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A Field Guide to
Designing A Health Communication Strategy
A Resource for Health Communication Professionals
Population Communication Services
Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs
Suggested Citation:
O’Sullivan, G.A., Yonkler, J.A., Morgan, W., and Merritt, A.P. A Field Guide to Designing a Health Communication Strategy, Baltimore, MD: Johns Hopkins Bloomberg
School of Public Health/Center for Communication Programs, March 2003.
Design:
Cecilia Snyder for American Institutes for Research/Prospect Center
This publication may be reproduced without permission provided that the material is distributed free of charge and that the Johns Hopkins Bloomberg School of
Public Health/Center for Communication Programs is acknowledged. Opinions
expressed in this report are those of the authors and do not necessarily reflect the
views of the sponsoring agencies.
Prepared by American Institutes For Research/Prospect Center and Johns Hopkins
Bloomberg School of Public Health/Center for Communication Programs, with
primary support from the United States Agency for International Development
under the Population Communication Services Project (DPE–3052–A–00–0014–00).
ii
A Field Guide to Designing a Health Communication Strategy
Acknowledgments
As the field of behavior change communication continues to evolve, there is an
ongoing need among policymakers, communication professionals, and program
staff for useful tools to help them apply their communication expertise in strategic
and innovative ways.
Since 1982, the Johns Hopkins University (JHU) Population Communication
Services (PCS) project has provided assistance worldwide to hundreds of national,
regional, and local organizations seeking to improve health outcomes for specific
audiences. JHU/PCS advocates creating a dynamic synergy between communication theory and practice to advance behavior changes in the areas of family
planning (FP), reproductive health, maternal/child health, human immunodeficiency virus (HIV) acquired immunodeficiency syndrome (AIDS), and environmental health. The strategic communication process used by JHU/PCS can be extended
beyond the realm of health and can be applied to other issues relevant to developing countries, such as democracy and governance. Similarly, the behavior
change communication framework employed by JHU/PCS can be applied to
individual behavior change efforts or can be used to influence community and
social norms.
The purpose of this book is to share a set of steps and tools with those in the field
to help ensure that behavior change communication efforts are developed strategically—with participation from all stakeholders, clear goals, segmented audiences, and effective messages based on sound research and credible theory. The
text is based on many years of experience in the field and is supplemented with
real-world examples and case studies.
A Field Guide to Designing a Health Communication Strategy
iii
Produced with support from the United States Agency for International Development (USAID), this Field Guide was developed collaboratively by JHU/PCS and
American Institutes for Research (AIR)/Prospect Center. The primary authors of the
guide were Gael O’Sullivan and Joan Yonkler of AIR/Prospect Center. Win Morgan
of AIR/Prospect Center served as a coauthor. The book was designed by Cecilia
Snyder with guidance from AIR/Prospect Center, and Jack Shea provided editorial
expertise. Illustrations were provided by JHU’s Media and Materials Clearinghouse
and Where There is No Artist, by Petra Röhr-Rouendaal.
The following colleagues at JHU/PCS provided information, examples, case studies, and review comments for various sections of this book: Rob Ainslie, Jane
Brown, Maria Elena Figueroa, Michelle Heerey, Ron Hess, Larry Kincaid, Susan
Krenn, Cheryl Lettenmaier, Gary Lewis, Ben Lozare, Morden Mayembe, Juan Carlos
Negrette, Patricia Poppe, Fitri Putjuk, Walter Saba, Elizabeth Serlemitsos,
Mohammed Shahjahan, Carol Underwood, and Jim Williams.
Phyllis Tilson Piotrow, Jose Rimon, and Gary Saffitz of JHU/PCS provided overall
strategic direction, and their insights were very much appreciated. Special thanks
go to Alice Payne Merritt of the Johns Hopkins Bloomberg School of Public
Health/Center for Communication Programs (CCP), whose able guidance, enduring patience, and collegial support made this book possible.
To request additional copies of this book, please complete the order form at the
back of the book, and return it to JHU/CCP. Since this Field Guide is designed to be
a “living” document that reflects progress in the field, users of this book are encouraged to provide feedback to JHU/CCP on how future versions can be improved to
best serve program needs.
Jane T. Bertrand, PhD, MBA
Professor, Bloomberg School
of Public Health
Director, Center for
Communcation Programs
iv
A Field Guide to Designing a Health Communication Strategy
Jose G. Rimon, II
Project Director
PCS
Johns Hopkins
Bloomberg School of
Public Health
Table of Contents
Acknowledgments ................................................................................... iii
Using This Book ........................................................................................ viii
Introduction .............................................................................................. 1
Chapter 1: Analysis of the Situation ......................................................... 17
Step 1: Identifying and Understanding the Problem ...........................................20
Step 2: Determining Potential Audiences ................................................................26
Step 3: Identifying Potential Communication Resources ..................................33
Step 4: Assessing the Environment .............................................................................39
Step 5: Summarizing Strengths, Weaknesses, Opportunities,
and Threats ............................................................................................................44
Chapter 2: Audience Segmentation ......................................................... 53
Step 1: Determining Audience Segments ................................................................55
Step 2: Prioritizing Audience Segments Within the Strategy ............................61
Step 3: Identifying Influencing Audiences...............................................................68
Step 4: Painting a Portrait of the Primary Audience .............................................72
Chapter 3: Behavior Change Objectives .................................................. 77
Step 1: Stating the Behavior Change That Will Meet
the Audience’s Health Needs..........................................................................80
Step 2: Stating How Much the Behavior Will Change ..........................................81
Step 3: Deciding the Timeframe Within Which the
Expected Change Will Occur ..........................................................................83
Step 4: Linking Behavior Change Objectives to
Program Objectives ...........................................................................................84
Step 5: Identifying Indicators to Track Progress .....................................................84
A Field Guide to Designing a Health Communication Strategy
v
Chapter 4: Strategic Approach ................................................................ 93
Step 1: Reviewing the Key Issue or Problem,
Audience Segments, and Objectives ...........................................................95
Step 2: Determining Long-Term Identity and
Positioning Strategy of the Behavior...........................................................96
Step 3: Exploring Strategic Alternatives ....................................................................110
Step 4: Determining Strategic Approach and Rationale ....................................117
Chapter 5: The Message Brief ................................................................... 121
Step 1: Identifying the Key Fact ....................................................................................127
Step 2: Identifying the Promise ....................................................................................128
Step 3: Defining the Support .........................................................................................129
Step 4: Describing the Competition for the Message ...........................................129
Step 5: Developing the Statement of the Ultimate
and Lasting Impression That the Audience Will Have After
Hearing or Seeing the Message ....................................................................131
Step 6: Describing the Desired User Profile ..............................................................132
Step 7: Identifying the Key Message Points .............................................................133
Chapter 6: Channels and Tools ................................................................. 139
Step 1: Choosing the Channels That Are the Most
Likely To Reach the Intended Audience ....................................................141
Step 2: Determining Tools ...............................................................................................153
Step 3: Integrating Messages, Channels, and Tools ...............................................162
Chapter 7: Management Plan................................................................... 165
Step 1: Identifying the Lead Organization and
Collaborating Partners .....................................................................................167
Step 2: Defining the Roles and Responsibilities
of Each Partner ....................................................................................................170
Step 3: Outlining How the Partners Will Work Together ......................................172
Step 4: Developing a Timeline for Implementing
the Strategy............................................................................................................173
Step 5: Developing a Budget.........................................................................................176
Step 6: Planning To Monitor Activities .......................................................................179
vi
A Field Guide to Designing a Health Communication Strategy
Chapter 8. Evaluation Plan ....................................................................... 193
Step 1: Identifying the Scope and Type of Evaluation .........................................195
Step 2: Planning for Monitoring and Impact Assessment ..................................197
Step 3: Identifying the Evaluation Design and
Sources of Data....................................................................................................208
Step 4: Tailoring the Evaluation to the Specific Situation .................................215
Step 5: Deciding Who Will Conduct the Evaluation .............................................216
Step 6: Planning To Document and Disseminate
Evaluation Results ..............................................................................................217
Chapter 9. Summary ................................................................................. 221
Staying on Strategy ..........................................................................................................222
The Strategy Test ................................................................................................................224
Why Ask “Why?” .................................................................................................................225
Strategy Summary Outline ............................................................................................226
Strategy Review .................................................................................................................229
Appendices ............................................................................................... 1-1
1: Behavior Change Theories
2: Case Studies
3: Glossary
4: Bibliography
A Field Guide to Designing a Health Communication Strategy
vii
Using This Book
The purpose of this strategic communication Field Guide is to provide practical
guidance to those who are in a position to design, implement, or support a strategic health communication effort. The emphasis of the guide is on developing a
comprehensive, long-term approach to health communication that responds
appropriately to audience needs. The guide is based on the idea that effective
strategic communication is based on the convergence of “senders” and “receivers”
in which the differences between the two begin to disappear. It is also based on
the recognition that communication, to be effective, must not be treated as a
“spare” wheel, used only when the efforts start to falter or fail, but as a “steering”
wheel that can serve as a basis for making informed choices. Strategic communication is collaborative and participatory in nature, follows a sound
decisionmaking process based on science, and creates sustainable efforts that
improve health outcomes.
