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GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide Communication GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide 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DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service • National Institutes of Health National Cancer Institute  Guide PlannersGuide PlannersGuide PlannersGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide 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GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide  Preface T his book is a revision of the original Making Health Communication Programs Work, first printed in 1989, which the Office of Cancer Communications (OCC, now the Office of Communications) of the National Cancer Institute (NCI) developed to guide communication program planning. During the 25 years that NCI has been involved in health communication, ongoing evaluation of our communication programs has affirmed the value of using specific communication strategies to promote health and prevent disease. Research and practice continue to expand our understanding of the principles, theories, and techniques that provide a sound foundation for successful health communication programs. The purpose of this revision is to update communication planning guidelines to account for the advances in knowledge and technology that have occurred during the past decade. To prepare this update, NCI solicited ideas and information from various health communication program planners and experts (see Acknowledgments). Their contributions ranged from reviewing and commenting on existing text to providing real-life examples to illustrate key concepts. In addition, the Centers for Disease Control and Prevention (CDC) provided extensive input as part of the agency’s partnership with NCI. Although communicating effectively about health is an exacting task, those who have the earlier version of this publication know that it is possible. We hope the ideas and information in this revision will help new health communication programs start soundly and mature programs work even better.  Acknowledgments Many health communication experts contributed to the revision of this book. For their invaluable input, we would like to thank: Elaine Bratic Arkin Health Communications Consultant Cynthia Bauer, Ph.D. U.S. Department of Health and Human Services John Burklow Office of Communication and Public Liaison National Institutes of Health Lynne Doner Health Communications Consultant Timothy Edgar, Ph.D. Westat Brian R. Flay University of Illinois at Chicago Vicki S. Freimuth, Ph.D. Office of Communication Centers for Disease Control and Prevention Joanne Gallivan, M.S., R.D. National Institute of Diabetes and Digestive and Kidney Diseases Karen Glanz, Ph.D., M.P.H. Cancer Research Center of Hawaii Bernard Glassman, M.A.T. Special Expert in Informatics National Cancer Institute Susan Hager Hager Sharp Jane Lewis, Dr.P.H. UMDNJ, School of Public Health Terry Long National Heart, Lung, and Blood Institute  Kathleen Loughrey, M.S., R.D. Health Communications Consultant Susan K. Maloney, M.H.S. Health Communications Consultant Joy R. Mara, M.A. Joy R. Mara Communications John McGrath National Institute of Child Health and Human Development Diane Miller, M.P.A. National Institute on Alcohol Abuse and Alcoholism Ken Rabin, Ph.D. Ruder Finn Healthcare, Inc. Scott C. Ratzan, M.D., M.P.A. Journal of Health Communication U.S. Agency for International Development Barbara K. Rimer, Dr.P.H. Division of Cancer Control and Population Sciences National Cancer Institute Victor J. Strecher, Ph.D., M.P.H. University of Michigan Tim L. Tinker, Dr.P.H., M.P.H. Widmeyer Communications We would especially like to thank Elaine Bratic Arkin, author of the original book, whose knowledge of health communication program planning made this revision possible, as well as Lynne Doner, whose broad-based consumer research and evaluation expertise has enhanced the book’s content and quality. Both have provided hours of review and consultation, and we are grateful to them for their contributions. Thanks to the staff of the Office of Communications, particularly Nelvis Castro, Ellen Eisner, and Anne Lubenow. And thanks to Christine Theisen, who coordinated the revisions to the original text. This document was revised in coordination with the Centers for Disease Control and Prevention during development of CDCynergy—a program-planning tool on CD-ROM.  Table of Contents Why Should You Use This Book? i Introduction 1 The Role of Health Communication in Disease Prevention and Control 2 What Health Communication Can and Cannot Do 3 Planning Frameworks, Theories, and Models of Change 7 How Market Research and Evaluation Fit Into Communication Programs 8 Selected Readings 9 Overview: The Health Communication Process 11 The Stages of the Health Communication Process 11 Stage 1: Planning and Strategy Development 15 Why Planning Is Important 16 Planning Steps 16 Common Myths and Misconceptions About Planning 48 Selected Readings 50 Stage 2: Developing and Pretesting Concepts, 53 Messages, and Materials Why Developing and Pretesting Messages and Materials Are Important 54 Steps in Developing and Pretesting Messages and Materials 54 Planning for Production, Distribution, Promotion, and Process Evaluation 86 Common Myths and Misconceptions About Materials Pretesting 86 Selected