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Population Communication Services
Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs

ii A Field Guide to Designing a Health Communication Strategy

Suggested Citation:
O’Sullivan, G.A., Yonkler, J.A., Morgan, W., and Merritt, A.P. A Field Guide to Design-
ing a Health Communication Strategy, Baltimore, MD: Johns Hopkins Bloomberg
School of Public Health/Center for Communication Programs, March 2003.

Design:
Cecilia Snyder for American Institutes for Research/Prospect Center

This publication may be reproduced without permission provided that the mate-
rial is distributed free of charge and that the Johns Hopkins Bloomberg School of
Public Health/Center for Communication Programs is acknowledged. Opinions
expressed in this report are those of the authors and do not necessarily reflect the
views of the sponsoring agencies.

Prepared by American Institutes For Research/Prospect Center and Johns Hopkins
Bloomberg School of Public Health/Center for Communication Programs, with
primary support from the United States Agency for International Development
under the Population Communication Services Project (DPE–3052–A–00–0014–00).

iiiA Field Guide to Designing a Health Communication Strategy

���������������

As the field of behavior change communication continues to evolve, there is an
ongoing need among policymakers, communication professionals, and program
staff for useful tools to help them apply their communication expertise in strategic
and innovative ways.

Since 1982, the Johns Hopkins University (JHU) Population Communication
Services (PCS) project has provided assistance worldwide to hundreds of national,
regional, and local organizations seeking to improve health outcomes for specific
audiences. JHU/PCS advocates creating a dynamic synergy between communica-
tion theory and practice to advance behavior changes in the areas of family
planning (FP), reproductive health, maternal/child health, human immunodefi-
ciency virus (HIV) acquired immunodeficiency syndrome (AIDS), and environmen-
tal health. The strategic communication process used by JHU/PCS can be extended
beyond the realm of health and can be applied to other issues relevant to devel-
oping countries, such as democracy and governance. Similarly, the behavior
change communication framework employed by JHU/PCS can be applied to
individual behavior change efforts or can be used to influence community and
social norms.

The purpose of this book is to share a set of steps and tools with those in the field
to help ensure that behavior change communication efforts are developed strate-
gically—with participation from all stakeholders, clear goals, segmented audi-
ences, and effective messages based on sound research and credible theory. The
text is based on many years of experience in the field and is supplemented with
real-world examples and case studies.

iv A Field Guide to Designing a Health Communication Strategy

Produced with support from the United States Agency for International Develop-
ment (USAID), this Field Guide was developed collaboratively by JHU/PCS and
American Institutes for Research (AIR)/Prospect Center. The primary authors of the
guide were Gael O’Sullivan and Joan Yonkler of AIR/Prospect Center. Win Morgan
of AIR/Prospect Center served as a coauthor. The book was designed by Cecilia
Snyder with guidance from AIR/Prospect Center, and Jack Shea provided editorial
expertise. Illustrations were provided by JHU’s Media and Materials Clearinghouse
and Where There is No Artist, by Petra Röhr-Rouendaal.

The following colleagues at JHU/PCS provided information, examples, case stud-
ies, and review comments for various sections of this book: Rob Ainslie, Jane
Brown, Maria Elena Figueroa, Michelle Heerey, Ron Hess, Larry Kincaid, Susan
Krenn, Cheryl Lettenmaier, Gary Lewis, Ben Lozare, Morden Mayembe, Juan Carlos
Negrette, Patricia Poppe, Fitri Putjuk, Walter Saba, Elizabeth Serlemitsos,
Mohammed Shahjahan, Carol Underwood, and Jim Williams.

Phyllis Tilson Piotrow, Jose Rimon, and Gary Saffitz of JHU/PCS provided overall
strategic direction, and their insights were very much appreciated. Special thanks
go to Alice Payne Merritt of the Johns Hopkins Bloomberg School of Public
Health/Center for Communication Programs (CCP), whose able guidance, endur-
ing patience, and collegial support made this book possible.

To request additional copies of this book, please complete the order form at the
back of the book, and return it to JHU/CCP. Since this Field Guide is designed to be
a “living” document that reflects progress in the field, users of this book are encour-
aged to provide feedback to JHU/CCP on how future versions can be improved to
best serve program needs.

Jane T. Bertrand, PhD, MBA Jose G. Rimon, II
Professor, Bloomberg School Project Director
of Public Health PCS
Director, Center for Johns Hopkins
Communcation Programs Bloomberg School of

Public Health

vA Field Guide to Designing a Health Communication Strategy

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Acknowledgments ……………………………………………………………………….. iii
Using This Book ……………………………………………………………………………. viii
Introduction …………………………………………………………………………………. 1

Chapter 1: Analysis of the Situation ………………………………………………… 17
Step 1: Identifying and Understanding the Problem …………………………………….20
Step 2: Determining Potential Audiences ……………………………………………………….26
Step 3: Identifying Potential Communication Resources …………………………….33
Step 4: Assessing the Environment …………………………………………………………………..39
Step 5: Summarizing Strengths, Weaknesses, Opportunities,
and Threats ………………………………………………………………………………………………44

Chapter 2: Audience Segmentation ………………………………………………… 53
Step 1: Determining Audience Segments ……………………………………………………….55
Step 2: Prioritizing Audience Segments Within the Strategy……………………….61
Step 3: Identifying Influencing Audiences………………………………………………………68
Step 4: Painting a Portrait of the Primary Audience ………………………………………72

Chapter 3: Behavior Change Objectives ………………………………………….. 77
Step 1: Stating the Behavior Change That Will Meet
the Audience’s Health Needs………………………………………………………………..80
Step 2: Stating How Much the Behavior Will Change ……………………………………81
Step 3: Deciding the Timeframe Within Which the
Expected Change Will Occur ………………………………………………………………..83
Step 4: Linking Behavior Change Objectives to
Program Objectives ……………………………………………………………………………….84
Step 5: Identifying Indicators to Track Progress ……………………………………………..84

vi A Field Guide to Designing a Health Communication Strategy

Chapter 4: Strategic Approach ………………………………………………………. 93
Step 1: Reviewing the Key Issue or Problem,
Audience Segments, and Objectives …………………………………………………..95
Step 2: Determining Long-Term Identity and
Positioning Strategy of the Behavior …………………………………………………..96
Step 3: Exploring Strategic Alternatives …………………………………………………………..110
Step 4: Determining Strategic Approach and Rationale ………………………………117

Chapter 5: The Message Brief …………………………………………………………. 121
Step 1: Identifying the Key Fact …………………………………………………………………………127
Step 2: Identifying the Promise …………………………………………………………………………128
Step 3: Defining the Support ……………………………………………………………………………..129
Step 4: Describing the Competition for the Message …………………………………….129
Step 5: Developing the Statement of the Ultimate
and Lasting Impression That the Audience Will Have After
Hearing or Seeing the Message …………………………………………………………..131
Step 6: Describing the Desired User Profile ……………………………………………………..132
Step 7: Identifying the Key Message Points …………………………………………………….133

Chapter 6: Channels and Tools ……………………………………………………….. 139
Step 1: Choosing the Channels That Are the Most
Likely To Reach the Intended Audience …………………………………………….141
Step 2: Determining Tools …………………………………………………………………………………..153
Step 3: Integrating Messages, Channels, and Tools ………………………………………..162

Chapter 7: Management Plan…………………………………………………………. 165
Step 1: Identifying the Lead Organization and
Collaborating Partners ………………………………………………………………………….167
Step 2: Defining the Roles and Responsibilities
of Each Partner ……………………………………………………………………………………….170
Step 3: Outlining How the Partners Will Work Together ………………………………..172
Step 4: Developing a Timeline for Implementing
the Strategy………………………………………………………………………………………………173
Step 5: Developing a Budget……………………………………………………………………………..176
Step 6: Planning To Monitor Activities ……………………………………………………………..179

viiA Field Guide to Designing a Health Communication Strategy

Chapter 8. Evaluation Plan …………………………………………………………….. 193
Step 1: Identifying the Scope and Type of Evaluation …………………………………..195
Step 2: Planning for Monitoring and Impact Assessment …………………………….197
Step 3: Identifying the Evaluation Design and
Sources of Data……………………………………………………………………………………….208
Step 4: Tailoring the Evaluation to the Specific Situation ……………………………215
Step 5: Deciding Who Will Conduct the Evaluation ………………………………………216
Step 6: Planning To Document and Disseminate
Evaluation Results ………………………………………………………………………………….217

Chapter 9. Summary ……………………………………………………………………… 221
Staying on Strategy …………………………………………………………………………………………….222
The Strategy Test ………………………………………………………………………………………………….224
Why Ask “Why?” …………………………………………………………………………………………………..225
Strategy Summary Outline ………………………………………………………………………………..226
Strategy Review …………………………………………………………………………………………………..229

Appendices ………………………………………………………………………………….. 1-1
1: Behavior Change Theories
2: Case Studies
3: Glossary
4: Bibliography

viii A Field Guide to Designing a Health Communication Strategy

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The purpose of this strategic communication Field Guide is to provide practical
guidance to those who are in a position to design, implement, or support a strate-
gic health communication effort. The emphasis of the guide is on developing a
comprehensive, long-term approach to health communication that responds
appropriately to audience needs. The guide is based on the idea that effective
strategic communication is based on the convergence of “senders” and “receivers”
in which the differences between the two begin to disappear. It is also based on
the recognition that communication, to be effective, must not be treated as a
“spare” wheel, used only when the efforts start to falter or fail, but as a “steering”
wheel that can serve as a basis for making informed choices. Strategic communi-
cation is collaborative and participatory in nature, follows a sound
decisionmaking process based on science, and creates sustainable efforts that
improve health outcomes.

