budget

Because this process is not linear, do not expect to complete a stage and then move to the next, never to go back.You will be exploring opportunities, researching issues, and refining plans and approaches as your organization implements the program. This ongoing, iterative process characterizes a successful communication program.

To help work through program planning and development, we suggest many steps within each stage.You may not find all of the steps suggested in each stage feasible for your program, or even necessary. As you plan, carefully examine available resources and what you want to accomplish with the program and then apply the steps that are appropriate for you. However, if you carefully follow the steps described in each stage of the process, your work in the next phase may be more productive.

Each of the four stages is described here; they are described in more detail in the subsequent sections of this book.

Stage 1: Planning and Strategy Development

In this book, all planning is discussed within the Planning and Strategy Development section, but the concepts you learn there apply across the life cycle of a communication program. During Stage 1 you create the plan that will provide the foundation for your program. By the end of Stage 1, you will have:

• Identified how your organization can use communication effectively to address a health problem
• Identified intended audiences
• Used consumer research to craft a communication strategy and objectives
• Drafted communication plans, including activities, partnerships, and baseline surveys for outcome evaluation

Planning is crucial for the success of any health communication program, and doing careful work now will help you avoid having to make expensive alterations when the program is under way.

Stage 2: Developing and Pretesting Concepts, Messages, and Materials

In Stage 2, you will develop message concepts and explore them with the intended audience using qualitative research methods. By the end of Stage 2, you will have:

• Developed relevant, meaningful messages
• Planned activities and drafted materials
• Pretested the messages and materials with intended-audience members

Getting feedback from intended audiences when developing messages and materials is crucial for the success of every communication program. Learning now what messages are effective with the intended audiences will help you avoid producing ineffective materials.

Stage 3: Implementing the Program

In Stage 3, you will introduce the fully developed program to the intended audience. By the end of Stage 3, you will have:

• Begun program implementation, maintaining promotion, distribution, and other activities through all channels
• Tracked intended-audience exposure and reaction to the program and determined whether adjustments were needed (process evaluation)
• Periodically reviewed all program components and made revisions when necessary

Completing process evaluations and making adjustments are integral to implementing the program and will ensure that program resources are always being used effectively.

Stage 4: Assessing Effectiveness and Making Refinements

In Stage 4, you will assess the program using the outcome evaluation methods you planned in Stage 1. By the end of Stage 4, you will have:

• Assessed your health communication program
• Identified refinements that would increase the effectiveness of future program iterations

Because program planning is a recurring process, you will likely conduct planning, management, and evaluation activities described in Stages 1–4 throughout the life of the program.

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 ⁴ 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 ⁵, 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.

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

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.

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.

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.

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.

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 ² 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 ² 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 Channel

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.

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).

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?

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 ⁴ for a partnership plan form.