The guide has three primary audiences:
l Program managers in developing countries who are responsible for designing
and implementing health programs.
l Communication specialists who are responsible for designing and executing
health communication strategies and for developing materials and messages.
l Policymakers and representatives of funding agencies who determine the
level of support for health communication strategies and the degree to which
communication efforts are integrated into other health program initiatives.
viii
A Field Guide to Designing a Health Communication Strategy
A program manager should find this book helpful in understanding the context
within which communication professionals design and implement health communication strategies. Program managers may find that issues identified in the
course of developing one health communication strategy have an impact on
other health programs on which they are working.
For a communication specialist, this book will provide a comprehensive set of
practical tools and steps to guide efforts to improve health among specific populations. Each chapter provides worksheets, examples, and tips to help the reader
apply the concepts and processes described.
For a policymaker, this book will demonstrate the role that strategic communication can play in addressing complex health problems. It will also emphasize the
need to continuously apply strategic communication principles to achieve longterm behavior change objectives.*
The process of designing a health communication strategy is participatory in
nature. Typically, a team of individuals will be involved in designing the strategy.
The communication specialist is often the primary staff person responsible for
creating the process in which all stakeholders, including the beneficiaries, participate in designing the strategy. The communication specialist works in close collaboration with the other stakeholders and team members, which at the national
or subnational level may include a variety of public and private sector agencies,
such as the Ministry of Health (MOH), service delivery groups (e.g., clinics, doctors’
offices, nurse-midwife associations), clients or audience members, advertising
agencies, research organizations, public relations (PR) firms, and other technical
consultants with relevant expertise.
As you read this book, keep in mind that it is designed to be a catalyst for your
own creative thinking. The steps and worksheets provided are flexible guidelines
that you can—and should—adapt to fit your own particular situation. The emphasis is on practical tips and advice as well as on examples to illustrate how to apply
*
The term “behavior change” is used in this book in a broad sense. It includes reinforcing existing behaviors,
when desired, or developing new behaviors when they do not exist.
A Field Guide to Designing a Health Communication Strategy
ix
Icon Key: Icons will appear throughout the
field guide to help you with the process of
developing a communication strategy.
Example
Worksheet
Tip
the concepts in real-life situations. The book contains summary sheets at the end
of each chapter that are designed to be compiled and used together in writing a
health communication strategy. It is important to note, however, that designing a
strategy is not a linear process. Strategy development is iterative in nature, and
you will likely have to revisit decisions made early in the process as more information becomes available and as you gain additional insight from and about the
audience.
To aid you in developing a strategy, the field guide offers illustrative examples,
worksheets, tips and other special features that can be easily identified through
the use of icons. In addition, every chapter ends with a Uganda communication
strategy summary statement that capsulizes the chapter’s main points. The
Uganda summary example can be identified through its own icon.
We hope that after you have read this book, you will have found it a useful tool
that helps design and implement health communication efforts that are truly
strategic.
Checklist
Questions to ask yourself
Important note
Uganda summary example
x
A Field Guide to Designing a Health Communication Strategy
Introduction
By the end of this introduction, the reader will understand:
l
l
l
l
The components of a communication strategy outline
Why the word “strategic is important in health communication
The importance of having a vision
The Process of Behavior Change (PBC) framework and the “P”
Process
l The definition and characteristics of strategic health
communication
As you embark on the process of developing a health communication strategy,
you will need to have a framework in mind to help organize the information
gathered. The following outline lists the components that should be included in
an integrated, multiyear, multiphased communication strategy. The elements in
this outline will be discussed in detail in the following chapters. You will note that
the communication strategy outline does not exactly match the chapter titles and
chapter subheadings. This discrepancy is intentional, as the communication
strategy outline is intended to be a synthesis of the strategic design process, while
the chapters include detailed steps to follow at each stage of the process.
A Field Guide to Designing a Health Communication Strategy
1
Communication Strategy Outline
I.
Analysis of the Situation
A. Purpose (Health situation that the program is trying to improve)
B. Key Health Issue (Behavior or change that needs to occur to improve the
health situation)
C. Context (Strengths, Weaknesses, Opportunities, and Threats [SWOT] that
affect the health situation)
D. Gaps in information available to the program planners and to the audience
that limit the program’s ability to develop sound strategy. These gaps will
be addressed through research in preparation for executing the strategy
E. Formative Research (New information that will address the gaps identified
above)
II.
Communication Strategy
F.
G.
H.
I.
J.
K.
III.
Management Considerations
A.
B.
C.
D.
IV.
2
Audiences (Primary, secondary and/or influencing audiences)
Objectives
Positioning and Long-Term Identity
Strategic Approach
Key Message Points
Channels and Tools
A Field Guide to Designing a Health Communication Strategy
Partner Roles and Responsibilities
Timeline for Strategy Implementation
Budget
Monitoring Plan
Evaluation—
Tracking Progress and Evaluating Impact
Overview
Consider, for example, the way an architect and a builder work together to produce a building for their client. Suppose, for example, that a city in your country
needs a new primary school. The Ministry of Education is the client. The Ministry
staff consult with an architect and discuss the overall characteristics of the need:
the number of students expected, the number of different classes, the location of
the school, and allocated budget and timeframe for completing the project. The
key stakeholders work together as a team to clarify what is needed.
The architect then analyzes the situation further, for example, specifying the
number of classes, the estimated number of boys, girls, teachers, and administrators, the number of floors the school should have, the number of offices for staff,
and the placement of hallways and stairways. The architect develops a strategic
design for the school, a design that meets the specified needs and is at the same
time feasible in terms of cost, materials, and labor.
TIP: As you read this book,
look for “your friend the
architect”at the beginning of
each chapter. His or her role in
designing the school will help
you understand the ideas
explained in the chapter.
In other words, the architect interprets data as well as the client’s needs and creates
a unique master plan, specifications, and detailed blueprints. The architect is a
strategic designer who works with his client to ensure that the client’s input is
taken into account. The builder’s role is similar to that of an implementer, who
develops a tactical plan to execute the strategy and ideas in the architect’s blueprint, while staying within the budget and meeting deadlines. He or she implements through a team of subcontractors: engineers, electricians, plumbers, carpenters, and designers. Without an overall strategy, a master plan, and detailed blueprints for the workers to follow, the finished building might look more like a house
than a school.
A Field Guide to Designing a Health Communication Strategy
3
Why the Emphasis on Strategic in Health Communication?
Strategic design is the hallmark of successful health programs. Over the past 20
years, health communicators have come to realize that collaboratively designed,
implemented, and evaluated health communication strategies will help achieve
the goal of improving health in a significant and lasting way by empowering
people to change their behavior and by facilitating social change. Sound communication strategies provide coherence for a health program’s activities and enhance the health program’s power to succeed. Strategic communication is the
program’s steering wheel, guiding it towards its goals. Strategic communication is
also the glue that holds the program together or the creative vision that integrates
a program’s multifaceted activities.
Prior to this era of strategic design, health communication in the 1960s was largely
characterized as the “medical era.” It operated under the assumption that, “If we
build it they will come.” This medical monologue model is often represented by
the image of a physician lecturing or talking to patients. The 1970s recognized the
need to reach beyond the clinics. Borrowing mainly from the agricultural extension model, field work was mostly supported by print materials and visual aids.
Mass media impact was considered modest due to limited reach. This period was
mainly described as the “field era,” moving from monologue to dialogue (Rogers,
1973). The 1980s saw the proliferation of social marketing with a move from
nonpaying clients to customers who ask and pay for services, and the use of
integrated marketing communication approaches borrowed from the commercial
sector. This period may be called the “social marketing” era. Health communication
in the 1990s to the present has evolved into what may be called the “strategic era,”
characterized by multichannel integration, multiplicity of stakeholders, increased
attention to evaluation and evidence-based programming, large-scale impact at
the national level, more pervasive use of mass media, and a communication
process in which participants (“senders and receivers”) both create and share
together (Rimon, 2001).
4
A Field Guide to Designing a Health Communication Strategy
The new, strategic era of communication is distinguished by several other important characteristics:
l Previously separate services are more integrated. It is becoming more common
to find a variety of services, such as family planning (FP), maternal and child
health, and sexually transmitted disease (STD) treatment and prevention
offered at the same location.
l Integration is also occurring among communication channels. Mass media,
community-based, and interpersonal channels are being used strategically to
reinforce one another and maximize impact.
l The role of the electronic media is becoming more prominent. New technologies are being added to the communication mix to reach more people in
innovative ways.
l Decentralization has shifted control and decisionmaking from the central
government to local communities.
l A multiplicity of stakeholders is involved at every step in the strategic communication process.
l Audience segmentation is becoming more sophisticated, which allows for
more tailored messages to audiences.
l A recognition that households and communities are producers of health and
play a different role in improving health than does the health service delivery
system.
l Increased attention to evaluation and evidence-based programming is providing much-needed data upon which to base decisions (Rimon, 2001).
Strategic Vision
The overarching component of a strategically oriented health communication
program is a powerful, well-articulated, long-term vision.