The guide has three primary audiences:

� Program managers in developing countries who are responsible for designing
and implementing health programs.

� Communication specialists who are responsible for designing and executing
health communication strategies and for developing materials and messages.

� Policymakers and representatives of funding agencies who determine the
level of support for health communication strategies and the degree to which
communication efforts are integrated into other health program initiatives.

ixA Field Guide to Designing a Health Communication Strategy

A program manager should find this book helpful in understanding the context
within which communication professionals design and implement health com-
munication strategies. Program managers may find that issues identified in the
course of developing one health communication strategy have an impact on
other health programs on which they are working.

For a communication specialist, this book will provide a comprehensive set of
practical tools and steps to guide efforts to improve health among specific popu-
lations. Each chapter provides worksheets, examples, and tips to help the reader
apply the concepts and processes described.

For a policymaker, this book will demonstrate the role that strategic communica-
tion can play in addressing complex health problems. It will also emphasize the
need to continuously apply strategic communication principles to achieve long-
term behavior change objectives.*

The process of designing a health communication strategy is participatory in
nature. Typically, a team of individuals will be involved in designing the strategy.
The communication specialist is often the primary staff person responsible for
creating the process in which all stakeholders, including the beneficiaries, partici-
pate in designing the strategy. The communication specialist works in close col-
laboration with the other stakeholders and team members, which at the national
or subnational level may include a variety of public and private sector agencies,
such as the Ministry of Health (MOH), service delivery groups (e.g., clinics, doctors’
offices, nurse-midwife associations), clients or audience members, advertising
agencies, research organizations, public relations (PR) firms, and other technical
consultants with relevant expertise.

As you read this book, keep in mind that it is designed to be a catalyst for your
own creative thinking. The steps and worksheets provided are flexible guidelines
that you can—and should—adapt to fit your own particular situation. The empha-
sis is on practical tips and advice as well as on examples to illustrate how to apply

* The term “behavior change” is used in this book in a broad sense. It includes reinforcing existing behaviors,

when desired, or developing new behaviors when they do not exist.

x A Field Guide to Designing a Health Communication Strategy

the concepts in real-life situations. The book contains summary sheets at the end
of each chapter that are designed to be compiled and used together in writing a
health communication strategy. It is important to note, however, that designing a
strategy is not a linear process. Strategy development is iterative in nature, and
you will likely have to revisit decisions made early in the process as more informa-
tion becomes available and as you gain additional insight from and about the
audience.

To aid you in developing a strategy, the field guide offers illustrative examples,
worksheets, tips and other special features that can be easily identified through
the use of icons. In addition, every chapter ends with a Uganda communication
strategy summary statement that capsulizes the chapter’s main points. The
Uganda summary example can be identified through its own icon.

We hope that after you have read this book, you will have found it a useful tool
that helps design and implement health communication efforts that are truly
strategic.

Icon Key: Icons will appear throughout the
field guide to help you with the process of
developing a communication strategy.

Example

Worksheet

Tip

Checklist

Questions to ask yourself

Important note

Uganda summary example

1A Field Guide to Designing a Health Communication Strategy

By the end of this introduction, the reader will understand:

� The components of a communication strategy outline
� Why the word “���������� is important in health communication
� The importance of having a vision
� The Process of Behavior Change (PBC) framework and the “P”

Process
� The definition and characteristics of strategic health

communication

As you embark on the process of developing a health communication strategy,
you will need to have a framework in mind to help organize the information
gathered. The following outline lists the components that should be included in
an integrated, multiyear, multiphased communication strategy. The elements in
this outline will be discussed in detail in the following chapters. You will note that
the communication strategy outline does not exactly match the chapter titles and
chapter subheadings. This discrepancy is intentional, as the communication
strategy outline is intended to be a synthesis of the strategic design process, while
the chapters include detailed steps to follow at each stage of the process.

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2 A Field Guide to Designing a Health Communication Strategy

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I. Analysis of the Situation

A. Purpose (Health situation that the program is trying to improve)
B. Key Health Issue (Behavior or change that needs to occur to improve the

health situation)
C. Context (Strengths, Weaknesses, Opportunities, and Threats [SWOT] that

affect the health situation)
D. Gaps in information available to the program planners and to the audience

that limit the program’s ability to develop sound strategy. These gaps will
be addressed through research in preparation for executing the strategy

E. Formative Research (New information that will address the gaps identified
above)

II. Communication Strategy

F. Audiences (Primary, secondary and/or influencing audiences)
G. Objectives
H. Positioning and Long-Term Identity
I. Strategic Approach
J. Key Message Points
K. Channels and Tools

III. Management Considerations

A. Partner Roles and Responsibilities
B. Timeline for Strategy Implementation
C. Budget
D. Monitoring Plan

IV. Evaluation—Tracking Progress and Evaluating Impact

3A Field Guide to Designing a Health Communication Strategy

��������

Consider, for example, the way an architect and a builder work together to pro-
duce a building for their client. Suppose, for example, that a city in your country
needs a new primary school. The Ministry of Education is the client. The Ministry
staff consult with an architect and discuss the overall characteristics of the need:
the number of students expected, the number of different classes, the location of
the school, and allocated budget and timeframe for completing the project. The
key stakeholders work together as a team to clarify what is needed.

The architect then analyzes the situation further, for example, specifying the
number of classes, the estimated number of boys, girls, teachers, and administra-
tors, the number of floors the school should have, the number of offices for staff,
and the placement of hallways and stairways. The architect develops a strategic
design for the school, a design that meets the specified needs and is at the same
time feasible in terms of cost, materials, and labor.

In other words, the architect interprets data as well as the client’s needs and creates
a unique master plan, specifications, and detailed blueprints. The architect is a
strategic designer who works with his client to ensure that the client’s input is
taken into account. The builder’s role is similar to that of an implementer, who
develops a tactical plan to execute the strategy and ideas in the architect’s blue-
print, while staying within the budget and meeting deadlines. He or she imple-
ments through a team of subcontractors: engineers, electricians, plumbers, carpen-
ters, and designers. Without an overall strategy, a master plan, and detailed blue-
prints for the workers to follow, the finished building might look more like a house
than a school.

TIP: As you read this book,
look for “your friend the
architect” at the beginning of
each chapter. His or her role in
designing the school will help
you understand the ideas
explained in the chapter.

4 A Field Guide to Designing a Health Communication Strategy

Why the Emphasis on ��������� in Health Communication?
Strategic design is the hallmark of successful health programs. Over the past 20
years, health communicators have come to realize that collaboratively designed,
implemented, and evaluated health communication strategies will help achieve
the goal of improving health in a significant and lasting way by empowering
people to change their behavior and by facilitating social change. Sound commu-
nication strategies provide coherence for a health program’s activities and en-
hance the health program’s power to succeed. Strategic communication is the
program’s steering wheel, guiding it towards its goals. Strategic communication is
also the glue that holds the program together or the creative vision that integrates
a program’s multifaceted activities.

Prior to this era of strategic design, health communication in the 1960s was largely
characterized as the “medical era.” It operated under the assumption that, “If we
build it they will come.” This medical monologue model is often represented by
the image of a physician lecturing or talking to patients. The 1970s recognized the
need to reach beyond the clinics. Borrowing mainly from the agricultural exten-
sion model, field work was mostly supported by print materials and visual aids.
Mass media impact was considered modest due to limited reach. This period was
mainly described as the “field era,” moving from monologue to dialogue (Rogers,
1973). The 1980s saw the proliferation of social marketing with a move from
nonpaying clients to customers who ask and pay for services, and the use of
integrated marketing communication approaches borrowed from the commercial
sector. This period may be called the “social marketing” era. Health communication
in the 1990s to the present has evolved into what may be called the “strategic era,”
characterized by multichannel integration, multiplicity of stakeholders, increased
attention to evaluation and evidence-based programming, large-scale impact at
the national level, more pervasive use of mass media, and a communication
process in which participants (“senders and receivers”) both create and share
together (Rimon, 2001).

5A Field Guide to Designing a Health Communication Strategy

The new, strategic era of communication is distinguished by several other impor-
tant characteristics:

� Previously separate services are more integrated. It is becoming more common
to find a variety of services, such as family planning (FP), maternal and child
health, and sexually transmitted disease (STD) treatment and prevention
offered at the same location.

� Integration is also occurring among communication channels. Mass media,
community-based, and interpersonal channels are being used strategically to
reinforce one another and maximize impact.

� The role of the electronic media is becoming more prominent. New technolo-
gies are being added to the communication mix to reach more people in
innovative ways.

� Decentralization has shifted control and decisionmaking from the central
government to local communities.

� A multiplicity of stakeholders is involved at every step in the strategic commu-
nication process.

