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U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES

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Making

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U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES

Public Health Service • National Institutes of Health

National Cancer Institute

Guide PlannersGuide PlannersGuide PlannersGuide

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

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

INTRODUCTION

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

INTRO

CHARACTERISTICS OF EFFECTIVE HEALTH COMMUNICATION CAMPAIGNS

Certain attributes can make health communication campaigns more effective.

Use the guidelines in this section to plan your campaign.

Define the communication campaign goal effectively:

• Identify the larger goal

• Determine which part of the larger goal could be met by a communication campaign

• Describe the specific objectives of the campaign; integrate these into a campaign plan

Define the intended audience effectively:

• Identify the group to whom you want to communicate your message

• Consider identifying subgroups to whom you could tailor your message

• Learn as much as possible about the intended audience; add information about beliefs,

current actions, and social and physical environment to demographic information

Create messages effectively:

• Brainstorm messages that fit with the communication campaign goal and the

intended audience(s)

• Identify channels and sources that are considered credible and influential by the

intended audience(s)

• Consider the best times to reach the audience(s) and prepare messages accordingly

• Select a few messages and plan to pretest them

Pretest and revise messages and materials effectively:

• Select pretesting methods that fit the campaign’s budget and timeline

• Pretest messages and materials with people who share the attributes of the

intended audience(s)

• Take the time to revise messages and materials based upon pretesting findings

Implement the campaign effectively:

• Follow the plans you developed at the beginning of the campaign

• Communicate with partners and the media as necessary to ensure the campaign

runs smoothly

• Begin evaluating the campaign plan and processes as soon as the campaign

is implemented

Note. Adapted from the University of Kansas Community Toolbox, Community

Workstation, available at

http://ctb.lsi.ukans.edu/tools/CWS/socialmarketing/outline.htm.

Accessed March 7, 2002.

Making Health Communication Programs Work

5

THEORIES GUIDE ACTION TO INCREASE MAMMOGRAPHY USE

Fox Chase Cancer Center, in cooperation with area managed care organizations, designed

a program that was based on key elements of the health belief model to encourage women

to have regular mammograms. Selected women received educational materials explaining

that virtually all women are at risk for breast cancer, regardless of the absence of

symptoms, and that risk increases with age (susceptibility). The materials stressed that

early detection brings not only the best chance of cure but also the widest range of

treatment choices (benefit). Women received a letter stating their physician’s support (cue

to action) and a coupon for a free mammogram (to overcome the cost barrier). Those who

did not have a mammogram within 90 days received different forms of reminders (cues to

action). In the most intensive reminder, a telephone counselor called selected women to

review their perceptions about susceptibility, benefits, and barriers. Program evaluation

showed that mammography use increased substantially.

The Fox Chase program also applied social learning theory in developing interventions to

encourage physician support of mammography and to improve clinical breast

examinations (CBEs). The planners examined the environmental and situational factors

that might affect physician behavior and tried to change the low expectations of

physicians about the benefits of breast screening. The interventions included

observational learning by watching an expert perform a CBE, an opportunity to increase

self-efficacy by practicing CBE with the instructor, and the use of a feedback report and

CME credits to reinforce physician skills.

In taking a community approach to change, a UCLA mammography program used a

diffusion of innovations model. Community analysis showed that women who were early

adopters (leaders) already had a heightened awareness of the value of mammography. To

reach middle adopters, the program mobilized the social influence of the early adopters by

using volunteers who had breast cancer to provide mammography information. The

program also provided highly individualized educational strategies linked to social

interaction approaches to reach late adopters. A social marketing framework influenced

the program’s planning approach, and media materials incorporated the health belief

model to promote individual behavior change.

Note. From “Audiences and Messages for Breast and Cervical Cancer Screenings,” by B. K. Rimer,

1995, Wellness Perspectives: Research, Theory, and Practice, 11(2), pp. 13–39. Copyright by University

of Alabama. Adapted with permission.

6

Introduction

INTRO

Communication programs can take

advantage of the strengths of each of the

above by using multiple methods. A program

to decrease tobacco use among youth, for

example, could include:

• Paid advertising to ensure that youth are

exposed to on-target, unfiltered

motivational messages

• Media advocacy to support regulatory or

policy changes to limit access to tobacco

• Public relations to support

anti-tobacco attitudes

• Media literacy instruction in schools

to reduce the influence of the

tobacco industry

• Entertainment education and advocacy

to decrease the depiction of tobacco use

in movies

• Partnerships with commercial enterprises

(such as retail chains popular

among youth) to spread the

anti-smoking message

Using multiple methods increases the need

for careful planning and program

management to ensure that all efforts are

integrated and consistently support program

goals and objectives.

Planning Frameworks, Theories,

and Models of Change

Sound health communication development

should draw upon theories and models that

offer different perspectives on the intended

audiences and on the steps that can

influence their change. No single theory

dominates health communication because

health problems, populations, cultures, and

contexts vary. Many programs achieve the

greatest impact by combining theories to

address a problem. The approach to health

communication we use in this book is based

on the social marketing framework.

(See Appendix B for an overview of some

other relevant theoretical models.) Social

marketing concentrates on tailoring

programs to serve a defined group and is

most successful when it is implemented as

NATIONAL OBJECTIVES FOR RESEARCH

AND

EVALUATION

The Health Communication chapter of

Healthy People 2010, the nationwide

health promotion and disease

prevention agenda, identifies increasing

the proportion of health

communication activities that include

research and evaluation as one of six

objectives for the field for the next

decade (objective 11-3). This objective

focuses attention on the need to make

research and evaluation integral parts of

initial program design. Research and

evaluation are used to systematically

obtain the information needed to

refine the design, development,

implementation, adoption, redesign,

and overall quality of a

communication intervention.

Making Health Communication Programs Work

7

a systematic, continuous process that is

driven at every step by decision-based

research, which is used as feedback to

adjust the program.*

Why Use Theories and Models?

Although theories cannot substitute for

effective planning and research, they offer

many benefits for the design of health

communication programs. At each stage of

the process outlined in this book, theories

and models can help answer key questions,

such as:

• Why a problem exists

• Whom to select

• What you need to know about the

population/intended audience before

taking action

• How to reach people and make an impact

• Which strategies are most likely to

cause change

Reviewing theories and models can suggest

factors to consider as you formulate your

objectives and approach, and can help you

determine whether specific ideas are likely

to work. Theories and models can guide

message and materials development, and

are also useful when you decide what to

evaluate and how to design evaluation tools.

How Market Research and Evaluation

Fit Into Communication Programs

Conducting market research is vital to

identifying and understanding intended

audiences and developing messages and

strategies that will motivate action.

Evaluations conducted before, throughout,

and after implementation provide data on

which to base conclusions about success or

failure and help to improve current and

future communication programs.

Evaluation should be built in from the start,

not tacked on to the end of a program.

Integrating evaluation throughout planning

and implementation ensures that you:

• Tailor messages, materials, and activities

to your intended audience

• Include evaluation mechanisms (e.g.,

include feedback forms with a

community guide)

• Define appropriate, meaningful,

achievable, and time-specific

program objectives

Evaluating your program’s communication

efforts enables you to:

• Understand what is and is not working,

and why

• Improve the effort while it is under way

and improve future efforts

• Demonstrate the value of the program to

interested parties such as partners,

funding agencies, and the public

• Help program staff see how its work

affects the intended audiences

In this book, we address appropriate

evaluation activities for each stage; see the

Communication Research Methods section

for a description of the different types of

research and evaluation that support each

stage of the health communication

process. See Appendix A for sample

forms and instruments.

* From Theory at a Glance: A Guide for Health Promotion

Practice (NIH Publication No. 97-3896), by the National

Cancer Institute, 1995. Bethesda, MD. In the

public domain.

8

Introduction

INTRO

Selected Readings

Andreasen, A. (1995). Marketing social

change: Changing behavior to promote

health, social development, and the

environment. San Francisco: Jossey-Bass.

Backer, T. E., Rogers, E. M., & Sopory, P.

(1992). Designing health communication

campaigns: What works. Thousand Oaks,

CA: Sage.

Bandura, A. (1986). Social foundations of

thought and action: A social cognitive theory.

Englewood Cliffs, NJ: Prentice-Hall.

Centers for Disease Control and Prevention.

(2001). CDCynergy 2001 [CD-ROM]. Atlanta.

Glanz, K., Lewis, F. M., & Rimer, B. K.

(Eds.). (1997). Health behavior and health

education: Theory, research, and practice

(2nd ed.). San Francisco: Jossey-Bass.

Glanz, K., & Rimer, B. K. (1995). Theory at a

glance: A guide for health promotion

practice (NIH Publication No. 97-3896).

Bethesda, MD: National Cancer Institute.

Goldberg, M. E., Fishbein, M. F., &

Middlestadt, S. E. (Eds.). (1997). Social

marketing: Theoretical and practical

perspectives. Mahwah, NJ: Erlbaum.

Green, L. W., & Kreuter, M. W. (1999). Health

promotion planning: An educational and

ecological approach (3rd ed.). Mountain

View, CA: Mayfield.

Maibach, E., & Parrott, R. L. (Eds.). (1995).

Designing health messages: Approaches

from communication theory and public

health practice. Thousand Oaks, CA: Sage.

National Cancer Institute. (1993). A picture

of health (NIH Publication No. 94-3604).

Rockville, MD: U.S. Department of Health

and Human Services.

Rimer, B. K. (1995). Audiences and

messages for breast and cervical cancer

screenings. Wellness Perspectives:

Research, Theory, and Practice, 11(2),

13–39.

Siegel, M., & Doner, L. (1998). Marketing

public health: Strategies to promote social

change. Gaithersburg, MD: Aspen.

U.S. Department of Health and Human

Services. (2000). Healthy people 2010 (2nd

Ed.; in two volumes: Understanding and

improving health and Objectives for

improving health.). Washington, DC: U.S.

Government Printing Office.

Making Health Communication Programs Work

9

GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide

OVERVIEW

GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide

OVERVIEW

Overview: The Health

Communication Process

In This Section:

• How the approach used in this book will help your organization produce

and implement a health communication program

• Each stage in the health communication process

The Stages of the Health Communication Process

For a communication program to be successful, it must be based on an

understanding of the needs and perceptions of the intended audience. In

this book, we incorporate tips on how to learn about the intended audience’s

needs and perceptions in each of the program stages. Remember, these

needs and perceptions may change as the project progresses, so be

prepared to make changes to the communication program as you proceed.

To help with planning and developing a health communication program, we

have divided the process into four stages: Planning and Strategy

Development; Developing and Pretesting Concepts, Messages, and

Materials; Implementing the Program; and Assessing Effectiveness and

Making Refinements. The stages constitute a circular process in which the

last stage feeds back into the first as you work through a continuous loop of

planning, implementation, and improvement.

1

2

3

4

Health

Communication

Program

Cycle

Planning and

Strategy

Development

Developing

and Pretesting

Concepts,

Messages,

and Materials

Implementing

the Program

Assessing

Effectiveness

and Making

Refinements

Use this book to produce and implement a

plan for a communication program. The final

plan will include the following components:

• General description of the program,

including intended audiences, goals,

and objectives

• Market research plans

• Message and materials development and

pretesting plans

• Materials production, distribution, and

promotion plans

• Partnership plans

• Process evaluation plan

• Outcome evaluation plan

• Task and time table

• Budget

Because this process is not linear, do not

expect to complete a stage and then move

to the next, never to go back.You will be

exploring opportunities, researching issues,

and refining plans and approaches as your

organization implements the program. This

ongoing, iterative process characterizes a

successful communication program.

To help work through program planning and

development, we suggest many steps within

each stage.You may not find all of the steps

suggested in each stage feasible for your

program, or even necessary. As you plan,

carefully examine available resources and

what you want to accomplish with the

program and then apply the steps that are

appropriate for you. However, if you carefully

follow the steps described in each stage of

the process, your work in the next phase

may be more productive.

Each of the four stages is described here;

they are described in more detail in the

subsequent sections of this book.

Stage 1: Planning and Strategy

Development

In this book, all planning is discussed within

the Planning and Strategy Development

section, but the concepts you learn there

apply across the life cycle of a

communication program. During Stage 1

you create the plan that will provide the

foundation for your program. By the end of

Stage 1, you will have:

• Identified how your organization can use

communication effectively to address a

health problem

• Identified intended audiences

• Used consumer research to craft a

communication strategy and objectives

• Drafted communication plans, including

activities, partnerships, and baseline

surveys for outcome evaluation

Planning is crucial for the success of any

health communication program, and doing

careful work now will help you avoid having

to make expensive alterations when the

program is under way.

Stage 2: Developing and Pretesting

Concepts, Messages, and Materials

In Stage 2, you will develop message

concepts and explore them with the

intended audience using qualitative

research methods. By the end of Stage 2,

you will have:

• Developed relevant, meaningful messages

• Planned activities and drafted materials

• Pretested the messages and materials

with intended-audience members

12

Overview

OVERVIEW

Getting feedback from intended audiences

when developing messages and materials is

crucial for the success of every

communication program. Learning now what

messages are effective with the intended

audiences will help you avoid producing

ineffective materials.

Stage 3: Implementing the Program

In Stage 3, you will introduce the fully

developed program to the intended

audience. By the end of Stage 3, you

will have:

• Begun program implementation,

maintaining promotion, distribution, and

other activities through all channels

• Tracked intended-audience exposure and

reaction to the program and determined

whether adjustments were needed

(process evaluation)

• Periodically reviewed all program

components and made revisions

when necessary

Completing process evaluations and making

adjustments are integral to implementing the

program and will ensure that program

resources are always being used effectively.

Stage 4: Assessing Effectiveness and

Making Refinements

In Stage 4, you will assess the program

using the outcome evaluation methods you

planned in Stage 1. By the end of Stage 4,

you will have:

• Assessed your health

communication program

• Identified refinements that would

increase the effectiveness of future

program iterations

Because program planning is a recurring

process, you will likely conduct planning,

management, and evaluation activities

described in Stages 1–4 throughout the

life of the program.

Making Health Communication Programs Work

13

GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide

STAGE 1

GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide

Planning and

Strategy Development

In This Section:

• Why planning is important

• Six steps of the planning process

• Assessing health issues and identifying solutions

• Defining communication objectives

• Defining intended audiences

• Exploring communication settings, channels, and activities

• Identifying potential partners and collaborating

• Developing a communication strategy and drafting communication

and evaluation plans

• Common myths about planning

Questions to Ask and Answer:

• What health problem are we addressing?

• What is occurring versus what should be occurring?

• Whom does the problem affect, and how?

• What role can communication play in addressing the problem?

• How and by whom is the problem being addressed? Are other

communication programs being planned or implemented?

(Look outside of your own organization.)

• What approach or combination of approaches can best influence the

problem? (Communication? Changes in policies, products, or services?

All of these?)

• What other organizations have similar goals and might be willing to

work on this problem?

• What measurable, reasonable objectives will we use to define success?

• What types of partnerships would help achieve the objectives?

• Who are our intended audiences? How will we learn about them?

• What actions should we encourage our intended audiences to take?

• What settings, channels, and activities are most appropriate for reaching

our intended audiences and the goals of our communication objectives?

(Interpersonal, organizational, mass, or computer-related media?

Community? A combination?)

• How can the channels be used most effectively?

• How will we measure progress? What baseline information will we use to

conduct our outcome evaluation?

STAGE 1

Why Planning Is Important

The planning you do now will provide the

foundation for your entire health

communication program. It will enable your

program to produce meaningful results

instead of just boxes of materials. Effective

planning will help you:

• Understand the health issue you

are addressing

• Determine appropriate roles for

health communication

• Identify the approaches necessary to bring

about or support the desired changes

• Establish a logical program

development process

• Create a communication program that

supports clearly defined objectives

• Set priorities

• Assign responsibilities

• Assess progress

• Avert disasters

Under the pressure of deadlines and

demands, it is normal to think, “I don’t have

time to plan; I have to get started NOW.”

However, following a strategic planning

process will save you time. Because you will

define program objectives and then tailor

your program’s activities to meet those

objectives, planning will ensure that you

don’t spend time doing unnecessary work.

Program objectives are generally broader

than communication objectives, described

in step 2 on page 20, and specify the

outcomes that you expect your entire

program to achieve. Many of the planning

activities suggested in this chapter can be

completed simultaneously. Even if your

program is part of a broader health

promotion effort that has an overall plan, a

plan specific to the communication

component is necessary.

Planning Steps

This chapter is intended to help you design

a program plan. The health communication

planning process includes the following six

steps explained in this chapter:

1. Assess the health issue or problem and

identify all the components of a possible

solution (e.g., communication as well as

changes in policy, products, or services).

2. Define communication objectives.

3. Define and learn about

intended audiences.

4. Explore settings, channels, and activities

best suited to reach intended audiences.

5. Identify potential partners and develop

partnering plans.

6. Develop a communication strategy for

each intended audience; draft a

communication plan.

To complete this process, use the

Communication Program Plan template in

Appendix A to help ensure that you don’t

miss any key points.

1. Assess the Health Issue/Problem and

Identify All Components of a Solution

The more you understand about an issue or

health problem, the better you can plan a

communication program that will address it

successfully. The purpose of this initial data

collection is to describe the health problem

or issue, who is affected, and what is

occurring versus what should be occurring.

Doing this will allow you to consider how

communication might help address the

issue or problem. In this step, review and

gather data both on the problem and on

what is being done about it.

16

Planning and Strategy Development

Review Available Data

• Community service agencies (for related

To collect available data, first check for

sources of information in your agency or

organization. Identify gaps and then seek

outside sources of information. Sources and

availability of information will vary by issue.

The types of information you should (ideally)

have at this stage include descriptions of:

• The problem or issue

• The incidence or prevalence of the

health problem

• Who is affected (the potential intended

audience), including age, sex, ethnicity,

economic situation, educational or reading

level, place of work and residence, and

causative or preventive behaviors. Be sure

to include more information than just

basic demographics

• The effects of the health problem on

individuals and communities (state,

workplace, region, etc.)

• Possible causes and preventive measures

• Possible solutions, treatments,

or remedies

To find this information, search these

common data sources:

• Libraries (for journal articles and texts)

• Health-related resources on the Internet

• Sources of health statistics (a local

hospital, a state health department, the

National Center for Health Statistics on the

CDC Web site)

• Administrative databases covering

relevant populations

• Government agencies, universities,

and voluntary and health

professional organizations

• Clearinghouses

service-use data)

• Corporations, trade associations,

and foundations

• Polling companies (for intended audience

knowledge and attitudes)

• Depositories of polling information (e.g.,

the Roper Center)

• Chambers of commerce

• Advertising agencies, newspapers,

and radio and television stations

(for media-use data, buying and

consumption patterns)

Both published and unpublished reports

may be available from these sources. A

number of federal health information

clearinghouses and Web sites also provide

information, products, materials, and

sources of further assistance for specific

health subjects. A helpful first step in

planning may be to contact the appropriate

Web sites and the health department to

obtain information on the health issue your

program is addressing. See Appendix C,

Information Sources, for listings of

additional sources of information, including

Internet resources.

Identify Existing Activities and Gaps

Find out what other organizations are doing

to address the problem, through

communication and other approaches,

such as advocating for policy or

technological changes. Contact these

organizations to discuss:

• What they have learned

• What information or advice they may have

to help you plan

• What else is needed (what gaps exist in

types of change needed, media or

activities available, intended audiences

STAGE 1

Making Health Communication Programs Work

17

served to date, messages and materials

directed at different stages of intended

audience behavior change)

• Opportunities for cooperative ventures

Gather New Data as Needed

You may find that the data you have

gathered does not give enough insight into

the health problem, its resolution, or

knowledge about those who are affected in

order to proceed. In other instances, you

may have enough information to define the

problem, know who is affected, and identify

the steps that can resolve it, but other

important information about the affected

populations may be unavailable or outdated.

To conduct primary research to gather more

information, see the Communication

Research Methods section.

Sometimes it is impossible to find sufficient

information about the problem. This may be

because the health problem has not yet

been well defined. In this case, you might

decide that a communication program is an

inappropriate response to that particular

problem until more becomes known.

Identify All Components of a Solution

Adequately addressing a health problem

often requires a combination of the

following approaches:

• Communication (to the general public,

patients, health care providers,

policymakers—whoever needs to make or

facilitate a change)

• Policy change (e.g., new laws, regulations,

or operating procedures)

• Technological change (e.g., a new or

redesigned product, drug, service, or

treatment; or changing delivery of existing

products, drugs, services, or treatments)

Yet all too often we rely on health

communication alone and set unrealistic

expectations for what it can accomplish. It is

vitally important to identify all of the

components necessary to bring about the

desired change and then to carefully

consider which of these components is

being—or can be—addressed. For example,

consider a woman who needs a

mammogram. The mammogram graphic

shows some of the problems that may

Communication Strategy

A Case Study: Mammogram

Solution: Requires

Communication

Strategy

Communication

to Doctors



Persuade doctors to

give mammogram

referrals to all women

in the appropriate

age group

Communication

to Women



Present the beneﬁts

(that women think are

important) of getting a

mammogram that will

outweigh her fears

My doctor

doesn’t

recommend a

mammogram.

I don’t think

I need it. I’m

afraid of getting a

mammogram.

Solution: Requires

Change in Policy

and Resources

My health

insurance

doesn’t cover

mammograms.

I can’t travel

40 miles to get a

mammogram and

I can’t miss

work.

Policy



Mandate coverage of

mammograms in

accordance with

screening guidelines

Technology



Outﬁt a van with

mammography

equipment and send

to her neighborhood

during nonworking

hours

18

Planning and Strategy Development

USING COMMUNICATION TO SUPPORT POLICY CHANGE

The goal of a communication campaign is not always to teach or to influence behavior; it

can also begin the process of changing a policy to increase health and wellness. This

might mean getting community leaders excited about a new “rails to trails” project or

working to bring up the issue of a lack of low-income housing. In each case, the final goal

(i.e., helping people exercise by increasing the number of walking/biking trails, making

sure that everyone in the community has a safe place to live by assigning more

apartments in newly built housing to low-income residents) is more than a

communication campaign can accomplish. However, the initial goal (gaining the support

of decision-makers who can change current policy) can be met.

One of the most popular and effective ways to build support for policy change is to work

with the media. Use the following questions to help plan your message:

• What is the problem you are highlighting?

• Is there a solution to it? If so, what is it?

• Whose support do you need to gain to make the solution possible?

• What do you need to do or say to get the attention of those who can make the

solution happen?

Once you have developed your message, create a media list that includes organizations,

such as newspapers and television stations; individuals, such as reporters, editors, and

producers; and other contacts. Keep this list updated as you communicate your message

and work to change policy. The following are a few methods to use:

• News releases

• Interviews

• Letters to the editor

• Media conferences

Media strategies are not the only way to build support for policy change. Also consider

attending and speaking at local meetings, approaching issue decision-makers either in

person or by letter, or working with and educating community members who are affected.

STAGE 1

Note. From American Public Health Association. APHA Media Advocacy Manual 2000.

Washington, DC. Adapted with permission.

Making Health Communication Programs Work

19

occur and potential solutions for each.

Solutions that communication programs

can help develop are highlighted.

Determine Whether Health Communication

Is Appropriate for the Problem and

Your Organization

Create a map that diagrams the

components of a problem and the steps

necessary to solve it (as in the mammogram

graphic) to help you determine a possible

role for health communication. In some

cases, health communication alone may

accomplish little or nothing without policy,

technological, or infrastructure changes

(e.g., successfully increasing physical

activity of employees in the workplace might

require employer policy changes to allow for

longer breaks or infrastructure changes

such as new walking paths). In some

instances, effective solutions may not yet

exist for a communication program to

support. For example, no treatment may

exist for an illness, or a solution may require

services that are not yet available. In these

cases, decide either to wait until other

program elements are in place or to

develop communication strategies directed

to policymakers instead of consumers

or patients.

If you determine that health communication

is appropriate, ask the following questions to

consider whether your organization is best

suited to carry it out:

• Does the organization have (or can it

acquire) the necessary expertise

and resources?

• Does the organization have the necessary

authority or mandate?

• Will the organization be duplicating efforts

of others?

• How much time does the organization

have to address this issue?

• What, if anything, can be accomplished

in that time?

2. Define Communication Objectives

Defining communication objectives will help

you set priorities among possible

communication activities and determine the

message and content you will use for each.

Once you have defined and circulated the

communication objectives, they serve as

a kind of contract or agreement about the

purpose of your communication, and

they establish what outcomes should

be measured.

It is important to create achievable

objectives. Many communication efforts are

said to fail only because the original

objectives were wildly unreasonable. For

example, it is generally impossible to

achieve a change of 100 percent. If you plan

to specify a numerical goal for a particular

objective, an epidemiologist or statistician

can help you determine recent rates of

change related to the issue so that you have

some guidance for deciding how much

change you think your program can achieve.

(Remember that commercial marketers

often consider a 2 to 3 percent increase in

sales to be a great success.) Fear of failure

should not keep you from setting

measurable objectives. Without them, there

is no way to show your program has

succeeded or is even making progress

along the way, which could reduce support

for the program among your supervisors,

funding agencies, and partners.

Because objectives articulate what the

communication effort is intended to do,

they should be:

• Supportive of the health program’s goals

• Reasonable and realistic (achievable)

• Specific to the change desired, the

population to be affected, and the time

20

Planning and Strategy Development

HOW COMMUNICATION CONTRIBUTES TO COMPLEX BEHAVIOR CHANGE

One can imagine how the process of change occurs: A woman sees some public service

announcements (PSAs) and a local TV health reporter’s feature telling her about the

“symptomless disease”—hypertension. She checks her blood pressure in a newly accessible

shopping mall machine, and the results suggest a problem. She tells her spouse, who has

also seen the ads, and he encourages her to have it checked. She goes to a physician who

confirms the presence of hypertension and encourages her to change her diet and return

for monitoring.

The physician has become more sensitive to the issue because of a recent article in the

Journal of the American Medical Association, some recommendations from a specialist

society, and a conversation with a drug retailer as well as informal conversations with

colleagues and exposure to television discussion of the issue.

Meanwhile, the patient talks with friends at work or family members about her

experience. They also become concerned and go to have their own pressure checked. She

returns for another checkup and her pressure is still elevated although she has reduced her

salt intake. The physician decides to treat her with medication. The patient is ready to

comply because all the sources around her—personal, professional, and media—are telling

her that she should.

This program is effective not because of a PSA or a specific program of physician

education. It is successful because the National High Blood Pressure Education Program

has changed the professional and public environment as a whole around the issue

of hypertension.

Note. From “Public Health Education and Communication as Policy Instruments for Bringing About

Changes in Behavior,” by R. Hornik. In Social Marketing: Theoretical and Practical Perspectives (pp.

49–50), by M. E. Goldberg, M. Fishbein, and S. E. Middlestadt (Eds.), 1997, Mahwah, NJ: Lawrence

Erlbaum Associates. Adapted with permission.

period during which change should

(you’ll design strategies and tactics for

take place

getting there later). Develop reasonable

• Measurable, to allow you to track progress

communication objectives by looking at the

toward desired results

health program’s goal and asking, “What

can communication feasibly contribute to

• Prioritized, to direct the allocation

attaining this goal, given what we know

of resources

about the type of changes the intended

audiences can and will make?”