A Field Guide to Designing a Health Communication Strategy
5
Example
The Coalition for Healthy Indonesia envisioned
“healthy individuals, families, and communities
in a healthy nation.” By 2010, their mission at
the individual/household level is that individuals and households (2000):
l
Are receiving health-related messages
through multiple channels.
l
Are knowledgeable about personal and
public health problems, are knowledgeable of types and sources of services to
prevent diseases and promote health, and
will be motivated to adopt healthy
behaviors and practices.
l
Understand their rights to a healthy
environment and to a basic package of
accessible, affordable, quality health
services.
l
Are participating in social, cultural,
religious, and other associations that
include health information, promotion,
and advocacy on their agendas.
l
Are exhibiting healthy behavior and
avoidance of health risk.
Every program needs a long-term vision. It can empower people
because it shows what is important. It can stimulate teamwork
because it shows what everyone needs to do. And it can
strengthen organizations because it generates new energy.
—(Piotrow, Kincaid, Rimon, & Rinehart, 1997).
A good strategic vision is one that is shared among all stakeholders. It is inspirational and concrete, suggests what people need to do, and engages participants.
The strategic vision should paint a mental picture of a desired scenario in the
future. It should reflect the core values and beliefs shared by team members, such
as the concept of people acting as producers of their own health. A good strategic
vision focuses not on the size of the problem at hand but on the possibility of
sharing in the creation of a better future.
[I have a vision of a society where] Nontechnical, everyday
people are able to easily use technology.
—Steve Jobs, Chairman, Apple Computers
I have a vision. I want to see an Indonesia twenty years from now
in which 80 percent of FP services are provided by the private
sector and 20 percent by the government, with government
serving only those who are poor or cannot afford to pay. Work
with us to make this vision a reality.
—Dr. Haryono Suyono, Chairman of the Indonesian National
Family Planning Coordinating Board (BKKBN), 1986
Good strategic visions are also practical and set the team’s sights on what is considered possible. Visions considered to be beyond the realm of possibility are
often disregarded as a leader’s fanciful dreams. A dream that is not thought
possible to achieve in real life is ignored.
6
A Field Guide to Designing a Health Communication Strategy
Successful elements of strategic visions:
l
l
l
l
Build on the core strengths of the program.
Reinforce a program’s history and culture while striving to achieve new goals.
Clarify the purpose and direction of communication activities.
Emphasize the power of teamwork.
The true test of a strategic vision is this: Does it provide direction, communicate
enthusiasm, kindle excitement, and foster commitment and dedication? If it does,
then the strategic vision can provide several benefits, including:
l Empowering the team to work toward a common goal because the vision
shows what is important. A vision stimulates teamwork because it shows
what everyone needs to do. Inspirational visions energize program activities,
giving them new strength upon which to draw when implementing strategies.
l Helping team members determine priority actions in relation to the program.
A vision helps people focus on attaining certain outcomes and on acting in ways
that will achieve those outcomes. When a clear vision is in place, it concentrates
power by avoiding arguments about whether to do something or not.
l Claiming the future. A vision supplies a calling for team members, creating
meaning for their work and a justifiable pride. By comparing the present with a
desired future, a vision creates a useful tension between what exists now and
how the team would like the world to be. It helps people recognize barriers to
achieving the desired state or condition by vividly describing the desired state
and making it seem attainable.
Effective communication efforts develop vision statements, with the participation
of stakeholders and beneficiaries, to set forth the direction that the team should
follow and to define clearly and succinctly how the communication activities will
affect the broader program environment. Sometimes a program mission statement is also developed to translate the overall thrust of the strategic vision into
more management-oriented goals and objectives. The vision statement should be
A Field Guide to Designing a Health Communication Strategy
7
a brief but compelling description of how the health situation or condition will
look after the communication activities have successfully reached their conclusion. This statement should become the catalytic force or organizing principle for
all subsequent strategic communication activities carried out by the team.
A Framework for Strategic Design
Many theoretical models and frameworks can guide the strategic design process
(see appendix 1). This book describes a framework known as the PBC; a framework
that has been used successfully in the field of health communication for many
years.
Process of Behavior Change
The PBC framework recognizes that behavior change—and thus communication
intended to influence behavior change—is a process. People usually move
through several intermediate steps in the behavior change process (Piotrow et al.,
1997). In addition, there is typically a correlation between increases in behaviors,
such as partner-to-partner dialogue about reproductive health and subsequent
use of reproductive health methods.
Furthermore, this framework suggests that people at different stages constitute
distinct audiences. Thus, they usually need different messages and sometimes
different approaches, whether through interpersonal channels, community channels, or mass media.
An audience can generally be described as:
l Preknowledgeable—Is unaware of the problem or of their personal risk.
l Knowledgeable—Is aware of the problem and knowledgeable about desired
behaviors.
l Approving—Is in favor of the desired behaviors.
l Intending—Intends to personally take the desired actions.
l Practicing—Practices the desired behaviors.
l Advocating—Practices the desired behaviors and advocates them to others.
8
A Field Guide to Designing a Health Communication Strategy
It is important to understand where the audience is in relation to these elements
before embarking on a strategy. Progress from one element to the next increases
the probability of behavior change and continuation.
Public policy and communication strategies influence both individual and collective change, establishing new community norms and, over time, providing support
for stronger and more effective policies and programs. The PBC can play an important role in creating an enabling environment to support new behaviors. Advocacy is a key element in this process and can help make the desired behavior
sustainable.
The PBC framework can work effectively together with a comprehensive project
design and implementation approach known as the Processes and Principles of
Health Communication—the “P” Process (Piotrow et al., 1997). The “P” Process was
developed in 1983 and is depicted by the figure on the right.
The “P” Process steps are:
1. Analysis—
Understand the nature of the health issue and barriers to
change: listen to potential audiences; assess existing program policies, resources, strengths, and weaknesses; and analyze communication resources.
2. Strategic Design—Decide on objectives, identify audience segments, position
the concept for the audience, clarify the behavior change model to be used,
select channels of communication, plan for interpersonal discussion, draw up
an action plan, and design for evaluation.
3. Development, Pretesting, Revision, and Production—Develop message
concepts, pretest with audience members and gatekeepers, revise and produce
messages and materials, and retest new and existing materials.
4. Management, Implementation, and Monitoring—Mobilize key organizations;
create a positive organizational climate; implement the action plan; and
monitor dissemination, transmission, and reception of program outputs.
5. Impact Evaluation—Measure impact on audiences, and determine how to
improve future projects.
6. Planning for Continuity—Adjust to changing conditions, and plan for
continuity and self-sufficiency.
A Field Guide to Designing a Health Communication Strategy
9
For almost two decades, the “P” Process has provided a solid framework that is
easily applied to strategy development, project implementation, technical assistance, institution building, and training. This framework is used collaboratively as a
guide by the various stakeholders involved in designing and implementing
strategic health communication programs.
Several qualities of the “P” Process make it a very useful tool for program planning
and implementation:
l It is systematic and rational.
l It is continually responsive to changing environments and can be adapted to
new research findings and data.
l It is practical for field applications at all levels.
l It is strategic in setting and pursuing long-term objectives.
When followed in sequence, the six steps of the “P” Process are helpful in developing effective program design. The focus of this book is on step 2—strategic design.
When reading through each chapter, keep step 2 of the “P” Process in mind to
reinforce the level of strategic decisionmaking that is required. The focus is on
designing, not implementing, a program.
Applying Step 2 of the “P” Process to design a communication strategy will also
require using information obtained from conducting an analysis of the situation.
Similarly, the strategic design process will require thinking ahead to issues involving the other steps of the “P” Process.
Definition and Characteristics of Strategic Health Communication
Strategic communication is based on a combination of:
1.
2.
3.
4.
5.
10
Data, ideas, and theories integrated by
A visionary design to achieve
Verifiable objectives by
Affecting the most likely sources and barriers to behavioral change, with the
Active participation of stakeholders and beneficiaries (Piotrow & Kincaid, 2001)
A Field Guide to Designing a Health Communication Strategy
In other words, strategic communication takes advantage of science and facts, in
addition to ideas and concepts, to set forth a long-term vision and realistic behavior change objectives to address a health issue. The vision and objectives are
developed through dialogue with the intended audience and various stakeholders.
In the dialogue process, both the “senders” and “receivers” are affected, moving
toward mutual adjustments and convergence. A blending of science and art is
essential to crafting a sound strategy.
Specific Characteristics
For communication to be strategic, it should be:
1. Results-oriented. The ultimate proof that a strategic communication effort is
effective lies in health outcomes. Research should be designed to gauge
increases in audience knowledge, approval, and adoption of healthy behaviors. Equally important is increasing the capacity of local partners to carry out
these kinds of programs on their own.
2. Science-based. A science- and research-based approach to communication
requires both accurate data and relevant theory. It begins with formative
research and adequate data to define a specific health problem, identify
feasible solutions, and describe the intended audience. This approach relies on
the health sciences to make sure that the content and context of a strategic
communication effort are correct. For example, in Brazil a series of focus
groups was conducted with potential audience members to identify the sexual
practices of street children, in an effort to determine the risk of contracting HIV/
AIDS. Results of the focus groups were compiled and analyzed according to
several variables, such as number of partners, type of partners (e.g., same sex,
commercial sex workers), type of sexual contact (e.g., oral, anal, vaginal), frequency, and reasons for the occurence of the sexual activity. This analysis
formed the basis for developing a communication strategy that was designed
to reduce HIV/AIDS transmission among Brazilian street children.