� Audience segmentation is becoming more sophisticated, which allows for
more tailored messages to audiences.

� A recognition that households and communities are producers of health and
play a different role in improving health than does the health service delivery
system.

� Increased attention to evaluation and evidence-based programming is provid-
ing much-needed data upon which to base decisions (Rimon, 2001).

Strategic Vision
The overarching component of a strategically oriented health communication
program is a powerful, well-articulated, long-term vision.

6 A Field Guide to Designing a Health Communication Strategy

Every program needs a long-term vision. It can empower people
because it shows what is important. It can stimulate teamwork
because it shows what everyone needs to do. And it can
strengthen organizations because it generates new energy.

—(Piotrow, Kincaid, Rimon, & Rinehart, 1997).

A good strategic vision is one that is shared among all stakeholders. It is inspira-
tional and concrete, suggests what people need to do, and engages participants.
The strategic vision should paint a mental picture of a desired scenario in the
future. It should reflect the core values and beliefs shared by team members, such
as the concept of people acting as producers of their own health. A good strategic
vision focuses not on the size of the problem at hand but on the possibility of
sharing in the creation of a better future.

[I have a vision of a society where] Nontechnical, everyday
people are able to easily use technology.

—Steve Jobs, Chairman, Apple Computers

I have a vision. I want to see an Indonesia twenty years from now
in which 80 percent of FP services are provided by the private
sector and 20 percent by the government, with government
serving only those who are poor or cannot afford to pay. Work
with us to make this vision a reality.

—Dr. Haryono Suyono, Chairman of the Indonesian National
Family Planning Coordinating Board (BKKBN), 1986

Good strategic visions are also practical and set the team’s sights on what is con-
sidered possible. Visions considered to be beyond the realm of possibility are
often disregarded as a leader’s fanciful dreams. A dream that is not thought
possible to achieve in real life is ignored.

Example

The Coalition for Healthy Indonesia envisioned
“healthy individuals, families, and communities
in a healthy nation.” By 2010, their mission at
the individual/household level is that individu-
als and households (2000):

� Are receiving health-related messages
through multiple channels.

� Are knowledgeable about personal and
public health problems, are knowledge-
able of types and sources of services to
prevent diseases and promote health, and
will be motivated to adopt healthy
behaviors and practices.

� Understand their rights to a healthy
environment and to a basic package of
accessible, affordable, quality health
services.

� Are participating in social, cultural,
religious, and other associations that
include health information, promotion,
and advocacy on their agendas.

� Are exhibiting healthy behavior and
avoidance of health risk.

7A Field Guide to Designing a Health Communication Strategy

Successful elements of strategic visions:

� Build on the core strengths of the program.
� Reinforce a program’s history and culture while striving to achieve new goals.
� Clarify the purpose and direction of communication activities.
� Emphasize the power of teamwork.

The true test of a strategic vision is this: Does it provide direction, communicate
enthusiasm, kindle excitement, and foster commitment and dedication? If it does,
then the strategic vision can provide several benefits, including:

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what everyone needs to do. Inspirational visions energize program activities,
giving them new strength upon which to draw when implementing strategies.

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A vision helps people focus on attaining certain outcomes and on acting in ways
that will achieve those outcomes. When a clear vision is in place, it concentrates
power by avoiding arguments about whether to do something or not.

� ��
����
���
������. A vision supplies a calling for team members, creating
meaning for their work and a justifiable pride. By comparing the present with a
desired future, a vision creates a useful tension between what exists now and
how the team would like the world to be. It helps people recognize barriers to
achieving the desired state or condition by vividly describing the desired state
and making it seem attainable.

Effective communication efforts develop vision statements, with the participation
of stakeholders and beneficiaries, to set forth the direction that the team should
follow and to define clearly and succinctly how the communication activities will
affect the broader program environment. Sometimes a program mission state-
ment is also developed to translate the overall thrust of the strategic vision into
more management-oriented goals and objectives. The vision statement should be

8 A Field Guide to Designing a Health Communication Strategy

a brief but compelling description of how the health situation or condition will
look after the communication activities have successfully reached their conclu-
sion. This statement should become the catalytic force or organizing principle for
all subsequent strategic communication activities carried out by the team.

A Framework for Strategic Design
Many theoretical models and frameworks can guide the strategic design process
(see appendix 1). This book describes a framework known as the PBC; a framework
that has been used successfully in the field of health communication for many
years.

Process of Behavior Change
The PBC framework recognizes that behavior change—and thus communication
intended to influence behavior change—is a process. People usually move
through several intermediate steps in the behavior change process (Piotrow et al.,
1997). In addition, there is typically a correlation between increases in behaviors,
such as partner-to-partner dialogue about reproductive health and subsequent
use of reproductive health methods.

Furthermore, this framework suggests that people at different stages constitute
distinct audiences. Thus, they usually need different messages and sometimes
different approaches, whether through interpersonal channels, community chan-
nels, or mass media.

An audience can generally be described as:

� Preknowledgeable—Is unaware of the problem or of their personal risk.
� Knowledgeable—Is aware of the problem and knowledgeable about desired

behaviors.
� Approving—Is in favor of the desired behaviors.
� Intending—Intends to personally take the desired actions.
� Practicing—Practices the desired behaviors.
� Advocating—Practices the desired behaviors and advocates them to others.

9A Field Guide to Designing a Health Communication Strategy

It is important to understand where the audience is in relation to these elements
before embarking on a strategy. Progress from one element to the next increases
the probability of behavior change and continuation.

Public policy and communication strategies influence both individual and collec-
tive change, establishing new community norms and, over time, providing support
for stronger and more effective policies and programs. The PBC can play an impor-
tant role in creating an enabling environment to support new behaviors. Advo-
cacy is a key element in this process and can help make the desired behavior
sustainable.

The PBC framework can work effectively together with a comprehensive project
design and implementation approach known as the Processes and Principles of
Health Communication—the “P” Process (Piotrow et al., 1997). The “P” Process was
developed in 1983 and is depicted by the figure on the right.

The “P” Process steps are:

1. Analysis—Understand the nature of the health issue and barriers to
change: listen to potential audiences; assess existing program policies, re-
sources, strengths, and weaknesses; and analyze communication resources.

2. Strategic Design—Decide on objectives, identify audience segments, position
the concept for the audience, clarify the behavior change model to be used,
select channels of communication, plan for interpersonal discussion, draw up
an action plan, and design for evaluation.

3. Development, Pretesting, Revision, and Production—Develop message
concepts, pretest with audience members and gatekeepers, revise and produce
messages and materials, and retest new and existing materials.

4. Management, Implementation, and Monitoring—Mobilize key organizations;
create a positive organizational climate; implement the action plan; and
monitor dissemination, transmission, and reception of program outputs.

5. Impact Evaluation—Measure impact on audiences, and determine how to
improve future projects.

6. Planning for Continuity—Adjust to changing conditions, and plan for
continuity and self-sufficiency.

10 A Field Guide to Designing a Health Communication Strategy

For almost two decades, the “P” Process has provided a solid framework that is
easily applied to strategy development, project implementation, technical assis-
tance, institution building, and training. This framework is used collaboratively as a
guide by the various stakeholders involved in designing and implementing
strategic health communication programs.

Several qualities of the “P” Process make it a very useful tool for program planning
and implementation:

� It is systematic and rational.
� It is continually responsive to changing environments and can be adapted to

new research findings and data.
� It is practical for field applications at all levels.
� It is strategic in setting and pursuing long-term objectives.

When followed in sequence, the six steps of the “P” Process are helpful in develop-
ing effective program design. The focus of this book is on step 2—strategic design.
When reading through each chapter, keep step 2 of the “P” Process in mind to
reinforce the level of strategic decisionmaking that is required. The focus is on
designing, not implementing, a program.

Applying Step 2 of the “P” Process to design a communication strategy will also
require using information obtained from conducting an analysis of the situation.
Similarly, the strategic design process will require thinking ahead to issues involv-
ing the other steps of the “P” Process.

Definition and Characteristics of Strategic Health Communication
Strategic communication is based on a combination of:

1. Data, ideas, and theories integrated by
2. A visionary design to achieve
3. Verifiable objectives by
4. Affecting the most likely sources and barriers to behavioral change, with the
5. Active participation of stakeholders and beneficiaries (Piotrow & Kincaid, 2001)

11A Field Guide to Designing a Health Communication Strategy

In other words, strategic communication takes advantage of science and facts, in
addition to ideas and concepts, to set forth a long-term vision and realistic behav-
ior change objectives to address a health issue. The vision and objectives are
developed through dialogue with the intended audience and various stakeholders.
In the dialogue process, both the “senders” and “receivers” are affected, moving
toward mutual adjustments and convergence. A blending of science and art is
essential to crafting a sound strategy.

Specific Characteristics
For communication to be strategic, it should be:

1. Results-oriented. The ultimate proof that a strategic communication effort is
effective lies in health outcomes. Research should be designed to gauge
increases in audience knowledge, approval, and adoption of healthy behav-
iors. Equally important is increasing the capacity of local partners to carry out
these kinds of programs on their own.