Readings 87 Stage 3: Implementing the Program 91 Preparing to Implement Your Program 92 Maintaining Media Relations After Launch 95 Working With the Media During a Crisis Situation 98 Managing Implementation: Monitoring and Problem Solving 98 Maintaining Partnerships 102 Common Myths and Misconceptions About Program Implementation 103 Selected Readings 104  Stage 4: Assessing Effectiveness and 107 Making Refinements Why Outcome Evaluation Is Important 108 Revising the Outcome Evaluation Plan 108 Conducting Outcome Evaluation 110 Refining Your Health Communication Program 121 Common Myths and Misconceptions About Evaluation 121 Selected Readings 123 Communication Research Methods 125 Types of Communication Research 126 Differences Between Qualitative and Quantitative Research Methods 126 Qualitative Research Methods 127 Quasi-Quantitative Research Methods: Pretesting Messages and Materials 141 Quantitative Research Methods 157 Additional Research Methods 161 Appendix A: Communication Planning 169 Forms and Samples Appendix B: Selected Planning Frameworks, Social 217 Science Theories, and Models of Change Appendix C: Information Sources 229 Appendix D: Selected Readings and Resources 235 Appendix E: Glossary 245  Guide PlannersGuide PlannersGuide PlannersGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide 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GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide  Why Should You Use This Book? T he planning steps in this book can help make any communication program work, regardless of size, topic, geographic span, intended audience, or budget. (intended audience is the term this book uses to convey what other publications may refer to as a target audience.) The key is reading all the steps and adapting those relevant to your program at a level of effort appropriate to the program’s scope. The tips and sidebars throughout the book suggest ways to tailor the process to your various communication needs. If you have limited funding, you might • Work with partners who can add their resources to your own • Conduct activities on a smaller scale • Use volunteer assistance • Seek out existing information and approaches developed by programs that have addressed similar issues to reduce developmental costs Don’t let budget constraints keep you from setting objectives, learning about your intended audience, or pretesting. Neglecting any of these steps could limit your program’s effectiveness before it starts. This book describes a practical approach for planning and implementing health communication efforts; it offers guidelines, not hard and fast rules.Your situation may not permit or require each step outlined in the following chapters, but we hope you will consider each guideline and decide carefully whether it applies to your situation. To request additional copies of this book, please visit NCI’s Web site at www.cancer.gov or call NCI’s Cancer Information Service at 1-800-4-CANCER (1-800-422-6237).  GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide INTRODUCTION GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide  INTRO Introduction In This Section: • The role of health communication in disease prevention and control • What health communication can and cannot do • Planning frameworks, theories, and models of change • How research and evaluation fit into communication programs Questions to Ask and Answer: • Can communication help us achieve all or some of our aims? • How can health communication fit into our program? • What theories, models, and practices should we use to plan our communication program? • What types of evaluation should we include?  The Role of Health Communication in Disease Prevention and Control There are numerous definitions of health communication. The National Cancer Institute and the Centers for Disease Control and Prevention use the following: The study and use of communication strategies to inform and influence individual and community decisions that enhance health. Use the principles of effective health communication to plan and create initiatives at all levels, from one brochure or Web site to a complete communication campaign. Successful health communication programs involve more than the production of messages and materials. They use research-based strategies to shape the products and determine the channels that deliver them to the right intended audiences. Since this book first appeared in 1989, the discipline of health communication has grown and matured. As research has continued to validate and define the effectiveness of health communication, this book has become a widely accepted tool for promoting public health. Healthy People 2010, the U.S. Department of Health and Human Services’ stated health objectives for the nation, contains separate objectives for health communication for the first time. Meanwhile, the availability of new technologies is expanding access to health information and raising questions about equality of access, accuracy of information, and how to use the new tools most effectively. 