A Field Guide to Designing a Health Communication Strategy
11
Strategic communication also depends upon appropriate social science models or
theories of behavior change, which might include:*
l
l
l
l
l
Stages of change/diffusion theories
Cognitive theories
Emotional response theories
Social process and influence theories
Mass media theories
3. Client-centered. A client-centered approach requires starting with an understanding from the client’s point of view of what the health needs are. Discussions with the potential audience provide insights about those health needs
and the barriers to meeting the expressed needs. Through research, especially
qualitative research and participatory learning approaches (PLA), members of
the intended audience can help shape appropriate messages and can offer
insights for other communication-related decisions that need to be made. A
client-centered approach also implies understanding strategic changes that
can affect the balance of power, including the gender balance of power, in
service programs. For example, encouraging greater community participation,
allowing clients to choose their own methods and treatment, or having clients
set the program priorities for health services are ways to strengthen a clientcentered approach.
4. Participatory. Strategic communication promotes participatory decision
making by stakeholders and beneficiaries in all stages of the “P” Process,
including planning, implementation, and evaluation. It is critical to involve the
key stakeholders at the inception of the strategy design process. Building a
sense of ownership will help ensure that the strategy will be implemented in a
meangingful way. See the resource book titled How To Mobilize Communities
for Health and Social Change published by Johns Hopkins Bloomberg School
of Public Health/CCP in collaboration with Save the Children for further information on this topic.
*See Appendix 1,“Behavior Change Theories”, for more information.
12
A Field Guide to Designing a Health Communication Strategy
5. Benefit-oriented. The audience must perceive a clear benefit in taking the
action promoted by the communication effort. This characteristic is closely
associated with the long-term identity and with the notion of positioning,
which is discussed in chapter 4.
6. Service-linked. Health promotion efforts should identify and promote specific
services, whether through health care delivery sites, providers, brand name
products, or ways to increase access to services and products. This approach
reinforces the concept of individual self-efficacy or the ability to resolve a
problem oneself and also supports the concept of collective self-efficacy or the
ability of a community to assert its will.
7. Multichanneled. Effective strategic communication uses a variety of means.
Communication strategies often integrate interpersonal communication (IPC),
community-based channels, and various media to create a dynamic, two-way
exchange of information and ideas. Additionally, research has shown that
often the effectiveness of messages being understood and acted upon increases with the number and type of channels used to disseminate them. This
is sometimes called the “dose” effect. Like a good carpenter who knows when
to use a hammer or a chisel, an effective communicator does not argue
whether mass media is better than IPC. Each tool has a role, and the communicator uses the tool or combination of tools that is most appropriate for the
situation.
8. Technically high quality. The strategic health communicator works with
competent agencies and individuals to:
l Design high-quality communication messages and materials.
l Produce professionally designed materials.
l Ensure that community-based activities are appropriate and well
done.
l Strengthen counseling skills.
A Field Guide to Designing a Health Communication Strategy
13
Investing resources wisely to design effective strategies and materials at the
outset will ultimately be more economical than cutting corners and producing
a campaign that conveys a substandard image. Simply put, quality costs less.
Another important point to remember is that focus demands sacrifice. Strategic communication is specific in what it attempts to accomplish and does not
try to be all things to all people.
9. Advocacy-related. Advocacy occurs on two levels: the personal/social level
and the policy or program level. Personal and social advocacy occurs when
current and new adopters of a behavior acknowledge their change and
encourage family members and friends to adopt a similar behavior. For example, individuals who have quit smoking often advocate to other smokers
that they should quit.
Policy or program advocacy occurs when the advocacy is aimed at change in
specific policies or programs. Seeking to influence behavior alone is insufficient if the underlying social factors that shape the behavior remain unchanged. Behavior change objectives will address individual behavior, but
policies, laws, strategies, and programs may also need to be influenced, so that
they support sustained behavior change. The two levels of advocacy reinforce
one another.
10. Expanded to scale. It is easy to ensure the effectiveness of a communication
intervention when applied to a small village or district. The real challenge is
whether the intervention can effect change on a much wider scale beyond a
village or the usual pilot areas. Communication strategies can be scaled up to
reach ever-larger populations and areas. In general, mass media interventions
are easier to scale up than community or interpersonal interventions. The latter
two can be costly to scale up and can be difficult to monitor.
14
A Field Guide to Designing a Health Communication Strategy
11. Programmatically sustainable. Strategic communication is not something
that is done once. A good strategy continues over time as it reaches new
audience members and adapts to changes in the environment. Continuity
must be in place at the organizational level, among leaders, and with the
donor community, to ensure that strategic communication efforts achieve
long-term impact.
12. Cost-effective. Strategic communication seeks to achieve healthy outcomes in
more efficient and cost-effective ways. Strategy designers must also examine
costs by the type of intervention, to try to achieve the optimal mix of activities
and channels.
Conclusion
A sound and effective health communication strategy should be based on an
overarching vision of what needs to be achieved to address a particular health
issue. The strategy should be integrated, have a long-term focus, should be responsive to individual behavior change needs, and should maximize the potential for
change on a broader societal level. Frameworks such as the PBC and the “P” Process for project design and implementation are useful tools to guide the process
of developing health communication strategies that get results. A combination of
science, facts, vision, stakeholder buy-in, and audience participation is essential for
success.
A Field Guide to Designing a Health Communication Strategy
15
References
Coalition for Healthy Indonesia Strategy Document (2000). (pp. 8).
Piotrow, P. T., Kincaid, D. L., Rimon, J. G. I., & Rinehart, W. (1997). Health Communication: Lessons from Family Planning and Reproductive Health. Westport, CT: Praeger
Publishers.
Piotrow, P. T. & Kincaid, D. L. (2001). Strategic Communication for International
Health Programs. In Rice and Atkin (Ed.), Public Communication Campaigns (3rd
ed., pp. 251). Sage Publications.
Rimon, J. G. I. (2001). Behavior Change Communication in Public Health. In Beyond
Dialogue: Moving Toward Convergence. Managua, Nicaragua: Presented at the
United Nations Roundtable on Development Communication.
16
A Field Guide to Designing a Health Communication Strategy
1
Chapter 1
Analysis of the Situation
By the end of this chapter, the reader will be able to conduct
an analysis of a particular health problem by completing the
following steps:
Step 1:
Identifying and Understanding the Problem
Step 2:
Determining Potential Audiences
Step 3:
Identifying Potential Communication Resources
Step 4:
Assessing the Environment
Step 5:
Summarizing the Strengths and Weaknesses of the
human, technological, and financial resources available
as well as the Opportunities for and Threats to effective
health communication in the current environment.
A Field Guide to Designing a Health Communication Strategy
17
Overview
After a preliminary meeting with the client, the next step of your friend the architect is to meet his client, the Ministry of Education, at the site of the proposed
school to look over the situation, analyze it, and make some preliminary observations. This analysis will help shape his plan for designing the school. Working with
the key stakeholders, the architect will refine many of these initial findings over
time.
For example, the architect looks over the building site, notes whether it is flat or
hilly, notes whether it is covered with trees or open space, and decides whether
heavy machinery can easily access the area. In other words, he identifies any
problems, and he notes their extent and the difficulty or ease with which they can
be overcome. He also begins to think of how teachers, students, and parents will
view this space. He thinks about their needs, such as natural light for the classrooms, air circulation, and ample room for sports activities and games.
With a mind to available resources, he examines the infrastructure to ensure that
water and electricity are readily available. He begins to think about engaging a
builder who has experience building a school and who has access to the kinds of
subcontractors who will do their jobs most efficiently, for example, engineers,
electricians, plumbers, carpenters, interior designers, and landscapers.
In much the same way, as you and your team begin the process of designing your
health communication strategy, your first undertaking is the analysis of the situation.
18
A Field Guide to Designing a Health Communication Strategy
This chapter offers guidance, practical tools, and approaches to help your team work
through the five steps of developing an analysis of the situation. At the end of this
chapter and at the end of most chapters, you will find a summary worksheet. The
Delivery of Improved Services for Health (DISH) project in Uganda is used
throughout this book to provide a comprehensive example showing how these
summary worksheets are to be completed. When compiled as a set, the information
in these summary worksheets will provide a concise overview of the key strategic
considerations upon which you will base your strategy. Once you and your team
have completed the analysis of the situation, you will have a more informed basis
for proceeding to the next stages of strategy development.
Developing a health communication strategy demands in the first place that you
understand all the factors that may have an impact on communication efforts.
Such an understanding, known as the analysis of the situation, serves as the guide
for all communication activities. Health communicators use the analysis of the
situation to observe, gather, organize, and assess relevant factors. These factors
include the nature and extent of the problem, audience characteristics, available
resources, and the communication environment. Thus, although the analysis of the
situation is not technically a part of step 2 of the “P” Process, which is the concern
of this book, its importance warrants inclusion here of the information that will
help you work through step 2.
The term “analysis of the situation” can be defined and used in many different
ways. In the context of this Field Guide, the term “analysis of the situation” refers to
the process of analyzing factors related specifically to the development of a
communication strategy.