2. Science-based. A science- and research-based approach to communication
requires both accurate data and relevant theory. It begins with formative
research and adequate data to define a specific health problem, identify
feasible solutions, and describe the intended audience. This approach relies on
the health sciences to make sure that the content and context of a strategic
communication effort are correct. For example, in Brazil a series of focus
groups was conducted with potential audience members to identify the sexual
practices of street children, in an effort to determine the risk of contracting HIV/
AIDS. Results of the focus groups were compiled and analyzed according to
several variables, such as number of partners, type of partners (e.g., same sex,
commercial sex workers), type of sexual contact (e.g., oral, anal, vaginal), fre-
quency, and reasons for the occurence of the sexual activity. This analysis
formed the basis for developing a communication strategy that was designed
to reduce HIV/AIDS transmission among Brazilian street children.

12 A Field Guide to Designing a Health Communication Strategy

Strategic communication also depends upon appropriate social science models or
theories of behavior change, which might include:*

� Stages of change/diffusion theories
� Cognitive theories
� Emotional response theories
� Social process and influence theories
� Mass media theories

3. Client-centered. A client-centered approach requires starting with an under-
standing from the client’s point of view of what the health needs are. Discus-
sions with the potential audience provide insights about those health needs
and the barriers to meeting the expressed needs. Through research, especially
qualitative research and participatory learning approaches (PLA), members of
the intended audience can help shape appropriate messages and can offer
insights for other communication-related decisions that need to be made. A
client-centered approach also implies understanding strategic changes that
can affect the balance of power, including the gender balance of power, in
service programs. For example, encouraging greater community participation,
allowing clients to choose their own methods and treatment, or having clients
set the program priorities for health services are ways to strengthen a client-
centered approach.

4. Participatory. Strategic communication promotes participatory decision
making by stakeholders and beneficiaries in all stages of the “P” Process,
including planning, implementation, and evaluation. It is critical to involve the
key stakeholders at the inception of the strategy design process. Building a
sense of ownership will help ensure that the strategy will be implemented in a
meangingful way. See the resource book titled How To Mobilize Communities
for Health and Social Change published by Johns Hopkins Bloomberg School
of Public Health/CCP in collaboration with Save the Children for further infor-
mation on this topic.

*See Appendix 1, “Behavior Change Theories”, for more information.

13A Field Guide to Designing a Health Communication Strategy

5. Benefit-oriented. The audience must perceive a clear benefit in taking the
action promoted by the communication effort. This characteristic is closely
associated with the long-term identity and with the notion of positioning,
which is discussed in chapter 4.

6. Service-linked. Health promotion efforts should identify and promote specific
services, whether through health care delivery sites, providers, brand name
products, or ways to increase access to services and products. This approach
reinforces the concept of individual self-efficacy or the ability to resolve a
problem oneself and also supports the concept of collective self-efficacy or the
ability of a community to assert its will.

7. Multichanneled. Effective strategic communication uses a variety of means.
Communication strategies often integrate interpersonal communication (IPC),
community-based channels, and various media to create a dynamic, two-way
exchange of information and ideas. Additionally, research has shown that
often the effectiveness of messages being understood and acted upon in-
creases with the number and type of channels used to disseminate them. This
is sometimes called the “dose” effect. Like a good carpenter who knows when
to use a hammer or a chisel, an effective communicator does not argue
whether mass media is better than IPC. Each tool has a role, and the communi-
cator uses the tool or combination of tools that is most appropriate for the
situation.

8. Technically high quality. The strategic health communicator works with
competent agencies and individuals to:

� Design high-quality communication messages and materials.
� Produce professionally designed materials.
� Ensure that community-based activities are appropriate and well

done.
� Strengthen counseling skills.

14 A Field Guide to Designing a Health Communication Strategy

Investing resources wisely to design effective strategies and materials at the
outset will ultimately be more economical than cutting corners and producing
a campaign that conveys a substandard image. Simply put, quality costs less.
Another important point to remember is that focus demands sacrifice. Strate-
gic communication is specific in what it attempts to accomplish and does not
try to be all things to all people.

9. Advocacy-related. Advocacy occurs on two levels: the personal/social level
and the policy or program level. Personal and social advocacy occurs when
current and new adopters of a behavior acknowledge their change and
encourage family members and friends to adopt a similar behavior. For ex-
ample, individuals who have quit smoking often advocate to other smokers
that they should quit.

Policy or program advocacy occurs when the advocacy is aimed at change in
specific policies or programs. Seeking to influence behavior alone is insuffi-
cient if the underlying social factors that shape the behavior remain un-
changed. Behavior change objectives will address individual behavior, but
policies, laws, strategies, and programs may also need to be influenced, so that
they support sustained behavior change. The two levels of advocacy reinforce
one another.

10. Expanded to scale. It is easy to ensure the effectiveness of a communication
intervention when applied to a small village or district. The real challenge is
whether the intervention can effect change on a much wider scale beyond a
village or the usual pilot areas. Communication strategies can be scaled up to
reach ever-larger populations and areas. In general, mass media interventions
are easier to scale up than community or interpersonal interventions. The latter
two can be costly to scale up and can be difficult to monitor.

15A Field Guide to Designing a Health Communication Strategy

11. Programmatically sustainable. Strategic communication is not something
that is done once. A good strategy continues over time as it reaches new
audience members and adapts to changes in the environment. Continuity
must be in place at the organizational level, among leaders, and with the
donor community, to ensure that strategic communication efforts achieve
long-term impact.

12. Cost-effective. Strategic communication seeks to achieve healthy outcomes in
more efficient and cost-effective ways. Strategy designers must also examine
costs by the type of intervention, to try to achieve the optimal mix of activities
and channels.

����������

A sound and effective health communication strategy should be based on an
overarching vision of what needs to be achieved to address a particular health
issue. The strategy should be integrated, have a long-term focus, should be respon-
sive to individual behavior change needs, and should maximize the potential for
change on a broader societal level. Frameworks such as the PBC and the “P” Pro-
cess for project design and implementation are useful tools to guide the process
of developing health communication strategies that get results. A combination of
science, facts, vision, stakeholder buy-in, and audience participation is essential for
success.

16 A Field Guide to Designing a Health Communication Strategy

������
��
Coalition for Healthy Indonesia Strategy Document (2000). (pp. 8).

Piotrow, P. T., Kincaid, D. L., Rimon, J. G. I., & Rinehart, W. (1997). Health Communica-
tion: Lessons from Family Planning and Reproductive Health. Westport, CT: Praeger
Publishers.

Piotrow, P. T. & Kincaid, D. L. (2001). Strategic Communication for International
Health Programs. In Rice and Atkin (Ed.), Public Communication Campaigns (3rd

ed., pp. 251). Sage Publications.

Rimon, J. G. I. (2001). Behavior Change Communication in Public Health. In Beyond
Dialogue: Moving Toward Convergence. Managua, Nicaragua: Presented at the
United Nations Roundtable on Development Communication.

17A Field Guide to Designing a Health Communication Strategy

1��������

���
��������������������
By the end of this chapter, the reader will be able to conduct
an analysis of a particular health problem by completing the
following steps:

Step 1: Identifying and Understanding the Problem

Step 2: Determining Potential Audiences

Step 3: Identifying Potential Communication Resources

Step 4: Assessing the Environment

Step 5: Summarizing the Strengths and Weaknesses of the
human, technological, and financial resources available
as well as the Opportunities for and Threats to effective
health communication in the current environment.

18 A Field Guide to Designing a Health Communication Strategy

��������

After a preliminary meeting with the client, the next step of your friend the archi-
tect is to meet his client, the Ministry of Education, at the site of the proposed
school to look over the situation, analyze it, and make some preliminary observa-
tions. This analysis will help shape his plan for designing the school. Working with
the key stakeholders, the architect will refine many of these initial findings over
time.

For example, the architect looks over the building site, notes whether it is flat or
hilly, notes whether it is covered with trees or open space, and decides whether
heavy machinery can easily access the area. In other words, he identifies any
problems, and he notes their extent and the difficulty or ease with which they can
be overcome. He also begins to think of how teachers, students, and parents will
view this space. He thinks about their needs, such as natural light for the class-
rooms, air circulation, and ample room for sports activities and games.

With a mind to available resources, he examines the infrastructure to ensure that
water and electricity are readily available. He begins to think about engaging a
builder who has experience building a school and who has access to the kinds of
subcontractors who will do their jobs most efficiently, for example, engineers,
electricians, plumbers, carpenters, interior designers, and landscapers.

In much the same way, as you and your team begin the process of designing your
health communication strategy, your first undertaking is the analysis of the situation.

19A Field Guide to Designing a Health Communication Strategy

1This chapter offers guidance, practical tools, and approaches to help your team work
through the five steps of developing an analysis of the situation. At the end of this
chapter and at the end of most chapters, you will find a summary worksheet. The
Delivery of Improved Services for Health (DISH) project in Uganda is used
throughout this book to provide a comprehensive example showing how these
summary worksheets are to be completed. When compiled as a set, the information
in these summary worksheets will provide a concise overview of the key strategic
considerations upon which you will base your strategy. Once you and your team
have completed the analysis of the situation, you will have a more informed basis
for proceeding to the next stages of strategy development.