2  INTRO What Health Communication Can and Cannot Do Understanding what health communication can and cannot do is critical to communicating successfully. Health communication is one tool for promoting or improving health. Changes in health care services, technology, regulations, and policy are often also necessary to completely address a health problem. Communication alone can: • Increase the intended audience’s knowledge and awareness of a health issue, problem, or solution • Influence perceptions, beliefs, and attitudes that may change social norms • Prompt action • Demonstrate or illustrate healthy skills • Reinforce knowledge, attitudes, or behavior • Show the benefit of behavior change • Advocate a position on a health issue or policy • Increase demand or support for health services • Refute myths and misconceptions • Strengthen organizational relationships Communication combined with other strategies can: • Cause sustained change in which an individual adopts and maintains a new health behavior or an organization adopts and maintains a new policy direction • Overcome barriers/systemic problems, such as insufficient access to care Communication cannot: • Compensate for inadequate health care or access to health care services • Produce sustained change in complex health behaviors without the support of a larger program for change, including components addressing health care services, technology, and changes in regulations and policy • Be equally effective in addressing all issues or relaying all messages because the topic or suggested behavior change may be complex, because the intended audience may have preconceptions about the topic or message sender, or because the topic may be controversial Communication Can Affect Multiple Types of Change Health communication programs can affect change among individuals and also in organizations, communities, and society as a whole: • Individuals—The interpersonal level is the most fundamental level of health-related communication because individual behavior affects health status. Communication can affect individuals’ awareness, knowledge, attitudes, self- efficacy, skills, and commitment to behavior change. Activities directed at other intended audiences for change may also affect individual change, such as involving patients in their own care. • Groups—The informal groups to which people belong and the community settings they frequent can have a significant impact on their health. Examples include relationships between customers and employees at a salon or restaurant, exercisers who go to the same gym, students and parents in a school setting, employees at a worksite, and patients and health professionals at a clinic. Activities aimed at this level can take advantage of these informal settings. Making Health Communication Programs Work 3  • Organizations—Organizations are groups with defined structures, such as associations, clubs, or civic groups. This category can also include businesses, government agencies, and health insurers. Organizations can carry health messages to their constituents, provide support for health communication programs, and make policy changes that encourage individual change. • Communities—Community opinion leaders and policymakers can be effective allies in influencing change in policies, products, and services that can hinder or support people’s actions. By influencing communities, health communication programs can promote increased awareness of an issue, changes in attitudes and beliefs, and group or institutional support for desirable behaviors. In addition, communication can advocate policy or structural changes in the community (e.g., sidewalks) that encourage healthy behavior. • Society—Society as a whole influences individual behavior by affecting norms and values, attitudes and opinions, laws and policies, and by creating physical, economic, cultural, and information environments. Health communication programs aimed at the societal level can change individual attitudes or behavior and thus change social norms. Efforts to reduce drunk driving, for example, have changed individual and societal attitudes, behaviors, and policies through multiple forms of intervention, including communication. Multistrategy health communication programs can address one or all of the above. Communication Programs Can Include Multiple Methods of Influence Health communicators can use a wide range of methods to design programs to fit specific circumstances. These methods include: • Media literacy—teaches intended audiences (often youth) to deconstruct media messages so they can identify the sponsor’s motives; also teaches communicators how to compose messages attuned to the intended audience’s point of view • Media advocacy—seeks to change the social and political environment in which decisions that affect health and health resources are made by influencing the mass media’s selection of topics and by shaping the debate about those topics • Public relations—promotes the inclusion of messages about a health issue or behavior in the mass media • Advertising—places paid or public service messages in the media or in public spaces to increase awareness of and support for a product, service, or behavior • Education entertainment—seeks to embed health-promoting messages and storylines into entertainment and news programs or to eliminate messages that counter health messages; can also include seeking entertainment industry support for a health issue • Individual and group instruction— influences, counsels, and provides skills to support desirable behaviors • Partnership development—increases support for a program or issue by harnessing the influence, credibility, and resources of profit, nonprofit, or governmental organizations 4 Introduction