One result of conducting an analysis of the situation is an understanding of the
gaps in your knowledge base that will need to be filled in order to move ahead
with the strategy development process. A quantitative measure of the current
situation as it relates to the audience is typically conducted in the form of a
baseline survey. Additional insights are often gained by using qualitative techniques, such as focus groups. The “Tips on Information Collection Methods” in
this chapter provide brief descriptions of some of the more commonly used
1
TIPS:Do’s and Don’tsTo Keep in Mind as
YouAnalyzeYourSituation
Do’s
Develop a clear outline before gathering
information. It will help keep you focused on
the important issues.
Ensure that the analysis will inform the
decisions of strategic components (identification of audiences, objectives, etc.) that will be
made later in the process.
Set a timetable for the process, and stay within
the parameters of the timetable.
Read, listen, and observe many sources of
information. No single source of information
will provide you with all the information that
you need.
Keep your summary statements as objective as
possible.
Keep a notebook for jotting down ideas for
strategy or tactics. Also, keep a list of challenges and opportunities that arise from
reviewing the data. Your notebook and the list
will give you a head start in writing the plan.
Document your progress by making note of
your key sources of information, so that you
can refer to them in future discussions.
A Field Guide to Designing a Health Communication Strategy
19
qualitative techniques. As you work through the steps in this chapter, keep a list
of the gaps and questions that you will need to answer through formative or
preliminary research.
Even under the best of circumstances, it is unlikely that you will have a complete
set of data to inform your decisions. The process of designing a health communication strategy is part art and part science. You will have to make judgments
throughout the process to decide how much importance to assign a particular
issue as well as to decide which approaches and strategies will work best.
Step 1
Identifying and Understanding the Problem
TIPS:Do’s and Don’tsTo Keep in Mind as
YouAnalyzeYourSituation
Don’ts
Do not write objectives and strategies as part
of the analysis of the situation. Keep your
analysis as factual as possible. Appending
objectives and strategies tempts you to adjust
the analysis to fit the proposed strategy and
objectives.
Do not give up if you cannot find the information that you need. Call on contacts, visit
libraries, and consult collaborating organizations. The answers are there, but you will not
always have data to substantiate every finding.
At times you will have to rely on the views of
knowledgeable individuals and your own
observations, in addition to research data, as
you begin to understand the situation.
20
The first step in conducting the analysis is to identify and understand the specific
health problem that will be the focus of the proposed communication effort.
Consider the health problem in the context of the overall strategic vision. To define
an effective communication strategy, you will need to compare the shared vision
with your understanding of the present situation, and you will need to understand
why there is a difference between the two.
Usually in a national health communication strategy and especially when health
programs and services are integrated, a number of different problems will be
identified that need attention. This series of problems is often dealt with over time
using phasing or sequencing techniques, layering of service delivery and communication channels to ensure maximum coverage, and clustering of health behaviors to promote integration.
However, it is important to identify the key problem related to each health behavior included in the strategy and to craft appropriate objectives and messages for
each of these problems. The key to a successful health communication strategy is
to focus on one specific problem at a time. Addressing too many problems at one
time or too general a problem often creates messages that confuse or overwhelm
the audience, limiting the impact of the communication.
A Field Guide to Designing a Health Communication Strategy
In some cases, you will not need to identify the problem. An existing strategy may
already point to what needs to be done, whether as directly related to an overall
program objective (see chapter 3, step 4) or, ideally, as related to the overall strategic vision, articulated by key leaders and policymakers. However, if the problem is
already identified, it is important to verify that it is still valid. You want to avoid
beginning with a preconceived notion about the problem that may be based on
old information, political concerns, or limited understanding of stakeholder
perceptions.
1
Understanding the Health Problem
Understanding the health problem means having a clear perception of its extent
and severity as well as of the behaviors that will prevent and treat the problem. In
the course of gaining such an understanding, you will become familiar with the
available sources of information about the problem.
The Extent of the Health Problem
Estimating the extent of a health problem is a factor in deciding how to communicate about it. Look for two key measures of extent: prevalence and incidence.
These measures are commonly available through the MOH.
Prevalence measures the proportion—usually, the percentage—of people in a
defined population who have the problem at a given time. For example:
l Last year, 65 percent of all sex workers in the northern region had gonorrhea.
l This month, 30 percent of all pregnant women in the eastern region between
the ages of 18 and 25 years were anemic.
Since prevalence is constantly changing, public health practitioners use the most
recent measurement in combination with incidence to estimate the extent of the
problem. Incidence measures the rate of new cases of a particular health problem
per thousand people in the population. For example:
l The number of cases of gonorrhea in the northern region is increasing by 10
percent per year.
A Field Guide to Designing a Health Communication Strategy
21
l The number of anemic pregnant women seen in antenatal clinics in the eastern region is increasing by 2 percent per year.
l Measurements of incidence help to estimate what the prevalence rate will be
in the future without any intervention. This information is usually available
from the MOH or from programs or projects dealing with the health problem.
The Severity of the Health Problem
Closely related to the extent of the health problem is its severity, which is
measured as:
l Mortality, or the number of people who die from the problem
l Morbidity, or the number of people who are permanently or temporarily
disabled by the problem
l The cost of the problem to an individual, the individual’s family, and society as
a whole
The MOH usually compiles information about a specific health problem’s rates of
mortality and morbidity. Organizations advocating attention to a health problem
often compile information about its costs to individuals and society. When defining the severity of a health problem, it is usually helpful to put the problem in
perspective by comparing its effects to those of other common diseases.
The data that you have gathered on the problem’s extent and severity will play an
important role when you develop your justification for spending resources to
prevent and treat the problem.
22
A Field Guide to Designing a Health Communication Strategy
1
Desired Prevention and Treatment Behaviors
Several potential behavior changes may be appropriate responses to a health
problem. Look beyond the factual information about the health problem to truly
understand the broader environmental context. Pinpointing the desired behavior
changes at the beginning of the planning process will help you and your team
design an appropriate strategy.
To be sure that your team is planning to communicate appropriate prevention
and treatment behaviors, talk with experts in the MOH, in the private sector, and in
your organization, and ask whether the desired behavior is, for example, to:
l Improve dietary habits.
l Visit a clinic.
l Use a particular product.
In this area, ascertaining the views of the potential audience is critical. Do they
perceive the problem in the same way as the experts? What would they like to see
happen to address the health problem? Gaining understanding about the
audience’s perceptions may lead you to design communication interventions
geared toward other groups, such as service providers or key influentials. Similarly,
talking to health care providers may yield important insights about the health
problem that may influence the strategy development process. Such insight may
also demonstrate the need to conduct policy advocacy or media advocacy to
address the health needs of the audience in a comprehensive way.
Information Sources
The information that you have gathered by identifying the extent and severity of
the problem and the desired prevention and treatment behavior will inform your
communication strategy. Review example 1.1 below, and then complete worksheet
1.1 to organize and summarize the information that you have collected.
Note: For Worksheet 1.1 and for all worksheets
in this book, use real data whenever possible.
If the specific information requested in the
worksheet is not available, complete the
worksheet to the best of your ability.
A Field Guide to Designing a Health Communication Strategy
23
Example: Nicaragua (Informe de . . . 2001)
Project Background: In October 1998, Hurricane Mitch cut an unprecedented
swath of destruction through the heart of Central America, leaving thousands
dead and billions of dollars (USD) in damage. In Nicaragua, more than 800,000
people suffered some degree of damage to their water supply system due to the
effects of the hurricane. Thanks to the rapid intervention by the Government of
Nicaragua and generous international assistance, the country quickly entered a
reconstruction phase.
USAID/Nicaragua funded a water and sanitation component as a crucial piece of
their Hurricane Mitch Reconstruction Project. Under this component, the Environmental Health Project (EHP) is responsible for the construction and repair of the
community water and sanitation infrastructure. The Mitch Project included a
behavior change communication component to promote better hygiene and
sanitation practices. A coalition of various partner organizations implemented the
project, with the ultimate goal of reducing the incidence of diarrheal diseases in
the areas affected by Hurricane Mitch.
This national effort was named the Blue Star Campaign, one of the most comprehensive diarrhea prevention programs undertaken at the national level. The local
population understood the value of health to the family, and the Blue Star symbol
represented the dreams or goals of the audience to achieve a better quality of life.
There were knowledge barriers, however, in that many people did not understand
the links between bacteria on hands, handling of food, and the onset of diarrhea.
Focusing on blocking the main pathways of diarrheal disease transmission, under
the Blue Star Campaign, a number of interdependent components worked synergistically to implement an effective diarrhea prevention program.
24
A Field Guide to Designing a Health Communication Strategy
1
Example 1.1: Health Problem Analysis Worksheet
Instructions: Identify up to three key health problems that you might address. Use
available data to estimate the prevalence, incidence, and severity of each problem.
List the prevention and treatment methods recommended to the population by
the program or organization with which you are working.