Be Reasonable

Communication efforts alone cannot achieve

Objectives describe the intermediate steps

all objectives. Appropriate purposes for

that must be taken to accomplish broader

communication include:

goals; they describe the desired outcome,

but not the steps involved in attaining it

STAGE 1

Making Health Communication Programs Work

21

• Creating a supportive environment for a

change (societal or organizational) by

influencing attitudes, beliefs, or policies

• Contributing to a broader behavior

change initiative by offering messages

that motivate, persuade, or enable

behavior change within a specific

intended audience

Raising awareness or increasing knowledge

among individuals or the organizations that

reach them is also feasible; however, do not

assume that accomplishing such an

objective will lead to behavior change. For

example, it is unreasonable to expect

communication to cause a sustained

change of complex behaviors or

compensate for a lack of health care

services, products, or resources.

The ability and willingness of the intended

audience to make certain changes also

affect the reasonableness of various

communication objectives. Keep this in mind

as you define the intended audiences in

planning step 2.Your objectives will be

reasonable for a particular intended

audience only if audience members both

can make a particular behavior change and

are willing to do so.

Be Realistic

Once your program has developed

reasonable communication objectives,

determine which of them are realistic, given

your available resources, by answering

these questions:

• Which objectives cover the areas that

most need to reach the program goal?

• What communication activities will

contribute the most to addressing

these needs?

PLANNING TERMS

Goal

The overall health improvement that an

organization or agency strives to create

(e.g., more eligible cancer patients will

take part in cancer clinical trials, or

more Americans will avoid fatal heart

attacks). A communication program

should be designed to support and

contribute to achieving this specific

desired improvement.

Communication Objectives

The specific communication outcomes

you aim to produce in support of the

overall goal (e.g., by 2005, 75 percent of

Americans will know that participating

in cancer research studies may be an

option for them; or by 2005, 50 percent

of rural adults over age 40 will know the

warning signs for a heart attack and

what to do if they occur). Objectives

should be attainable, measurable, and

time specific.

Strategy

The overall approaches the program

takes. Strategies derive from and

contribute to achieving defined goals

and objectives. They should be based on

knowledge about effective

communication, the intended

audience’s needs and characteristics,

and your program’s capabilities,

timelines, and resources. (See planning

step 6 for more information on

developing a communication strategy

and evaluation plan.)

22

Planning and Strategy Development

• What resources are available? Include:

— Staff and other human resources—

committee members, associates from

other programs, volunteers, and others

who have the requisite skills and time

— Overhead resources such as computer

time, mailing costs, and printing

— Services available from another source,

such as educational materials available

free or at cost and the effort by other

organizations willing to help

— Information about the issue, the

intended audience, the community, and

media structures, or about available

educational materials

— Budget available to fund the program

— Time (weeks, months, or years

available to complete the program)

• What supportive factors exist (e.g.,

community activities, other organizations’

interests, positive community attitudes)?

• What barriers exist (e.g., obstacles to

approval, absence of funding, sensitivity of

an issue, intended audience constraints)?

• Which objectives would best use the

resources your program has identified and

best fit within the identified constraints?

Your answers to the last question should

become your priority objectives. Sometimes

you may feel so constrained by a lack of

funds that proceeding appears impossible.

An honest assessment may lead you to

conclude that a productive communication

effort is not possible. However, creative

use of the resources already identified

may enable you to develop a communication

program that can make valuable

contributions.

3. Define and Learn About

Intended Audiences

In this step, determine whom you want to

reach based on decisions made in the

previous two steps.

Begin by identifying intended populations for

a program based on the epidemiology of the

problem (who is most affected? at risk?) and

other factors contributing to the problem.

Intended populations are often defined very

broadly, using just a few descriptors (e.g.,

women over age 50). Intended audiences

are carved from these broad population

groups and defined more narrowly based on

characteristics such as attitudes,

demographics, geographic region, or

patterns of behavior. Examples might

include physically inactive adolescents,

heavy smokers with low education and

income levels who are fatalistic about health

issues, or urban African-American men with

hypertension who live in the South. Because

the intended audience’s ability and

willingness to make a behavior change

affects the extent to which communication

objectives are reasonable and realistic, it is

most efficient to select intended audiences

and develop communication objectives

(planning steps 2 and 3) in tandem.

STAGE 1

SAMPLE COMMUNICATION OBJECTIVES

By 2005, the number of women (over age 50; Washington, DC, residents; income under

$45,000) who say they get annual screening mammograms will have increased by 25 percent.

By the end of our campaign, more than 50 percent of students at South Salem High School

will report having increased the number of servings of fruits and vegetables they eat (on

most days) by one.

Making Health Communication Programs Work

23

GOALS AND OBJECTIVES:

H

EALTHY PEOPLE 2010

Healthy People 2010, the Nation’s

prevention agenda for the next decade,

is designed to achieve two overarching

goals: 1) increase the quality and years

of healthy life, and 2) eliminate health

disparities. For the first time, the Health

Communication chapter of Healthy

People 2010 includes objectives to

improve the quality of health

communication interventions, the skills

of health professionals, the reach and

quality of interactive communication

media, and the health literacy of people

with inadequate or marginal literacy

skills. Meeting these communication

objectives will contribute to the

achievement of the overarching goals.

Some communication efforts that could

contribute to the achievement of these

goals include the following:

• Interventions to improve the

communication skills of health care

providers and patients

• Assistance for people searching for and

using health information

• Education for consumers and patients

about important health topics and

relevant risks, preventive measures,

and ways to access the health

care system

See www.health.gov/healthypeople

to learn more.

Note. U.S. Department of Health and Human

Services. (2000). Healthy People 2010 (2nd

ed.; in two volumes: Understanding and

Improving Health and Objectives for Improving

Health). Washington, DC: U.S. Government

Printing Office. In the public domain.

Move From Intended Population to Specific

Intended Audiences

Defining subgroups of a population

according to common characteristics is

called segmentation. Segmentation can help

you develop messages, materials, and

activities that are relevant to the intended

audience’s current behavior and specific

needs, preferences, beliefs, cultural

attitudes, knowledge, and reading habits. It

also helps you identify the best channels for

reaching each group, because populations

also differ in factors such as access to

information, the information sources they

find reliable, and how they prefer to learn.

Increase your program’s effectiveness by

developing strategies that are attuned to the

needs and wants of different intended

audience segments. In fact, given the

diversity of the general public, trying to

reach everyone with one message or

strategy may result in an approach that does

not effectively reach those most able or

ready to change. Be aware, though, that

moving from a mass-market strategy to a

differentiated strategy will add economic and

staff resource costs for each additional

segment. Segment a population into specific

intended audiences using the following

characteristics to define them:

• Behavioral—health-related activities or

choices, degree of readiness to change a

behavior, information-seeking behavior,

media use, and lifestyle characteristics

• Cultural—language proficiency and

language preferences, religion, ethnicity,

generational status, family structure,

degree of acculturation, and lifestyle

factors (e.g., special foods, activities)

• Demographic—occupation, income,

educational attainment, family situation,

and places of residence and work

24

Planning and Strategy Development

• Physical—sex, age, type and degree of

exposure to health risks, medical

condition, disorders and illnesses, and

family health history

• Psychographic—attitudes, outlook on life

and health, self-image, opinions, beliefs,

values, self-efficacy, life stage, and

personality traits

The key to success is to segment the

intended population on characteristics

relevant to the health behavior to be

changed. A logical starting point is the

behavior itself: When possible, compare

those who engage in the desired behavior

with those who do not and identify the

determinants of their behavior. Many

planners simply rely on demographic,

physical, or cultural segmentations.

However, people who share these

characteristics can be very different in terms

of health behavior. For example, consider

two 55-year-old African-American women.

They work together in the same department.

They have the same amount of schooling

and comparable household incomes. They

live next door to each other, attend the same

church, and often invite each other’s family

over for meals. They enjoy the same

television shows, listen to the same radio

stations, and often discuss articles that they

both read in the paper. Neither has a family

history of breast cancer, and both had

children before age 30.Yet one woman goes

for annual mammograms and the other has

never had one. A demographic, physical, or

cultural segmentation would group these

women together, yet one is a member of the

intended audience for health

communications about mammography and

the other is not.

Select Intended Audiences

Once you have identified intended audience

segments, begin to set priorities and select

DATABASES HELP NCI IDENTIFY

AND

COMMUNICATE WITH INTENDED-

A

UDIENCE SEGMENTS

To help identify and understand its

intended audiences, NCI’s Office of

Communications (OC) uses a unique

database that combines health behavior

information with geographic,

demographic, and lifestyle data. OC

uses this information to create

Consumer Health Profiles that give a

portrait of the intended audience

segments most in need of cancer

prevention and detection messages.

Consumer Health Profiles describe:

• Which populations within a region

most need cancer education and

outreach and where these populations

live, including maps (e.g., which areas

of a state have the lowest cancer

screening rates)

• How to reach these populations, based

on factors such as media habits and

knowledge, attitudes, and beliefs

about cancer

Consumer Health Profiles are useful not

only in locating an intended audience

but also in understanding people better.

NCI’s Cancer Information Service and

its partners have used the profiles to

plan media buys and direct mailings to

increase the number of women

participating in low-cost mammography

screening programs. For more

information, contact CIS’s Partnership

Program at 1-800-4-CANCER or the

Office of Communications at

301-496-6667.

STAGE 1

Making Health Communication Programs Work

25

the intended audiences (e.g., those

segments with whom you will communicate).

As you select your intended audiences,

distinguish among the audiences your

program will address. Primary intended

audiences are those you want to affect in

some way; you may have one or several

primary intended audiences. If you have

more than one, set priorities among them

to help order your planning and allocate

resources. Secondary intended audiences,

or gateway audiences, are those with

influence on the primary intended audiences

or those who must do something to help

cause the change in the primary intended

audiences. These intended audiences might

need different kinds of messages and tools

to make the desired change.

Select intended audiences by answering the

following questions for each segment:

• What is a reasonable and realistic

communication objective for this intended

audience? In other words, what behavior

change can the intended audience make,

and how willing is this group to make that

change? Sometimes an intended

audience can’t make a behavior change—

or can’t make it easily—until a policy

change is instituted or a new or improved

product is developed. If your program

cannot provide the necessary policy or

technological changes, perhaps another

intended audience would be a better

choice. (See Appendix B for a description

of relevant theories and models of

behavior change that may help you

answer this question.)

• Will achieving that communication

objective with this intended audience

adequately contribute to attaining the

health program goal? (See planning step 2.)

intended audience size factors

prominently in the answer to this question.

It is important to choose a segment or

segments large enough that changes in

their behavior will make a worthwhile

contribution to your program’s goal. If your

program’s goal is population-wide

improvement, asking a larger intended

audience to make a small change may get

you closer to the goal and require fewer

resources than helping a small group

make a very large change.

• To what extent would members of this

segment benefit from the communication?

Some segments may already engage in

the desired behavior or may be close to it

(e.g., eating four servings of fruits and

vegetables each day, but not five).

• How well can available resources and

channels reach this segment? If you must

rely on mass communication (e.g., mass

media, public events), yet one-on-one skill

modeling is needed to help this segment

make a behavior change, your program’s

resources will be wasted.

• For secondary intended audiences, to

what extent does this audience influence

the primary intended audiences?

• To what extent will we be able to measure

progress? See the Communication

Research Methods section for a

discussion of measurement

considerations.

Answering these questions will also help

you determine who will not be members of

an intended audience. Ruling out intended-

audience segments will allow you to make

decisions regarding message development

and dissemination more easily and will help

ensure that all program resources are spent

productively. Two examples of intended

26

Planning and Strategy Development

audiences are 1) teens who smoke, and

2) women over age 50 who are not having

regular mammograms.

Learn More About the Intended Audiences

You probably need to know more about the

intended audiences than you learned from

the initial research. Sometimes planners

conduct consumer research on all potential

intended audiences to help them set

objectives, complete intended audience

segmentation, and set priorities. At other

times, they define and set priorities among

intended audiences based on initial

research and then conduct more intensive

research with selected intended audiences.

The approach often depends upon the

amount of existing secondary research

and the resources available to conduct

primary research.

To learn about an intended audience, find

answers to the following questions:

• What does the intended audience

already know about the topic? Do

intended audience members have

any misconceptions?

• What are the intended audience

members’ relevant attitudes, beliefs, and

perceptions of barriers to change?

• How “ready” is the intended audience to

change? (Based upon the stages of

change model—see Appendix B for

a description.)

• What benefit do intended audience

members already associate with making

the behavior change?

• What social, cultural, and economic

factors will affect program development

and delivery?

• When and where (times, places, states of

mind) can the intended audience best

be reached?

• What communication channels (e.g.,

mass media, organization meetings,

Internet sites) reach this intended

audience? Which do its members prefer?

Find credible? (Look to the census for

this information.)

• Do certain individuals (or gatekeepers)

either have particular influence with this

intended audience or control access to it?

What is their degree of influence?

• What are the intended audience’s

preferences in terms of learning styles,

appeals, language, and tone?

See the Communication Research Methods

section to learn ways to gather information

about intended audiences.

4. Explore Settings, Channels, and

Activities to Reach Intended Audiences

In this step, begin to think about the best

ways to reach the intended audiences.

To reach intended audiences effectively and

efficiently, first identify the settings (times,

places, and states of mind) in which they are

most receptive to and able to act upon the

message. Next, identify the channels

through which your program’s message can

be delivered and the activities that can be

used to deliver it. In making these decisions,

weigh what will best:

• Reach the intended audience

• Deliver the message

Explore Settings

To identify possible settings for reaching the

intended audience, think of the following:

• Places where your program can reach the

intended audience (e.g., at home, at

school or work, in the car, on the bus or

STAGE 1

Making Health Communication Programs Work

27

train, at a community event, in the local

Interpersonal Channels

health care provider’s office or clinic)

• Times when intended audience members

may be most attentive and open to your

program’s communication effort

• Places where they can act upon

the message

• Places or situations in which they will find

the message most credible

Sometimes a given setting may be a good

place to reach the intended audience but not

a good place to deliver the message. For

example, a movie theater slide might be a

great way to reach the intended audience,

but if the message is “call this number to

sign up for this health program,” people may

not be receptive to (or able to act upon) the

message—and they are unlikely to recall the

message or the number later, when they can

act on it. In contrast, if you reach people

while they are preparing dinner—or in the

grocery store—with a message to increase

fruit and vegetable consumption, they are

likely to be receptive to and able to act upon

the message.

Explore Channels and Activities

Message delivery channels have changed

significantly in the decade since this book

first appeared. Today, channels are more

numerous, are often more narrowly focused

on an intended audience, and represent

changes that have occurred in health care

delivery, the mass media, and society.

Consider the following channels:

• Interpersonal

• Group

• Organizational and community

• Mass media

• Interactive digital media

Interpersonal channels (e.g., physicians,

friends, family members, counselors,

parents, clergy, and coaches of the intended

audiences) put health messages in a

familiar context. These channels are more

likely to be trusted and influential than

media sources. Developing messages,

materials, and links into interpersonal

channels may require time; however, these

channels are among the most effective,

especially for affecting attitudes, skills, and

behavior/behavioral intent. Influence through

interpersonal contacts may work best when

the individual is already familiar with the

message, for example, from hearing it

through mass media exposure. (Similarly,

mass media are most effective at changing

behavior when they are supplemented with

interpersonal channels.)

Group Channels

Group channels (e.g., brown bag lunches at

work, classroom activities, Sunday school

discussions, neighborhood gatherings, and

club meetings) can help your program more

easily reach more of the intended audience,

retaining some of the influence of

interpersonal channels. Health messages

can be designed for groups with specific

things in common, such as workplace,

school, church, club affiliations, or favorite

activities, and these channels add the

benefits of group discussion and affirmation

of the messages. As with interpersonal

channels, working through group channels

can require significant levels of effort.

Influence through group channels is more

effective when groups are already familiar

with the message through interpersonal

channels or the others described here.

28

Planning and Strategy Development

DOCTOR TO PATIENT: THE INTERPERSONAL CHANNEL

Interpersonal channels have shown great success in delivering credible messages that

produce desired results. When the one-to-one message comes from the doctor, people are

especially likely to listen. Good communication between health care providers and

individuals is so important to achieving positive health outcomes that the Health

Communication chapter of Healthy People 2010 includes an objective to “increase the

proportion of persons who report that their health care providers have satisfactory

communication skills” (objective 11-6). In addition, the chapter on cancer includes an

objective to “increase the proportion of physicians and dentists who counsel their at-risk

patients about tobacco-use cessation, physical activity, and cancer screening”

(objective 3-10).

Examples of the results of physician-patient communication include:

• Doctor-patient communication has been associated with improved recovery from

surgery, shortened hospital stays, lower blood pressure and blood sugar, and better

health status.

• People who quit smoking in response to physician advice are more likely to make

repeated attempts to quit and are more likely to remain off cigarettes.

• Women in a national survey said a major reason they never had a mammogram was,

“My doctor never recommended one.” When a Massachusetts program increased the

number of physicians who recommended mammography, screening rates also rose.

• Most people in a national survey said their preferred source of information about

prescription medicines is their physician. When patients and physicians communicate,

compliance improves.

STAGE 1

Making Health Communication Programs Work

29

Organizational and Community Channels

Organizations and community groups, such

as advocacy groups, can disseminate

materials, include your program’s messages

in their newsletters and other materials,

hold events, and offer instruction related to

the message. Their involvement also can

lend their credibility to your program’s

efforts. Organizational/community channels

can offer support for action and are two-way,

allowing discussion and clarification,

enhancing motivation, and

reinforcing action.

Mass Media Channels

Mass media channels (e.g., radio, network

and cable television, magazines, direct mail,

billboards, transit cards, newspapers) offer

many opportunities for message

dissemination, including mentions in news

programs, entertainment programming

(“entertainment education”), public affairs

programs, “magazine” and talk shows

(including radio audience call-ins), live

remote broadcasts, editorials (television,

radio, newspapers, magazines), health and

political columns in newspapers and

magazines, posters, brochures, advertising,

and public service campaigns.You may

decide to use a variety of formats and

media channels, always choosing from

among those most likely to reach the

intended audiences.

Mass media campaigns are a tried-and-true

communication approach. They have been

conducted on topics ranging from general

health to specific diseases, from prevention

to treatment. Overall, research has

demonstrated the effectiveness of mass

media approaches in:

• Raising awareness

• Stimulating the intended audience to seek

information and services

• Increasing knowledge

• Changing attitudes and even achieving

some change (usually) in self-reported

behavioral intentions and behaviors

However, behavior change is usually

associated with long-term, multiple-

intervention campaigns rather than with

one-time communication-only programs.

Interactive Digital Media Channels

Interactive digital media channels (e.g.,

Internet Web sites, bulletin boards,

newsgroups, chat rooms, CD-ROMs, kiosks)

are an evolving phenomenon and are useful

channels that should have even greater

reach in the future. These media allow

communicators to deliver highly tailored

messages to and receive feedback from the

intended audience. These channels are

capable of producing both mass

communication and interpersonal

interaction. Use these media to:

• Send individual messages via

electronic mail

• Post program messages (such as

information about health-related

campaigns) on Internet sites that large

numbers of computer users access

30

Planning and Strategy Development

INTERNET AND MULTIMEDIA CHANNELS

CD-ROMs—Computer disks that can contain an enormous amount of information,

including sound and video clips and interactive devices.

Chat rooms—Places on the Internet where users hold live typed conversations. The

“chats” typically involve a general topic. To begin chatting, users need chat software, most

of which can be downloaded from the Internet for free.

Electronic mail (e-mail)—A technology that allows users to send and receive messages to

one or more individuals on a computer via the Internet.

Interactive television—Technologies that allow television viewers to access new

dimensions of information (e.g., link to Web sites, order materials, view additional

background information, play interactive games) through their television during related

TV programming.

Intranets—Electronic information sources with limited access (e.g., Web sites available

only to members of an organization or employees of a company). Intranets can be used to

send an online newsletter with instant distribution or provide instant messages or links to

sources of information within an organization.

Kiosks—Displays containing a computer programmed with related information. Users

can follow simple instructions to access personally tailored information of interest and, in

some cases, print out what they find. A relatively common health application is placing

kiosks in pharmacies to provide information about medicines.

Mailing lists (listservs)—E-mail–based discussions on a specific topic. All the subscribers

to a list can elect to receive a copy of every message sent to the list, or they may receive a

regular “digest” disseminated via e-mail.

Newsgroups—Collections of e-mail messages on related topics. The major difference

between newsgroups and listservs is that the newsgroup host does not disseminate all the

messages the host sends or receives to all subscribers. In addition, subscribers need special

software to read the messages. Many Web browsers, such as Internet Explorer, contain this

software. Some newsgroups are regulated (the messages are screened for appropriateness to

the topic before they are posted).

Web sites—Documents on the World Wide Web that provide information from an

organization (or individual) and provide links to other sources of Internet information.

Web sites give users access to text, graphics, sound, video, and databases. A Web site can

consist of one Web page or thousands of Web pages. Many health-related organizations

have their own Web sites.

STAGE 1

Making Health Communication Programs Work

31

COMMUNICATION CHANNELS AND ACTIVITIES: PROS AND CONS

Type of Channel

Interpersonal

Channels

Organizational

and Community

Channels

Mass Media

Channels

Newspapers

Radio

Activities Pros Cons

• Hotline counseling • Can be credible • Can be expensive

• Patient counseling

• Permit two-way • Can be time-consuming

• Instruction

discussion • Can have limited

• Informal discussion

• Can be motivational, intended audience

influential, supportive reach

• Most effective for teaching • Can be difficult to link

and helping/caring into interpersonal

channels; sources need

to be convinced and

taught about the

message themselves

• Town hall meetings and • May be familiar, trusted,

• Can be costly, time-

other events and influential

consuming to establish

• Organizational meetings • May provide more

• May not provide

and conferences motivation/support than

personalized attention

• Workplace campaigns media alone

• Organizational

• Can sometimes be

constraints may require

inexpensive

message approval

• Can offer shared

• May lose control of

experiences

message if adapted to

• Can reach larger intended

fit organizational needs

audience in one place

• Ads

• Can reach broad intended • Coverage demands a

• Inserted sections on a

audiences rapidly newsworthy item

health topic (paid)

• Can convey health • Larger circulation

• News

news/breakthroughs more papers may take only

• Feature stories

thoroughly than TV or

paid ads and inserts

• Letters to the editor

radio and faster than • Exposure usually limited

• Op/ed pieces

magazines to one day

• Intended audience has • Article placement

chance to clip, reread, requires contacts and

contemplate, and pass may be time-consuming

along material

• Small circulation papers

may take PSAs

• Ads (paid or public

• Range of formats

• Reaches smaller

service placement)

available to intended

intended audiences

• News

audiences with known

than TV

• Public affairs/talk shows

listening preferences

• Public service ads run

• Dramatic programming

• Opportunity for direct

infrequently and at low

(entertainment

intended audience

listening times

education)

involvement (through call-

• Many stations have

in shows)

limited formats that may

• Can distribute ad scripts

not be conducive to

(termed “live-copy ads”),

health messages

which are flexible

• Difficult for intended

and inexpensive

audiences to retain or

pass on material

Continued on next page...

32

Planning and Strategy Development

COMMUNICATION CHANNELS AND ACTIVITIES: PROS AND CONS CONTINUED...

Type of Channel Activities Pros

Cons

Radio continued...

Television

Internet

• Ads (paid or public

service placement)

• News

• Public affairs/talk shows

• Dramatic programming

(entertainment

education)

• Web sites

• E-mail mailing lists

• Chat rooms

• Newsgroups

• Ads (paid or public

service placement)

• Paid ads or specific

programming can reach

intended audience when

they are most receptive

• Paid ads can be

relatively inexpensive

• Ad production costs are low

relative to TV

• Ads allow message and its

execution to be controlled

• Reaches potentially the

largest and widest range of

intended audiences

• Visual combined with audio

good for emotional appeals

and demonstrating behaviors

• Can reach low income

intended audiences

• Paid ads or specific

programming can reach

intended audience when

most receptive

• Ads allow message and its

execution to be controlled

• Opportunity for direct

intended audience

involvement (through

call-in shows)

• Can reach large numbers

of people rapidly

• Can instantaneously update

and disseminate information

• Can control information

provided

• Can tailor information

specifically for

intended audiences

• Can be interactive

• Can provide health

information in a graphically

appealing way

• Can combine the

audio/visual benefits of TV

or radio with the

self-paced benefits of

print media

• Can use banner ads to

direct intended audience to

your program’s Web site

• Ads are expensive

to produce

• Paid advertising is

expensive

• PSAs run infrequently

and at low viewing times

• Message may be

obscured by

commercial clutter

• Some stations reach

very small

intended audiences

• Promotion can result in

huge demand

• Can be difficult for

intended audiences

to retain or pass

on material

• Can be expensive

• Many intended

audiences do not have

access to Internet

• Intended audience must

be proactive—must

search or sign up

for information

• Newsgroups and chat

rooms may

require monitoring

• Can require

maintenance over time

STAGE 1

Making Health Communication Programs Work

33

• Create and display advertisements

• Survey and gather information from

computer users

• Engage intended audiences in

personalized, interactive activities

• Exchange ideas with peers and partners

Using interactive digital media is not without

challenges. If you choose to do so, consider

credibility and access issues.

Credibility. Anyone can put information on

the Internet, and it may or may not be

accurate. Thus it is important to demonstrate

the credibility of your organization when you

use this channel to disseminate health

information. This will help ensure that users

trust the information they receive.

To improve the quality of health information

on the Internet, Healthy People 2010

includes an objective to increase the

proportion of health-related Web sites that

disclose information that can be used to

assess the site’s quality (objective 11-4). To

improve quality, health Web sites should

disclose the following information:

• The identity of the developers and

sponsors of the site, how to contact them,

and information about any potential

conflicts of interest or biases

• The explicit purpose of the site, including

any commercial purposes and advertising

• The original sources of the content

on the site

• How the privacy and confidentiality of any

personal information collected from users

is protected

• How the site is evaluated

• How content is updated

Access. The average computer user is

affluent and well educated. Although access

to this medium is increasing, it is definitely

not universal; television and radio are better

choices to reach a larger intended audience.

The U.S. Department of Commerce issues

reports on the “digital divide,” the gap

between those with access to computers

and the Internet and those without. Healthy

People 2010 includes an objective to

increase from 26 to 80 the percentage of

households with access to the Internet so

that individuals will be able to get the

information and services they need to

address their health concerns

(objective 11-1).

Weigh Pros and Cons

As illustrated in the table Communication

Channels and Activities: Pros and Cons,

each type of channel—and activity used

within that channel—has benefits and

drawbacks. Weigh the pros and cons by

considering the following factors:

• Intended audiences you want to reach:

—

Will the channel and activity reach and

influence the intended audiences (e.g.,

individuals, informal social groups,

organizations, society)?

—

Are the channel and activity acceptable

to and trusted by the intended

audiences, and can they

influence attitudes?

• Your message:

—

Is the channel appropriate for

conveying information at the desired

level of simplicity or complexity?

—

If skills need to be modeled, can the

channel model and demonstrate

specific behaviors?

• Channel reach:

—

How many people will be exposed to

the message?

34

Planning and Strategy Development

BEST CHOICE: USING MULTIPLE CHANNELS TO REACH INTENDED AUDIENCES

Using several different channels increases the likelihood of reaching more of the intended

audiences. It also can increase repetition of the message, improving the chance that

intended audiences will be exposed to it often enough to absorb and act upon it. For these

reasons, a combination of channels has been found most effective in producing desired

results, including behavior change.

For example, Center for Substance Abuse Prevention (CSAP) communication grantees have

combined channels in unique ways that reflect their communities. One grantee used

posters in community facilities, placed radio spots, and distributed brochures through

community sites and requests by radio listeners. Another used a satellite network to show

videos, made small group presentations through organizations, and worked with schools

to promote at-home activities. Yet another promoted its message through a music and

visual arts training program that resulted in a live performance and television broadcast of

the program’s art and musical creations.