Developing a health communication strategy demands in the first place that you
understand all the factors that may have an impact on communication efforts.
Such an understanding, known as the analysis of the situation, serves as the guide
for all communication activities. Health communicators use the analysis of the
situation to observe, gather, organize, and assess relevant factors. These factors
include the nature and extent of the problem, audience characteristics, available
resources, and the communication environment. Thus, although the analysis of the
situation is not technically a part of step 2 of the “P” Process, which is the concern
of this book, its importance warrants inclusion here of the information that will
help you work through step 2.

The term “analysis of the situation” can be defined and used in many different
ways. In the context of this Field Guide, the term “analysis of the situation” refers to
the process of analyzing factors related specifically to the development of a
communication strategy.

One result of conducting an analysis of the situation is an understanding of the
gaps in your knowledge base that will need to be filled in order to move ahead
with the strategy development process. A quantitative measure of the current
situation as it relates to the audience is typically conducted in the form of a
baseline survey. Additional insights are often gained by using qualitative tech-
niques, such as focus groups. The “Tips on Information Collection Methods” in
this chapter provide brief descriptions of some of the more commonly used

TIPS: Do’s and Don’ts To Keep in Mind as
You Analyze Your Situation

Do’s
Develop a clear outline before gathering
information. It will help keep you focused on
the important issues.

Ensure that the analysis will inform the
decisions of strategic components (identifica-
tion of audiences, objectives, etc.) that will be
made later in the process.

Set a timetable for the process, and stay within
the parameters of the timetable.

Read, listen, and observe many sources of
information. No single source of information
will provide you with all the information that
you need.

Keep your summary statements as objective as
possible.

Keep a notebook for jotting down ideas for
strategy or tactics. Also, keep a list of chal-
lenges and opportunities that arise from
reviewing the data. Your notebook and the list
will give you a head start in writing the plan.

Document your progress by making note of
your key sources of information, so that you
can refer to them in future discussions.

20 A Field Guide to Designing a Health Communication Strategy

qualitative techniques. As you work through the steps in this chapter, keep a list
of the gaps and questions that you will need to answer through formative or
preliminary research.

Even under the best of circumstances, it is unlikely that you will have a complete
set of data to inform your decisions. The process of designing a health communi-
cation strategy is part art and part science. You will have to make judgments
throughout the process to decide how much importance to assign a particular
issue as well as to decide which approaches and strategies will work best.

������
��� �
��

�� ��� ������ �

������������

The first step in conducting the analysis is to identify and understand the specific
health problem that will be the focus of the proposed communication effort.
Consider the health problem in the context of the overall strategic vision. To define
an effective communication strategy, you will need to compare the shared vision
with your understanding of the present situation, and you will need to understand
why there is a difference between the two.

Usually in a national health communication strategy and especially when health
programs and services are integrated, a number of different problems will be
identified that need attention. This series of problems is often dealt with over time
using phasing or sequencing techniques, layering of service delivery and commu-
nication channels to ensure maximum coverage, and clustering of health behav-
iors to promote integration.

However, it is important to identify the key problem related to each health behav-
ior included in the strategy and to craft appropriate objectives and messages for
each of these problems. The key to a successful health communication strategy is
to focus on one specific problem at a time. Addressing too many problems at one
time or too general a problem often creates messages that confuse or overwhelm
the audience, limiting the impact of the communication.

TIPS: Do’s and Don’ts To Keep in Mind as
You Analyze Your Situation

Don’ts
Do not write objectives and strategies as part
of the analysis of the situation. Keep your
analysis as factual as possible. Appending
objectives and strategies tempts you to adjust
the analysis to fit the proposed strategy and
objectives.

Do not give up if you cannot find the informa-
tion that you need. Call on contacts, visit
libraries, and consult collaborating organiza-
tions. The answers are there, but you will not
always have data to substantiate every finding.
At times you will have to rely on the views of
knowledgeable individuals and your own
observations, in addition to research data, as
you begin to understand the situation.

21A Field Guide to Designing a Health Communication Strategy

1In some cases, you will not need to identify the problem. An existing strategy may
already point to what needs to be done, whether as directly related to an overall
program objective (see chapter 3, step 4) or, ideally, as related to the overall strate-
gic vision, articulated by key leaders and policymakers. However, if the problem is
already identified, it is important to verify that it is still valid. You want to avoid
beginning with a preconceived notion about the problem that may be based on
old information, political concerns, or limited understanding of stakeholder
perceptions.

Understanding the Health Problem
Understanding the health problem means having a clear perception of its extent
and severity as well as of the behaviors that will prevent and treat the problem. In
the course of gaining such an understanding, you will become familiar with the
available sources of information about the problem.

The Extent of the Health Problem
Estimating the extent of a health problem is a factor in deciding how to communi-
cate about it. Look for two key measures of extent: prevalence and incidence.
These measures are commonly available through the MOH.

Prevalence measures the proportion—usually, the percentage—of people in a
defined population who have the problem at a given time. For example:

� Last year, 65 percent of all sex workers in the northern region had gonorrhea.

� This month, 30 percent of all pregnant women in the eastern region between
the ages of 18 and 25 years were anemic.

Since prevalence is constantly changing, public health practitioners use the most
recent measurement in combination with incidence to estimate the extent of the
problem. Incidence measures the rate of new cases of a particular health problem
per thousand people in the population. For example:

� The number of cases of gonorrhea in the northern region is increasing by 10
percent per year.

22 A Field Guide to Designing a Health Communication Strategy

� The number of anemic pregnant women seen in antenatal clinics in the east-
ern region is increasing by 2 percent per year.

� Measurements of incidence help to estimate what the prevalence rate will be
in the future without any intervention. This information is usually available
from the MOH or from programs or projects dealing with the health problem.

The Severity of the Health Problem
Closely related to the extent of the health problem is its severity, which is
measured as:

� Mortality, or the number of people who die from the problem

� Morbidity, or the number of people who are permanently or temporarily
disabled by the problem

� The cost of the problem to an individual, the individual’s family, and society as
a whole

The MOH usually compiles information about a specific health problem’s rates of
mortality and morbidity. Organizations advocating attention to a health problem
often compile information about its costs to individuals and society. When defin-
ing the severity of a health problem, it is usually helpful to put the problem in
perspective by comparing its effects to those of other common diseases.

The data that you have gathered on the problem’s extent and severity will play an
important role when you develop your justification for spending resources to
prevent and treat the problem.

23A Field Guide to Designing a Health Communication Strategy

1Desired Prevention and Treatment Behaviors
Several potential behavior changes may be appropriate responses to a health
problem. Look beyond the factual information about the health problem to truly
understand the broader environmental context. Pinpointing the desired behavior
changes at the beginning of the planning process will help you and your team
design an appropriate strategy.

To be sure that your team is planning to communicate appropriate prevention
and treatment behaviors, talk with experts in the MOH, in the private sector, and in
your organization, and ask whether the desired behavior is, for example, to:

� Improve dietary habits.
� Visit a clinic.
� Use a particular product.

In this area, ascertaining the views of the potential audience is critical. Do they
perceive the problem in the same way as the experts? What would they like to see
happen to address the health problem? Gaining understanding about the
audience’s perceptions may lead you to design communication interventions
geared toward other groups, such as service providers or key influentials. Similarly,
talking to health care providers may yield important insights about the health
problem that may influence the strategy development process. Such insight may
also demonstrate the need to conduct policy advocacy or media advocacy to
address the health needs of the audience in a comprehensive way.

Information Sources
The information that you have gathered by identifying the extent and severity of
the problem and the desired prevention and treatment behavior will inform your
communication strategy. Review example 1.1 below, and then complete worksheet
1.1 to organize and summarize the information that you have collected.

Note: For Worksheet 1.1 and for all worksheets
in this book, use real data whenever possible.
If the specific information requested in the
worksheet is not available, complete the
worksheet to the best of your ability.

24 A Field Guide to Designing a Health Communication Strategy

Example: Nicaragua (Informe de . . . 2001)
Project Background: In October 1998, Hurricane Mitch cut an unprecedented
swath of destruction through the heart of Central America, leaving thousands
dead and billions of dollars (USD) in damage. In Nicaragua, more than 800,000
people suffered some degree of damage to their water supply system due to the
effects of the hurricane. Thanks to the rapid intervention by the Government of
Nicaragua and generous international assistance, the country quickly entered a
reconstruction phase.

USAID/Nicaragua funded a water and sanitation component as a crucial piece of
their Hurricane Mitch Reconstruction Project. Under this component, the Environ-
mental Health Project (EHP) is responsible for the construction and repair of the
community water and sanitation infrastructure. The Mitch Project included a
behavior change communication component to promote better hygiene and
sanitation practices. A coalition of various partner organizations implemented the
project, with the ultimate goal of reducing the incidence of diarrheal diseases in
the areas affected by Hurricane Mitch.

This national effort was named the Blue Star Campaign, one of the most compre-
hensive diarrhea prevention programs undertaken at the national level. The local
population understood the value of health to the family, and the Blue Star symbol
represented the dreams or goals of the audience to achieve a better quality of life.
There were knowledge barriers, however, in that many people did not understand
the links between bacteria on hands, handling of food, and the onset of diarrhea.
Focusing on blocking the main pathways of diarrheal disease transmission, under
the Blue Star Campaign, a number of interdependent components worked syner-
gistically to implement an effective diarrhea prevention program.