Worksheet 1.1: Health Problem Analysis
A Field Guide to Designing a Health Communication Strategy
25
Step 2
Determining Potential Audiences
TIPS: Practical Techniques for Analyzing the Situation
1. Read
To collect quantitative and qualitative studies and reports
pertaining to health and communication, first contact the
Ministry of Planning, MOH, and Ministry of Information. They may
recommend other government agencies that can provide the
type of information you want. Private organizations also collect
good quantitative data, but these surveys may be too costly or
unavailable due to proprietary issues.Ask for both published and
unpublished documents, including internal reports, that cover
the subjects in which you are interested, such as:
Literature reviews
Population-based surveys
Service and sales statistics
Focus-group discussion
reports
Evaluation reports of other
health programs
Analyses of health care and
health delivery systems
DHS and other household
surveys of knowledge,
attitudes, and practices
Inventories of communication
materials available at clinic
sites
Census data
Donors’ country reports
Economic reports
Policy documents
Workshop reports
Management reports
Supervisory reports
Technical assistance
reports
Training needs
assessments
Interview records
Service delivery
records
Action plans
Progress reports
Project evaluations
University papers
Journal articles
Get as many samples of health communication materials as you
can for future reference. Printed materials, such as brochures and
posters, are easy to transport, and you may be able to obtain
audio or videocassettes as well. If you don’t know the language,
ask for a written translation.
26
The primary audience for a communication strategy will usually be the people who
are at risk of or who are suffering from a particular health problem. One exception to
this is children, in which case their caregivers are usually addressed as the key
influencing audience. To help identify potential audiences, review the available
research about the extent of the condition or disease. Sources of this information
include the MOH, local health centers, and national health surveys. Medical and
public health personnel can explain how the problem spreads and can identify
those at risk or affected by it. There may well be gaps in available information that
will require formative research or baseline studies before you can understand
enough about potential audiences to clearly articulate and describe who they are.
Identify Common Audience Characteristics
As you identify potential audiences, group them according to common characteristics, such as age range, gender, occupation, residence, or number of children, as
well as by lifestyle and access to print, radio, and television media. Look for characteristics that differentiate the potential audience from persons who are not at risk
or do not have the health problem. Make sure that your analysis is gender-sensitive by considering the different gender roles and relationships among potential
audience members. How are the potential audiences currently behaving in relation to the concepts of gender equity and gender equality? Also look at whether
members of potential audience groups have a high degree of perceived social
support, which can play an important role in an individual’s ability to change.
Table 1.1 presents common group characteristics and examples of audience
groupings.
Identify Behavior Change Stage
For each audience, look for information that identifies current health behaviors
compared with desired or recommended health behaviors. How close or far away
are they from adopting the behaviors? One useful approach is to categorize your
potential audience according to the PBC framework presented in the “Introduction.”
A Field Guide to Designing a Health Communication Strategy
TIPS: Practical Techniques for Analyzing the Situation
To develop estimates of the stage of behavior change of the potential audiences, review existing quantitative data, such as Demographic and Health Surveys (DHS) and census data. Both sources may
provide relevant information about the stage of behavior change of
various groups of people within a country’s population. DHS generally ask about knowledge, attitudes, and practices relative to reproductive, maternal, and child health. The latest DHS is generally available from your local MOH or from the USAID office. If not, Macro
International, Inc., can provide copies of DHS reports for various
countries.*
Often the existing audience data are insufficient for making decisions related to a communication strategy. You may need to work
with research experts to design and implement a quantitative
baseline survey that generates reliable information about audience
characteristics, behavioral issues, barriers to behavior change, etc.
Similarly, it is often useful to conduct qualitative research, such as
focus groups, with potential audience members to yield rich, descriptive information about the audience. Sometimes this is coupled with
one-on-one interviews with key stakeholders to get additional
insights. You and your team members will need to make judgments
about what preliminary research, if any, is required, and you should
also consider timing and budget issues when addressing this issue.
In addition to reviewing formal studies, interview local experts to get
their opinions on the stage of behavior of the group in question. Also,
to gain additional insight, talk with program personnel who work
with the potential audience on a daily basis.
*Macro International, Inc., 11785 Beltsville Drive, Calverton MD 20705, USA,
phone: (301) 572-0200, fax: (301) 572-0999, email: reports@macroint.com
1
2. Listen
Another way to get the information you need to analyze the situation is to
conduct interviews. Interviews will help you:
l
l
Solicit the needs, views, and perspectives of those identified as stakeholders
in the program, including the audience
Identify potential resources for assisting with health communication
Before conducting the interview, develop an interview questionnaire to ensure
that you ask all the questions you intend to ask.
To help complete your understanding of the situation, conduct interviews with
representatives of at least five types of groups:
l
l
l
l
l
Potential audience members
Agenda setters (policymakers and researchers)
Organizations providing health services and products
Media
Donors and technical assistance organizations
Potential interviewees are any persons, groups, or entities that can shape the
direction of a communication effort, provide vital resources, or serve as an
implementing partner.
Examples of those to interview include:
Senior program managers within
your program
Directors of organizations providing
related health services
Representatives of religious
organizations in areas where health
problems exist
Community leaders in areas where
health problems exist
Directors of service delivery
Directors of logistics management
Political leaders with a demonstrated interest in health
Potential clients
Traditional healers
Directors of radio and television
stations
Journalists and editors of magazines and newspapers
Donor representatives
Representatives of ministries or
directorates concerned with
women’s issues
University representatives
Clients of clinics offering health
services
Clinic supervisors
Service providers International
organizations working in health
A Field Guide to Designing a Health Communication Strategy
27
Table 1.1:
Possible Common Characteristics of Potential Audiences
(Schiffman & Kanuk, 1995)
28
A Field Guide to Designing a Health Communication Strategy
1
Identify Known Barriers to Behavior Change
As you interview program workers, health experts, community representatives,
and members of the potential audience, ask why they think the audiences are not
adopting the desired health behaviors.
Often one of the main barriers to adopting behaviors is the fact that the audience
is preknowledgeable. In Bangladesh, for example, a situation analysis for the
National Tuberculosis Control Strategy revealed that most people, especially in
rural areas, did not know that treatment is provided free of cost from Government
health facilities.
However, you and your team must also consider barriers that go beyond awareness and knowledge. Look for barriers in the following categories to give you a
more complete picture of the situation:
TIPS: Practical Techniques for
Analyzing the Situation
3. Observe
As you travel the country, ask as many
questions as possible, and take lots of notes
about what you see. Make sure that you
spend time in rural areas as well as urban,
and if there are strong regional differences
due to religious or cultural traditions, try to
visit different regions so that you obtain a
balanced view of the country.
Observe the following:
Counseling sessions
Group health talks in clinics
Community outreach efforts
Presence of health messages, materials,
and activities in places where intended
audiences live and work
Observation is one of the best tools not
only to assess what is going on, but also to
note some of the strategies that seem to
work best to reach a certain group of
people. For example:
Do most mothers consult traditional healers
about their children’s health?
Will a family use its scarce financial resources
to pay for preventive health care?
A Field Guide to Designing a Health Communication Strategy
29
Understanding the barriers to change—even those that may be beyond the ability
of communication to change—is important for making strategic communication
decisions. This knowledge will help you estimate the degree of change that can be
achieved within a given timeframe.
Identify Key Influencers
After you have identified your potential audiences, find out who influences their
health behaviors. Talk with program managers who work in the community as
well as community workers who visit the audience regularly. Review relevant
research findings. Make informal visits to communities and homes. Talk with
members of the potential audience and community leaders about the health
problem.
Review examples 1.2a and 1.2b, and then complete worksheets 1.2a and 1.2b.
30
A Field Guide to Designing a Health Communication Strategy
Example 1.2a: Potential Primary Audiences Worksheet
Instructions: Identify groups of people with common characteristics who are
suffering from or at risk of the health problem. Complete the table for each
potential audience.
1
Example: Nicaragua
Worksheet 1.2a: Potential Primary Audiences
Instructions: Identify groups of people with common characteristics who are
suffering from or at risk of the health problem. Complete the table for each
potential audience.
A Field Guide to Designing a Health Communication Strategy
31
Example 1.2b: Potential Influencing Audiences Worksheet
Instructions: Identify groups of people with common characteristics who potentially can influence audiences for your communication efforts. Complete the table
for each potential primary audience.
Example: Nicaragua
Worksheet 1.2b: Potential Influencing Audiences
Instructions: Identify groups of people with common characteristics who potentially can influence audiences for your communication efforts. Complete the table
for each potential audience.
32
A Field Guide to Designing a Health Communication Strategy
1
Step 3
Identifying Potential Communication Resources
Step 3 in analyzing the situation is to gain an understanding of the communication environment, including current health communication activities and available resources. Chapter 6, “Channels and Tools,” provides a guide for selecting the
channels that your team will use to convey the message to the intended audience.
The focus here is on identifying and assessing potential resources that can help
you carry out a communication program.
Health communicators define communication channels broadly as a delivery
system for messages to reach intended audiences. They have categorized them as
“interpersonal,” “community-oriented,”and “mass media.” The latter two channels
are particularly effective when the goal is to change community or cultural norms.
Interpersonal channels focus on either one-to-one or one-to-group communication. One-to-one channels include peer to peer, spouse to spouse, and health clinic
worker to client. An example of one-to-group communication may be a community-based outreach worker meeting with a women’s cooperative. Interpersonal
channels use verbal and nonverbal communication.
Community-oriented channels focus on spreading information through existing
social networks, such as a family or a community group. This channel is effective
when dealing with community norms and offers the opportunity for audience
members to reinforce one another’s behavior.
Mass-media channels reach large audiences. They are particularly effective at
agenda setting and contributing to the establishment of new social norms. Formats range from educational to entertainment and advertising, and include
television, radio, and print media, such as magazines, newspapers, outdoor and
transit boards, the Internet, and direct mail.