Note. Center for Substance Abuse Prevention Communications Cooperative Agreements. (1996).

Bridging the Gap for People with Disabilities. Rockville, MD: U.S. Department of Health and Human

Services. In the public domain.

STAGE 1

—

Can the channel meet intended

audience interaction needs?

—

Can the channel allow the intended

audience to control the pace of

information delivery?

• Cost and accessibility:

—

Does your program have the resources

to use the channel and the activity?

• Activities and materials:

—

Is the channel appropriate for the

activity or material you plan to

produce? (Decisions about activities

and channels are interrelated and

should be made in tandem. See Stage

2 for a list of possible materials for

health programs and a discussion of

decision factors.)

—

Will the channel and activity reinforce

messages and activities you plan

through other routes to increase

overall exposure among the

intended audiences?

5. Identify Potential Partners

Working with other organizations can be a

cost-effective way to enhance the credibility

and reach of your program’s messages. Many

public health institutions seek out partner

organizations to reach particular intended

audiences.

The benefits to your program of forming

partnerships can include:

• Access to an intended audience

• More credibility for your message or

program because the intended audiences

consider the potential partner to be a

trusted source

• An increase in the number of messages

your program will be able to share with

intended audiences

• Additional resources, either tangible or

intangible (e.g., volunteers)

• Added expertise (e.g., training capabilities)

Making Health Communication Programs Work

35

• Expanded support for your organization’s

priority activities

• Cosponsorship of events and activities

You may partner with one or a few

organizations to accomplish specific

projects. Some communication initiatives

may call for tapping into or assembling a

coalition of organizations with a shared goal.

In some cases, you may need to assemble

many organizations that support particular

recommendations or policies. At other times,

you may want the organizations to play an

active role in developing and implementing

communication activities.

To encourage selected groups to partner

with your organization, consider the benefits

you can offer, such as:

• Added credibility

• Access to your organization’s data

• Assurance of message accuracy

• Liaison with other partners

Decide Whether You Want Partners

Although working with partners can be

essential to achieving communication

objectives, there are also drawbacks that

you should recognize and prepare to

address. Working with other

organizations can:

• Be time consuming—Identifying potential

partners, persuading them to work with

your program, gaining internal approvals,

and coordinating planning and training all

take time.

• Require altering the program—Every

organization has different priorities and

perspectives, and partners may want to

make minor or major program changes

to accommodate their own structure

or needs.

• Result in loss of ownership and control of

the program—Other organizations may

change the time schedule, functions, or

even the messages, and take credit for

the program.

Decide how much flexibility you would be

willing to allow a partner in the program

without violating the integrity of your

program, its direction, and your own

agency’s procedures. If you decide to

partner with other organizations,

consider which:

• Would best reach the intended audiences

• Might have the greatest influence and

credibility with the intended audiences

• Will be easiest to persuade to work with

you (e.g., organizations in which you know

a contact person)

• Would require less support from you

(e.g., fewer resources)

Develop Partnering Plans

Think about the roles potential partners

might play in your program and use the

suggestions below to help identify specific

roles for partners:

• Supplemental printing, promotion, and

distribution of materials

• Sponsorship of publicity and promotion

• Purchase of advertising space/time

• Creation of advertising about your

organization’s priority themes

and messages

• Underwriting of communication materials

or program development with

your organization

See Appendix A for a partnership plan form.

36

Planning and Strategy Development

WORKING WITH FOR-PROFIT PARTNERS

The National Cancer Institute uses these guidelines when considering

commercial partners.

Policies

• The National Cancer Institute will not consider any collaboration that endorses a

specific commercial product, service, or enterprise.

• The National Cancer Institute name and logo may be used only in conjunction with

approved projects and only with the written permission of NCI. NCI retains the right to

review all copy (e.g., advertising, publicity, or for any other intended use) prior to

approval of the use of the NCI name and logo.

• The National Cancer Institute will formally review each proposal for partnership.

• No company will have an exclusive right to use the NCI name and logo, messages,

or materials.

• Confidentiality cannot be guaranteed for any collaboration with a federal program.

Criteria for Reviewing Corporations Prior to Partnership Negotiations

• Company is not directly owned by a tobacco company and is not involved in

producing, marketing, or promoting tobacco products.

• Company does not have any products, services, or promotional messages that conflict

with NCI policies or programs (e.g., the company does not market known carcinogens

or market some other product that NCI would not consider medically or

scientifically acceptable).

• Company is not currently in negotiation for a grant or contract with NCI.

• Company does not have any unresolved conflicts or disputes with NCI or NIH.

• Establishing a partnership with this company will not create tensions/conflicts with

another NCI partner or federal program.

• Company or institution satisfactorily conforms with standards of health or medical care.

• There is evidence that the company would be interested in becoming a partner

with NCI.

Working With Partners

Developing and Maintaining Coalitions

The staff person responsible for working

Community coalitions have become an

with partners should be:

important force in health promotion.

Coalitions have all of the advantages of

• A good manager who is able to balance

partnerships plus another benefit. Because

all program components

they harness the resources and

• A team player who is able to work with

commitment of multiple organizations, the

other organizations

attention those organizations pay to an

• Diplomatic and willing to negotiate

issue is institutionalized for long-term action.

The strongest potential partners may be

• Willing to share credit for success

interested in joining coalitions.

STAGE 1

Making Health Communication Programs Work

37

STEPS FOR INVOLVING PARTNERS IN THE PROGRAM

1. Choose organizations, agencies, or individuals (e.g., physicians) that can bring the

resources, expertise, or credibility your program needs.

2. Consider which roles partners might play to best support the program.

3. Involve representatives of the organizations you want to work with as early as

appropriate in program planning.

4. Give partners the program rationale, strategies, and messages (in ready-to-use form).

Remember that strategic planning, creative messages, and quality production are the

most difficult aspects of a communication program to develop and may be the most

valuable product you can offer to a community organization.

5. Give partners advance notice so that they can build their part of the program into

their schedule, and negotiate what will be expected of them.

6. Allow partners to personalize and adapt program materials to fit their circumstances

and give them a feeling of ownership, but don’t let them stray from the strategy.

7. Ask partners what they need to implement their part of the program. Beyond the

question of funding, consider other assistance, training, information, or tools that

would enable them to function successfully.

8. Provide partners with new local/regional/national contacts or linkages that they will

perceive as valuable for their ongoing activities.

9. Give partners an appropriate amount of work. Give them a series of small, tangible,

short-term responsibilities, as well as a feedback/tracking mechanism.

10. Gently remind partners that they are responsible for their activities; help them

complete tasks, but don’t complete tasks for them.

11. Assess progress through the feedback/tracking mechanism and help make adjustments

to respond to the organization’s needs and to keep the program on track.

12. Provide moral support by frequently saying “thank you” and by providing other

rewards (e.g., letters or certificates of appreciation).

13. Give partners a final report of what was accomplished and meet to discuss follow-up

activities and resources they might find useful. Make sure that they feel they are a part

of the program’s success.

14. Share one final, tremendous “Thank you for a job well done.”

38

Planning and Strategy Development

39

Coalitions often grow from informal

partnerships or advisory bodies created

around special projects. Experience in

working together lays the groundwork for

a long-term association.

Use the following guidelines to create a

successful coalition:

• Formalize the relationship to create

greater commitment. Formal

arrangements include written memoranda

of understanding, by-laws, mission

statements, or regular reminders of the

coalition’s purpose and progress.

• Make sure that the responsibilities of each

organization and its staff are clear. In

particular, staff members need to know

whether to take direction from the coalition

chairperson or from the agency that pays

their salary.

• Structure aspects of the coalition’s

operation. Elect officers. Form standing

committees. Have regularly scheduled

meetings with written agenda and

minutes. Expect and support action, not

just discussion, at these meetings.

Circulate action items resulting from

meetings among coalition members.

Establish communication channels and

use them frequently.

• Ensure the involvement of representatives

who show leadership characteristics, such

as the ability to obtain resources, problem-

solve, and promote collaboration and

equality among members. Members with

political knowledge, administrative or

communication skills, or access to the

media and decision-makers are

also valuable.

• Create and reinforce positive expectations

by providing information on the coalition’s

progress. Optimism and success sustain

member interest.

• Formalize accountability and develop

criteria for judging whether coalition

members are honoring their commitments.

• Be flexible. Losing prospective partners

can limit a program’s effectiveness.

• Provide training to help members

complete their tasks. For example,

coalition members may need training in

how to be effective advocates for your

program’s issues.

• Give members a stake in the coalition and

an active role in decision-making.

• Seek external resources to augment

member resources.

• Evaluate the effectiveness of the coalition

periodically and make necessary changes.

This should include process evaluation of

the coalition’s functioning and assessment

of the coalition’s impact on the health

problem being addressed.

6. Develop a Communication Strategy;

Draft Communication and

Evaluation Plans

At this point your program has:

• Defined intended audiences and the

actions you want their members to take

(communication objectives)

• Explored the settings, channels, and

activities that can be used to reach them

• Identified potential partners

• Developed partnering plans

In this step, you will use this information as

the basis for developing a communication

strategy and drafting communication and

evaluation plans.

40

Planning and Strategy Development

Develop a Communication Strategy

Statement (Creative Brief)

In this context, a strategy is a

communication approach your program

plans to take with a specific intended

audience; while you may develop many

different communication materials and use a

variety of activities, the strategies are

guiding principles for all program products

and activities. A communication strategy

includes everything you need to know to

communicate with the intended audience. It

defines the intended audience, describes

the action its members should take, tells

how they will benefit (from their perspective,

not necessarily from a public health

perspective), and how you can reach them.

A communication strategy is:

• Based on knowledge of the intended

audience’s wants, needs, values,

and accessibility

• Guided by general communication

research as well as theories and models

of behavior

• Tempered by the realities of available

resources and deadlines

Developing the strategy statement provides

a good test of whether your program has

enough information to begin developing

messages. It also gives you an opportunity

to obtain management and partner buy-in

for the approach.You may be tempted to

skip this step, but do not. Having an

approved strategy statement will save time

and effort later. The statement provides both

a foundation and boundaries for all the

materials you produce and all the activities

you conduct.

The communication strategy statement is

sometimes called a creative brief because it

is used to brief the creative team. In

addition, sharing the strategy statement with

management and partners allows you to

make sure there is support for your

program’s approach before resources are

expended and makes easier the approvals

and cooperation you may need later.

For each of the intended audiences, write a

creative brief (see Appendix A for a template

to use) that includes the following:

• A definition and description of the

intended audience (intended-audience

profile). Think of one person in the

intended audience and describe him or

her, rather than describing the group. The

information you gathered in planning step

3 should provide the basis for this section.

• A description of the action the intended

audience members should take as a result

of exposure to the communication. The

action is the change the communication

objective specifies (planning step 2). If you

haven’t already done so, now is the time to

find out if intended audience members are

willing and able to take the action—and to

identify the current behavior that you want

to change. Knowing what an intended

audience currently does—and why it does

it—will provide important insights into the

behavior change process and can be used

to develop communications that

demonstrate replacing the old behavior

with the new one.

• A list of any obstacles to taking action.

Common obstacles include intended

audience beliefs, social norms, time or

peer pressures, costs, ingrained habits,

misinformation, and product

inaccessibility. The “map” you created in

planning step 1 should identify many of

the obstacles, particularly those related to

product inaccessibility (e.g., a woman

can’t get to a mammography location, a

worker has no access to fruits or

vegetables at break times, a condom isn’t

available at the time of intercourse).

STAGE 1

Making Health Communication Programs Work

41

SAMPLE STRATEGY STATEMENT

Draft Creative Brief Used for NCI 5 A Day for Better Health Program Concept

Development and Testing (June 2001)

Intended Audiences—African-American and Latino adults (men and women) with

primary responsibility for shopping and food preparation who have children under the

age of 13 and have household incomes of $25,000 to $50,000 who believe they and their

families should eat more fruits and vegetables.

Objective(s)—1) to believe that increasing their fruit and vegetable (f/v) intake is possible

(provides a “can do” self-efficacy element), and 2) to increase their f/v intake (gets at the

behavioral element, which is the ultimate goal; provides the “do it” element).

Obstacles

• Low salience/competition with everyday concerns and priorities

• Storage

• Low self-efficacy

• Children’s reaction/sensory

• Cost, convenience, freshness (cost, both out of pocket and perishability, is a top barrier

among African Americans)

• Not filling and don’t taste good (Latino issues)

• Safety (safety/pesticide issues are top barriers for eating vegetables for Latinos)

• Lack of planning time

• Preparation time (preparation time is a “top” barrier for eating vegetables among

African Americans)

• Lack of familiarity with certain fruits and vegetables

• Competition with other food products; i.e., fast foods

• Nutritional concerns about frozen/canned; e.g., canned are high in sodium; and for

Latinos, “not as healthy” misconception

• Lack of confidence in ability to get fruits and vegetables outside the home (survey

data, Latinos)

Key Promise

• If we eat more fruits and vegetables every day, I’ll feel good knowing we’re setting a

good example for our children and investing in a healthy future.

• If my family members eat more fruits and vegetables, they will function at their best and

protect their health as well as feel more energetic, help control their weight, and cleanse

their system.

• If we eat more fruits and vegetables every day, my family will stay healthy while

reducing its risk of cancer or heart disease in the future.

• If we have plenty of fruits and vegetables available for our family, we will be setting a

good example and teaching our children good, lifelong eating habits.

Continued on next page...

42

Planning and Strategy Development

SAMPLE STRATEGY STATEMENT CONTINUED...

Support Statements

• Fruit and vegetable consumption helps people feel good, look good, and maintain

their weight.

• Fruit and vegetable consumption provides generous amounts of fiber and promotes

digestive health.

• Obesity and childhood diabetes are epidemic.

• Fruit and vegetable consumption reduces the risk of heart disease/cancer.

Tone—Urgency without fear; positive…

Media

• TV PSAs

• Radio PSAs/Live announcer scripts

• Posters

• Newspaper ads

• Billboard and Metro Transit ads

• Earned Media (“Do Yourself a Flavor”)—African-American/Latino women can send

Graham Kerr recipes that he can select and feature

• Web site

• Articles in women’s magazines

Other Channels/Intermediaries

• Produce for Better Health

• State coordinators

Openings

• Traveling home from work

• Mother’s Day

• Community outreach (health fairs, in-store events such as taste tests or demonstrations),

grassroots programs

Creative Considerations

• Adaptable to local needs (state health profiles)

• Focus on more than one fruit or vegetable (equal opportunity)

• Appetite appeal, culturally appropriate, cross-cultural concepts that can be tailored

in execution

• Focus groups that include men and women and low-income ($25,000 or less in San

Antonio) participants at each site, which may drive creative to accommodate low

literacy; this is a good thing if we have both English- and Spanish-speaking people in

the intended audience. (Note: Creative executions should be intended audience specific,

while the concepts will cross over and work for both ethnic groups.)

STAGE 1

Making Health Communication Programs Work

43

The additional information you gathered

about the intended audience in

planning step 3 should also help you

identify obstacles.

• The consumer-perceived benefit of taking

the action. Many theories and models of

behavior change include the idea that

people change their behavior because

they expect to receive some benefit (e.g.,

gain in time, money, enjoyment, potential

gain in stature among peers) that

outweighs the personal cost of the

behavior change. Short-term, high-

probability personal benefits generally are

more effective than long-term population

benefits (e.g., “stop smoking to smell

better and be more attractive” rather than

“stop smoking to reduce your risk of

developing lung cancer”).

• A description of the support that will make

the benefit, and its ability to attain it,

credible to the intended audience. Support

can be provided through hard data, peer

testimonials about success or satisfaction,

demonstrations of how to perform the

action, or statements from organizations

the intended audience finds credible. Tailor

the particular supports you use to the

concerns intended audience members

have about the action. For example, if they

are worried they can’t do it, a

demonstration may be warranted; if they

question why they should take the action

or whether it will have the promised health

benefit, hard data or statements from

credible organizations may be in order; if

they don’t believe they need to take the

action (e.g., they deny being in the

intended audience), a peer testimonial can

be compelling.

• The settings, channels, and activities that

will reach intended audience members—

particularly when they will be receptive to

or able to act upon the message. This

information should come from the work

you did in planning step 4.

• The image your program plans to convey

through the tone, look, and feel of

messages and materials. The goal should

be to convey an image that 1) convinces

intended audience members that the

communication is for them, and 2) is

culturally appropriate. Image is conveyed

largely through executional details. Printed

materials convey image through typeface,

layout, visuals, color, language, and paper

stock used. Web materials convey image

through design, typeface, color, layout,

and ease of use. Audio materials convey

image through voices, language, and

music; in addition to these details, video

materials convey image through visuals,

characteristics of the actors (including

their clothing and accessories), camera

angles, and editing. Work with the creative

team to develop the image you select.

The information in Appendix B and the

information you learned about your intended

audience in planning step 3 are the

foundation for strategy development. Use

this information to prepare a document

similar to the NCI sample strategy statement

provided here. At first, you may have

question marks next to some items, or lists

of possibilities for actions, benefits, support,

or image.You can fill in the answers, narrow

down the list, and get overall reactions to

the strategy by conducting research with the

intended audience. (See the Communication

Research Methods section for suggestions

on how to obtain this input.) Developing the

communication strategy is usually an

iterative process; as you learn more about

one element, other elements will likely need

to be adjusted.

The communication strategy provides all

program staff—including writers, creative

staff, and evaluators—with the same

direction for developing all messages and

materials. In a cooperative program with

partner organizations, the strategy

44

Planning and Strategy Development

statement can also help all players

• Message and materials development and

communicate consistent themes and take

similar action. Some organizations choose to

produce report-length strategy statements

that contain additional information, such as

background on the health problem being

addressed, extensive intended audience

profiles, and situation analyses.

Once your program has decided on a

communication strategy, all program elements

should be compatible with it. This means

every program task should contribute to

reaching the established objectives and be

designed to reach the identified intended

audiences; all messages and materials

should incorporate the benefits and other

information from the strategy statement.

As you learn more about the intended

audiences and their perceptions, you may

need to alter or refine the strategy statement.

However, it should be changed only to reflect

information that will strengthen your

program’s ability to reach the communication

objectives. Do not alter your strategy simply to

accommodate a great idea that doesn’t match

the objectives.

Draft Communication Plan

All of the elements of your planning should be

recorded in a communication plan that will

become your “blueprint.” It should be used to:

• Explain the plans within your agency and

with others

• Support and justify budget requests

• Provide a record of where your

program began

• Show the program’s planned evolution

over time

Include the following sections in the plan:

testing plans

• Implementation plans, including plans

for distribution, promotion, and

process evaluation

• Outcome evaluation plans

• Tasks and timeline

A template for a communication plan that

includes all of these sections is in Appendix

A. During Stage 1, prepare initial drafts of all

plan sections except distribution and

promotion. Realize that some of the

sections, such as implementation and

process evaluation (see Stage 3), may not

be as detailed as others at this point.

Draft Outcome Evaluation Plans

Outcome evaluation is used to assess the

degree to which the communication

objectives are achieved. Conducting useful

outcome evaluation can be challenging

because of the following constraints:

• Many standard evaluation approaches

assume a direct cause-and-effect

relationship between the stimulus (your

program’s communication) and the

intended audience’s response to it.

However, it can be impossible to isolate

the effects of a particular communication

activity, or even the effect of a

communication program on a specific

intended audience, because change does

not often occur as a result of just one

specific activity.

• Communication programs generally occur

in a real-world setting, where there are

many other influences on the intended

audiences. Other activities (and often

other organizations) may be addressing

the same problem. Attributing change to

program activities may be very difficult.

STAGE 1

• Communication strategy

• Partnering plans

Making Health Communication Programs Work

45

• Communication objectives can be

reasonable but not measurable because

of reasons such as:

— The change is too small for available

methodologies to detect (e.g., a

2 percent increase over the course of a

year in the number of women age 50 or

over who get a mammogram would

have important public health benefits,

but would not be detectable by a survey

with a typical 3.1 percent margin

of error).

— The change is difficult to measure

validly or reliably (e.g., self-reports of

behavior are often unreliable).

Plan Outcome Evaluation Activities

Before you begin to plan for outcome

evaluation, review Stage 4 for descriptions

of common methodologies. As you plan,

keep the following tips in mind:

• Ensure that the evaluation design is

appropriate for the particular

communication activity. Experimental

designs, in which a treatment group

(people exposed to the communication) is

compared to a control group (people not

exposed to the communication), are the

gold standard of outcome evaluation.

However, they often cannot be used to

assess communication activities, largely

because untreated control groups may not

exist, particularly for national-, state-, or

community-based efforts. Even if people

are not exposed to your program’s

communication, they are likely to be

exposed to some communication on the

same topic. In these situations,

appropriate designs include comparisons

between cross-sectional studies (such as

independent surveys taken at different

points in time), panel studies (the same

people are interviewed or observed

multiple times), and time series analyses

(comparisons between projections of what

would have happened without the

intervention versus what did happen).

However, each is appropriate in different

situations; seek the advice of an

evaluation expert before selecting

a design.

• Consider how the communication activity

is expected to work and the time period in

which it is expected to work. Then make

sure it is evaluated in accordance with

those expectations. For example, if you

expect people to need at least five to eight

exposures to the message before they will

take action, make sure that you allow

sufficient implementation time to achieve

the intended level of exposure. If you

expect people to take action immediately

after exposure, then the outcome

measurement should take place soon

after that. Conversely, if you don’t expect

to see effects for at least a year, outcomes

shouldn’t be measured until then.

Communication programs are often

deemed “failures” because they don’t

reach people with sufficient repetition to

work—either because they are

inadequately funded or because

everything runs late and they are not in

place long enough before outcomes are

measured. (Use process evaluation to

track the level of intensity and the duration

of message exposure to learn why

expected outcomes did or did not occur.)

• Consider what level of evidence is

acceptable for your outcome evaluation

purpose (e.g., to report back to

management or funding agencies).

• Consider what baseline measures you

have available or can collect and how to

track changes related to desired outcomes

(e.g., how, and how often, data will

be collected).

• Ensure that you measure change against

the communication objectives and not

46

Planning and Strategy Development

against your program’s goal. For example, 2. Take another look at these sections after

if the communication objective is to

increase the percentage of women age

50 or older who ask their doctor about a

mammogram, you would measure how

many women asked their doctor about a

mammogram, not how many women got

a mammogram.

• Ensure that progress toward outcomes is

captured. For example, if you expect

people to think about changing a behavior,

and perhaps try changing it a few times

before making and sustaining the change,

make sure the evaluation can capture

these intermediate outcomes. If the

objective is to increase the percent of

people engaging in moderate exercise on

most days of the week, it would be

important to determine 1) people’s current

behavior, and 2) whether they have

thought about increasing their amount of

activity, taken steps to increase it, or

increased it some weeks but

not consistently.

Appendix A contains an outcome evaluation

form. Although you may not be ready to

complete final evaluation planning now, it is

important to put together a general plan so

that your program can collect any necessary

baseline data before implementation begins,

build any needed evaluation mechanisms

into the program, and ensure that evaluation

resources are allocated. To get started, do

the following:

1. Read Stage 4 (Assessing Effectiveness

and Making Refinements) and look at the

table at the beginning of the

Communication Research Methods

chapter. What you learn about evaluation

may affect what you choose to do with

the program.

your initial communication plan is

complete to be sure the evaluation

activities will be appropriate and valuable.

3. Involve an evaluation expert familiar with

evaluating communication programs

during initial planning. His or her advice

can help prevent time-consuming fixes

later by ensuring you develop a program

that can be validly evaluated (e.g., making

sure data collection mechanisms are in

place, making sure baseline data are

collected for comparison later).

Create a Timetable

Finally, produce a time schedule for

development, implementation, and

evaluation. The schedule should include

every task you can think of from the time

you write the plan until the time you intend

to complete the program. The more tasks

you build into the timetable now, the more

likely you will remember to assign the work

and keep on schedule. Also, detailing the

tasks will make it easier to decide what

resources will be required. If you forget

important intermediate steps, your

program’s costs and schedule

might change.

The timetable should be considered a

flexible management tool. Review and

update it regularly (e.g., once a month) so

that it can function dually to manage and

track progress. Many managers believe

computer-based tools are especially useful

for this task. Project management computer

software contains schedule forms that you

can fill in and monitor on the computer and

print out for staff and others involved.

STAGE 1

Making Health Communication Programs Work

47

Common Myths and Misconceptions

About Planning

Myth: Our program can’t afford to conduct

intended audience research.

Fact:

Your program can’t afford not to

conduct intended audience research.

Without it, you do not know for sure whom to

select, where to reach them, what to ask

them to do, or how to ask it. The information

you need to develop effective communication

may be relatively inexpensive or free.

Resources include literature searches,

information available free from government

health agencies, and advisory groups and

representatives of the intended audience.

For example, the National Cancer Institute’s

5 A Day for Better Health Program media

campaign used primary research to identify

its intended audiences, actions they would

be willing to take, and benefits they would

find compelling, but used existing marketing

databases to obtain a great deal of

information about their lifestyles, interests,

outlook, and media habits. The cost for

analyzing the databases was substantially

less than it would have been to conduct and

analyze additional primary research.

Myth: Market research isn’t relevant for a

health program.

Fact:

Health program planners can use the

methodologies and types of information

normally associated with market research in

many ways, including:

• Understanding why individuals would

choose or not choose to undertake a new

behavior, other preferences regarding the

behavior, how communicators should talk

about the behavior (tone and language),

and where individuals seek out or

receive information

• Creating a multidimensional portrait of the

intended audience for communication

planning; knowing only health-related

factors limits understanding of the whole

person your program is trying to influence

and does not provide guidance on when

and where to reach the person or what to

say to persuade the intended audience

• Supporting strategy development for

policy initiatives by helping to describe

opinion leaders, policymakers, and

their constituents

Myth: We don’t have time for planning.

Our boss (or funding agency or partner

organization) wants us to get started

right away.

Fact:

Making health communication

programs work requires planning, but

planning need not be a long-term, time-

consuming activity. Nor should all the

activities suggested in this section be

conducted en masse, before any other

actions are taken. Planning is easiest and

best done bit by bit—related to and just in

time for the programmatic tasks it governs.

For example, you need certain kinds of

information about the intended audiences in

order to define them, select them, and set

objectives.You need different information to

guide message development; gather each

type as you need it.

One person should not be doing all planning

tasks. Divide responsibilities for individual

tasks such as managing market research or

drafting the strategic plan and have the

whole planning team (or manager) reconcile

and revise to create the final plan.

48

Planning and Strategy Development

Myth: If we work with partner

organizations that represent the intended

audience, we’ll have access to all the

channels we need.

Fact:

Channels you access through a

partner organization may be very useful, but

they may miss intended audience segments

the organization does not represent, and

they may not be the most credible or

effective way to influence the intended

audience. Using additional channels will

help reinforce your program’s messages

and enhance the likelihood that the intended

audience will recall them.

Myth: It’s best to use the channels we’re

comfortable with and have used before.

Fact:

Selecting the right channels is as

important to success as developing effective

materials or having a sound strategy. If the

intended audience never sees/hears the

message, doesn’t believe it because it

comes from an unrespected source, or

doesn’t attend to it because it comes from

a noninfluential source, the time and money

your program spends developing the

message will be wasted. While you may

well make good use of channels where you

have previous contacts, determine whether

these channels alone will reach and

influence intended audiences before relying

solely on them.

Myth: If we use only one channel, we

should use mass media.