25A Field Guide to Designing a Health Communication Strategy

1Example 1.1: Health Problem Analysis Worksheet

Instructions: Identify up to three key health problems that you might address. Use
available data to estimate the prevalence, incidence, and severity of each problem.
List the prevention and treatment methods recommended to the population by
the program or organization with which you are working.

Worksheet 1.1: Health Problem Analysis

26 A Field Guide to Designing a Health Communication Strategy

�������
������

����� �
������
� ���

The primary audience for a communication strategy will usually be the people who
are at risk of or who are suffering from a particular health problem. One exception to
this is children, in which case their caregivers are usually addressed as the key
influencing audience. To help identify potential audiences, review the available
research about the extent of the condition or disease. Sources of this information
include the MOH, local health centers, and national health surveys. Medical and
public health personnel can explain how the problem spreads and can identify
those at risk or affected by it. There may well be gaps in available information that
will require formative research or baseline studies before you can understand
enough about potential audiences to clearly articulate and describe who they are.

Identify Common Audience Characteristics
As you identify potential audiences, group them according to common character-
istics, such as age range, gender, occupation, residence, or number of children, as
well as by lifestyle and access to print, radio, and television media. Look for charac-
teristics that differentiate the potential audience from persons who are not at risk
or do not have the health problem. Make sure that your analysis is gender-sensi-
tive by considering the different gender roles and relationships among potential
audience members. How are the potential audiences currently behaving in rela-
tion to the concepts of gender equity and gender equality? Also look at whether
members of potential audience groups have a high degree of perceived social
support, which can play an important role in an individual’s ability to change.
Table 1.1 presents common group characteristics and examples of audience
groupings.

Identify Behavior Change Stage
For each audience, look for information that identifies current health behaviors
compared with desired or recommended health behaviors. How close or far away
are they from adopting the behaviors? One useful approach is to categorize your
potential audience according to the PBC framework presented in the “Introduction.”

TIPS: Practical Techniques for Analyzing the Situation

1. Read
To collect quantitative and qualitative studies and reports
pertaining to health and communication, first contact the
Ministry of Planning, MOH, and Ministry of Information. They may
recommend other government agencies that can provide the
type of information you want. Private organizations also collect
good quantitative data, but these surveys may be too costly or
unavailable due to proprietary issues.Ask for both published and
unpublished documents, including internal reports, that cover
the subjects in which you are interested, such as:

Get as many samples of health communication materials as you
can for future reference. Printed materials, such as brochures and
posters, are easy to transport, and you may be able to obtain
audio or videocassettes as well. If you don’t know the language,
ask for a written translation.

Literature reviews
Population-based surveys
Service and sales statistics
Focus-group discussion
reports
Evaluation reports of other
health programs
Analyses of health care and
health delivery systems
DHS and other household
surveys of knowledge,
attitudes, and practices
Inventories of communication
materials available at clinic
sites
Census data
Donors’ country reports

Economic reports
Policy documents
Workshop reports
Management reports
Supervisory reports
Technical assistance
reports
Training needs
assessments
Interview records
Service delivery
records
Action plans
Progress reports
Project evaluations
University papers
Journal articles

27A Field Guide to Designing a Health Communication Strategy

1

To develop estimates of the stage of behavior change of the poten-
tial audiences, review existing quantitative data, such as Demo-
graphic and Health Surveys (DHS) and census data. Both sources may
provide relevant information about the stage of behavior change of
various groups of people within a country’s population. DHS gener-
ally ask about knowledge, attitudes, and practices relative to repro-
ductive, maternal, and child health. The latest DHS is generally avail-
able from your local MOH or from the USAID office. If not, Macro
International, Inc., can provide copies of DHS reports for various
countries.*

Often the existing audience data are insufficient for making deci-
sions related to a communication strategy. You may need to work
with research experts to design and implement a quantitative
baseline survey that generates reliable information about audience
characteristics, behavioral issues, barriers to behavior change, etc.
Similarly, it is often useful to conduct qualitative research, such as
focus groups, with potential audience members to yield rich, descrip-
tive information about the audience. Sometimes this is coupled with
one-on-one interviews with key stakeholders to get additional
insights. You and your team members will need to make judgments
about what preliminary research, if any, is required, and you should
also consider timing and budget issues when addressing this issue.

In addition to reviewing formal studies, interview local experts to get
their opinions on the stage of behavior of the group in question. Also,
to gain additional insight, talk with program personnel who work
with the potential audience on a daily basis.

TIPS: Practical Techniques for Analyzing the Situation

2. Listen
Another way to get the information you need to analyze the situation is to
conduct interviews. Interviews will help you:

� Solicit the needs, views, and perspectives of those identified as stakeholders
in the program, including the audience

� Identify potential resources for assisting with health communication

Before conducting the interview, develop an interview questionnaire to ensure
that you ask all the questions you intend to ask.

To help complete your understanding of the situation, conduct interviews with
representatives of at least five types of groups:

� Potential audience members
� Agenda setters (policymakers and researchers)
� Organizations providing health services and products
� Media
� Donors and technical assistance organizations

Potential interviewees are any persons, groups, or entities that can shape the
direction of a communication effort, provide vital resources, or serve as an
implementing partner.

Examples of those to interview include:

Senior program managers within
your program
Directors of organizations providing
related health services
Representatives of religious
organizations in areas where health
problems exist
Community leaders in areas where
health problems exist
Directors of service delivery
Directors of logistics management
Political leaders with a demon-
strated interest in health
Potential clients

Traditional healers
Directors of radio and television
stations
Journalists and editors of maga-
zines and newspapers
Donor representatives
Representatives of ministries or
directorates concerned with
women’s issues
University representatives
Clients of clinics offering health
services
Clinic supervisors
Service providers International
organizations working in health*Macro International, Inc., 11785 Beltsville Drive, Calverton MD 20705, USA,

phone: (301) 572-0200, fax: (301) 572-0999, email: [email protected]

28 A Field Guide to Designing a Health Communication Strategy

Table 1.1: Possible Common Characteristics of Potential Audiences
(Schiffman & Kanuk, 1995)

29A Field Guide to Designing a Health Communication Strategy

1Identify Known Barriers to Behavior Change
As you interview program workers, health experts, community representatives,
and members of the potential audience, ask why they think the audiences are not
adopting the desired health behaviors.

Often one of the main barriers to adopting behaviors is the fact that the audience
is preknowledgeable. In Bangladesh, for example, a situation analysis for the
National Tuberculosis Control Strategy revealed that most people, especially in
rural areas, did not know that treatment is provided free of cost from Government
health facilities.

However, you and your team must also consider barriers that go beyond aware-
ness and knowledge. Look for barriers in the following categories to give you a
more complete picture of the situation:

TIPS: Practical Techniques for
Analyzing the Situation

3. Observe
As you travel the country, ask as many
questions as possible, and take lots of notes
about what you see. Make sure that you
spend time in rural areas as well as urban,
and if there are strong regional differences
due to religious or cultural traditions, try to
visit different regions so that you obtain a
balanced view of the country.

Observe the following:
Counseling sessions
Group health talks in clinics
Community outreach efforts
Presence of health messages, materials,
and activities in places where intended
audiences live and work

Observation is one of the best tools not
only to assess what is going on, but also to
note some of the strategies that seem to
work best to reach a certain group of
people. For example:

Do most mothers consult traditional healers
about their children’s health?

Will a family use its scarce financial resources
to pay for preventive health care?

30 A Field Guide to Designing a Health Communication Strategy

Understanding the barriers to change—even those that may be beyond the ability
of communication to change—is important for making strategic communication
decisions. This knowledge will help you estimate the degree of change that can be
achieved within a given timeframe.

Identify Key Influencers
After you have identified your potential audiences, find out who influences their
health behaviors. Talk with program managers who work in the community as
well as community workers who visit the audience regularly. Review relevant
research findings. Make informal visits to communities and homes. Talk with
members of the potential audience and community leaders about the health
problem.

Review examples 1.2a and 1.2b, and then complete worksheets 1.2a and 1.2b.

31A Field Guide to Designing a Health Communication Strategy

1Example 1.2a: Potential Primary Audiences Worksheet
Instructions: Identify groups of people with common characteristics who are
suffering from or at risk of the health problem. Complete the table for each
potential audience.

Example: Nicaragua

Worksheet 1.2a: Potential Primary Audiences
Instructions: Identify groups of people with common characteristics who are
suffering from or at risk of the health problem. Complete the table for each
potential audience.

32 A Field Guide to Designing a Health Communication Strategy

Example 1.2b: Potential Influencing Audiences Worksheet
Instructions: Identify groups of people with common characteristics who poten-
tially can influence audiences for your communication efforts. Complete the table
for each potential primary audience.

Example: Nicaragua

Worksheet 1.2b: Potential Influencing Audiences
Instructions: Identify groups of people with common characteristics who poten-
tially can influence audiences for your communication efforts. Complete the table
for each potential audience.

