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U.S. Copyright Law (title 17 of U.S. code) governs the reproduction and redistribution of copyrighted material. Downloading this document for the purpose of redistribution is prohibited. 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’ Meetings—To 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 Analysis—In 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. 36 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. 38 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. 40 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. 42 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 46 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. 50 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 52 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. 54 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. 56 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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SWOT Analysis
Student’s Name
Institution

The major strengths of the Friendship Circle Organization are the ability to target
teenagers. Teenagers are critical audiences and consumers of social media. They are
easy to convince and love exploring. Using this strategy, it is easy to make outreach
and communicate messages to them with ease. One of the main values of the
organization is based on “'Teens have boundless energy.” (Friendshipcicle, 2021)
This gives the organization an edge when it comes to communication. I...


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