Fact:

In the past, many programs may have

concentrated on mass media, particularly

public service announcements. Today,

however, many other effective channels

exist and relying on mass media alone may

not achieve some communication program

goals. Although it may take time, effort, and

possibly outside expertise to learn about

and use new channels, the potential rewards

make this a good investment in your

program’s future and in your organization’s

long-term skill/knowledge base.

Myth: Using interactive digital media

requires major technical capabilities we

don’t have, and we can’t keep up.

Fact:

Using interactive digital media

effectively does require professional

expertise in product design—just as

professional expertise is needed to create

other types of communication vehicles and

develop effective evaluations. Consultants

from other branches of your organization,

universities, a volunteer pool, or commercial

firms can help. Some advertising/creative

firms are beginning to develop expertise in

these media, or you can use experts to

advise you on the electronic end while you

take care of the communication aspects.

These media are changing rapidly, just as

the computer field as a whole. However, if

you determine that interactive digital

channels will be very effective in reaching

the intended audience, networking with

peers, and conducting program research,

the investment may pay off.

STAGE 1

Making Health Communication Programs Work

49

Myth: If you don’t have interactive digital

media in your program, you are missing out

on today’s hottest communication

opportunity and will look very out of date

and low tech to your peers.

Fact:

Remember, interactive digital media

are just other channels. The same steps

discussed in this guide still apply, and good

communication principles and skills are still

paramount. The key selection factor is how

well these media will reach the intended

audience and how suited they are to

carrying the message. The intended

audience may not have sufficient access to

computers or have the skills or

attitudes/interest to seek information

through them. And, despite their potential,

much remains to be learned about their best

uses and how intended audiences respond

to and interact with them.

Selected Readings

American Cancer Society. (2001). Cancer

facts and figures. Atlanta.

American Public Health Association. (2000).

APHA media advocacy manual 2000.

Washington, DC.

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marketing research. Homewood, IL: Dow

Jones-Irvin.

Andreasen, A. (1995). Marketing social

change: Changing behavior to promote

health, social development, and the

environment. San Francisco: Jossey-Bass.

Calvert, P. (Ed.). (1996). The

communicator’s handbook: Tools,

techniques, and technology (3rd ed.).

Gainesville, FL: Maupin House.

Center for Substance Abuse Prevention.

(1994). Following specific guidelines will

help you assess cultural competence in

program design, application, and

management [Technical Assistance

Bulletin]. Washington, DC: U.S. Government

Printing Office.

Center for Substance Abuse Prevention.

(1998). Evaluating the results of

communication programs [Technical

Assistance Bulletin]. Washington, DC: U.S.

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Center for Substance Abuse Prevention

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(1996). Bridging the gap for people with

disabilities. Rockville, MD: U.S. Department

of Health and Human Services.

Centers for Disease Control and Prevention.

(1996). The prevention marketing initiative:

Applying prevention marketing (CDC

Publication No. D905). Atlanta.

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(2000). Beyond the brochure (CDC

Publication No. PDF-821K). Atlanta.

Davis, J. (Ed.). (2001). Health and medicine

on the Internet: An annual guide to the

World Wide Web for health care

professionals. Los Angeles: Practice

Management Information Corporation.

The Dialog Corporation. (2001). Packaged

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sourcebook/researchline/pf.html.

Eng, T. R., & Gustafson, D. H. (Eds.). (1999).

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emergence of interactive health

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Glanz, K., Lewis, F. M., & Rimer, B. K. (Eds.).

Schooler, C., Chaffee, S. H., Flora, J. A., &

(1997). Health behavior and health education:

Theory, research, and practice (2nd ed.). San

Francisco: Jossey-Bass.

Glanz, K., & Rimer, B. K. (1995). Theory at a

glance: A guide for health promotion practice

(NIH Publication No. 97-3896). Bethesda, MD:

National Cancer Institute.

Goldberg, M. E., Fishbein, M. F., &

Middlestadt, S. E. (Eds.). (1997). Social

marketing: Theoretical and practical

perspectives. Mahwah, NJ: Erlbaum.

Jernigan, D. H., & Wright, P. A. (1996). Media

advocacy: Lessons from community

experiences. Journal of Public Health Policy,

17, 306–330.

Maibach, E., Maxfield, A., Ladin, K., & Slater,

M. (1996). Translating health psychology into

effective health communication. Journal of

Health Psychology, 1, 261–277.

Matiella, A. C. (Ed.). (1990). Getting the word

out: A practical guide to AIDS materials

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Miller, J., & Pifer, L. K. (1993). Public

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United States, 1993: A report to the National

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(SEER) Program.

Roser, C. (1998). Health campaign channels:

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impact. Human Communication Research,

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health audience segmentation. Journal of

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public health: Power of prevention. Thousand

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STAGE 1

Making Health Communication Programs Work

51

GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide

STAGE 2

GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide

Developing and Pretesting

Concepts, Messages, and Materials

In This Section:

• Why developing and pretesting concepts, messages, and materials

are important

• General steps in developing and pretesting concepts, messages,

and materials

• Reviewing existing materials

• Deciding what materials to develop

• Developing effective materials

• Planning for production, distribution, promotion, and process evaluation

• Common myths and misconceptions about pretesting

Questions to Ask and Answer:

• What materials will fit our strategy, appeal to our intended audience,

and adequately convey our message? How can we make the materials

as effective as possible?

• Do we need to create new materials? What types?

• How do we develop culturally appropriate messages and materials?

• How do we develop effective materials for low-literacy

intended audiences?

• How can we make sure the materials will be used?

• When and how should we pretest our materials?

• How can we keep pretesting costs down?

• What should we do with pretest results?

• How can we get the best results from creative and research

professionals? From reviewers?

STAGE 2

Why Developing and Pretesting

Messages and Materials Are Important

Developing and pretesting messages and

materials are important because they allow

you to learn early in the program which

messages will be most effective with the

intended audiences. Knowing this will save

your program time and money by ensuring

that you do not go through the entire

development process with an ineffective

message. Positive results from pretesting

can also give you early buy-in from

your organization.

See Appendix B for descriptions of theories

and models that suggest important audience

factors to consider when creating messages

so they are both acceptable and persuasive

to the intended audience.

Steps in Developing and Pretesting

Messages and Materials

In Stage 1, you created a communication

strategy statement. In Stage 2, you will use

the strategy you developed as a guide to:

1. Review existing materials

2. Develop and test message concepts

3. Decide what materials to develop

4. Develop messages and materials

5. Pretest messages and materials

1. Review Existing Materials

Message and materials development and

production can be time-consuming and

costly. Because this process is creative and

has tangible results, it is frequently the key

developmental step for a health

communication program. Before you begin

developing and producing new materials,

however, determine whether creating them

is necessary.

You may have discovered existing

communication materials (booklets, leaflets,

posters, public service announcements,

videotapes) while gathering data to plan the

program. If not, look now.You may find

materials at the following sources:

• Health departments (in your state or

other states)

• University or public libraries

• Voluntary organizations

• Health professional associations

• Community-based coalitions

• Clearinghouses, Web sites, and telephone

information services relevant to the issue

• Materials produced by the National

Institutes of Health, the Centers for

Disease Control and Prevention, or other

agencies in the U.S. Department of Health

and Human Services

• Healthfinder

®

, the Federal gateway to

health information, to identify relevant

Federal clearinghouses and other Federal

information sources

(www.healthfinder.gov)

See Appendix C for additional contact

information for these suggested sources.

If you find materials related to the health

issue, decide whether they are appropriate

for your program, either as they are or with

modifications. Using the communication

strategy statement as a guide, consider the

following questions:

• Are the messages accurate, current,

complete, and relevant?

• Are the materials appropriate for the

intended audience in format, style,

cultural considerations, and readability

level? If not, could they be modified to

be appropriate?

54

Developing and Pretesting Concepts, Messages, and Materials

• Are the materials likely to meet the See Appendix A for a sample form that you

communication objectives? can modify to help you conduct a materials

review.You also may want to test promising

Pretesting, discussed later in Stage 2, can

materials with the intended audience (see

help you answer these questions. Check

step 2). If the materials prove to be

with the group that originally produced the

inappropriate, you will have gained valuable

materials to learn about:

information for modifying them or developing

• Results of any pretesting

new materials.

• Effectiveness of the materials to date

2. Develop and Test Message Concepts

• Whether the group has advice or

recommendations related to your

The communication strategy statement and

program’s needs

the other planning you did in Stage 1 form

If you are considering using existing the basis for developing message concepts.

materials, also ask the original producer Message concepts are messages in rough

these questions: form and represent ways of presenting the

information to the intended audiences.

• Are they available?

These may include statements only or

• Could your organization receive

statements and visuals. Do not develop the

permission to use the materials? Modify

actual messages at this point. (If you create

them? Note: Materials produced by the

two or more concepts for each message,

Federal Government are not copyrighted

you will be able to explore which alternative

and may be used freely.

works best.)

• Are they affordable?

In this step, you will learn about the

• How have they been used?

components that go into developing and

• How have they been received?

NCI ADAPTS PAIN BROCHURES FOR READERS WITH LOW LITERACY SKILLS

When a panel of experts set new guidelines for cancer pain control, NCI wanted to share

its practical recommendations with patients. A sophisticated handbook was already

available for well-educated readers, and NCI staff searched for existing materials that

might work for readers with lower literacy skills. They found several local clinic and

cancer center publications that could potentially fill this need, but each was at too high a

reading level, lacked appealing graphics, and needed to be updated to reflect panel

recommendations. NCI decided to adapt the existing pieces and worked with the original

producers and specialists to develop easy-to-read materials and graphics. The revised

brochure was reviewed in draft by partnering clinics and health professionals and

pretested using focus groups and nurse-administered patient questionnaires.

One of the objectives included in Healthy People 2010 is to “improve the health literacy of

persons with inadequate or marginal literacy skills” (objective 11-2). NCI’s initiative to

adapt a brochure from previous materials illustrates how increases in health literacy will

come not only with improvements in individuals’ skills, but also with improvements in

the materials used to communicate critical information to patients and consumers.

STAGE 2

Making Health Communication Programs Work

55

testing message concepts, including experts, and others. See the Communication

working with creative professionals, creating Research Methods section for tips on working

culturally appropriate communication with market research experts.

concepts, choosing a type of appeal, and

testing concepts.

Working With Creative Professionals

To develop, pretest, and eventually produce

Developing a communication campaign

messages and materials, assemble a team

usually involves working with creative

of creative professionals, market research

professionals, either within your organization

NCI’S CANCER RESEARCH AWARENESS INITIATIVE: FROM MESSAGE CONCEPTS TO

FINAL MESSAGE

In 1996, the NCI’s Office of Communications (OC), then the Office of Cancer

Communications, launched the Cancer Research Awareness Initiative to increase the

public’s understanding of the process of medical discoveries and the relevance of

discoveries to people’s lives. OC’s concept development and message testing for this

initiative included the following activities.

Three values of medical research were selected for concept development:

1. Progress (e.g., we are achieving breakthroughs)

2. Benefits (e.g., prevention, detection, and treatment research are benefiting all of us)

3. Hope (e.g., we are hopeful that today’s research will yield tomorrow’s breakthroughs)

Based on these values, the following message concepts were developed and explored in

focus groups with intended audience members:

• Research has led to real progress in the detection, diagnosis, treatment, and

prevention of cancer

• Everyone benefits from cancer research in some fashion

• Cancer research is conducted in universities and medical schools across the country

• Cancer research gives hope

• At the broadest level, research priorities are determined by societal problems and

concerns; at the project level, research priorities are driven primarily by past research

successes and current opportunities

The following messages were crafted after listening to intended audience members’

reactions and their language and ideas about the importance of medical research:

A: Cancer Research: Discovering Answers for All of Us

B: Cancer Research: Because Cancer Touches Us All

C: Cancer Research: Discovering More Answers Every Day

D: Cancer Research: Because Lives Depend on It

E: Cancer Research: Only Research Cures Cancer

Mall-intercept interviews were conducted to pretest them. Based on responses from the

intended audience in these interviews, message D was selected as the program theme.

56

Developing and Pretesting Concepts, Messages, and Materials

or on a contract basis. In either case,

managing the relationship effectively is

critical to getting the creative materials

you want:

• Get to know and feel comfortable with the

people who will be working on the project.

If you are considering a contract with an

advertising agency, public relations firm,

or consulting firm, interview the

professionals who will staff your effort (not

just the agency representatives who solicit

your business) and review samples of

their specific work (not just the agency’s).

Write into the contract who will work on

the project.

• Be a good client. Use the creative brief to

lay out the communication strategy

(developed in Stage 1) and make sure the

team understands the brief and that it

must be followed. Think about what you

want before you discuss the assignment

and show the creative team examples of

other materials that worked well or didn’t

and explain why. If you say, “I don’t know

what I want; you’re the creative one,” you

lose a valuable opportunity to give creative

professionals the fundamental direction

they want and need. This does not mean

asking for a blue brochure; it means

helping members of the creative staff

understand the objectives and concerns

and what you’ve learned about the

intended audience so that they can use

their expertise to suggest effective

approaches. Discuss sensitive issues, key

content points, and other aspects that you

want to see conveyed in the messages

and materials, based on your knowledge

and expertise.

• Agree at the outset to what pretesting and

approvals will be required, when they will

occur, and how long they will take.

• Discuss the theoretical grounding of the

communication effort and help creative

professionals understand and apply health

communication theory to messages and

materials development. Brainstorm with

them about how the theory might shape

the messages and materials and evaluate

works in progress with this perspective

in mind.

• Involve the creative team in concept

exploration and pretesting. Ask its

members what questions they would like

addressed and make sure they can

observe (not participate in) concept

exploration sessions. Listening to the

intended audience can help them craft

messages and materials that use

language and ideas that the audience will

identify with.

• Assess draft messages and materials

against the creative brief and what you

know about an intended audience

member’s point of view. If the intended

audience is urban teens at high risk of

pregnancy, and you are a middle-aged

suburbanite, recognize that the materials

most likely to be effective with the

intended audience may not appeal to

you at all.

• Trust the team’s professional expertise,

provided that the material is consistent

with your program’s strategy and the

intended audience’s culture. While you

have a key role to play in ensuring the

appropriateness and accuracy of

substantive content and in maintaining the

program’s strategic focus, developing the

team’s insights and commitment will keep

the team involved.

Developing Culturally

Appropriate Communications

Culture encompasses the values, norms,

symbols, ways of living, traditions, history,

and institutions shared by a group of people.

Culture affects how people perceive and

respond to health messages and materials,

and it is intertwined in health behaviors and

STAGE 2

Making Health Communication Programs Work

57

attitudes. Often, an individual is influenced

by more than one culture; for example,

teenagers are influenced by their individual

family cultures as well as the norms, values,

and symbols that comprise teen culture in

their locale.

To develop effective health communications,

you must understand key aspects of the

cultures influencing the intended audience

and build that understanding into the

communication strategy. Messages must

take into account cultural norms in terms of

what is asked (e.g., don’t ask people to

make a behavior change that would violate

cultural norms), what benefit is promised in

exchange (in some cultures, community is

most important; in others, individual benefit

is), and what image is portrayed. The

symbols, metaphors, visuals (including

clothing, jewelry, and hairstyles), types of

actors, language, and music used in

materials all convey culture.

While it is important to acknowledge and

understand the cultures within an intended

audience, developing separate messages

and materials for each cultural group is not

always necessary or even advisable. For

example, when print materials for a state

program for low-income people depicted

people of only one race, some intended

audience members who were of that race

felt singled out and said the materials

suggested that only members of their racial

group were poor. Careful intended audience

research can help your program identify

messages and images that resonate across

groups—or identify situations in which

different messages or images are likely to

work best.

According to a Center for Substance Abuse

Prevention Technical Assistance Bulletin,

culturally sensitive communications:

58

Developing and Pretesting Concepts, Messages, and Materials

• Acknowledge culture as a predominant educational level, occupation, income

force in shaping behaviors, values, level, and acculturation to mainstream

and institutions

• Reflect and respect the attitudes and

• Understand and reflect the diversity within values of the intended audience; some

cultures. In designing messages that are examples of attitudes and values that are

culturally appropriate, the following interrelated with culture include:

dimensions are important: — Whether the individual or the

— Primary cultural factors linked to race, community is of primary importance

ethnicity, language, nationality, — Accepted roles of men, women,

and religion and children

— Secondary cultural factors linked to — Preferred family structure (nuclear

age, gender, sexual orientation, or extended)

IDENTIFYING MESSAGES THAT RESONATE ACROSS CULTURES

As part of an effort to design messages that are meaningful and appealing to women in

different ethnic groups and to older women, NCI’s Office of Communications conducted

separate focus groups with African-American, American-Indian, Asian, Caucasian, and

Latina women.

The groups tested 10 motivational messages about mammography. Once participants had

individually selected the motivational messages they found most and least persuasive, the

moderator led them in a more detailed discussion of each message’s strengths and

weaknesses. Throughout the discussion, the moderator probed participants’ knowledge,

attitudes, and behaviors concerning breast cancer and mammography, sometimes

exploring underlying motivations and barriers.

Across focus groups, the following message elements were viewed most positively:

• Breast cancer can develop at any time

• All women are at risk—even those age 65 and older, or those without a family history

• Mammograms can detect breast cancer early

• Early detection can save lives

The least persuasive messages made explicit reference to issues that were considered

turnoffs, fear and age. Participants were uncomfortable with messages that specified age

and, in some cases, gender. Many said that cancer was a risk for all people (some pointed

out that men can get breast cancer), stating that older women (i.e., over 40) should not be

singled out. The notion of a mammogram being able to “save your life” was persuasive not

only because it was positive but also because it did not distinguish between age groups. In

general, messages that seemed to tell women what to think were deemed offensive, while

messages that were phrased as explanation or encouragement were more effective.

Note. From Multi-Ethnic Focus Groups to Test Motivational Messages on Mammography and Breast Cancer,

by National Cancer Institute, August 2000. Bethesda, MD. In the public domain.

STAGE 2

Making Health Communication Programs Work

59

— Relative importance of folk wisdom, life

experience, and value of common

sense compared with formal education

and advanced degrees

— Ways that wealth is measured (material

goods, personal relationships)

— Relative value put on different age

groups (youth versus elders)

— Whether people are more comfortable

with traditions or open to new ways

— Favorite and forbidden foods

— Manner of dress and adornment

— Body language, particularly whether

touching or proximity is permitted in

specific situations

• Are based on concepts and materials

developed for and with the involvement of

the intended audience. (Substituting

culturally specific images, spokespeople,

language, or other executional detail is not

sufficient unless the messages have been

tested and found to resonate with the

intended audience. Formative research

with audience members takes on added

CHOOSING MESSAGES FOR YOUNG SENSATION SEEKERS

Research has found that some youth have a preference for novel experiences and stimuli.

Called “sensation seekers,” members of this group have four subcategories that represent

degrees of the characteristic:

1. Thrill- and adventure-seeking (e.g., parachuting and scuba diving)

2. Experience-seeking (e.g., nonconforming lifestyle and musical tastes, drugs,

unconventional friends)

3. Disinhibition (sensation through social stimulation; e.g., parties, social drinking, a

variety of sex partners)

4. Boredom susceptibility (restlessness when things are the same for too long)

Some health communicators working on drug abuse prevention programs have found that

focusing on sensation seekers with messages that appeal to this aspect of their

personalities can be effective in promoting attention to and recall of the message and in

affecting factors such as behavioral intention and attitudes.

For example, a University of Kentucky program designed for adolescents a creative high-

sensation television PSA that focused on the importance of alternatives to substance use

for meeting sensation needs. The PSA, titled “Common,” featured heavy metal music and

quick-action cuts of high-sensation activities. “Wasted,” which had the highest sensation

value, also had heavy metal music and displayed the words “wasted,” “blasted,” “stoned,”

and “fried.” Voice-over and illustrative footage accompanied each word (e.g., “with drugs

you can get fried” had footage of a monk’s self-immolation). It closed with the words

“without drugs you can still get high” and offered examples of high-sensation alternatives.

Note. From “Reaching At-Risk Populations in a Mass Media Drug Abuse Prevention Campaign:

Sensation Seeking as a Targeting Variable,” by P. Palmgreen et al. In Drugs & Society 8(3), pp. 29–45.

1995, Binghamton, NY: Haworth Press. Adapted with permission.

60

Developing and Pretesting Concepts, Messages, and Materials

importance when planners and designers

have different cultural backgrounds than

the intended audience does.)

• Refer to cultural groups using terms that

members of the group prefer (e.g., many

people resent the term “minority” or

“nonwhite.” Preferred terms are often

based on nationality, such as Japanese

or Lakota.)

• Use the language of the intended

audience, carefully developed and tested

with the involvement of the audience

Choosing the Type of Appeal

To capture the intended audience’s

attention, you can scare people, tug at their

hearts, make them laugh, make them feel

good, or give them straight facts. What will

work best? The answer generally depends

on the intended audience’s preferences,

what your program is asking people to do,

and how you plan to use the appeal in

asking them to do it.

Positive emotional appeals show the

benefits intended audience members will

gain when they take the action portrayed in

the message. Research has shown that, in

general, messages that present a major

benefit but do not address any drawbacks

tend to be most appropriate when intended

audience members are already in favor of

an idea or practice. In contrast, messages

that present a major benefit and directly

address any major drawbacks work best

when people are not favorably predisposed.

Humorous appeals can work for simple

messages, especially if most competing

communication is not humorous. The humor

should be appropriate for the health issue

and convey the main message; otherwise,

people tend to remember the joke but not

the message. Also, humorous

messages can become irritating if repeated

too frequently.

Threat (or fear) appeals have been shown to

be effective with two groups. Research has

shown that such appeals tend to be more

effective with “copers” (people who are not

anxious by nature) and “sensation seekers”

(certain youth), and when exposure to the

message is voluntary (picking up a brochure

rather than mandatory attendance at a

substance abuse prevention program).

Research has also shown that, to be

effective, a threat appeal should include:

• A compelling threat of physical or

social harm

• Evidence that the intended audience is

personally vulnerable to the threat

• Solutions that are both easy to perform

(i.e., intended audience members believe

they have the ability to take the action)

and effective (i.e., taking the action will

eliminate the threat)

In general, however, the effectiveness of

threat appeals is widely debated.

The most appropriate type of appeal may

differ from this general guidance,

depending upon gender, age, ethnicity,

severity of the problem, and the intended

audience’s relationship to the problem.

For more information, please consult the

following sources under Selected Readings

at the end of this section: Backer, Rogers,

and Sopory (1992); Goldberg, Fishbein, and

Middlestadt (1997); Kotler and Roberto

(1989); Maibach and Parrott (1995);

Palmgreen et al. (1995); Siegel

and Doner (1998).

STAGE 2

Making Health Communication Programs Work

61

Concept Testing

Once you have defined intended audiences

and communication strategies and have

developed message concepts, testing the

concepts with intended audiences can help

you decide on message appeals (e.g., fear-

arousing versus factual), spokespersons

(e.g., a scientist, public official, or member

of the intended audience), and language

(determined by listening to research

participants’ language). Testing is especially

important if the program deals with a new

issue, because it will help you understand

where the issue fits within the larger

context of the intended audience’s life

and perceptions.

Concept testing will help save your program

time and money because it will identify

CANCER RISK MESSAGE CONCEPT DEVELOPMENT

To provide cancer risk information to the public in ways that it could be readily

understood and used, NCI conducted a series of focus groups to learn what the groups

thought of different methods for communicating about risks. The following insights from

the groups underscored the importance of considering both word usage and presentation

methods when developing message concepts and materials:

• Participants said that they want cancer risk messages to give them hope for preventing

cancer and that risk information is less threatening when written in optimistic terms.

• When faced with “bad news” about cancer risks, they said that they look for why it does

not apply to them.

• They wanted risk messages to address key questions such as “How serious is the risk?”

and “What can be done to reduce or avoid the risk?” as well as explain how and where

to get additional information.

• Word choice also influences how information is perceived; “risk” raises alarm, while

“chance” minimizes it.

• Use of vague or unfamiliar terms (including “fourfold,” “relative risk,” “lifetime risk”)

gives people reason to discount the information.

• Combining brief text and visuals (such as charts, graphs) can increase attention and

understanding.

• Statistical risk information was difficult for many participants to understand;

percentages were more understandable than ratios, but in either case accompanying

explanations of the seriousness of the risk were needed.

• Participants were interested in “the complete picture”—that is, what is known and what

is not yet known about a risk, and what it means for “human beings.”

• The source of risk information colors credibility, with participants saying that they are

less likely to trust the media or a source with a business interest and more likely to trust

risk information supplied by a physician or medical journal.

Note. From How the Public Perceives, Processes, and Interprets Risk Information: Findings from Focus Group

Research with the General Public, by the National Cancer Institute, June 1998. In the public domain.

62

Developing and Pretesting Concepts, Messages, and Materials

which messages work best with intended

audiences. Use concept testing to identify:

• Which concept has the strongest appeal

and potential for effect

• Confusing terms or concepts

• Language used by the intended audience

• Weaker concepts that should

be eliminated

• New concepts

Concepts can be presented in a number

of ways. The key is to convey the major

characteristics of the appeal along with the

action your program wants intended

audience members to take and the benefit

they will receive as a result. Focus groups

or in-depth interviews are most appropriate

for concept testing because they permit

discovery of:

• How an intended audience thinks about

an issue

• How its members react to different

appeals or aspects of a message concept

• Why they react that way

Message concept tests often ask

participants to rank a group of concepts

from most to least compelling and then to

explain their rankings. Participants then

discuss benefits and problems associated

with each concept. Health communicators

often use a sentence or brief paragraph to

describe a concept to participants. For

example, the following are two “don’t smoke”

concepts for teens:

1. Smoking harms your appearance.

2. Cigarette advertisers have created a myth

that smoking makes a person more

attractive. They’re lying.

While both concepts address attractiveness,

the first concept uses it as the focal point of

a negative appeal (to avoid becoming less

attractive, don’t smoke), whereas the

second concept uses a factual approach

and a different benefit—avoid being

manipulated by the tobacco industry—

designed to appeal to teens’ strong desire

not to be manipulated.

In each of the concepts above, both the

action the intended audience members

should take and the benefit are implied, not

stated. This approach works in situations

where the desired behavior is obvious. In

other situations, the behavior or the benefit

will need to be mentioned, as in the

following examples:

• Mammograms detect breast cancer long

before a lump can be felt. And finding it

early can save your life

• If you’re concerned about getting breast

cancer, getting a mammogram may give

you peace of mind

More detail on the structure of a concept

test is provided later in this section under

Conducting Concept Tests and Materials

Pretests and in the Communication

Research Methods section.

3. Decide What Materials to Develop

Once you have message concepts that are

effective with the intended audience,

determine the material formats (e.g.,

brochure, videotape) that will best suit your

program by evaluating:

• The nature of the message (e.g., its

complexity, sensitivity, style)

• The function of the message (e.g., to

call attention to an issue or to teach a

new skill)

STAGE 2

Making Health Communication Programs Work

63

HEALTH COMMUNICATION MATERIALS OPTIONS

Interpersonal Channels

• Fact sheet with a list of questions for patients to ask health care providers

• Physician pads for patient counseling (similar to prescription pads, but used to

provide information)

• Slides and a script to assist presenters

• How-to booklets and talking points for discussions in private homes or within

the family

• Videos to trigger discussion

• Telephone information service scripts and responses

• Tailored communications, such as letters or personalized newsletters (see page 71)

Organizational Channels

• Newsletters

• Educational programs (in-person, audiovisual, computerized, print)

• Speeches

• Tailored letters to members

• In-house radio or video broadcasts

• Kiosks/displays

• Buttons, refrigerator magnets, or other giveaways

• Add-ons to regular communication (e.g., messages handed out with paychecks or

organization notices)

• Event banners, flyers, stickers, buttons

• Conference exhibits, presentation slides

• Spokesperson training materials

Community Channels

• Displays for beauty and barber shops, pharmacies, grocery stores, airports, libraries,

transit, and other public venues

• Posters

• Inserts with bills, in or on shopping bags

• Community newsletters

• Health fair exhibits and handouts

• Letters, e-mail to organize community response

• Kiosks in shopping malls, post offices

• Handouts for meetings with community leaders, lawmakers

• Spokesperson training materials

Mass Media Channels

• Audio or video news releases or B-roll

• Cartoons/comics

• Direct-mail letters, brochures

• Photonovellas

• Magazine and newspaper articles

Continued on next page...