33A Field Guide to Designing a Health Communication Strategy

1������
��� �
��

����� �
��������
���
� ����������

Step 3 in analyzing the situation is to gain an understanding of the communica-
tion environment, including current health communication activities and avail-
able resources. Chapter 6, “Channels and Tools,” provides a guide for selecting the
channels that your team will use to convey the message to the intended audience.
The focus here is on identifying and assessing potential resources that can help
you carry out a communication program.

Health communicators define communication channels broadly as a delivery
system for messages to reach intended audiences. They have categorized them as
“interpersonal,” “community-oriented,”and “mass media.” The latter two channels
are particularly effective when the goal is to change community or cultural norms.

Interpersonal channels focus on either one-to-one or one-to-group communica-
tion. One-to-one channels include peer to peer, spouse to spouse, and health clinic
worker to client. An example of one-to-group communication may be a commu-
nity-based outreach worker meeting with a women’s cooperative. Interpersonal
channels use verbal and nonverbal communication.

Community-oriented channels focus on spreading information through existing
social networks, such as a family or a community group. This channel is effective
when dealing with community norms and offers the opportunity for audience
members to reinforce one another’s behavior.

Mass-media channels reach large audiences. They are particularly effective at
agenda setting and contributing to the establishment of new social norms. For-
mats range from educational to entertainment and advertising, and include
television, radio, and print media, such as magazines, newspapers, outdoor and
transit boards, the Internet, and direct mail.

TIPS: Information Collection Methods

The following types of “formative” research and
PLA will provide you with essential information
to guide your strategy decisions.
����������
��
������
�To access different
dimensions of a strategy’s potential impact on
people and their environments, you can use
many “stakeholder techniques.” For example,
talk with program managers, community health
workers (CHWs), clinic staff, and community
leaders about the situation. When possible,
gather together those who have an interest in or
control over addressing the problem to have
them share insights on causes and contributors
to the problem. While interviewing them or
hosting a meeting, find out what they are doing
now to address the problem, and why. Ask them
to help you identify key strategic communica-
tion issues.

����� ������
�
�In the context of participa-
tory development, gender analysis helps you to
understand how gender differences affect
access to resources and the participation of
women in development activities. Such an
analysis will help you to take appropriate
measures to ensure that women are not
excluded. Ideally, gender analysis should not be
a separate participatory method but should be
integral to all participatory methods.

(continued on following page)

34 A Field Guide to Designing a Health Communication Strategy

Ongoing Communication Activities
A wide variety of communication channels is available. Your challenge is to find
those that can reach the potential audiences that you have identified. Three
approaches can help:
� Describe communication efforts already going on through the identified

communication channels and media.

� Talk to other people who have conducted communication campaigns in the
country. This approach is a good starting point for identifying local partners
and for understanding the obstacles and opportunities involved in local
communication efforts.

Categorize these activities according to the channels described above. Remember to:

� Look for media use surveys of potential audiences. DHS can be a helpful
resource here. In addition, many countries survey media use by the population.

� Ask advertising agencies if a media survey is available. Interview program
managers at organizations communicating with your audiences. They can give
you a good idea about what has worked and what has not.

� Visit the communities where your audience lives, and make an inventory of
existing media channels. Describe the sizes and types of the audience that they
reach.

One approach to identifying the key communication channels is to interview the
program managers of existing health projects. As you identify the activities, note
the gatekeepers—the individuals or organizations responsible—for each activity.
Note the main channels and formats used by these organizations. Focus on their
messages as well as the intended audience. This activity will give you an under-
standing of the messages already being communicated and the extent to which
they were well received.

TIPS: Information Collection Methods

(continued from previous page)

������������ �
����
�� ���
���� ��� �

��� � �—This technique focuses primarily
on local people’s views, how they perceive
their conditions and their lives, and how to
change them. Two methods predominate:

Focus Group Discussions—Have a trained
focus group moderator discuss the health
problem with a few groups of between 6
and 12 members of your potential audiences
for 1 or 2 hours. Find out about their perspec-
tives on the problem, including possible
causes and contributors. Find out about the
group’s sources of information and influence
as well as their levels of knowledge, beliefs,
and attitudes.

Interviews with potential audience
members—Informally interview those who
are potential audiences for your effort. Visit
with both those currently affected and
those at risk. Ask them about their perspec-
tives on the health problem. Try to interview
both those who are already practicing
behaviors that promote health and those
who are not.

�������
�� —Visit places where related
health supplies and services are offered.
Observe how easy or difficult it is for clients to
access a provider. Observe several client/
provider interactions, allowing that your
presence will change the interaction some-
what. Observe the conditions within which
they are exchanging information. Make notes
about your observations.

35A Field Guide to Designing a Health Communication Strategy

1Communication, Organizational, and Professional Resources
In addition to identifying health-related programs and activities, identify the
organizations and professionals who are helping to carry them out. Ask these
people questions like the following:

� Who has experience producing health education materials?

� Which are the top advertising firms in the area?

� Who can produce television and radio programs?

� Which organizations provide training to service providers and community
workers?

� Are there networks or associations of communication organizations? If so,
what is their membership and scope?

Complete worksheets 1.3.a, 1.3.b, and 1.3.c to help summarize your findings.

36 A Field Guide to Designing a Health Communication Strategy

Example 1.3a: Health Communication Channels Worksheet
Instructions: Identify health communication channels in your area by name and
type as well as the type of audiences reached.

Example: Nicaragua

Worksheet 1.3a: Health Communication Channels
Instructions: Identify health communication channels in your area by name and
type as well as the type of audiences reached.

37A Field Guide to Designing a Health Communication Strategy

1Example 1.3b: Current Health Communication Worksheet
Instructions: Identify relevant communication efforts in your area.

Example: Nicaragua

Worksheet 1.3b: Health Communication Efforts
Instructions: Identify relevant communication efforts in your area.

38 A Field Guide to Designing a Health Communication Strategy

Example 1.3c: Health Communication Assistance Worksheet
Instructions: Identify organizations or individuals who can help you carry out a
communication initiative.

Example: Nicaragua

Worksheet 1.3c: Health Communication Assistance
Instructions: Identify organizations or individuals who can help you carry out a
communication initiative.

39A Field Guide to Designing a Health Communication Strategy

1�����
������

�����! ”
�� �� �

The fourth step in analyzing the situation is to assess key aspects of the environment
where the strategy will be implemented. Sometimes a health issue requires promo-
tion of a behavior and does not involve a product or service (i.e., breastfeeding). In
other instances the health problem requires products that are easily accessible (i.e.,
soap for hand washing). Still other health issues require an interaction with the
health service delivery system (i.e., immunization). These considerations should be
clarified as part of the process of assessing the environment.

Health Service and/or Product and Behavior Support
Assessing the availability, accessibility, affordability, and acceptability of services,
products, and behaviors will lead to knowledge of the capacity of service provid-
ers and supply outlets to help the communication effort.

Availability
Consult with personnel and logistics managers in the programs that the communi-
cation effort will be promoting. Ask them to estimate their current capacity and
current demand. Key questions include:

� Can they increase their capacity to meet increased demand?

� How quickly can they respond to stockouts and understaffing?

� Will they be able to handle additional clients? Will enough supplies be avail-
able, and will these supplies be available on a regular basis?

Ask yourself if you will be creating expectations that existing services cannot
meet. If so, you should consider whether promoting the desired behavior is
counterproductive.

TIP: Make note of the products,
services, or behavioral supports
that are offered to help people
adopt the healthier behavior
you will be promoting and
which organizations are
offering the products and
services.

40 A Field Guide to Designing a Health Communication Strategy

It is also important to conduct a competitive analysis to understand the broader
environment and to identify potential barriers to success. First, designate whether
you will be promoting a product, service, or behavior. Then, within the chosen
category, list all of the competitors that you know about. For example, when
promoting a behavior such as breastfeeding, the competition may consist of social
pressure not to breastfeed, as well as baby formula sold through commercial
channels. See chapter 5, “The Message Brief,” for additional information about
competition considerations when developing messages.

Accessibility
Where services or supplies are apparently available, ask whether those who need
them can get them. For example, in some countries where contraceptives are
readily available, sexually active, unmarried women cannot get access to them
because of cultural or legal restrictions. Determining the level of accessibility
before starting a specific campaign is crucial.

Affordability
Ask if the primary audience can afford the services and supplies. Think beyond
monetary cost. How much does it cost in time and effort to get the service or item?
If someone has to take a day off from work to get it, how much does this lose them
in wages? Understanding potential constraints like these will help you design a
more effective strategy.

Acceptability
Ask how socially acceptable it is to get and use the product or item. In some
countries, for example, it is socially unacceptable for a woman to purchase
condoms, even for her husband. In other countries, certain contraceptives are
unacceptable because they require a woman to touch her genitals. Interview
service providers and users about these issues to find out if barriers exist to pro-
moting certain behaviors.

Review the questions and findings about these four issues with the program man-
agers who are responsible for service delivery and distribution of products. Find out
if there are any current service or supply issues. Consider visiting several service
delivery sites to test availability and several supply outlets to test accessibility.

41A Field Guide to Designing a Health Communication Strategy

1Social, Economic, and Political Conditions
Social, economic, and political conditions can limit health communication. Crime,
unemployment, poverty, and social upheaval all affect health behavior. Consult
program managers about social conditions that may impact their ability to promote
health issues. Read about current affairs. Ask about pending legislation that may
affect the effective promotion of health behaviors. Make note of other development
issues that will be competing for resources and the attention of your audiences.