TIPS: Information Collection Methods
The following types of “formative” research and
PLA will provide you with essential information
to guide your strategy decisions.
Stakeholders MeetingsTo access different
dimensions of a strategy’s potential impact on
people and their environments, you can use
many “stakeholder techniques.” For example,
talk with program managers, community health
workers (CHWs), clinic staff, and community
leaders about the situation. When possible,
gather together those who have an interest in or
control over addressing the problem to have
them share insights on causes and contributors
to the problem. While interviewing them or
hosting a meeting, find out what they are doing
now to address the problem, and why. Ask them
to help you identify key strategic communication issues.
Gender AnalysisIn the context of participatory development, gender analysis helps you to
understand how gender differences affect
access to resources and the participation of
women in development activities. Such an
analysis will help you to take appropriate
measures to ensure that women are not
excluded. Ideally, gender analysis should not be
a separate participatory method but should be
integral to all participatory methods.
(continued on following page)
A Field Guide to Designing a Health Communication Strategy
33
TIPS: Information Collection Methods
(continued from previous page)
Local Level Information Gathering and
Planning—This technique focuses primarily
on local people’s views, how they perceive
their conditions and their lives, and how to
change them. Two methods predominate:
Focus Group Discussions—Have a trained
focus group moderator discuss the health
problem with a few groups of between 6
and 12 members of your potential audiences
for 1 or 2 hours. Find out about their perspectives on the problem, including possible
causes and contributors. Find out about the
group’s sources of information and influence
as well as their levels of knowledge, beliefs,
and attitudes.
Interviews with potential audience
members—Informally interview those who
are potential audiences for your effort. Visit
with both those currently affected and
those at risk. Ask them about their perspectives on the health problem.Try to interview
both those who are already practicing
behaviors that promote health and those
who are not.
Observation—Visit places where related
health supplies and services are offered.
Observe how easy or difficult it is for clients to
access a provider. Observe several client/
provider interactions, allowing that your
presence will change the interaction somewhat. Observe the conditions within which
they are exchanging information. Make notes
about your observations.
34
Ongoing Communication Activities
A wide variety of communication channels is available. Your challenge is to find
those that can reach the potential audiences that you have identified. Three
approaches can help:
l Describe communication efforts already going on through the identified
communication channels and media.
l Talk to other people who have conducted communication campaigns in the
country. This approach is a good starting point for identifying local partners
and for understanding the obstacles and opportunities involved in local
communication efforts.
Categorize these activities according to the channels described above. Remember to:
l Look for media use surveys of potential audiences. DHS can be a helpful
resource here. In addition, many countries survey media use by the population.
l Ask advertising agencies if a media survey is available. Interview program
managers at organizations communicating with your audiences. They can give
you a good idea about what has worked and what has not.
l Visit the communities where your audience lives, and make an inventory of
existing media channels. Describe the sizes and types of the audience that they
reach.
One approach to identifying the key communication channels is to interview the
program managers of existing health projects. As you identify the activities, note
the gatekeepers—the individuals or organizations responsible—for each activity.
Note the main channels and formats used by these organizations. Focus on their
messages as well as the intended audience. This activity will give you an understanding of the messages already being communicated and the extent to which
they were well received.
A Field Guide to Designing a Health Communication Strategy
Communication, Organizational, and Professional Resources
In addition to identifying health-related programs and activities, identify the
organizations and professionals who are helping to carry them out. Ask these
people questions like the following:
1
l Who has experience producing health education materials?
l Which are the top advertising firms in the area?
l Who can produce television and radio programs?
l Which organizations provide training to service providers and community
workers?
l Are there networks or associations of communication organizations? If so,
what is their membership and scope?
Complete worksheets 1.3.a, 1.3.b, and 1.3.c to help summarize your findings.
A Field Guide to Designing a Health Communication Strategy
35
Example 1.3a: Health Communication Channels Worksheet
Instructions: Identify health communication channels in your area by name and
type as well as the type of audiences reached.
Example: Nicaragua
Worksheet 1.3a: Health Communication Channels
Instructions: Identify health communication channels in your area by name and
type as well as the type of audiences reached.
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A Field Guide to Designing a Health Communication Strategy
1
Example 1.3b: Current Health Communication Worksheet
Instructions: Identify relevant communication efforts in your area.
Example: Nicaragua
Worksheet 1.3b: Health Communication Efforts
Instructions: Identify relevant communication efforts in your area.
A Field Guide to Designing a Health Communication Strategy
37
Example 1.3c: Health Communication Assistance Worksheet
Instructions: Identify organizations or individuals who can help you carry out a
communication initiative.
Example: Nicaragua
Worksheet 1.3c: Health Communication Assistance
Instructions: Identify organizations or individuals who can help you carry out a
communication initiative.
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A Field Guide to Designing a Health Communication Strategy
1
Step 4
Assessing the Environment
The fourth step in analyzing the situation is to assess key aspects of the environment
where the strategy will be implemented. Sometimes a health issue requires promotion of a behavior and does not involve a product or service (i.e., breastfeeding). In
other instances the health problem requires products that are easily accessible (i.e.,
soap for hand washing). Still other health issues require an interaction with the
health service delivery system (i.e., immunization). These considerations should be
clarified as part of the process of assessing the environment.
Health Service and/or Product and Behavior Support
Assessing the availability, accessibility, affordability, and acceptability of services,
products, and behaviors will lead to knowledge of the capacity of service providers and supply outlets to help the communication effort.
Availability
Consult with personnel and logistics managers in the programs that the communication effort will be promoting. Ask them to estimate their current capacity and
current demand. Key questions include:
TIP: Make note of the products,
services, or behavioral supports
that are offered to help people
adopt the healthier behavior
you will be promoting and
which organizations are
offering the products and
services.
l Can they increase their capacity to meet increased demand?
l How quickly can they respond to stockouts and understaffing?
l Will they be able to handle additional clients? Will enough supplies be available, and will these supplies be available on a regular basis?
Ask yourself if you will be creating expectations that existing services cannot
meet. If so, you should consider whether promoting the desired behavior is
counterproductive.
A Field Guide to Designing a Health Communication Strategy
39
It is also important to conduct a competitive analysis to understand the broader
environment and to identify potential barriers to success. First, designate whether
you will be promoting a product, service, or behavior. Then, within the chosen
category, list all of the competitors that you know about. For example, when
promoting a behavior such as breastfeeding, the competition may consist of social
pressure not to breastfeed, as well as baby formula sold through commercial
channels. See chapter 5, “The Message Brief,” for additional information about
competition considerations when developing messages.
Accessibility
Where services or supplies are apparently available, ask whether those who need
them can get them. For example, in some countries where contraceptives are
readily available, sexually active, unmarried women cannot get access to them
because of cultural or legal restrictions. Determining the level of accessibility
before starting a specific campaign is crucial.
Affordability
Ask if the primary audience can afford the services and supplies. Think beyond
monetary cost. How much does it cost in time and effort to get the service or item?
If someone has to take a day off from work to get it, how much does this lose them
in wages? Understanding potential constraints like these will help you design a
more effective strategy.
Acceptability
Ask how socially acceptable it is to get and use the product or item. In some
countries, for example, it is socially unacceptable for a woman to purchase
condoms, even for her husband. In other countries, certain contraceptives are
unacceptable because they require a woman to touch her genitals. Interview
service providers and users about these issues to find out if barriers exist to promoting certain behaviors.
Review the questions and findings about these four issues with the program managers who are responsible for service delivery and distribution of products. Find out
if there are any current service or supply issues. Consider visiting several service
delivery sites to test availability and several supply outlets to test accessibility.
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A Field Guide to Designing a Health Communication Strategy
Social, Economic, and Political Conditions
Social, economic, and political conditions can limit health communication. Crime,
unemployment, poverty, and social upheaval all affect health behavior. Consult
program managers about social conditions that may impact their ability to promote
health issues. Read about current affairs. Ask about pending legislation that may
affect the effective promotion of health behaviors. Make note of other development
issues that will be competing for resources and the attention of your audiences.
1
Based on the following examples, complete the corresponding worksheets.
Example 1.4a: Health Service and Product Support Worksheet
Instructions: Identify services and products that help people prevent or treat the
health problem. Indicate the availability, accessibility, acceptability, and
affordability of each one.
Example: Nicaragua
A Field Guide to Designing a Health Communication Strategy
41
Worksheet 1.4a: Health Service and Product Support
Instructions: Identify services and products offered in your area for helping people
prevent and treat the health problem. Briefly describe each according to its availability, accessibility, acceptability, and affordability.
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A Field Guide to Designing a Health Communication Strategy
1
Example 1.4b: Social, Economic, or Political Conditions
Instructions: Identify any major influences that may affect your ability to
communicate effectively.
Example: Nicaragua
Worksheet 1.4b: Social, Economic, or Political Conditions
Instructions: Identify any major influences that may affect your ability to
communicate effectively.
A Field Guide to Designing a Health Communication Strategy
43
Step 5
Summarizing Strengths, Weaknesses,
Opportunities, and Threats
TIP: Avoid writing a long list
of SWOT. Prioritize your list,
and include only those that
you believe will have a
major impact on your
communication strategy.