64

Developing and Pretesting Concepts, Messages, and Materials

HEALTH COMMUNICATION MATERIALS OPTIONS CONTINUED...

• Newspaper inserts

• Media kits

• Music news releases/music videos

• Op-eds or letters to the editor

• Posters

• Radio, TV, print advertisements (paid or public service)

• Radio or TV programming

Interactive Digital Media Channels

• Ads on Web sites

• E-mail messages

• CD-ROMs

• Interactive quiz or game on Web site

STAGE 2

• The activities and channels selected

during Stage 1 (e.g., whether you will be

most likely to reach the intended audience

through a school, library, physician, the

media, or a combination of these)

• The budget and other available resources

Most important: Make sure that your

program’s decisions about materials fit

with the activities and channels you selected

and will contribute to reaching the

communication objectives developed

in Stage 1.

If your program has to develop new

materials, doing so will probably represent

a major expenditure. Make sure to choose

formats that your program can afford; don’t

allot so much of your budget to materials

production that you can’t afford sufficient

quantities, distribution promotion support,

or process evaluation. The list of materials

options below will give you ideas of

possible approaches. Don’t stop there; use

your knowledge of the intended audience

to combine, adapt, and devise new ways

to get the message across. Explore your

program’s preliminary decisions about

materials with the intended audience

or partners, perhaps in conjunction with

getting reactions to message concepts.

4. Develop Messages and Materials

The following guidelines will help your

program develop materials that intended

audiences understand, accept, and use:

• Ensure the message is accurate:

— Scientific accuracy is vital to producing

desired outcomes and to your

program’s credibility. This is particularly

important because of rapid changes in

advice and information for many health

topics; often, what is accurate one year

is no longer current the next. For this

reason, experts on the health topic

should always review your program’s

messages. However, you may have to

work with them to get them to accept

language that is simple enough for a

nonscientific intended audience to

understand. At times it may be helpful

to share pretest results with them or

Making Health Communication Programs Work

65

PATCHES: AN INNOVATIVE FORMAT TO REACH GIRLS

The Department of Health and Human Services, Substance Abuse and Mental Health

Services Administration’s Center for Substance Abuse Prevention’s Girl Power! campaign

partnered with the Girl Scouts of the USA to develop a Girl Power! Girl Scout patch

program. Girl Power!, a national public health education program, addresses a wide range

of issues affecting adolescent girls. The overall goal of Girl Power! is to delay and reduce

the use of alcohol, tobacco, and illicit drugs among girls ages 9–14. This program also

addresses related issues such as physical activity, nutrition, and mental health. Girl Power!

and the Girl Scouts cooperate in an ongoing relationship. Through the Girl Scouts, the

Center for Substance Abuse Prevention’s Girl Power! campaign materials are distributed to

over 2.8 million girls around the country. To see other formats both groups use to reach

girls, visit www.girlpower.gov or jfg.girlscouts.org.

66

Developing and Pretesting Concepts, Messages, and Materials

PRESENTATION OPTIONS FOR ADVERTISING AND AUDIOVISUAL MATERIALS

Animation—Use for young children and as an eye-catching approach for adults (older

children may consider some animation silly or “babyish”). Use animation to demonstrate

desired actions or to address abstract subjects (e.g., respite care), sensitive subjects (like

AIDS), or several disparate intended audiences (e.g., different ethnic groups) at once.

Demonstrations—Use an audiovisual format to demonstrate the desired health behavior,

especially if your program must teach skills.

Slice of life—Use a dramatization within an “everyday” or familiar setting to help the

intended audience relate to the message. A simple story is easy to remember; you might

choose to present the health problem and show the solution. This style can be both

credible and memorable, but it may not work with all intended audiences.

Testimonials—Use a credible presenter to lend credibility to the message. A recognizable

spokesperson may be attention grabbing. The most credible and relevant presenter may

vary for different intended audiences and may be an intended audience representative,

an authority (e.g., a physician), or a celebrity connected with the health issue.

STAGE 2

get them to sit in on research with the

intended audience so that they are

exposed to the intended audience’s

level of knowledge and

scientific sophistication.

• Be consistent:

— All messages in all materials and

activities should reinforce one another

and follow the communication strategy.

No matter how creative, compelling, or

wonderful a message is, if it does not fit

the strategy statement, objectives, and

identified intended audiences, throw it

out. Don’t compete with your own

campaign for attention.

— Recognize inconsistencies between the

message and what the intended

audience may have heard from other

sources due to controversies among

scientists, government agencies, and

advocacy groups. The best way to

determine whether and how to address

such inconsistencies is to ask the

intended audience what impact the

disparities have on them and what they

need from your program to make

decisions and take the desired action.

— Use the same graphic identity in all

campaign elements. In print materials,

use the same or compatible colors,

types of illustrations, and typefaces

throughout the campaign. If there is a

logo or theme, use it in all materials.

Graphics and messages should

reinforce each other, not send

different signals.

• Be clear:

— Keep it simple. Clear messages for lay

intended audiences contain as few

technical/scientific/bureaucratic terms

as possible and eliminate information

that the audience does not need in

order to make necessary decisions or

take desired actions (such as overly

detailed background about disease

physiology, research uncertainties, or

Making Health Communication Programs Work

67

68

background about your organization).

Readability tests (see the

Communication Research Methods

section for instructions and limitations)

can help determine the reading level

required to understand material and

can help writers be conscientious

about the careful selection of words

and phrases.

— Prominently feature the action you want

the intended audience to take. Give

people an explicit recommendation of

what you want them to do as a result of

the message. Don’t assume they will

figure it out for themselves. For

example, pretesting showed that a

brochure about taking part in AIDS

research studies was very well received

by a grateful and emotional intended

audience. However, no one recognized

that the purpose of the booklet was to

encourage people to consider

participating in research studies and to

talk about it with their health care

providers. Instead, almost everyone

thought the purpose was to give them

hope and comfort. The booklet was

revised to be more straightforward

without compromising the hopeful tone

intended audiences liked.

— Demonstrate the health behavior or

skills (if appropriate).

• Be relevant to the intended audience:

— Include incentives for the intended

audience to take the recommended

steps, beyond the health benefits they

will receive. Audience research will

help you understand what the intended

audience might value. Incentives may

be psychological (you’ll feel more in

control); altruistic (you’ll help others by

participating in a research study);

economic (not smoking saves

money); social (exercise is a fun

group activity, where you can make

friends, see friends); family-driven

(do it for them); or ego-driven (sun

exposure causes wrinkles).

— Choose a presentation style

appropriate to the intended audience’s

norms and expectations; people must

be able to see themselves in what your

program presents. For example,

intended audience preferences can

help determine whether to take a

rational or emotional approach, a

serious or light tone. Use a light,

humorous approach if appropriate, but

pretest to be sure that it works and

doesn’t offend the intended audience.

Responses to humor vary greatly.

— Keep regional differences in mind. A

lush, green park will not look like the

Southwest and an urban clinic will not

be familiar to people who live in a rural

area. The organization of the health

care system and the way medical and

social services agencies work together

also differ from region to region.

— Use intended audience experience

when creating materials. The intended

audience will learn new information

more easily when you build from the

familiar to the unfamiliar (e.g., “When

you have a headache that won’t go

away, you take an aspirin to relieve it.

But that is not the best way to control

cancer pain. Cancer pain medicines

work best if you take them before

your pain becomes severe and keep

taking them on the schedule your

doctors advise.”)

— Create the message to match the

readiness of the intended audience to

make a change. The Stages of Change

model (see Appendix B) describes five

stages that people pass through in

making behavior changes:

precontemplation, contemplation,

preparation, action, and maintenance.

Messages created to match readiness

to change start where the intended

audience starts. For example, it is

unrealistic to expect an intended

audience that has never heard of the

problem to immediately make changes.

A realistic outcome is beginning to

raise awareness of the issue

(precontemplation) and helping move

the intended audience to a consideration

of the change (contemplation).

• Be credible:

— Use celebrity spokespeople selectively.

Choose celebrity spokespeople who

are directly associated with the

message (e.g., using an athlete to

promote exercise or cancer survivor to

promote early detection) and who

practice the desired health habit. Check

with the intended audience about the

suitability of the celebrity. (For example,

while a famous television personality

was well liked by members of the

intended audience for a physical

activity promotion program, they said

she was not relevant to them because

she could afford a personal trainer to

make exercise easier.) Realize that

while celebrities can help gain attention

for the message, they may also

compete with the message for attention

or be unappealing to some intended

audiences. In addition, your program

will probably need to build its schedule

around theirs, and celebrity

involvement can cause production

delays and extra costs. Caution: A

network may not use TV PSAs

featuring a rival network’s star.

— Be sure that the person who presents

the message is seen as a credible

source of information, whether as an

authority, celebrity, or intended

audience representative.You may also

want to partner with organizations that

are credible with the intended audience

and emphasize their involvement. If the

message involves health services and

STAGE 2

Making Health Communication Programs Work

69

TIPS FOR DEVELOPING TV ADS

General

• Keep messages short and simple—just one or two key points.

• Use language and style appropriate for the intended audience.

• Repeat the main message as many times as possible.

• Recommend a specific action.

• Demonstrate the health problem, behavior, or skill (if relevant).

• Provide new, accurate, straightforward information.

• Be sure the message, language, and style are considered relevant by the

intended audience.

• Be sure that the message presenter is seen as a credible source of information, whether

an authority, celebrity, or intended audience representative.

Development

• Select an appropriate approach (e.g., testimonial, demonstration, or slice-of-life format).

• Be sure every word works.

• Use a memorable slogan, theme, music, or sound effects to aid recall.

• Check for consistency with campaign messages in other media formats.

Appeal

• Use positive rather than negative appeals.

• Emphasize the solution as well as the problem.

• Use a light, humorous approach, if appropriate, but pretest to be sure that it works and

doesn’t offend the intended audience.

• Avoid high degrees of fear arousal, unless the fear is easily resolved and the message is

carefully tested.

Visuals

• Use only a few characters.

• Make the message understandable from the visual portrayal alone.

• Superimpose text on the screen to reinforce the oral message’s main point.

Timing

• Identify the main issue in the first 10 seconds in an attention-getting way.

• Use 30-second spots to present and repeat the complete message; use 10-second spots

only for reminders.

• If the action is to call, show the phone number on the screen for at least 5 seconds, and

reinforce orally.

• Summarize or repeat the main point/message at the close.

70

Developing and Pretesting Concepts, Messages, and Materials

health care coverage, it is particularly

pitching a news story or producing an

important to have a source that the

intended audience believes is

unbiased, i.e., does not have a vested

(profit-driven) interest in people taking

the recommended action. For example,

consumers may dismiss health

practices an employer or government

agency suggests they take if they

perceive the motivation is just to save

the organization money.

• Be appealing:

— Produce variations of materials to

appeal to specific intended audience

segments. For example, NCI used

several different covers on a

mammography booklet to appeal to

different cultures. Similarly, audio

materials can be produced using

culturally specific voices or music.

Of course, changing executional detail

to appeal to specific intended audience

segments is appropriate only if the

underlying communication strategy

and messages have been tested with

those audiences.

— Get the intended audience’s attention.

Given the number of health and other

messages intended audiences receive,

yours must stand out to be noticed.

The best way to command attention will

differ among intended audiences. It

can be useful to know what has

interested them before, but concept

testing and message testing will help

ensure that your program’s approach

will grab their interest.

— Produce high quality materials. If you

feel you have to skimp on production,

choose a simpler way of presenting the

message. Producing poor quality

materials wastes funds and can damage

your program’s credibility and your own.

— Entertain while you educate when

using mass media. Whether you are

ad, remember that the mass media are

viewed as a source of information and

entertainment, not education.

Therefore, if the complete message is

too complicated, or simply not

considered interesting enough for use

by the media, redesign the message

so that it is more appealing to media

professionals and their perceptions

about what their intended audience

wants. Working with media professionals

will help ensure that your program’s

messages are interesting as well as

accurate and may help you obtain

greater exposure for the program.

Tailored Communications

Tailored communications are much more

refined than communications created for a

particular intended audience or segment of

the population. If you can tailor each

message for each individual, it is likely to be

even more effective. Tailored

communications are produced for each

person based upon what is known about the

individual. Obtain this information from

health plan data, surveys, medical records,

and other sources. This information permits

matching people with messages appropriate

for them. The following are two examples of

tailored communication:

• A series of letters (e.g., to give smokers

information about and support for quitting)

from which paragraphs are selected to

send to each individual based on past

behavior—on barriers to, for example,

quitting, or on other unique combinations

of characteristics

• A cover letter, referring readers to the

pages of an enclosed booklet that most

relate to their interests and concerns

STAGE 2

Making Health Communication Programs Work

71

With the help of a computer and ordinary

word processing software, individual letters

can be tailored within a mass mailing,

brochures can be printed on demand for

a specific patient, or telephone counselors

can appropriately focus their assistance

and follow up with messages tied to the

advice they gave.

When personal data are not available,

interactive computer programs can prompt

individuals to input key personal

characteristics that direct the software to

prepare individually tailored messages

immediately (e.g., on a Web site or at a

kiosk in a public location). NCI’s 5 A Day

Web site (

www.5aday.gov/ ) allows users to

chart their fruit and vegetable consumption

and exercise and offers positive reinforcement

in response to the behaviors they report.

Evaluation has shown that tailored

communications can, in some

circumstances, increase message effects,

although much research remains to be done

on how and why.

To use tailored communications, review

the planning information from Stage 1

and determine:

• The important individual characteristics

that affect a particular health behavior

(i.e., differences in readiness to change

behavior, or perceived benefits of or

barriers to changing the behavior)

• Appropriate messages tailored to address

individual characteristics (these messages

may be identified or confirmed through

primary research with each group, or

through collaboration with a behavior

change specialist or a subject matter

expert, such as a genetic counselor

or physician)

Then:

• Create a “library” of messages tied to each

relevant characteristic, such as gender or

risk factors (“as a woman who began

smoking in the last five years…”)

• Use word processing software with a mail

merge feature that will match variations in

personal characteristics with appropriate

messages and produce the materials in

the desired format

Tailoring is not always possible or

necessary. However, think about using some

of the principles of personalizing messages

when appropriate and when funding is

available. Find more information about

tailored communications in the Selected

Readings at the end of this section or use

NCI’s quick-start tutorial on the Internet at

http://dino.nci.nih.gov/public/glassman/

TailoringGuide.

Developing Effective Print Materials for

Low-Literacy Intended Audiences

Many intended audiences have a hard time

understanding health materials written in

technical language. This is especially true of

intended audiences with low literacy skills.

Present the message in a more easily

understood way to these intended

audiences by making specific choices about

writing style, vocabulary, typography, layout,

graphics, and color. These choices affect

whether the message is read and how well

intended audiences with low literacy skills

understand it. A great deal of health

information and promotion is organized

around the use of print materials, often

written far beyond the literacy skills of

intended audiences. Differences in the

ability to read and understand materials

related to personal health appear to

contribute to health disparities. The link

72

Developing and Pretesting Concepts, Messages, and Materials

TAILORED COMMUNICATIONS: HEALTHY BIRTHDAYS

In two 1999 projects, researchers designed tailored birthday cards and newsletters to

increase breast and cervical cancer screening and smoking cessation, primarily among

low-income African Americans.

In one study, the cards and newsletters were individually tailored based upon ethnicity,

gender, and the individual’s readiness to change according to the Stages of Change model.

Smokers received either:

• Provider prompting

• Tailored cards and newsletters

• Tailored cards and newsletters and telephone counseling

The tailored cards and newsletters showed a highly significant quitting effect. Thirty-three

percent of smokers who received only the tailored cards and letters quit smoking

compared to thirteen percent of smokers who received provider prompting and

nineteen percent of smokers who received the tailored cards and newsletters and

telephone counseling.

In the other study, people who received the tailored birthday cards and newsletters

showed higher rates of Pap tests and general cancer screening.

Image created by

Bernard Glassman and

Barbara K. Rimer.

STAGE 2

Note. From Glassman, B., Rimer, B. K. (1999). “Is There a Use for Tailored Print Communications in

Cancer Risk Communications?” (Monograph of the Journal of the National Cancer Institute, No. 25)

In the public domain.

Making Health Communication Programs Work

73

between literacy and health disparities

underlies the Healthy People 2010 objective

to “improve the health literacy of persons

with inadequate or marginal literacy skills”

(objective 11-2).

A common misconception is that low-literacy

materials are synonymous with low-reading-

level materials. That is, if you avoid

polysyllabic words and long sentences,

you’ve met the need. In fact, low literacy

encompasses more than reading level, and

meeting this need requires that you

complete the same planning and research

steps and adhere to the same fundamental

communication principles that you would

use for any other health communication

material. The difference is that certain

aspects of the process must be done with

particular rigor. The following list includes

pointers for designing materials for low-

literacy intended audiences:

• Include only the information needed to

convey the behavioral objective and

support the intended audience in attaining

it. Strictly limit content because poor

readers struggle with every word, often

reading letter by letter. Keep the piece

short and focused, and let the

communication strategy statement guide

you in answering the question, “From the

many possible information points, which

ones will predispose and enable the

reader to take the desired action?” The

biggest challenge will be excluding

concepts and content points that fall

outside of the category of “information the

reader must know.” Do not include

information just because it may interest

the reader or because you are trying to

promote your organization’s work.

• Organize topics in the order the reader

will use them. Less skilled readers have

particular difficulty connecting topics and

processing the flow of an argument.

• Present the most important points first

and last. Studies show that intended

audiences with limited literacy skills

remember these best.

• Group information into chunks, with a

clear, ordered format. Use steps (1, 2, 3),

chronology (by time of day), or topical

arrangement (main heading,

subheadings), depending on how the

person will use the information.

• Respect the intended audience. This is

especially critical when designing low-

literacy materials. Examples abound of

well-intentioned materials that talk down to

readers or have childlike or simple cartoon

illustrations. The low-literacy population

encompasses people of different ages,

genders, cultures, and socioeconomic

status, including highly intelligent adults

with significant life experience who just

cannot read very skillfully.

• Follow these guidelines.

— Use short sentences and paragraphs.

— Write in the active voice.

— Clarify concepts with examples.

— Avoid jargon, technical terms,

abbreviations, and acronyms.

— Include a glossary if necessary (but

define key words within the sentence).

— Give the reader an action step he or

she can take right away (e.g., call

your clinic, send in a request); this

tends to improve retention of

information and encourages the reader

to begin practicing the desired

behaviors immediately.

— Use graphics and design to make the

reader’s job easier and to increase

comprehension and recall; make sure

they support, rather than compete

with, the text.

— Don’t assume that pictorial signs,

symbols, and charts are more effective

than words for low-literacy intended

audiences. Some experts suggest that

74

Developing and Pretesting Concepts, Messages, and Materials

“universal” symbols, such as a stop

sign, an arrow, or a big black “X,”

usually test well. Don’t confuse this

intended audience with large, busy

matrices—for example, functionally

illiterate individuals have trouble using

a bus schedule.

— Avoid using all capital letters; they are

other urinary problems.

The initial medical workup typically includes a physical exam called a digital rectal

examination (DRE), a urinalysis to check for infection or bleeding, and a blood test to

measure kidney function. Some physicians may also check the amount of prostate-specific

antigen (PSA) using a PSA test to help rule out the likelihood of cancer. PSA is a protein

that is produced by the cells of the prostate gland.

Continued on next page...

164

Communication Research Methods

EXAMPLE USING THE SMOG READABILITY FORMULA CONTINUED...

In addition, other tests may help a urologist—a doctor who specializes in disorders of the

urinary tract and the male reproductive tract—to determine if BPH has affected the

bladder or kidneys. These include tests that measure the speed of urine flow, pressure in

the bladder during urination, and how much urine is left in the bladder after urinating.

Some other tests that are widely used, according to an expert panel sponsored by the

United States Public Health Service (USPHS) practice guidelines, are expensive, sometimes

risky, and, for most men, unnecessary. These include cystoscopy, in which the doctor

inserts a viewing tube up the urethra to get a direct look at the bladder; an x-ray called a

urogram, in which urine is made visible on an x-ray after dye is injected into a vein; and

ultrasound, which obtains images of the kidneys and bladder after a probe is placed on

the abdomen.]

Treating BPH

About half of men with BPH develop symptoms serious enough to warrant treatment. BPH

cannot be cured, but its symptoms can be relieved by surgery or by drugs in many cases.

BPH does not necessarily grow worse. According to one review, mild to moderate

symptoms worsened in only about 20 percent of the cases. They improved (without any

specific treatment) in another 20 percent and stayed about the same in the rest.

[Men whose symptoms are mild enough often opt for an approach called watchful

waiting. This means that they report for regular checkups and have further treatment only

if and when their symptoms become too bothersome.

The USPHS Clinical Practice Guidelines call watchful waiting “an appropriate treatment

strategy for the majority of patients.” Men who choose watchful waiting should have

regular, perhaps annual, checkups, including DREs and laboratory tests.

For those who choose watchful waiting, a number of simple steps may help to reduce

bothersome symptoms. These include limiting fluid intake in the evening, especially

beverages containing alcohol or caffeine, which can trigger the urge to urinate and can

interfere with sleep; taking time to empty the bladder completely; and not allowing long

intervals to pass without urinating.

Men monitoring prostate conditions should also be aware that certain medications they

are taking for other ailments may make their symptoms worse. These include some over-

the-counter cough and cold remedies, prescribed tranquilizers, antidepressants, and drugs

to control high blood pressure. Switching to a different prescription may help.

Watchful waiting, of course, is not always enough for BPH, and surgery or drug therapy

may be required.]

Continued on next page...

METHODS

Making Health Communication Programs Work

165

EXAMPLE USING THE SMOG READABILITY FORMULA CONTINUED...

Readability Test Calculations

Total Number of Polysyllabic Words

Nearest Perfect Square

Square Root

Constant

SMOG Reading Grade Level

= 104

= 100

= 10

= 3

= 13

We have calculated the reading grade level for this example. Compare your results to ours,

and then check both with the SMOG conversion table:

SMOG CONVERSION TABLE*

Total Polysyllabic Word Counts

0 – 2

3 – 6

7 – 12

13 – 20

21 – 30

31 – 42

43 – 56

57 – 72

73 – 90

91 – 110

111 – 132

133 – 156

157 – 182

183 – 210

211 – 240

Approximate Grade Level

(± 1.5 Grades)

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

* Developed by Harold C. McGraw, Office of Educational Research, Baltimore County Schools,

Towson, Maryland.

166

Communication Research Methods

causing discomfort to those whose reading

ability you are testing, you can integrate a

WRAT or a Cloze test into the pretest

interview. For example, in a recent pretest

conducted by the National Cancer Institute,

the interviewers introduced the WRAT test

as the last part of the pretest. They stated,

“Thank you for helping with the questions

on the chemotherapy booklet. We need your

help with one last part—a word list. This will

take only a few minutes. The word list will

help us understand how difficult the words

are in the chemotherapy booklet.” This

integrated approach spared participants

the pressure or potential embarrassment

of “failing a reading test.”

The WRAT is based on word recognition

and does not measure comprehension or

vocabulary. The WRAT is an efficient way

to determine reading levels and takes only

a short time to administer.

The WRAT involves listening to the

participant read from a prepared list of

words, arranged in increasing order of

difficulty. Pronouncing the word correctly

shows that the reader recognizes the

word. The WRAT focuses on recognition

because, at the most basic level, if a

person does not recognize a word,

comprehension is impossible.

The test is over after the reader

mispronounces 10 words. The test

administrator notes the level at which the

last mispronunciation occurred. The “stop”

level equates to a grade level of reading

skills.You can compare this level with the

reading level of your intended audience to

see if your pretest readers are a

representative match for that audience.

The Cloze technique measures the reader’s

ability to comprehend a written passage.

Because it requires readers to process

information, it may take up to 30 minutes

to administer.

In a Cloze test, text appears with every fifth

word omitted. The reader tries to fill in the

blanks. This task demonstrates how well

he or she understands the text. The reader’s

ability to supply the correct word also reflects

his or her familiarity with sentence structure.

While packaged Cloze tests are available,

Leonard and Cecilia Doak’s Teaching

Patients with Low Literacy Skills explains

how to make up and score a Cloze test

yourself, based on the materials you are

pretesting. The book also discusses use of

the WRAT to assess reading levels.

Making Health Communication Programs Work

167

METHODS

GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide

APPENDIX A

GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide

Communication Planning

Forms and Samples

The following is a listing of forms and samples that appear in this appendix.

Stage 1: Planning and Strategy Development

• Communication Program Plan

— Sample Promotion Plan

— Partnership Plan

— Evaluation Plan

• Strategy Statement/Creative Brief Template

Stage 2: Developing and Pretesting Concepts, Messages,

and Materials

• Sample Focus Group Screener Form

• Sample Focus Group Moderator’s Guide

• Sample Intercept Questionnaire

Stage 3: Implementing the Program

• Breast Cancer Materials User Survey

• Breast Cancer Risk Assessment Tool Evaluation: Summary

of Responses

Communication Research Methods

Please also see Stage 2 forms listed above.

• Producing Rough-Cut Video for Pretesting/Theater Testing

• Sample Theater-Style Pretest Questionnaire

• Sample Script for Hosting a Theater-Style Test

• Tabulating Responses to Closed- and Open-Ended Questions

• Average Ratings for Commercial Ads to Help Interpret Standard

Pretesting Questions

APPENDIX A

Stage 1: Planning and

Strategy Development

Forms and Samples

Communication Program Plan

Overview

Name of Program:

Sponsoring Agency:

Contact Person:

Issue or Problem to Be Addressed:

Evidence of Need (why the program is being developed):

Program Objective(s):

Communication Objective(s):

Primary intended audiences (in priority order; include pertinent characteristics and rationale):

Secondary intended audiences (in priority order with rationale):

Market Research

Market Research Plans (include pretesting):

APPENDIX A

Activities (list for each intended audience):

Continued on next page...

171

Messages (list for each defined market):

Materials to Be Developed/Adapted:

Materials Distribution and Program Promotion

Promotion/Materials Distribution Plan (see sample provided):

Key Tasks, Timeline, and Resources Needed (list person responsible; address fixed deadlines

and required approvals):

Partnerships

Potential Partner Organizations (describe their roles):

Partnership Plan (see separate form provided):

Evaluation Plan (see separate form provided):

172

Sample Promotion Plan

Promotion Plan for New Mammography Materials

National Cancer Institute

Office of Communications

Audiences: Primary Women in their 40s and older

Women at increased risk for breast cancer

Secondary Partners and advocates in the effort to reduce breast cancer

State and local health agency leaders

Health professionals and cancer research organizations

policymakers and interested public

Medical media

Products: The National Cancer Institute has developed the following new mammography

educational materials.

• Understanding Breast Changes: A Health Guide for All Women

This booklet includes information about many breast changes that are

not cancer and explains the procedures used to discover the presence

of breast cancer.

• Mammograms . . . Not Just Once, But for a Lifetime!

A 2-page, easy-to-read pamphlet that defines mammography, describes who

needs this important examination, and explains the procedure step-by-step.

• The Facts About Breast Cancer and Mammography

An 8-page booklet explaining the risk factors for breast cancer and the benefits

and limitations of mammography.

• Over Age 40? Consider Mammograms

A set of 5 posters, each featuring a woman from a special population.

For display in health care settings.

• Mammograms . . . Not Just Once, But for a Lifetime!

An attractive bookmark with facts on breast cancer and mammography

(25 to a pack).

• Why Get Mammograms?

A physician’s pad with tear-off fact sheets on mammograms for patients.

Includes NCI’s new recommendations, risk factors for breast cancer, and the

benefits and limitations of mammography.

• Breast Cancer Risk Assessment Package

A computer tool that helps physicians determine an individual woman’s 5-year

and lifetime risk of developing invasive breast cancer. (The materials review

form and the evaluation report NCI completed after this tool was released are

included later in this appendix.)

APPENDIX A

Continued on next page...

173

Promotion/Materials Distribution Plan:

NCI’s Office of Communications will promote the availability of these new materials to

organizations, health professionals, patients and the public, and the media in the

following ways:

Organizations

• Develop and distribute a breast cancer materials promotional brochure and copies of the

materials to the Cancer Information Service, and ask CIS to make the new materials

available to callers and their outreach partners.

• Distribute the promotional brochure and copies of the new materials to recipients on the

in-house mailing list. The in-house list includes breast cancer advocacy and voluntary

organizations, NCI-designated cancer centers’ public affairs and patient education networks,

nurses, physicians, occupational health care professionals, high school science teachers,

medical writers, dieticians, librarians, patient educators, genetic counselors, social workers,

health program planners, and community educators.

Health Professionals

• Distribute letters announcing the availability, including ordering information and copies of the

new materials, to the American College of Physicians, American College of Family Physicians,

Oncology Nursing Society (ONS), the Breast Cancer Progress Review Group, and attendees

of CDC’s meeting “Integrating Public Health Programs for Cancer Control” mailing lists.

• Develop a print public service announcement promoting the availability of the materials and

publish it in the Journal of the National Cancer Institute, CIS outreach and cancer center

newsletters, and other medical and association journals.

• Announce the availability of the materials in NCI’s column in the American College of

Obstetrics and Gynecology newsletter.

• Distribute the promotional brochure and materials at NCI’s fall exhibits, including CDC’s

“Integrating Public Health Programs for Cancer Control” meeting, American Public Health

Association, American Academy of Family Physicians, and ONS. Display a sign announcing

the availability of NCI’s new mammography materials.

Patients and the Public

• Consumer Information Center Spring Catalog will include the Facts About Breast Cancer

and Mammograms and CIC will send out a “New for Consumers” news release regarding

the booklet.

• Include mammography materials with ordering information on OC’s home page for patients,

the public, and the media.

Media

• Promote availability through the media, particularly women’s magazines, minority

publications, and medical journals.

174

Continued on next page...

Evaluation:

OC will evaluate its promotion efforts in the following ways:

• Track requests for the materials.

• Analyze feedback from readers who return bounceback evaluation cards from Understanding

Breast Changes: A Health Guide for All Women.

• Analyze feedback from recipients of the materials that included fax-back feedback form.

175

APPENDIX A

Partnership Plan

Program Title:

Communication Objective(s):

Intended audiences:

Potential Partner Organizations (in priority order):

Potential Partner Roles/Tasks:

Benefits to Partners of Participation in Program:

Other Considerations (such as your organization’s constraints or policies):

Steps Planned to Approach and Engage Potential Partners:

176

Continued on next page...

Negotiated Partners/Roles of Each:

Mechanisms for Communicating/Working Together:

Plans for Measuring Accomplishments:

Plans for Completing (Ending) Partnerships:

APPENDIX A

177

Evaluation Plan

Program name:

Communication objectives:

Intended audiences:

Identify each type of evaluation to be conducted (formative, process, and outcome):

For each type of evaluation, include:

Evaluation questions to be answered:

Data collection methods (e.g., telephone surveys, participant evaluation forms in

the classroom):

Analysis plan (what you are going to do with the data gathered to answer the

questions posed):

Evaluation products and use of evaluation data (e.g., final report to recommend program

revisions, conference presentation to share lessons learned with others):

Also include how you are going to get the evaluation done (tasks, time schedule, resource

requirements, persons responsible):

178

Strategy Statement/Creative Brief Template

1. Intended audiences

Whom do you want to reach with your communication? Be specific.

2. Objectives

What do you want your intended audiences to do after they hear, watch, or experience

this communication?

3. Obstacles

What beliefs, cultural practices, peer pressure, misinformation, etc. stand between your

audience and the desired objective?

4. Key Promise

Select one single promise/benefit that the audience will experience upon hearing, seeing, or

reading the objectives you’ve set?

5. Support Statements/Reasons Why

Include the reasons the key promise/benefit outweighs the obstacles and the reasons what

you’re promising or promoting is beneficial. These often become the messages.

6.Tone

What feeling or personality should your communication have? Should it be authoritative, light,

emotional…? Choose a tone.

7. Media

What channels will the communication use, or what form will the communication take?

Television? Radio? Newspaper? Internet? Poster? Point-of-purchase? Flyer? All of the above?

8. Openings

What opportunities (times and places) exist for reaching your audience?

9. Creative Considerations

Anything else the creative people should know? Will it be in more than one language?

Should they make sure that all nationalities are represented?

APPENDIX A

NOTE: All creative briefs must be accompanied by a page summarizing the background situation.

179

Stage 2: Developing and Pretesting

Concepts, Messages, and Materials

Forms and Samples

Sample Focus Group Screener Form

NCI/NIEHS Environmental Focus Group Project

Screening Questionnaire for North Carolina, Iowa, and California

Group 1: The Public “Touched by Cancer”

Group 2: The Public “NOT Touched by Cancer”

Summary of recruiting specifications for each group

Equal mix of men and women

Spread of ages 35–60

High school degree or some college

50% white; 50% mix of African American, Hispanic, and Asian

50% with children < age 10; 50% with children age 10+ or no children

Experience with cancer:

Group 1 – “Touched by cancer” only

Group 2 – “Not touched by cancer” only

Interested but not well informed about environmental/health issues

Not an opinion leader or activist

Never worked in the health/medical or environmental field

Not been in a focus group in the past year

(RECRUIT FOR 9–10 TO SHOW PER GROUP)

1. Good morning/evening. My name is_______, and I’m a researcher calling from (INSERT

NAME OF FACILITY) in (INSERT LOCATION). We are talking to people to learn their

opinions on some health-related issues that concern many Americans. Is there an adult in

the household between the ages of 35 and 60? ONCE SPEAKING TO ADULT, REPEAT

FIRST TWO SENTENCES IF NECESSARY. THEN ASK: Would you be willing to answer a

few questions?

a.Yes (CONTINUE)

b. No (THANK AND END)

Note whether respondent is male or female and recruit an equal mix for each group.

2. First, I need to ask you some basic information. Which category best describes your age?

a. Under 35 (THANK AND END)

b. 35–43 (CONTINUE)

c. 44–52 (CONTINUE)

d. 53–60 (CONTINUE)

e. 61 or older (THANK AND END)

Recruit 4 from each age category, with good age spread.

3. What is the highest grade you have completed in school? READ LIST IF NECESSARY.

a. 8th grade or less (THANK AND END)

b. Some high school (grades 9, 10, or 11) (THANK AND END)

c. High school graduate (CONTINUE)

d. GED (High school equivalency) (CONTINUE)

Continued on next page...

181

APPENDIX A

e. Some college/2-year college/technical school/

associate degree (CONTINUE)

f. College graduate (THANK AND END)

g. Some graduate school/post-graduate degree (THANK AND END)

For each group, recruit half with high school diploma or GED and half with some college.

4. We want to make sure we represent different ethnic and racial groups in our study. Would

you describe yourself as… ? (READ AND RECORD)

a. Hispanic or Latino/Latina (SKIP TO Q.6)

b. Not Hispanic or Latino/Latina (CONTINUE)

5. Next, would you describe yourself as…? (READ AND RECORD)

a. White (SKIP TO Q.7)

b. Black or African American (SKIP TO Q.7)

c. American Indian or Alaskan Native (THANK AND END)

d. Asian (CONTINUE)

e. Native Hawaiian or Other Pacific Islander (THANK AND END)

Recruit 4 from each age category, with good age spread.

6. (FOR HISPANICS AND ASIANS ONLY) What language do you usually speak at home?

a. English only (CONTINUE)

b. Another language only (THANK AND END)

c. English and another language equally (CONTINUE)

For each group, recruit 2 Hispanics and 2 Asians having English as their primary language.

Make sure ALL participants speak clearly and are easy to understand (no heavy accents).

7. Do you have any children under the age of 10, either by birth or adoption?

a.Yes (CONTINUE)

b. No (CONTINUE)

For each group, recruit half with children UNDER age 10, and half with children age 10 and

older or no children.

8. How would you describe your overall health? Would you say it was…?

(READ AND RECORD)

a. Excellent(CONTINUE)

b. Good (CONTINUE)

c. Fair (CONTINUE)

d. Poor (CONTINUE)

9. Now I’d like to ask you about several health conditions. Please tell me if either you, a

member of your immediate family, or a close friend has been diagnosed with any of these

conditions in the past 5 years? (READ LIST. IF ASKED, “IMMEDIATE FAMILY” INCLUDES

SPOUSE, GRANDPARENT, PARENT, SIBLING, OR CHILD.)

182

Continued on next page...

Ye s N o

a. Heart disease? (CONTINUE) (CONTINUE)

b. Diabetes? (CONTINUE) (CONTINUE)

c. Cancer? (RECRUIT FOR GRP 1) (RECRUIT FOR GRP 2)

Recruit participants who say “YES” to cancer for group 1 (“Touched by Cancer Group”).

Recruit those who say “NO” to cancer for group 2 (“NOT Touched by Cancer Group”).

10. There are a number of issues in the news, and it’s hard to keep up with every area. I’m

going to read you a brief list of issues. Please tell me if you are “very interested,”

“interested,” “somewhat interested,” or “not at all interested” in each issue. (READ LIST) Are

you very interested, interested, somewhat interested, or not at all interested in…? (INSERT

ISSUE; CIRCLE ONE RESPONSE FOR EACH ISSUE)

ISSUE:

Very

interested

Interested

Somewhat

interested

Not at all

interested

a. School issues

b. Economy and

business issues

c. Environment and

health issues

(GO TO B)

(GO TO C)

(CONTINUE)

(GO TO B)

(GO TO C)

(CONTINUE)

(GO TO B)

(GO TO C)

(THANK & END)

(GO TO B)

(GO TO C)

(THANK & END)

11. Now I’d like to go through the list again; for each issue, please tell me whether you consider

yourself “well informed,” “moderately informed,” or “poorly informed.” (READ LIST) Are you

well informed, moderately informed, or poorly informed about…? (INSERT ISSUE; CIRCLE

ONE RESPONSE FOR EACH ISSUE)

ISSUE Well informed Moderately informed Poorly informed

a. School issues

b. Economy and business issues

c. Environment and health issues

(GO TO B)

(GO TO C)

(THANK & END)

(GO TO B)

(GO TO C)

(CONTINUE)

(GO TO B)

(GO TO C)

(CONTINUE)

12. In the past 12 months, have you done any of the following? (READ LIST AND CIRCLE ALL

THAT APPLY. IF RESPONDENT HAS DONE 3 OR MORE, THANK AND END. IF

RESPONDENT HAS DONE 2 OR LESS, CONTINUE.)

a. Written a letter to the newspaper?

b. Written an article?

c. Written to your Congressman or Senator?

d. Made a speech?

e. Worked for a political party?

f. Served on a committee for some local organization?

g. Held or ran for political office?

h. Served as an officer of some club or organization?

i. Been a member of some group for better government?

APPENDIX A

Continued on next page...

183

13. Have you ever had a job in the following areas?

Ye s N o

a. In the health or medical field? (THANK AND END) (CONTINUE)

b. In the environmental area? (THANK AND END) (CONTINUE)

14. Have you ever participated in a focus group or been paid to be part of a discussion group?

a.Yes (CONTINUE)

b. No (SKIP TO 16)

15. How recently did you participate in the focus group?

a. Within the past year (THANK AND END)

b. More than a year ago (CONTINUE)

16. We are conducting an informal group discussion on health issues, and your views would be

valuable in helping us better understand this area. The discussion will take place in

(INSERT NAME OF TOWN/CITY) on (INSERT DATE) at 5:30 p.m. (Group 1) or 8:00 p.m.

(Group 2) at (INSERT FACILITY ADDRESS). The discussion will last two hours, and there

will be no attempt to sell you anything. We are simply interested in your opinions. We will

pay you $____________ as a way of thanking you for participating.You will also be given a

light meal or snack. Would you be interested in attending?

a. No (THANK AND END)

b. Yes (RECORD NAME, ADDRESS, PHONE NUMBER BELOW)

NAME:

ADDRESS:

PHONE NO:

Will attend: (CHECK ONE)

______ Group 1 (“Touched by cancer”)

______ Group 2 (“NOT touched by cancer”)

Let me mention two additional things:

1) If you wear reading glasses, please be sure to bring them to the discussion, as there may

be some reading involved; and

2) Please be aware that we have a no-smoking policy. If you have any questions or find that

you can’t attend, please call us right away at ______________________ so that we can find

a replacement.

Thank you for your time and for agreeing to participate in this discussion.

184

Sample Focus Group Moderator’s Guide

Cancer and the Environment

Moderator’s Guide for NCI/NIEHS Focus Groups

A. Introduction (3 minutes)

Good evening, my name is ____________, and I’ll be your moderator this evening. Welcome to

our focus group discussion tonight.

A focus group is a small group discussion that focuses on a particular topic in depth. Tonight

we will be talking about various health issues. I’m not an expert in the topics we’ll be discussing

tonight, and I’m not here to give you information. I’m here to listen to your ideas and thoughts

on these issues. It’s also important for you to know that I’m an independent consultant and do

not work for the sponsors of this discussion.

In a focus group, there are no right or wrong answers, only opinions, and I’d like to hear from all

of you about equally. It’s important that I hear what each of you thinks, because your thoughts

may be similar to those of many other people who aren’t here at this table tonight.Your ideas

are extremely important to us, and I’m interested in your comments and opinions. Please feel

free to speak up even if you disagree with someone else here. It’s OK to disagree, because it’s

helpful to hear different points of view. I’m also interested in any questions you may have as we

go along.

We have a lot of ground to cover in the next two hours, so, for the sake of time, I may jump

ahead to the next topic from time to time, but please stop me if you want to add anything.

We’re audiotaping and videotaping our discussion. Everything you say is important to us, and

we want to make sure we don’t miss any comments. Later, we’ll go through all of your

comments and use them to prepare a report on our discussion. I want to assure you, however,

that all of your comments are confidential and will be used only for research purposes. Nothing

you say will be connected with your name. Also, if there are any questions you would prefer not

to answer, please feel free not to respond to them.

There are also some colleagues of mine behind the one-way mirror who are interested in what

you have to say.

B. Warm Up (10 minutes)

[While participants are in the waiting room, they will be given magazines and asked to tear out

a picture by which to introduce themselves to the group.]

1. I’d like to begin by having each of you tell us your first name and a little about yourself—and

show us the picture you chose to introduce yourself to us.

2. What are some of the health problems that you personally worry about (not necessarily

health problems you have, but are concerned about getting)?

APPENDIX A

Continued on next page...

185

C. Perceptions and Beliefs About Cancer (25 minutes)

1. Now I’d like to talk specifically about cancer. If I had never heard of “cancer” before, how

would you describe it to me? What is it?

2. [Draw stick figure on easel] This is Pat, and all we know about her/him is that she/he has

cancer. I’d like to talk about how she/he came to have cancer. What do you think are some

of the reasons why she/he might have gotten cancer? [List on easel]

3. Now that you’ve told me some possible causes of cancer, how do you think cancer actually

develops in a person? How would you describe what happens inside the body? How do the

things on our list actually cause cancer? (Probe: gene mutation/gene malfunctioning)

4. Do you have any idea how scientists know what causes cancer and what doesn’t? How do

they go about finding out?

5. How concerned are you about cancer on a scale of 1–10, where “1” is “Not at all concerned”

and “10” is “Very concerned”? How much do you think about it? When do you think about it?

[For older groups] Did you feel differently about cancer when you were younger? [If yes]

How so? [For younger participants] Do you think you’ll feel the same way about cancer

when you’re 50? How do you think you’ll feel then?

6. Is there one particular type of cancer you are most concerned about? Why?

D. Cancer and the Environment (25 minutes)

1. [Drawing exercise] Now we’re going to be discussing cancer and the environment. On the

sheet of paper in front of you, I’d like you to take a couple of minutes and draw or write

something on the theme of “Cancer and the Environment.” You can draw or list anything that

fits with this theme; then we’ll talk about it in a couple of minutes. [After 2–3 minutes] Now

let’s talk about what you drew or wrote on this theme. Who would like to start?

2. Are you familiar with the word “carcinogen”? If I didn’t know what that meant, how would you

describe it to me? How many cancer-causing agents or carcinogens do you think there are?

(A few? Many?)

3. I’ve heard some people say, “Everything is a carcinogen.” What do you think of that

statement? Do you think that any substance/chemical can cause cancer if the dose is

high enough?

4. Which is of greatest concern to you—carcinogens out-of-doors, in the workplace, or

at home? (Probe: concern for selves versus concern for children) In general, are you

more concerned about carcinogens in the food you eat, the water you drink, or the air

you breathe?

5. What specific environmental agents/chemicals are you most concerned about? [List on

easel] (Probe: fluoride, gasoline, electrical power lines, food additives such as aspartame or

other sweeteners, dry cleaning solvents, fat in the diet, meat, air pollution, radiation, glass

wool insulation, talc, pesticides, prescription drugs)

6. Are any of the items we listed (above) of particular concern to you here in your local area?

Which ones? How concerned are you about them?

186

Continued on next page...

7. What are your thoughts about people having a genetic predisposition to cancer? Are some

groups of people more prone to cancer from the environment than others? Which

ones/why? (Probe: children, elderly, women, specific races, smokers) What have you heard

about childhood cancer and the environment?

8. Can people do anything to decrease their chance of getting cancer from the environment?

How well do you think these things work in preventing cancer? Do you personally do

anything now to decrease your chances of getting cancer? (Probe: cancer screening for

early detection, diet changes, dietary supplements, organic food, exercise, immunity

boosters like antioxidants or vitamins C & E)

E. Information Needs (10 minutes)

1. Has there been any environmental cancer concern in the past few years that you’ve tried to

find information about? How did you go about it? Where did you find the most valuable

information? Did you get enough information (or enough good information)? Were there any

questions you couldn’t find enough information about?

2. In general, do you have enough information to protect yourself and/or your children from

cancer-causing agents? If no, what kind of information do you need?

3. If you wanted to find out more about something that is suspected of causing cancer in your

local area, or at home, or at work, where would you look for information? (Probe:

newspapers, magazines, Internet, TV news, books that list carcinogens, etc.)

4. Do you know of any organizations or government agencies that try to protect the public from

things in the environment that might cause cancer? Which ones? How would you get in

touch with them if you had questions? Do you think you would get in touch with them?

F. Developing a Brochure (45 minutes)

1. The sponsors of this focus group want to develop a brochure about cancer and the

environment. We want your help in telling us what you, the public, want to know. Imagine

that we are the committee charged with the task of developing this brochure about cancer

and the environment, and we want to give people information they would be interested in

having about this topic. Let’s brainstorm for a few minutes about what type of information

should be included in this brochure. [List suggested information on easel] Is there anything

else that should be covered in our brochure?

2. Now, let’s go a step further. If you could have any questions answered about cancer and the

environment in this brochure, what questions would you want answered? [List questions]

3. Now I’d like to show you a draft outline for a new brochure and get your reactions. [Pass out

NCI/NIEHS outline with introductory paragraph]

a. What’s your general reaction to this draft outline?

b. Is there anything you especially like about it?

c. Is there anything you especially dislike?

d. Is anything confusing?

e. Which parts would be most useful to you?

f. What would you do with a brochure with this information?

APPENDIX A

Continued on next page...

187

4. In the time remaining, I’d like to show you a booklet about cancer and the environment that

was produced a while back. Please take about 5 minutes to examine the booklet as a whole,

and then pick one question/answer to read thoroughly. Once you’ve looked over the booklet,

I’d like to talk with you about your overall reactions. [Give participants 5 minutes to

review booklet]

a. What are your general reactions to this booklet?

b. Was there anything you especially liked?

c. Was there anything you especially disliked?

d. Was anything confusing?

e. Was anything missing that you would have liked to see included?

f. What did you think about the Q&A format?

g. What did you think about the tone? Level of detail? Amount of information?

h. How useful would a booklet like this be to you?

i. What question/answer section did you pick to read thoroughly? [Take tally]

j. Why did you pick that section? What did you get out of it? Did you want to

know more?

5. A number of you told me that you hear conflicting information about what does and doesn’t

cause cancer, and that this information changes from week to week. How do you think we

can make sense of this for the public in our brochure?

G. Close (2 minutes)

1. We’ve come to the end of our discussion. The sponsors of this focus group are the National

Cancer Institute (NCI) and the National Institute of Environmental Health Sciences (NIEHS).

Both these organizations are part of the National Institutes of Health (NIH), which is part of

the Federal Government. [If time permits] Are you familiar with either the National Cancer

Institute or the National Institute for Environmental Health Sciences?

2. Do you have any additional comments you would like to make on tonight’s topics?

3. On behalf of NCI and NIEHS, I want to thank you for your participation.Your opinions tonight

will be very valuable as they create and develop materials about cancer and the

environment for the public. Please stop at the front desk on your way out.

188

Sample Intercept Questionnaire

Central-Location Intercept Questionnaire

National Eye Institute, National Institutes of Health

Introduction

Good morning/afternoon/evening.

My name is _____________________, and I work for _______________, a marketing

research company located here in _________________ mall. We are conducting a study of

different ideas for television public service announcements. I would like to show you a couple

and get your reaction to them. The interview will take approximately 15 minutes, and you will

receive $5.00 for your time. Would you be willing to spend a few minutes answering

some questions?

1. To make sure we are representing different groups in our study, would you describe

yourself as:

White..............................

African American ...........

Hispanic .........................

Some other race ............

2. Are you 40 years old or older? (African American only)

Yes............ 

No ............. (Thank & End)

3. Are you 60 years old or older? (Anyone, including African American)

Yes............ 

No ............. (Thank & End)

4. Gender

Male .......... 

Female ...... 

Note to interviewer: Repeat questions 5–10 for both storyboards. Ask questions 11–16 after

questions have been answered for the last storyboard.

Now I am going to show you ideas for two advertisements and ask you a few questions about

each. I am going to show you storyboards that represent what the advertisement will be like.

I will read the information that goes with each storyboard aloud as you see it.

Continued on next page...

189

APPENDIX A

Storyboard Sequence: Black Out, POV

5. Which of the following would describe your general reaction to this ad?

a. Do you really like it?.............................................................................. 

b. Do you think it is just ok? ...................................................................... 

c. Do you not like it very much?................................................................ 

d. Do you not like it at all?......................................................................... 

e. Don’t know/refused ............................................................................... 

6. What is the main message of this ad? (Do not prompt—check all that apply)

a. Everyone should have an eye exam . . . . . . . . . . . . . . . . . . . . . . . . . .

b. Everyone should have a dilated eye exam . . . . . . . . . . . . . . . . . . . . .

c. People at risk for glaucoma should have a dilated eye exam . . . . . . .

d. Eye disease is treatable if diagnosed in time . . . . . . . . . . . . . . . . . . . .

e. Other ___________________________________________________

7. Does this advertisement motivate you to do anything? If so, what does it motivate

you to do? (Do not prompt—check all that apply)

a. Get an eye exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

b. Get a dilated eye exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

c. Tell someone else to get an eye exam . . . . . . . . . . . . . . . . . . . . . . . . .

d. Tell someone else to get a dilated eye exam . . . . . . . . . . . . . . . . . . . .

e. Ask a health professional about eye disease/glaucoma . . . . . . . . . . .

f. Tell someone else to ask a health professional about eye

disease/glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

g. Other ___________________________________________________

If not, why not? (Do not prompt—check all that apply)

a. S/he does not presently have glaucoma . . . . . . . . . . . . . . . . . . . . . . .

b. S/he does not presently know someone who has glaucoma . . . . . . . .

c. Message has good information, but respondent doesn’t feel

the need to act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

d. Message is boring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

e. Message is unclear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

f. Other ___________________________________________________

8. If you saw this advertisement on television, how likely do you think you would be to get a

dilated eye exam at least every 2 years or to tell someone else to get a dilated eye exam at

least every 2 years?

a. Very likely . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

b. Somewhat likely . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

c. Not too likely . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

d. Don’t know/refused . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

190

Continued on next page...

___________________________________________________________

9. How well does each of the following words/attributes describe what you just saw?

a. Is it attention-getting? very much a little not at all

b. Is it interesting? very much a little not at all

c. Is it direct/to the point? very much a little not at all

d. Is it useful information? very much a little not at all

10. Was there anything in the advertisement that you found confusing or hard to understand?

(Do not prompt—check all that apply)

a. Nothing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

b. Confused in general . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

c. Message not clear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

d. Words were hard to understand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

e. Too much information presented . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

f. Message didn’t relate to me . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

g. Other ___________________________________________________

Note to interviewer: Ask the following questions after showing both advertisements.

11a. Which advertisement do you like the best?

POV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Black Out . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Why? ______________________________________________________

11b. Which advertisement do you like the least?

POV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Black Out . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Why? ______________________________________________________

The following questions are optional, but will help to provide background for this study.

12. Which of the following categories includes your age?

40 through 49..............................................................................................

50 through 59..............................................................................................

60 through 69..............................................................................................

70 through 79..............................................................................................

80 and older................................................................................................

APPENDIX A

Continued on next page...

191

13. Have you ever been diagnosed with glaucoma?

Yes ..............................................................................................................

No ...............................................................................................................

14. Do any of your friends or family members have glaucoma?

Yes ..............................................................................................................

No ...............................................................................................................

15. What was the last grade you completed in school? Stop me when I get to the right

category. (Interviewer read choices.)

Less than high school .................................................................................

High school diploma, GED, or technical school ..........................................

Any college or beyond.................................................................................

16. Which of the following categories contains your household’s annual income? Stop me

when I get to the right category. (Interviewer read choices.)

<20,000.......................................................................................................

20K – <35K .................................................................................................

35K – <60K .................................................................................................

60K – 75K ...................................................................................................

>75K ...........................................................................................................

Declined to answer .....................................................................................

Thank you very much for giving us your time.Your feedback has been most helpful.

192

APPENDIX A

193

Stage 3: Implementing the Program

Forms and Samples

Breast Cancer Materials User Survey

Please help us make this tool more effective by answering the following questions:

1. Did you use the assessment tool in your practice? ___YES ___NO

IF NO, please explain:

2. Who was the primary user? ___Doctor ___Nursing staff ___Office staff ___Other

IF OTHER, please specify:

3. In what setting did you use the tool? (Check all that apply)

___Office/consult room ___Reception/waiting room

___Exam room ___Resource room

___Nurse’s station/area ___Other (specify:_____________________________)

4. Was the assessment tool…

a. Easy to use? ___YES ___NO

b. Appropriate in length? ___YES ___NO

c. Useful in discussing breast cancer risk with your patients? ___YES ___NO

d. Complete? (I.e., no additional information needed?) ___YES ___NO

e. Understandable? (I.e., were patients able to understand

the assessment outcome sheet?) ___YES ___NO

5. If you responded “NO” to any part of question 4, please explain here:

APPENDIX A

6. Would you recommend this disk to others? ___YES ___NO

Continued on next page...