The next step is to summarize what you have learned to form a foundation for
your communication strategy. Many strategic planners use the SWOT framework:
Strengths, Weaknesses, Opportunities, and Threats.
Summarizing Key Strengths and Weaknesses
Review the resources that you control, and list key strengths and weaknesses in
your ability to communicate effectively. Involve your colleagues in creating this
list. Review financial, human, and technological resources that can be devoted to
the communication initiative.
Summarizing Key Opportunities and Threats
Similarly, ask the following questions:
l What key opportunities are there for improving health through communication?
l What threatens the ability to improve health through communication?
Based on the following example, complete the corresponding worksheet to
summarize your findings.
44
A Field Guide to Designing a Health Communication Strategy
1
Example 1.5: SWOT Analysis Worksheet
Example: Nicaragua
Worksheet 1.5: SWOT Analysis
A Field Guide to Designing a Health Communication Strategy
45
Now you are ready to summarize what you have learned from analyzing the
situation by completing worksheet 1.6, “Situation Summary.” When you reach
chapter 9 of the book, you will combine worksheet 1.6 with seven other summary
worksheets (one each for chapters 2, 3, 4, 5, and 7 and two summary worksheets for
chapter 6, “Channels and Tools”). Taken together, this set of summary worksheets
will provide the information and guidance that you need to write a health communication strategy.
Example 1.6: Situation Summary Worksheet
Instructions: Review the worksheets that you have completed. Refer to them to
complete the following summary of your situation.
Example 1: Nicaragua
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A Field Guide to Designing a Health Communication Strategy
Example 1.6: Situation Summary Worksheet
Instructions: Review the worksheets that you have completed. Refer to them to
complete the following summary of your situation.
1
Example 2: Uganda (Communication Strategy...2001)
At the end of this chapter and at the end of most chapters, you will find a summary
worksheet. The DISH project in Uganda is used throughout this book to provide a
comprehensive example showing how these summary worksheets are to be
completed. When compiled as a set, the information in these summary worksheets
will provide a concise overview of the key strategic considerations upon which
you will base your strategy.
Project Background: The long-term and permanent methods (LTPMs) of FP were
highly underutilized in Uganda. Permanent methods include tubal ligation (TL)
and vasectomy. The long-term method used in this example is Norplant. Despite
strong FP campaigns and a survey among new FP acceptors that noted an increase in the desire to space or limit births altogether, the use of LTPMs remained
significantly low.
In 1997, the DISH project conducted a survey of nine districts and found that only
4 percent of married women were using TL, less than 0.26 percent of married
women were using Norplant, and no men reported using vasectomy. When asked
why, clients cited many reasons for the LTPMs not being more widely used, including inaccessible and unreliable services, lack of awareness, fears and misconceptions about the methods, and poor quality services.
The DISH II project, along with the MOH and other partners, developed a strategy
to expand the availability and to improve the quality of these services through
connected activities related to training and supervision of medical personnel,
provision of equipment and supplies, and targeted behavior change communication messages for the different audience segments.
A Field Guide to Designing a Health Communication Strategy
47
Example 1.6: Situation Summary Worksheet (Uganda)
48
A Field Guide to Designing a Health Communication Strategy
Worksheet 1.6: Situation Summary
Instructions: Review the worksheets that you have completed. Refer to them to
complete the following summary of your situation.
A Field Guide to Designing a Health Communication Strategy
1
49
Conclusion
This chapter has given you the necessary tools to analyze your situation. By now, you should be well on
your way to:
l Identifying and understanding the problem
l Determining potential audiences
l Identifying potential communication resources
l Assessing the environment where you will be communicating
l Summarizing the key Strengths and Weaknesses of the human, technological, and financial resources
available as well as the Opportunities for and Threats to effective health communication in the
current environment
Once these five steps are completed, you are ready to move on to step 2 of the “P” Process—strategy
design.
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A Field Guide to Designing a Health Communication Strategy
1
References
Communication Strategy to Conserve/Improve Public Health, October 1999 September 2001 (2001). Johns Hopkins University/Center for Communication
Programs.
Informe de Resultados de la Encuesta de Linea de Base para la Campaña La
Estrella Azul (2001). (pp. 24). Johns Hopkins University/Center for Communication
Programs.
Schiffman, L. G. & Kanuk, L. L. (1995). Consumer behavior. Englewood Cliffs, NJ:
Prentice-Hall.
A Field Guide to Designing a Health Communication Strategy
51
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A Field Guide to Designing a Health Communication Strategy
Chapter 2
Audience Segmentation
2
By the end of this chapter, the reader will be able to complete the
audience segmentation process by completing the following
steps:
Step 1:
Determining Audience Segments
Step 2:
Prioritizing Audience Segments Within the Strategy
Step 3:
Identifying Influencing Audiences
Step 4:
Painting a Portrait of the Primary Audience
A Field Guide to Designing a Health Communication Strategy
53
Overview
In the forefront of the architect’s mind at every stage of design are the audience
and the audience’s needs. In our example of designing a school, the audience
includes students of different sexes and ages, teachers, parents, administrators, and
visitors. Because of its different needs and depending on the actual situation, the
architect may segment the audience into these groups.
He also considers the needs of people who will influence the intended audience,
such as officials from the Ministry of Education and other government officials.
For each segment he creates a mental picture to ensure that he plans and designs
classrooms, a library, auditoriums, offices, and play areas in accordance with the
needs of each segment.
Similarly, you and your team may need to segment your audience to design the
most effective and efficient strategy for communicating with it.
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A Field Guide to Designing a Health Communication Strategy
The term “audience segmentation” means dividing and organizing an audience
into smaller groups of people who have similar communication-related needs,
preferences, and characteristics. Health communicators segment audiences to
achieve the most appropriate and effective ways to communicate with these
groups. As discussed in Chapter 1, health communicators identify several potential audiences for the communication strategy. Each audience consists of people
who will directly benefit from the desired behavior changes. Your task is to determine the audiences on which to focus communication efforts.
2
This chapter provides four steps as a guide for carrying out the segmentation
process to determine the primary, secondary, and influencing audiences. Following these steps will lead to the decisions and descriptions that will form the core of
the audience portion of your communication strategy.
Step 1
Determining Audience Segments
The first question for you to resolve is whether you need to segment the audience
at all. If the potential audience as a whole can be effectively reached through the
same set of channels and receive the same set of messages, you do not need to
segment. In most cases, however, the audience will benefit from being segmented,
and your communication activities will be more effective. Indeed, health communicators have found that to most effectively promote behavior change, they need
to segment the audience and design several different customized messages,
appeals, or calls to action.
The question of available resources also influences your audience segmentation
decisions. The costs involved in developing and executing separate communication efforts for several groups may outweigh the benefits. If resources are limited
but segmenting the audience is warranted, it may be appropriate to focus on
either fewer segments or to look for ways to leverage funds with other programs.
Review the guidelines on the next page, and complete worksheets 2.1 and 2.2 to
help you reach audience segmentation decisions.
A Field Guide to Designing a Health Communication Strategy
55
Guidelines To Help Determine When It May Be Useful To Segment
an Audience
It may be useful to segment audiences in the following cases:
1. When it is useful to separate users of a product from nonusers or people who
practice a behavior from people who do not practice the behavior, segment
accordingly.
Examples: Users and Nonusers
Messages to men who have never used a condom will be different from those
who have used a condom but not on a regular basis. The former group requires
information on the advantages of condom use. The latter may require more
research on why they do not use condoms regularly, and any effective communication plan must design messages to address their concerns.
The same is true for child immunization. Immunization programs often address
families to get their children immunized, as if the caregivers were thinking of this
subject for the first time. In many countries, however, the problem is that families
aren’t making sure that their children get the required number of immunizations.
Based on these different behavior stages—nonpracticing and practicing—communicators segment the audience and develop the communication strategies
correspondingly: one to convince caregivers to begin an immunization program
and the other to encourage them to bring the children in for the full course of
treatment.
Health communicators identified maternal mortality as a key problem and pregnant women as the potential audience for a message about antenatal care. Some
pregnant women may not go to a provider of antenatal care at all, while some
may not start going until the second or third trimester of the pregnancy. The first
audience may need to understand the advantages of going to a provider of
antenatal care. The second audience already understands the need for antenatal
care but may need to understand the advantages of antenatal care during the first
trimester.
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A Field Guide to Designing a Health Communication Strategy
2. When separate groups within an audience require different types of information or motivation to promote behavior change, segment by information
needs and motivation.
Segmenting the Audience
The Romania Example
Examples: Users at Different Stages of Behavior
A potential audience for contraceptive use may be defined as
women of reproductive age. Within that group, however, young women may
want two or fewer children, and modern contraceptive methods may be a solution. On the other hand, older women with three or more children may want to
consider permanent contraceptive methods. Although both groups consist of
married women of reproductive age, their information needs are different.
Information needs:
An undifferentiated communication strategy may encourage women to choose
an inappropriate solution or may not give them a strong enough reason to seek a
FP method that best suits them. Segmenting the broader audience of married
women of reproductive age into those who wish to space out their pregnancies
and those who wish to limit the number of children that they have results in more
focused and appropriate communication strategies.
In many countries, a large proportion of adolescents are already sexually active,
and the desi...
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