195

7. Other comments or suggestions:

8. Are you: ___a doctor? ___other health professional? ___office staff? ___other?

IF OTHER, please specify:

THANK YOU. PLEASE FAX THIS FORM TO (XXX) XXX-XXXX.

196

Breast Cancer Risk Assessment Tool Evaluation

Summary of Responses

Background

The Breast Cancer Risk Assessment tool is a computer program that allows physicians and

others to estimate a woman’s lifetime risk of developing invasive breast cancer. The Breast

Cancer Risk Assessment Tool was promoted and distributed via NCI’s cancerTrials Web site;

trade, consumer, and health professional media; and voluntary and advocacy organizations.

The approximately 18,000 copies of the tool (each included the survey from the previous

pages) were sent to:

Cancer patients (46 percent)

Clinicians (40 percent)

Scientists (4 percent)

Media (1 percent)

Other (9 percent)

Because the majority of the survey’s respondents were doctors and other clinicians, the

findings do not reflect the above distribution.

Findings

These findings are based upon a sample of 125 surveys returned:

• Almost all respondents (97 percent) said they would recommend the tool to others.

• Most respondents (84 percent) had used the tool in their practice. For those who had not,

it was usually because the person was not a physician or was retaining it for personal use.

• An overwhelming majority found the assessment tool easy to use (99 percent), appropriate

in length (97 percent), and understandable (99 percent). A strong majority found the tool

useful in discussing breast cancer risk with patients (94 percent).

• Almost three-quarters of respondents found the tool to be complete (68 percent).

A substantial number of respondents who did not find the tool to be complete (32 percent)

provided comments and suggestions to support their opinions. In general, respondents

suggested that the tool:

— Determine whether treatment with tamoxifen was indicated or not

—

Include risk information relative to a woman’s menopausal status

— Include risk information for patients previously diagnosed with breast cancer

Conclusions

Based upon the feedback, it appears that health care providers are using the tool and generally

find it easy to use, appropriate in length, understandable, and helpful in discussing breast

cancer risk with their patients. A substantial number of respondents (32 percent) did not find

the tool to be complete, mainly because they felt it did not provide enough information about

other risk factors that may play a role in calculating a patient’s individualized risk estimate of

invasive breast cancer.

APPENDIX A

197

Communication Research Methods

Forms and Samples

Producing Rough-Cut Video for Pretesting/Theater Testing

The three most commonly produced forms of rough messages for pretesting are:

1. Animatics—Simple line drawings are videotaped in sequence to depict your message

2. Photomatics—Photographs are videotaped in sequence to depict your message

3. Rough live action—An actual run-through of the script is videotaped using simplified

sets, live actors, easily accessible locations, or simulated backgrounds (e.g., rear

screen projection of the set)

All three of the above types of messages include an audiotaped delivery of the script.

The following table lists some advantages and disadvantages of each type of rough message.

Type of Rough Message Advantages

Disadvantages

Animatic Less expensive than others

May not approximate script

Fewer logistical arrangements

No props required

Needs artist who can render

clear line drawings

No location settings

Easiest to produce

Photomatic

More realistic than animatic

More costly than animatic

Can be inexpensive and easy

to produce if location, props,

and actors are available

More logistical arrangements

than animatic

Rough live action

More realistic than animatic

or photomatic

Can be inexpensive if

location, props, and actors

are readily available

Many logistical

arrangements and

rehearsals required

May be more difficult to

make changes

APPENDIX A

Continued on next page...

199

The closer the rough message approximates final production quality, the more likely the pretest

results will predict audience response accurately. The illustrations should be realistic, the

characters should look like those you plan to use in the final spot, facial expressions should

reflect the mood and tone of the script, and the settings should be sketched in detail. If

photographs are used, the pictures of people and places should be clear and should resemble

those to be used in the final message. Pay attention to the setting, wardrobe, props, camera

angle, and perspective. Review the processed photographs and select the clearest ones for

producing the rough message.

When producing animatics or photomatics, the illustrations or photographs must be large

enough and clear enough for videotaping. Each illustration or photograph should be at least

9

" x 12" so that the camera can capture sufficient detail. Larger sizes also permit camera

movement (e.g., moving from left to right) within the frame to create a sense of motion or

action. If you produce a photomatic, using slides projected on a screen allows you to create

whatever size scene you want.

The video portion of an animatic or a photomatic is produced by videotaping each scene,

frame by frame. Simulate motion by moving the camera in or out (zooming), left to right

(panning), or up and down. Record the audio portion of the rough message and then edit to

exactly the right length.

Finally, edit the videotape “to time” (30 or 60 seconds), using the soundtrack as a guide. The

video and audio tracks are then mixed together to produce the rough message.

If you decide to use live action instead of pictures, use nonprofessional actors (e.g., friends or

coworkers) to enact the script in a setting that closely approximates that to be used in final

production. The visuals and the sound should be recorded at the same time. To minimize the

number of times the live action must be taped, the actors should rehearse and the production

crew should be briefed ahead of time.

Minimizing Production Costs

Animatics, photomatics, and rough live action PSAs can be produced with the help of a

professional production company, your agency’s audiovisual staff, a local television station, or a

local college or university. A professional production company will be the most expensive

option; the latter three options will be less expensive. For example, a local television station

may donate its services for producing your spot, or a television production instructor may assist

you at no charge (except for the cost of the videotape) by making the production of your rough

message a student assignment.

There are several ways to help control the costs and the production quality of your rough ad:

1. Create a detailed production plan that addresses the following questions:

• What scenes will appear on the screen and in what order?

• How long will each scene be on the screen?

• What camera movements will be needed in each scene?

• How will scenes be edited together (e.g., fades, dissolves, or direct cuts)?

• What portions of the soundtrack go with each scene?

2. Send your production plan in advance to the person who will be helping you, and have extra

copies on hand at the production session.

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Continued on next page...

3. Make sure your script and production plan for the rough message are complete and timed

in advance.

4. Prerecord the audio track before the visuals are shot.

5. Make sure your illustrations, photographs, and/or slides are in the right order when you

arrive for the production session.

6. Finally, remember that you are producing a rough message. Save perfection for

final production!

Rough message production costs may be further reduced by using amateur talent (e.g., friends

or coworkers) who can do a respectable job recording the script. These same people may be

used for photographs or in a rough live action spot. Shooting the visuals and recording the

soundtrack on the same day may also save time and money. Finally, consider contacting a local

radio station for recording the soundtrack. The station may provide its facilities free of charge or

at a lower rate than a recording studio.

Animatics may be less expensive and faster to produce than photomatics because they are

composed of artists’ renditions. While you may have to buy the artwork, you eliminate costs for

talent (actors), location setting (i.e., obtaining clearance to rent or use property), props, and

travel. However, drawings may not communicate the realities or subtleties of the visual portion

of the message as well as photographs or rough live action. These drawbacks can be

minimized by using a good illustrator and a good, clear soundtrack.

Photomatics may be more expensive than animatics, depending upon the cost of the

photography. The availability of people who can represent the characters, the accessibility of an

appropriate location, and the rate your photographer charges are the major factors that affect

costs. These costs can be kept down by working with people who are readily available and by

arranging all the details in advance. The major advantage of producing a photomatic over an

animatic is that you can produce a more realistic and believable rendition of the final message.

Compare the costs of an illustrator versus those of a photographer and factor in the logistics

involved when deciding whether you should produce an animatic or a photomatic.

A rough live action message can be the least expensive way to produce your message in

rough form if:

• You are using amateur talent who can do a respectable run-through of the script

• Your script can be produced in a readily accessible location that does not require a lot of

set-up time

• Your production crew can videotape the run-through with a minimum number of takes

We recommend that you videotape rather than film the rough message for pretesting because

editing and processing are usually less expensive. Home or studio video equipment can be

used to produce any of the three rough message forms.

201

APPENDIX A

Sample Theater-Style Pretest Questionnaire

Part I

Thank you for watching this program. One of the reasons it was shown tonight was to get your

reaction to it—to see what parts you liked and what parts you didn’t like.

1. Was there any part of the program that you especially liked?

2. Was there anything about the program that you disliked?

3. Please indicate your overall reaction to the program by circling one of the phrases below:

a. A great program, would like to see it again

b. A pretty good program

c. Just so-so, like a million others

d. Another bad program

4. Would you recommend the program to your friends? Why or why not?

Part II

For each commercial that you remember seeing, please write down what the message said

and what the message showed on the dotted lines. Write down the main idea each message

was trying to get across on the solid lines.

a. What did the message say?

b. What did the message show?

c. What was the main idea each message was trying to get across?

202

Continued on next page...

1. a.

b.

c.

2. a.

b.

c.

3. a.

b.

c.

4. a.

b.

c.

5. a.

b.

c.

Part III

1. This evening you saw an ad. Now that you have seen the ad twice, please tell us what you

think was the main message of the ad?

2. In your opinion, was there anything in particular that was worth remembering about the ad?

a.Yes

b. No

2a. If yes, what was worth remembering?

Continued on next page...

203

APPENDIX A

3. In your opinion, what type of person was this ad talking to?

a. Someone like me

b. Someone else, not me

3a. If someone else, why?

4. In your opinion, was there anything in the ad that was confusing or hard to understand?

a.Yes

b. No

4a. If yes, what was confusing?

5. We would now like you to describe the ad. From each pair of words or phrases, please circle

the one that you feel best describes the message.

a. Believable

b. Not believable

a. Well done

b. Not well done

a. Convincing

b. Not convincing

a. Made its point

b. Didn’t make its point

a. Interesting

b. Not interesting

a. Pleasant

b. Not pleasant

a. Informative

b. Not informative

204

Continued on next page...

Part IV

[Following are sample questions for each message characteristic. Feel free to adapt these

questions to your needs, or develop your own questions. Make sure your pretest questionnaire

covers all aspects of your ad.]

Use of Music

1. Please circle the one answer from each pair that best describes your feelings about the

music in the ad.

a. Appropriate to the message

b. Not appropriate to the message

a. Effective in getting the message across

b. Not effective in getting the message across

a. Could understand the words to the music

b. Could not understand the words to the music

2. Overall, how would you describe the music in the ad?

a. The music fit the message

b. The music did not fit the message

c. I don’t remember the music

Use of Famous Spokesperson

1. Which of the following best describes________________ [name of spokesperson], the

announcer in the ad?

a. Singer

b. Actor

c. Comedian

d. Athlete

e. Don’t know

2. Please circle the one answer from each pair of phrases that best describes your feelings

about the announcer, ___________________ [name of spokesperson].

a. Believable

b. Not believable

a. Appropriate to the message

b. Not appropriate to the message

a. Gets the message across

b. Does not get the message across

APPENDIX A

Continued on next page...

205

Use of Telephone Number or Address

1. The phone number (or address) was on the screen long enough for me to remember it or

write it down.

a. Agree

b. Disagree

c. Neither agree nor disagree

Request for a Particular Action

1. What did the ad ask you to do?

Instructions for Performing a Specific Health Behavior

1. Please circle one answer from each pair of phrases that best describes your feelings about

the instructions regarding________________[fill in behavior] in the ad.

a. Clear and easy to understand

b. Confusing, hard to understand

a. I would be able to perform_____________________________ [fill in behavior] after

seeing this ad.

b. I would not be able to perform_________________________ [fill in behavior] after

seeing this ad.

Presentation of Technical or Medical Information

1. The ad presented technical (or medical) information. Please select one answer from each

pair of phrases that best describes your feelings about the information.

a. The ad did a good job of presenting technical information.

b. The ad did a poor job of presenting technical information.

a. I understood all the terms in the ad.

b. I had difficulty understanding the terms in the ad.

206

Continued on next page...

Presentation of New Information

1. How much, if any, of the information in the ad was new to you?

a. All of it

b. Most of it

c. Some of it

d. None of it

2. Overall, how useful was the information in the ad to you?

a. Very useful

b. Somewhat useful

c. Not very useful

d. Not useful at all

e. Don’t know/not sure

Promotion of a Sponsoring Organization

1. From among the following choices, please indicate the organization that sponsored this ad.

[Include your organization and fill in appropriate alternatives.]

a. CARE

b. Baylor College of Medicine

c. Save the Children Foundation

d. Don’t know/Not sure

Characters Who Are Supposed to Be Typical of the Intended Audience

[The word “characters” in these questions could be substituted with “man,” “woman,”

“family,” “children,” etc.]

1. Which of the following statements best describes the characters in the ad?

a. The characters in the ad reminded me of people I know.

b. The characters in the ad did not remind me of people I know.

2. Overall, how would you describe the characters in the ad? Please select one response from

each group.

a. Realistic

b. Not realistic

a. Helped me to understand the message

b. Did not help me to understand the message

APPENDIX A

Continued on next page...

207

3. Overall, how would you describe the characters in the ad? Please select one answer from

each group.

a. Appealing

b. Not appealing

a. Get the message across

b. Do not get the message across

a. Believable

b. Not believable

a. Easy to understand

b. Not easy to understand

Use of a Voice-Over Announcer

1. Please circle the one answer from each pair of phrases that best describes your feelings

about the announcer.

a. Believable

b. Not believable

a. Appropriate to the message

b. Not appropriate to the message

a. Gets the message across

b. Does not get the message across

a. Easy to understand

b. Hard to understand

Presentation of Controversial or Unpleasant Information

1. Some people have mentioned different feelings they had during or after watching the ad.

Please circle the opinion that comes closest to yours.

a. The ad made me uncomfortable, and I had difficulty paying attention to it.

b. The ad interested me, so I paid attention to it.

c. I had no particular feeling about the ad.

2. Overall, how do you think most people would feel about this ad if they saw it on television

at home?

a. Suitable to show on television at any time

b. Suitable to show, but only at certain times

c. Not suitable to show at any time

208

Continued on next page...

Part V

[Listed below are sample questions to be used for identifying the characteristics of your

pretest participants. Some of these questions also may be used as screening questions to

recruit participants from a specific group.]

Demographic Information

1. What is your sex?

a. Male

b. Female

2. What is your age?

a. Under 18

b. 18–24

c. 25–34

d. 35–44

e. 45–49

f. 50–54

g. 55–60

h. Over 60

3. How far did you go in school?

a. Eighth grade or less

b. Some high school

c. High school graduate

d. Some college

e. College graduate

4. Do you have children?

a.Yes (go to question 4a)

b. No (go to question 5)

4a. Please circle the age categories in which your children belong. Circle as many as apply.

a. 1–5 years old

b. 6–10 years old

c. 11–15 years old

d. 16–20 years old

e. 21 or over

5. Which of the following statements best describes you?

a. I currently smoke.

b. I used to smoke, but have now stopped.

c. I have never smoked.

APPENDIX A

Continued on next page...

209

6. Have you ever been told by a doctor or a nurse that you have . . .

a. Heart disease

b. High blood pressure

c. Cancer

d. Emphysema

e. Other

7. To the best of your knowledge, have you ever been exposed to . . .

a. Asbestos

b. Other toxic chemicals

c. Etc.

8. Which of the following best describes your race or ethnic background?

a. American Indian or Alaskan native

b. Asian

c. Black or African American

d. Hispanic or Latino

e. Native Hawaiian or Other Pacific Islander

f. White

210

Sample Script for Hosting a Theater-Style Test

Introduction

Good evening. I’m ____________________________________, and I’d like to thank you all for

coming today (tonight). I think we’re all going to have a good time. Just a few more words of

introduction and we’ll get started. We’ve asked you here because we feel that it’s very

important to get your ideas about new television program material. So consider this your

chance to give the TV program producers your opinions . . .

Keep in mind that what we’re interested in is your own personal views. We don’t want you to tell

us what you think we want to hear or what your spouse thinks or anyone else—we need your

own opinions.

There are no right answers and no wrong answers. So, please don’t discuss the program or

your answers with the people around you.

Also, please make sure that you write your answers clearly in the space provided on the

questionnaire we’ve given you, and be sure that you don’t move to a new section of the

questionnaire until I ask you to.

Do you have any questions about this procedure? I’ll answer any other questions you have at

the end of the test session. Okay? Now enjoy the show.

[Play the pretesting program videotape]

Reactions to the Program

All right. Now we’d like to find out about your reactions to the program—what parts you liked

and what parts you didn’t like. I’d like you to turn to the first page of the questionnaire and

answer the questions. Please don’t go on to the next page until I ask you to.

Reactions to the Ads

All right. Now we’d like to find out about your reactions to the advertisements you saw—what

you liked and what you didn’t like. I’d like you to turn to the second section of the questionnaire

and answer the questions. Please don’t go on to the next section until I ask you to.

Reactions to Your Ad

All right. Now we’d like to find out about your reactions to one specific ad. I will play it again and

then ask you to complete a few more questions. [Play your ad again] Now I’d like you to turn to

the next section of the questionnaire and answer the questions.

211

APPENDIX A

Tabulating Responses to Closed- and Open-Ended Questions

Tabulating Responses to Closed-Ended Questions

Closed-ended questions force participants to select a response from several alternatives.

A quick method for tabulating or counting responses to each question is to use a

blank questionnaire:

1. Take the first questionnaire and record the answers to each closed-ended question by

making a check mark in the right-hand column next to the appropriate response.

2. Repeat this procedure for every questionnaire.

3. Tally the total number of check marks and then calculate the percentage of participants

who gave each response.

Tabulating Responses to Open-Ended Questions

Tabulating or counting responses to open-ended questions is more time consuming. Open-

ended questions allow participants to express themselves in their own words. For example:

• What did the message say?

• What did the message show?

• What was the main idea the message was trying to get across?

The easiest way to analyze these questions is to write each question at the top of a separate

blank page (the coding sheet). Because participants are answering in their own words, the first

step is to group the responses into categories (e.g., correct, partially correct, and incorrect).

When categorizing the audience recall and main idea responses, use the ad script and your

own statement of the message’s main points to guide the analysis. For some open-ended

questions (e.g., “What, if anything, did you like about the message?” or “What, if anything, did

you dislike?”), you may wish to classify the responses as favorable or unfavorable.

Use the following procedure to tally the responses:

1. Take the first questionnaire and record the answers to each open-ended question by

making a check mark in the appropriate column (e.g., favorable or unfavorable).

2. Repeat this procedure for every questionnaire.

3. Tally the total number of check marks in each column and then calculate the percentage

of participants who gave each type of response.

Once you have tabulated the responses to each question, your interpretation should be guided

by the objectives you set forth in the planning stage.

212

Average Ratings for Commercial Ads to Help Interpret

Standard Pretesting Questions

1

Variable/Descriptor Females 18–65 Males 18–65

% Who Completely Agree

2

% Who Completely Agree

2

:30 Rough :30 Finished :30 Rough :30 Finished

Com’l Norm Com’l Norm Com’l Norm Com’l Norm

Effective main idea (% of 40 40 40 40

respondents who agree

on a single main idea)

Appropriate 49 53 48 54

Attention-getting 35 47 34 44

Believable 38 40 37 40

Confusing 4 5 5 6

Convincing 31 33 28 31

Effective 36 43 --- ---

Informative 36 36 37 37

Interesting 23 30 23 35

Meaningful 23 28 --- ---

Relevant 28 29 25 29

Something you could relate to 36 37 37 34

Told you something important 23 25 28 28

Told you something new 30 28 26 27

Worth remembering 22 33 19 ---

1

This table, based on the Ipsos-ASI, Inc., Market Research Database of Diagnostic Norms, includes national

averages for standard copy test questions used in testing commercial ads. Please note that these norms are

derived from national telephone interviews (rather than mall intercepts or theater testing) and include findings

from stand-alone viewing.

2

Responses are on a 3-point scale: completely agree, somewhat agree, do not agree at all.

APPENDIX A

Continued on next page...

213

This table can be helpful in comparing your ad pretest to previous pretest results. This

comparison should not be the sole basis of your analysis. Rather, the ranges should serve as

guidelines. They are designed to help you extract meaning from the percentages you compute

for your test ad. Before drawing any conclusions or making recommendations, you should

analyze the results for every question.

This book cannot provide ranges or guidelines for the questions that relate specifically to your

test ad. Therefore, you will have to interpret the percentages on your own. Ask yourself how

critical it is for the majority of participants to respond in a certain manner to each question. For

example, if the test ad communicates the main idea through music, it is essential that a large

majority report being able to understand the words to the music. On the other hand, if the

music in the ad serves only as background sound, then it is not as critical for the lyrics to be

understood.

It is important to examine how many responses to open-ended questions fall into each

category (correct, partially correct, or incorrect; favorable or unfavorable). Ideally, the majority

of responses will fall into the correct category. This pattern tends to confirm that the test ad is

meeting its objectives. On the other hand, if the majority of responses are categorized as

partially correct or incorrect, the ad may not be meeting your communication objectives.

Statistical Techniques

You can use statistical techniques to analyze subgroup information (e.g., males vs. females, or

younger participants vs. older ones) only if you boost the sample size to at least 50 participants

in each subgroup. If you recruit only 50 participants in total, the sample will be too small to be

reviewed by subgroup. Comparing findings between subgroups that are too small can be

misleading and may result in faulty conclusions.

Do not try to make generalizations from the results of this pretest to ad messages in general.

Each ad pretest you conduct will provide direction for making changes that might be necessary

before final production and for improving the potential effectiveness of each particular

message. The sample size and the methodology used do not allow for formulating definitive

conclusions about what your message’s impact will be after it is distributed.

214

APPENDIX A

215

GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide

APPENDIX B

GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide

Selected Planning Frameworks,

Social Science Theories, and

Models of Change

*

APPENDIX B

* From Theory at a Glance: A Guide for Health Promotion Practice (NIH Publication No.

97-3896), by the National Cancer Institute, 1995. Bethesda, MD. In the public domain.

Planning Systems/Frameworks

Once health communications planners identify a health problem, they can use a planning

framework such as the two described below: social marketing and PRECEDE-PROCEED.

These planning systems can help identify the social science theories most appropriate for

understanding the problem or situation. Thus, planners use the theories and models described

below within the construct of a planning framework.

Using planning systems like social marketing and PRECEDE-PROCEED increases the odds of

program success by examining health and behavior at multiple levels. Planning system

perspectives emphasize changing people, their environment, or both.

Social Marketing

Social marketing has been defined as “the application of commercial marketing technologies to

the analysis, planning, execution, and evaluation of programs designed to influence the

voluntary behavior of target audiences in order to improve their personal welfare and that of

their society” (Andreason, 1995). This definition encompasses several key aspects of the social

marketing approach; it is seen as:

1. A key benefit to individuals and society; not focused on profit and organizational benefits as

commercial marketing practices are

2. A focus on behavior, not awareness or attitude change

3. An approach centered on the target audience’s having a primary role in the process

Social marketing practices are based on commercial marketing practices that make the

consumer the central focus for planning and conducting a program. The program's

components address:

• Price—what the consumer must give up in order to receive the program’s benefits (these

costs may be intangible [e.g., changes in beliefs or habits] or tangible [e.g., money, time,

or travel])

• Product—what the program is trying to change within the intended audience and what the

audience stands to gain

• Promotion—how the exchange is communicated (e.g., appeals used)

• Place—what channels the program uses to reach the intended audience (e.g., mass media,

community, or interpersonal)

The formulation of price, product, promotion, and place evolves from research with the

consumers to determine what benefits and costs they would consider acceptable and how

they might be reached. Lessons learned from social marketing stress the importance of

understanding the intended audiences and designing strategies based on their wants and

needs rather than what good health practice directs that they should do.

For Further Reading

Andreason, A. (1995). Marketing social change: Changing behavior to promote health, social

development, and the environment. San Francisco: Jossey-Bass.

218

Kotler, P., & Roberto, E. L. (1989). Social marketing: Strategies for changing public behavior.

New York: Free Press.

Lefebvre, R. C., & Rochlin, L. (1997). Social marketing. In K. Glanz, F. M. Lewis, & B. K. Rimer

(Eds.), Health behavior and health education: Theory, research, and practice (2nd ed.).

San Francisco: Jossey-Bass.

PRECEDE-PROCEED

The PRECEDE-PROCEED framework is an approach to planning that examines the factors

contributing to behavior change. These include:

• Predisposing factors—the individual’s knowledge, attitudes, behavior, beliefs, and values

before intervention that affect willingness to change

• Enabling factors—factors in the environment or community of an individual that facilitate or

present obstacles to change

• Reinforcing factors—the positive or negative effects of adopting the behavior (including

social support) that influence continuing the behavior

These factors require that individuals be considered in the context of their community

and social structures, and not in isolation, when planning communication or health

education strategies.

PRECEDE-PROCEED Framework

PRECEDE

PHASE 5

PHASE 4

PHASE 3

PHASE 2

PHASE 1

Administration

Educational and

Behavioral and

Epidemiological

Social

and Policy

Organizational

Environmental

Diagnosis

Health

Promotion

Health

education

Policy regulation

organization

Predisposing

factors

Reinforcing

factors

Enabling

factors

Behavior and

lifestyle

Environment

Health

Quality

of life

PHASE 6 PHASE 7

PHASE 8 PHASE 9

Implementation Process

Impact

Outcome

Evaluation

PROCEED

219

APPENDIX B

For Further Reading

Green, L. W., & Kreuter, M. W. (1999). Health promotion planning: An educational and

ecological approach (3rd ed.). Mountain View, CA: Mayfield.

Green, L. W., & Ottoson, J. M. (1999). Community and population health (8th ed.). New York:

McGraw-Hill.

Selected Social Science Theories, Models, and Constructs

Individual Level

Behavioral Intentions

Studies of behavioral intentions suggest that the likelihood of intended audiences’ adopting a

desired behavior can be predicted by assessing (and subsequently trying to change or

influence) their attitudes toward and perceptions of benefits of the behavior, along with how

they think that their peers will view their behavior. Research by Fishbein and Ajzen supports

the idea that individuals’ and society’s (perceived) attitudes are an important predecessor to

action. Therefore, an important step toward influencing behavior is a preliminary assessment

of intended audience attitudes, and subsequent tracking is necessary to identify any

attitudinal changes.

For Further Reading

Fishbein, M., & Ajzen, I. (1975). Belief, attitude, intention and behavior: An introduction to

theory and research. Reading, MA: Addison-Wesley.

Communications for Persuasion

William McGuire has described the steps an individual must be persuaded to pass through to

assimilate a desired behavior. These steps are:

• Exposure to the message

• Attention to the message

• Interest in or personal relevance of the message

• Understanding of the message

• Personalizing the behavior to fit one’s life

• Accepting the change

• Remembering the message and continuing to agree with it

• Being able to think of it

• Making decisions based on bringing the message to mind

• Behaving as decided

• Receiving positive reinforcement for behavior

• Accepting the behavior into one’s life

220

To communicate the message successfully, five communication components all must work:

1. Credibility of the message source

2. Message design

3. Delivery channel

4. Intended Audience

5. Intended behavior

Paying attention to McGuire’s steps helps ensure that a communication program plan

addresses all the factors that determine whether a message is received and absorbed, that the

program is staged over time to address intended audience needs as they differ over time, and

that progress is being made toward behavior change.

For Further Reading

McGuire, W. J. (1984). Public communication as a strategy for inducing health-promoting

behavioral change. Preventive Medicine, 13(3), 299–313.

Stages of Change

The basic premise of the stages-of-change construct, the central construct of the

transtheoretical model, is that behavior change is a process and not an event and that

individuals are at varying levels of motivation, or readiness, to change. People at different

points in the process of change can benefit from different interventions, matched to their stage

at that time.

By knowing an individual’s current stage, you can help set realistic program goals.You can also

tailor messages, strategies, and programs to the appropriate stage.

Five distinct stages are identified in the stages-of-change construct:

1. Precontemplation

2. Contemplation

3. Decision/determination

4. Action

5. Maintenance

It is important to note that this is a circular, not a linear, model. People don’t go through the

stages and “graduate”; they can enter and exit at any point, and often recycle.

For Further Reading

Prochaska, J. O., & Velicer, W. F. (1997). The transtheoretical model of health behavior change.

American Journal of Health Promotion, 12(1), 38–48.

APPENDIX B

221

Health Belief Model

The health belief model (HBM) was originally designed to explain why people did not

participate in programs to prevent or detect diseases. The core components of HBM include:

• Perceived susceptibility—the subjective perception of risk of developing a particular

health condition

• Perceived severity—feelings about the seriousness of the consequences of developing

a specific health problem

• Perceived benefits—beliefs about the effectiveness of various actions that might reduce

susceptibility and severity (taken together, perceived susceptibility and severity are

labeled “threat”)

• Perceived barriers—potential negative aspects of taking specific actions

• Cues to action—bodily or environmental events that trigger action

More recently, HBM has been amended to include the notion of self-efficacy as another

predictor of health behaviors—especially more complex ones in which lifestyle changes must

be maintained over time. A wide variety of demographic, social, psychological, and structural

variables may also impact people’s perceptions and, indirectly, their health-related behaviors.

Some of the more important variables include educational attainment, age, gender,

socioeconomic status, and prior knowledge.

For Further Reading

Janz, N. K., & Becker, M. H. (1984). The health belief model: A decade later. Health Education

Quarterly, 11, 1–47.

Strecher, V. J., & Rosenstock, I. M. (1997). The health belief model. In K. Glanz, F. M. Lewis,

& B. K. Rimer (Eds.), Health behavior and health education: Theory, research, and practice

(2nd ed.). San Francisco: Jossey-Bass.

Consumer Information Processing Model

The consumer information processing (CIP) model was not developed specifically to study

health-related behavior, nor to be applied in health promotion programs, but it has many useful

applications in the health arena. Information is a common tool for health education and is often

an essential foundation for health decisions.

Information can increase or decrease people’s anxiety, depending on their information

preferences and how much and what kind of information they are given. Also, illness and its

treatments can interfere with information processing. By understanding the key concepts and

processes of CIP, health educators can examine why people use or fail to use health

information and design informational strategies to better chances for success. CIP theory

reflects a combination of rational and motivational ideas. The use of information is an

intellectual process; however, motivation drives the search for information and how much

attention people pay to it. The central assumptions of CIP are that 1) individuals are limited in

how much information they can process, and 2) to increase the usability of information, they

222

combine bits of information into “chunks” and create decision rules, known as heuristics, to

make choices faster and more easily. According to basic CIP concepts, before people will use

health information, it must be 1) available, 2) seen as useful and new, and 3) processable, or

format-friendly.

For Further Reading

Bettman, J. R. (1979). An information processing theory of consumer choice. Reading, MA:

Addison-Wesley.

Interpersonal Level

Social Cognitive Theory

Social cognitive theory (SCT) explains behavior in terms of triadic reciprocality (“reciprocal

determinism”) in which behavior, cognitive and other interpersonal factors, and environmental

events all operate as interacting determinants of one another. SCT describes behavior as

dynamically determined and fluid, influenced by both personal factors and the environment.

Changes in any of these three factors are hypothesized to render changes in the others.

One of the key concepts in SCT is the environmental variable: observational learning. In

contrast to earlier behavioral theories, SCT views the environment as not just a variable that

reinforces or punishes behaviors, but one that also provides a milieu where an individual can

watch the actions of others and learn the consequences of those behaviors. Processes

governing observational learning include:

• Attention—gaining and maintaining attention

• Retention—being remembered

• Reproduction—reproducing the observed behavior

• Motivation—being stimulated to produce the behavior

Other core components of SCT include:

• Self-efficacy—judgment of one’s capability to accomplish a certain level of performance

• Outcome expectation—judgment of the likely consequence such behavior will produce

• Outcome expectancies—the value placed on the consequences of the behavior

• Emotional coping responses—strategies used to deal with emotional stimuli, including

psychological defenses (denial, repression), cognitive techniques such as problem

restructuring, and stress management

• Enactive learning—learning from the consequences of one’s actions (versus

observational learning)

• Rule learning—generating and regulating behavioral patterns, most often achieved through

vicarious processes and capabilities (versus direct experience)

• Self-regulatory capability—much of behavior is motivated and regulated by internal

standards and people’s self-evaluative reactions to their own actions

APPENDIX B

223

For Further Reading

Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory.

Englewood Cliffs, NJ: Prentice-Hall.

Lefebvre, R. C. (2000). Theories and models in social marketing. In P. N. Bloom & G. T.

Gundlach (Eds.), Handbook of marketing and society. Thousand Oaks, CA: Sage.

Organization/Community/Societal Level

Organizational Change Theory

Organizations are complex and layered social systems, composed of resources, members,

roles, exchanges, and unique cultures. Thus, organizational change can best be promoted by

working at multiple levels within the organization. Understanding organizational change is

important in promoting health to help establish policies and environments that support healthy

practices and create the capacity to solve new problems. While there are many theories of

organization behavior, two are especially promising in public health interventions: stage theory

and organizational development (OD) theory.

Stage theory is based on the idea that organizations pass through a series of steps or stages

as they change. By recognizing those stages, strategies to promote change can be matched

to various points in the process of change. An abbreviated version of stage theory involves

four stages:

1. Problem definition (awareness)

2. Initiation of action (adoption)

3. Implementation

4. Institutionalization

OD theory grew out of the recognition that organizational structures and processes influence

worker behavior and motivation. OD theory concerns the identification of problems that impede

an organization’s functioning, rather than the introduction of a specific type of change. Human

relations and quality of work-life factors are often the targets of OD problem diagnosis, action

planning, interventions, and evaluation. A typical OD strategy involves process consultation,

in which an outside specialist helps identify problems and facilitates the planning of

change strategies.

Stage theory and OD theory have the greatest potential to produce health-enhancing change

in organizations when they are combined. That is, OD strategies can be used at various stages

as they are warranted. Simultaneously, the stages signal the need to involve organization

members and decision-makers at various points in the process.

224

For Further Reading

Beyer, J. M., & Trice, H. M. (1978). Implementing change: Alcoholism policies in work

organizations. New York: Free Press.

Porras, J. I., & Roberston, P. J. (1987). Organization development theory: A typology and

evaluation. In R. W. Woodman & W. A. Pasmore (Eds.), Research in organizational change and

development (Vol. 1). Greenwich, CT: JAI Press.

Community Organization Theory

Community organization theory has its roots in theories of social networks and support. It

emphasizes active participation and developing communities that can better evaluate and solve

health and social problems. Community organization is the process by which community

groups are helped to identify common problems or goals, mobilize resources, and develop and

implement strategies for reaching their goals. It has roots in several theoretical perspectives:

the ecological perspective, social systems perspective, social networks, and social support.

It is also consistent with social learning theory (SLT) and can be successfully used along

with SLT-based strategies. Community organization is composed of several alternative

change models:

• Locality development (also called community development) uses a broad cross-section of

people in the community to identify and solve its own problems. It stresses consensus

development, capacity building, and a strong task orientation; outside practitioners help to

coordinate and enable the community to successfully address its concerns.

• Social planning uses tasks and goals, and addresses substantive problem solving, with

expert practitioners providing technical assistance to benefit community consumers.

• Social action aims to increase the problem-solving ability of the community and to achieve

concrete changes to redress social injustice that is identified by a disadvantaged or

oppressed group.

Although community organization does not use a single unified model, several key concepts

are central to the various approaches. The process of empowerment is intended to stimulate

problem solving and activate community members. Community competence is an approximate

community-level equivalent of self-efficacy plus behavioral capability, which are the confidence

and skills to solve problems effectively. Participation and relevance go together: They involve

citizen activation and a collective sense of readiness for change. Issue selection concerns

identifying “winnable battles” as a focus for action, and critical consciousness stresses the

active search for root causes of problems.

Social action approaches to community organizing go beyond the traditional notion of

geographic and political boundaries. Communities of people who share common health

problems have coalesced to attract attention to and to obtain power to address their needs—

including health services, antidiscrimination policies, and more research funding. Foremost

among these groups presently are AIDS activists. Women’s health advocates have also used

social action to pressure powerful institutions to address their problems; breast cancer is now

a focus for action and advocacy among breast cancer survivors and their relatives. They have

used media advocacy as a powerful tool in their efforts.

APPENDIX B

225

Media advocacy is the strategic use of mass media as a resource for advancing a social or

public policy initiative. It is an important, and often essential, part of social action and advocacy

campaigns because the media focus public concern and spur public action. The core

components of media advocacy are developing an understanding of how an issue relates to

prevailing public opinions and values and designing messages that frame the issues so as to

maximize their impact and attract powerful and broad public support.

For Further Reading

Rothman, J., & Tropman, J. E. (1987). Models of community organization and macro practice:

Their mixing and phasing. In F. M. Cox, J. L. Ehrlich, J. Rothman, & J. E. Tropman (Eds.),

Strategies of community organization (4th ed.). Itasca, IL: Peacock.

Diffusion of Innovations Theory

Diffusion of innovations theory addresses how new ideas, products, and social practices

spread within a society or from one society to another. The challenge of diffusion requires

approaches that differ from those focused solely on individuals or small groups. It involves

paying attention to the innovation (a new idea, product, practice, or technology) as well as to

communication channels and social systems (networks with members, norms, and

social structures).

A focus on the characteristics of innovations can improve the chances that they will be adopted

and hence diffused. It also has implications for how an innovation is positioned to maximize its

appeal. Some of the most important characteristics of innovations are their:

• Relative advantage—is it better than what was there before?

• Compatibility—fit with intended audience

• Complexity—ease of use

• Trialability—can it be tried out first?

• Observability—visibility of results

Communication channels are another important component of diffusion of innovations theory.

Diffusion theories view communication as a two-way process rather than one of merely

“persuading” an intended audience to take action. The two-step flow of communication—in

which opinion leaders mediate the impact of mass media—emphasizes the value of social

networks (or interpersonal channels) over and above mass media for adoption decisions.

For Further Reading

Green, L. W., Gottlieb, N. H., & Parcel, G. S. (1987). Diffusion theory extended and applied. In

W. B. Ward (Ed.), Advances in health education and promotion. Greenwich, CT: JAI Press.

Rogers, E. M. (1983). Diffusion of innovations (3rd ed.). New York: Free Press.

226

APPENDIX B

227

GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide

APPENDIX C

GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide

Information Sources

APPENDIX C

National Sources of Health-Related Information

Agency for Healthcare Research and Quality (AHRQ)

Publication Clearinghouse

P.O. Box 8547

Silver Spring, MD 20907-8547

1-800-358-9295

www.ahrq.gov

American Cancer Society (ACS)

1599 Clifton Road, NE

Atlanta, GA 30329

1-800-ACS-2345

www.cancer.org

Cancer Information Service

National Cancer Institute

6116 Executive Boulevard, SMC 8322

Room 3036A

Bethesda, MD 20892

1-800-4-CANCER (1-800-422-6237)

Center for Substance Abuse Prevention

National Clearinghouse for Alcohol and Drug Information

P.O. Box 2345

Rockville, MD 20847-2345

1-800-729-6686

Centers for Disease Control and Prevention (CDC)

www.cdc.gov

Centers for Medicare and Medicaid Services

7500 Security Boulevard

Baltimore, MD 21244-1850

1-800-638-6833 (Medicare)

202-690-6145 (Press Office)

www.cms.gov

Health Promotion Online—Canada

Partnerships and Marketing Division

Health Promotion and Programs Branch

Health Canada

55 St. Clair Avenue East, 4th Floor

Toronto, Ontario

M4T 1M2

www.hc-sc.gc.ca/hppb/hpo

230

National Center for Chronic Disease Prevention and Health Promotion

Division of Cancer Prevention and Control

4770 Buford Highway, NE

Atlanta, GA 30341-3724

770-488-4880

770-488-4727 (fax)

www.cdc.gov/nccdphp

National Center for Health Statistics

6525 Belcrest Road

Hyattsville, MD 20782-2003

301-458-4636

www.cdc.gov/nchs

Roper Center for Public Opinion Research

341 Mansfield Road

Unit 1164

University of Connecticut

Storrs, CT 06269-1164

860-486-4440

www.ropercenter.uconn.edu

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Washington, DC 20201

202-619-0257

1-877-696-6775

www.os.dhhs.gov

Internet Resources

Combined Health Information Database

http://chid.nih.gov

Community Toolbox

http://ctb.lsi.ukans.edu

Health Education Professional Resources

www.nyu.edu/education/hepr/index.html

Healthfinder

(To locate Federal Clearinghouse and other Federal information sources)

www.healthfinder.gov

APPENDIX C

231

Journals

American Journal for Health Promotion

1660 Cass Lake Road

Suite 104

Keego Harbor, MI 48320

248-682-0707

248-682-1212 (fax)

www.healthpromotionjournal.com/index.htm

American Journal of Health Behavior

American Academy of Health Behavior

P.O. Box 4593

Star City, WV 26504-4593

http://131.230.221.136/ajhb

American Journal of Public Health

American Public Health Association

800 I Street, NW

Washington, DC 20001

202-777-APHA

202-777-2534 (fax)

www.apha.org/journal/AJPH2.htm

Health Education and Behavior

Society for Public Health Education

1015 15th Street, NW

Suite 410

Washington, DC 20005

202-408-9804

202-408-9815 (fax)

inf[email protected] (e-mail)

www.sph.umich.edu/hbhe/heb

Health Education Research

Oxford University Press

2001 Evans Road

Cary, NC 27513

www.oup.co.uk/healed

232

Journal of Health Communication

Department of International Public Health

School of Public Health and Health Services

The George Washington University

2175 K Street, NW

Suite 820

Washington, DC 20037

www.aed.org/jhealthcom

Journal of the American Medical Association

515 North State Street

Chicago, IL 60610

312-464-5000

http://jama.ama-assn.org

Morbidity and Mortality Weekly Report (MMWR)

Centers for Disease Control and Prevention

1600 Clifton Road

Atlanta, GA 30333

www.cdc.gov/mmwr

The New England Journal of Medicine

10 Shattuck Street

Boston, MA 02115-6094

617-734-9800

617-734-4457 (fax)

www.nejm.org

Social Marketing Quarterly

Best Start Social Marketing

4809 East Busch Boulevard

Suite 104

Tampa, FL 33617

813-971-2119

813-971-2280 (fax)

APPENDIX C

233

GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide

APPENDIX D

GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide

Selected Readings

and Resources

APPENDIX D

Academy for Educational Development. (1995). A tool box for building health communication

capacity. Washington, DC.

Adler, E. (1993). Everyone’s guide to successful publications: How to produce powerful

brochures, newsletters, flyers, and business communications, start to finish. Berkeley, CA:

PeachPit.

Agency for International Development, Academy for Educational Development. (1992).

Results and realities: A decade of experience in communication for child survival.

Washington, DC.

Agency for Toxic Substances and Disease Registry. (1994). Guidelines for planning and

evaluating environmental health education programs. Atlanta.

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

American Marketing Association, New York Chapter. (2001). The focus group directory.

New York.

American Marketing Association, New York Chapter. (2001/2002). Green Book: International

directory of marketing research companies and services. New York.

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

Washington, DC.

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

Andreasen, A. (1995). Marketing social change: Changing behavior to promote health, social

development, and the environment. San Francisco: Jossey-Bass.

Arkin, E. B., Romano, R. M., Van Nevel, J. P., & McKenna, W. (1993). Effect of the mass media

in promoting calls to the Cancer Information Service. In The Cancer Information Service: A 15-

year history of service and research (Monograph of the Journal of the National Cancer

Institute, No. 14).

Backer, T. E., Rogers, E. M., & Sopory, P. (1992). Designing health communication campaigns:

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GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide

APPENDIX E

GuideAPlanner’sGuideAPlanner’sGuideAPlanner’sGuide

Glossary

APPENDIX E

Attention. A pretesting measure used to describe a message’s ability to attract listener or

viewer attention; this is often measured as “recall” of a message or image.

Attitudes. An individual’s predispositions toward an issue, person, or group, which influence

his or her response to be positive or negative, favorable or unfavorable.

Baseline study. The collection and analysis of data regarding an intended audience or

situation prior to intervention.

Bounceback card. A short questionnaire, often on a business-reply postcard, that is

distributed with materials to collect process evaluation data.

Central-location intercept interviews. A method used for pretesting messages and

materials. It involves “intercepting” potential intended audience members at a highly trafficked

location (such as a shopping mall), asking them a few questions to see if they fit the intended

audience’s characteristics, showing them the messages or materials, and then administering a

questionnaire of predominantly closed-ended questions. Because respondents form a

convenience sample, the results cannot be projected to the population. Also called mall

intercept interviews.

Channel. The route of message delivery (e.g., mass media channels include television, radio,

newspapers, magazines; interpersonal channels include health professional to patient;

community channels include community events, such as health fairs or sporting events).

Closed-ended questions. Questions that provide respondents with a list of possible answers

from which to choose; also called multiple choice, forced-choice, or fixed-choice questions.

Communication concepts. See message concepts.

Communication objectives. The specific outcomes you expect exposure to your

communications will produce in support of the program’s overall goal.

Communication strategy. A statement that describes:

• The intended audience members

• The settings, channels, and activities that should be used to reach them

• The image that program communications should convey

• The action intended audience members should take as a result of exposure to

your communication

• A compelling benefit they will receive by taking the action

• Support that convinces them they will experience the benefit

Communication strategy statement. A written document containing the communication

strategy, which may be supplemented with additional information such as background on the

health problem, the goals the communication program is designed to help attain, or more

thorough intended audience profiles. This document provides the direction and consistency for

all program messages and materials.

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Comprehension. A pretesting measure used to determine whether messages are

clearly understood.

Consumer panel. A research study in which the buying behavior and other characteristics

of a group of consumers are studied over time. Data can be collected through periodic

questionnaires, consumer diaries, UPC scanners, or a combination of techniques. Because

information is collected at multiple times, changes in behavior over time can be examined

and panel members can be recontacted and asked additional questions that are specific to

a particular health problem or communication effort. Consumer panel data are subject to the

same limitations of any panel study (e.g., sample possibly being misrepresentative due to

selection bias, difficulty in ensuring participation over time, and inability to control the

drop-out rate).

Convenience samples. Samples that consist of respondents who are typical of the intended

audience and who are easily accessible; results cannot be projected to the entire population

being studied.

Creative brief. A short (one- to two-page) version of the communication strategy statement,

used to guide development of materials and activities. The short creative brief is sometimes

used in place of the longer communication strategy statement, especially if the program is not

very complex.

Diagnostic information. The results of pretesting research that indicate the strengths and

weaknesses in messages and materials.

Education entertainment. A form of health communication in which educational content and

information is intentionally incorporated into an entertainment format (e.g., songs, comics,

nonnews television or radio programming, movies).

Environmental factors. Factors that are external to an individual but can influence the

individual’s behavior (e.g., policies, access to services, geography, physical features such as

sidewalks and parks).

Focus group. A qualitative research technique in which an experienced moderator guides

about 8 to 10 participants through a discussion of a selected topic, allowing them to talk freely

and spontaneously. Focus groups are often used to identify previously unknown issues or

concerns or to explore reactions to potential actions, benefits, or concepts during the planning

and development stages.

Formative evaluation. Evaluative research conducted during program development. May

include state-of-the art reviews, pretesting messages and materials, and pilot testing a

program on a small scale before full implementation.

Frequency. The average number of times an audience is exposed to a specific

media message.

Gatekeeper. An organization or individual you must work with before you can reach an

intended audience (e.g., an organization, a schoolteacher, a television public service director).

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Geodemographic databases. Customized computer programs that combine many

variables—such as demographic, lifestyle, behavior, and geographic information—from

different surveys into one analysis.

Goal. The overall health improvement an organization or agency strives to create.

Health belief model. A conceptual framework of health behavior stating that health behavior is

a function of both knowledge and motivation. Specifically, the model emphasizes the role of

perceived vulnerability to a condition, perceived severity of the condition, perceived benefits of

the recommended action, perceived barriers to the advised action, cues to action, and self-

efficacy in terms of one’s ability to take action.

Impact evaluation. A type of research designed to identify whether and to what extent

a program contributed to accomplishing its stated goals (here, more global than

outcome evaluation).

In-depth interviews. A type of qualitative research in which a trained interviewer guides an

individual through a discussion of a selected topic, allowing the person to talk freely and

spontaneously. This technique is often used to identify previously unknown issues or concerns,

or to explore reactions to potential actions, benefits, or concepts during the planning and

development stages.

Intended audience. The audience selected for program messages and materials (see

segmentation). The primary intended audience consists of those individuals the program

is designed to affect. The secondary intended audience is the group (or groups) that can

help reach or influence the primary audience. (intended audience is also referred to as

“target audience.”)

Intended population. A broad definition of the audience for a program. The intended

population is defined by the epidemiology of the problem and factors contributing to it (e.g.,

women ages 40 and over for a mammography screening program).

Internet. A global network connecting millions of computers all over the world, allowing for the

exchange of information.

Low literacy. A limited ability to use printed and written information to function in society, to

achieve one’s goals, and to develop one’s knowledge and potential.

Media advocacy. The strategic use of mass media to reframe issues, shape public discussion,

or build support for a policy, point of view, or environmental change.

Media literacy. Having the skills to deconstruct media messages to identify the sponsor’s

motives and to construct or compose media messages representing the intended audience’s

point of view. This is often taught to youth so they can evaluate the media messages directed

toward them.

248

Message concepts. Brief statements, sometimes accompanied by visuals, that present key

aspects of the communication strategy (e.g., action to be taken, benefit promised in exchange,

support for the benefit) to the intended audience. Message concepts often differ in terms of the

type of appeal used; one may be factual, one may be emotional, and one may demonstrate the

action to be taken.

Objectives. See communication objectives.

Omnibus survey. A national survey conducted by a research organization that includes

questions on varied topics for various sponsoring organizations. This method of survey

research allows multiple organizations to add questions to construct one questionnaire,

reducing survey costs to participating organizations.

Open-ended questions. Questions that allow an individual to respond freely in his or her own

words, in contrast to closed-ended or fixed-choice questions.

Outcome evaluation. Research designed to assess the extent to which a program achieved

its objectives.

Over-recruiting. Recruiting more respondents than required to compensate for expected

“no-shows.”

Polysyllabic words. Words that contain three or more syllables.

Pretesting. A type of formative evaluation that involves systematically gathering intended

audience reactions to messages and materials before the messages and materials are

produced in final form.

Primary intended audience. See intended audience.

Probe. A technique used primarily in qualitative research (e.g., focus groups, in-depth

interviews) to solicit additional information about a question or issue. Probes should be neutral

(e.g., “What else can you tell me about _____?”), not directive (“Do you think the pamphlet was

suggesting that you take a particular step, such as changing your diet?”).

Process evaluation. Research conducted to document and study the functioning of different

components of program implementation; includes assessments of whether materials are being

distributed to the right people and in what quantities, whether and to what extent program

activities are occurring, and other measures of how and how well the program is working.

Program objectives. The specific outcomes that you expect your entire program to achieve.

These will be broader than communication objectives, but must also specify outcomes.

PSA. A public service announcement; an advertisement that a mass media outlet (e.g.,

magazine, newspaper, radio station, television station, Web site, outdoor venue) prints or

broadcasts without charging the sponsoring organization.

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249

Public relations. Marketing activities designed to raise the public’s awareness about a

product, service, individual, or issue; management of an organization’s public image that helps

the public understand the organization and its products.

Qualitative research. Subjective research that involves obtaining reactions and impressions

from small numbers of people by engaging them in discussions. The information gathered

should not be described in numerical terms, and generalizations about the intended audience

cannot be made. Qualitative research is useful for exploring reactions and uncovering

additional ideas, issues, or concerns.

Quantitative research. Research designed to gather objective information by asking a large

number of people identical (and predominantly closed-ended) questions. Results are

expressed in numerical terms (e.g., 35 percent are aware of X and 65 percent are not), and,

if the respondents are a representative random sample, quantitative data can be used to

draw conclusions about the intended audience as a whole. Quantitative research is useful

for measuring the extent to which knowledge, attitudes, or behaviors are prevalent in an

intended audience.

Random sample. A sample of respondents selected from an intended population in which

every member of the population had an equal chance of being included.

Reach. The number of people or households exposed to a specific media message during a

specific period of time.

Readability testing. Using a formula to predict the approximate reading level (usually

expressed in grades) a person must have achieved in order to understand written material.

Recall. In pretesting, a measure that describes the extent to which respondents remember

seeing or hearing a message that was shown in a competitive media environment—usually

centers on recall of the main idea, not the verbatim message.

Search engine. A mechanism for finding Web sites or documents contained on Web sites.

To make sure others can find your site, you can register it with popular search engines (e.g.,

Yahoo!) by providing a description of your site and a few keywords.

Secondary intended audience. See intended audience.

Segmentation. Subdividing an overall population into homogeneous subsets in order to better

describe and understand a group, predict behavior, and tailor messages and programs to

match specific interests, needs, or other group characteristics. Segments may be demographic

(e.g., age, sex, education, life cycle), geographic (e.g., Southeastern U.S., rural, north side of

town), or psychographic (e.g., personality, lifestyle, usage patterns, risk factors, benefits

sought), or they may be based on a combination of these factors.

Self-administered questionnaires. Questionnaires that are filled out by respondents

themselves (rather than by an interviewer).

Settings. Times, places, and states of mind during which an intended audience is attentive

and open to a message and finds it credible.

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Social cognitive theory. A theory of human behavior that stresses the dynamic

interrelationships among people, their behavior, and their environment. While the environment

shapes, maintains, and constrains behavior, people are not passive in the process; they can

create and change their environments. A basic premise of the theory is that people learn not

only through their own experiences but also by observing the actions of others and the results

of those actions. Social learning theory was the precursor to social cognitive theory.

Social marketing. The application and adaptation of commercial marketing concepts to the

planning, development, implementation, and evaluation of programs that are designed to bring

about behavior change to improve the welfare of individuals or their society. Social marketing

emphasizes thorough market research to identify and understand the intended audience and

what is preventing them from adopting a certain health behavior, and to then develop, monitor,

and constantly adjust a program to stimulate appropriate behavior change. Social marketing

programs can address any or all of the traditional marketing mix variables—product, price,

place, or promotion.

Stages-of-change model. A theoretical framework that explains behavior change as a

process rather than as an event. The model identifies individuals at various stages of readiness

to attempt, to make, and to sustain a behavior change. The stages are precontemplation,

contemplation, decision/determination, action, and maintenance.

Strategy. The overall approaches a program takes.

Tailored communication. Messages crafted for and delivered to each individual based on

individual needs, interests, and circumstances.

Target audience. See intended audience.

Web site. A location on the World Wide Web containing documents or files. Each site is owned

and managed by an individual, company, or organization.

World Wide Web. A part of the Internet designed to facilitate navigation of the network through

graphic user interfaces and hypertext links.

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APPENDIX E