Based on the following examples, complete the corresponding worksheets.

Example 1.4a: Health Service and Product Support Worksheet
Instructions: Identify services and products that help people prevent or treat the
health problem. Indicate the availability, accessibility, acceptability, and
affordability of each one.

Example: Nicaragua

42 A Field Guide to Designing a Health Communication Strategy

Worksheet 1.4a: Health Service and Product Support
Instructions: Identify services and products offered in your area for helping people
prevent and treat the health problem. Briefly describe each according to its avail-
ability, accessibility, acceptability, and affordability.

43A Field Guide to Designing a Health Communication Strategy

1Example 1.4b: Social, Economic, or Political Conditions
Instructions: Identify any major influences that may affect your ability to
communicate effectively.

Example: Nicaragua

Worksheet 1.4b: Social, Economic, or Political Conditions
Instructions: Identify any major influences that may affect your ability to
communicate effectively.

44 A Field Guide to Designing a Health Communication Strategy

TIP: Avoid writing a long list
of SWOT. Prioritize your list,
and include only those that
you believe will have a
major impact on your
communication strategy.

�����#
������
$

�����
���%�&��’ �����%
(������
�
��%�� ��)������

The next step is to summarize what you have learned to form a foundation for
your communication strategy. Many strategic planners use the SWOT framework:
Strengths, Weaknesses, Opportunities, and Threats.

Summarizing Key Strengths and Weaknesses
Review the resources that you control, and list key strengths and weaknesses in
your ability to communicate effectively. Involve your colleagues in creating this
list. Review financial, human, and technological resources that can be devoted to
the communication initiative.

Summarizing Key Opportunities and Threats
Similarly, ask the following questions:

� What key opportunities are there for improving health through communication?

� What threatens the ability to improve health through communication?

Based on the following example, complete the corresponding worksheet to
summarize your findings.

45A Field Guide to Designing a Health Communication Strategy

1Example 1.5: SWOT Analysis Worksheet

Example: Nicaragua

Worksheet 1.5: SWOT Analysis

46 A Field Guide to Designing a Health Communication Strategy

Now you are ready to summarize what you have learned from analyzing the
situation by completing worksheet 1.6, “Situation Summary.” When you reach
chapter 9 of the book, you will combine worksheet 1.6 with seven other summary
worksheets (one each for chapters 2, 3, 4, 5, and 7 and two summary worksheets for
chapter 6, “Channels and Tools”). Taken together, this set of summary worksheets
will provide the information and guidance that you need to write a health com-
munication strategy.

Example 1.6: Situation Summary Worksheet
Instructions: Review the worksheets that you have completed. Refer to them to
complete the following summary of your situation.

Example 1: Nicaragua

47A Field Guide to Designing a Health Communication Strategy

1Example 1.6: Situation Summary Worksheet
Instructions: Review the worksheets that you have completed. Refer to them to
complete the following summary of your situation.

Example 2: Uganda (Communication Strategy…2001)
At the end of this chapter and at the end of most chapters, you will find a summary
worksheet. The DISH project in Uganda is used throughout this book to provide a
comprehensive example showing how these summary worksheets are to be
completed. When compiled as a set, the information in these summary worksheets
will provide a concise overview of the key strategic considerations upon which
you will base your strategy.

Project Background: The long-term and permanent methods (LTPMs) of FP were
highly underutilized in Uganda. Permanent methods include tubal ligation (TL)
and vasectomy. The long-term method used in this example is Norplant. Despite
strong FP campaigns and a survey among new FP acceptors that noted an in-
crease in the desire to space or limit births altogether, the use of LTPMs remained
significantly low.

In 1997, the DISH project conducted a survey of nine districts and found that only
4 percent of married women were using TL, less than 0.26 percent of married
women were using Norplant, and no men reported using vasectomy. When asked
why, clients cited many reasons for the LTPMs not being more widely used, includ-
ing inaccessible and unreliable services, lack of awareness, fears and misconcep-
tions about the methods, and poor quality services.

The DISH II project, along with the MOH and other partners, developed a strategy
to expand the availability and to improve the quality of these services through
connected activities related to training and supervision of medical personnel,
provision of equipment and supplies, and targeted behavior change communica-
tion messages for the different audience segments.

48 A Field Guide to Designing a Health Communication Strategy

Example 1.6: Situation Summary Worksheet (Uganda)

49A Field Guide to Designing a Health Communication Strategy

1 Worksheet 1.6: Situation Summary
Instructions: Review the worksheets that you have completed. Refer to them to
complete the following summary of your situation.

50 A Field Guide to Designing a Health Communication Strategy

�� ����
�

This chapter has given you the necessary tools to analyze your situation. By now, you should be well on
your way to:

� Identifying and understanding the problem

� Determining potential audiences

� Identifying potential communication resources

� Assessing the environment where you will be communicating

� Summarizing the key Strengths and Weaknesses of the human, technological, and financial resources
available as well as the Opportunities for and Threats to effective health communication in the
current environment

Once these five steps are completed, you are ready to move on to step 2 of the “P” Process—strategy
design.

51A Field Guide to Designing a Health Communication Strategy

1����������

Communication Strategy to Conserve/Improve Public Health, October 1999 –
September 2001 (2001). Johns Hopkins University/Center for Communication
Programs.

Informe de Resultados de la Encuesta de Linea de Base para la Campaña La
Estrella Azul (2001). (pp. 24). Johns Hopkins University/Center for Communication
Programs.

Schiffman, L. G. & Kanuk, L. L. (1995). Consumer behavior. Englewood Cliffs, NJ:
Prentice-Hall.

52 A Field Guide to Designing a Health Communication Strategy

53A Field Guide to Designing a Health Communication Strategy

2
��������

��
��������������
��
By the end of this chapter, the reader will be able to complete the
audience segmentation process by completing the following
steps:

Step 1: Determining Audience Segments

Step 2: Prioritizing Audience Segments Within the Strategy

Step 3: Identifying Influencing Audiences

Step 4: Painting a Portrait of the Primary Audience

54 A Field Guide to Designing a Health Communication Strategy

�����
��

In the forefront of the architect’s mind at every stage of design are the audience
and the audience’s needs. In our example of designing a school, the audience
includes students of different sexes and ages, teachers, parents, administrators, and
visitors. Because of its different needs and depending on the actual situation, the
architect may segment the audience into these groups.

He also considers the needs of people who will influence the intended audience,
such as officials from the Ministry of Education and other government officials.
For each segment he creates a mental picture to ensure that he plans and designs
classrooms, a library, auditoriums, offices, and play areas in accordance with the
needs of each segment.

Similarly, you and your team may need to segment your audience to design the
most effective and efficient strategy for communicating with it.

55A Field Guide to Designing a Health Communication Strategy

2

The term “audience segmentation” means dividing and organizing an audience
into smaller groups of people who have similar communication-related needs,
preferences, and characteristics. Health communicators segment audiences to
achieve the most appropriate and effective ways to communicate with these
groups. As discussed in Chapter 1, health communicators identify several poten-
tial audiences for the communication strategy. Each audience consists of people
who will directly benefit from the desired behavior changes. Your task is to deter-
mine the audiences on which to focus communication efforts.

This chapter provides four steps as a guide for carrying out the segmentation
process to determine the primary, secondary, and influencing audiences. Follow-
ing these steps will lead to the decisions and descriptions that will form the core of
the audience portion of your communication strategy.

������
�����
�
���
��
�������� ����

The first question for you to resolve is whether you need to segment the audience
at all. If the potential audience as a whole can be effectively reached through the
same set of channels and receive the same set of messages, you do not need to
segment. In most cases, however, the audience will benefit from being segmented,
and your communication activities will be more effective. Indeed, health commu-
nicators have found that to most effectively promote behavior change, they need
to segment the audience and design several different customized messages,
appeals, or calls to action.

The question of available resources also influences your audience segmentation
decisions. The costs involved in developing and executing separate communica-
tion efforts for several groups may outweigh the benefits. If resources are limited
but segmenting the audience is warranted, it may be appropriate to focus on
either fewer segments or to look for ways to leverage funds with other programs.
Review the guidelines on the next page, and complete worksheets 2.1 and 2.2 to
help you reach audience segmentation decisions.

56 A Field Guide to Designing a Health Communication Strategy

Guidelines To Help Determine When It May Be Useful To Segment
an Audience
It may be useful to segment audiences in the following cases:

1. When it is useful to separate users of a product from nonusers or people who
practice a behavior from people who do not practice the behavior, segment
accordingly.

Examples: Users and Nonusers

Messages to men who have never used a condom will be different from those
who have used a condom but not on a regular basis. The former group requires
information on the advantages of condom use. The latter may require more
research on why they do not use condoms regularly, and any effective communi-
cation plan must design messages to address their concerns.

The same is true for child immunization. Immunization programs often address
families to get their children immunized, as if the caregivers were thinking of this
subject for the first time. In many countries, however, the problem is that families
aren’t making sure that their children get the required number of immunizations.
Based on these different behavior stages—nonpracticing and practicing—com-
municators segment the audience and develop the communication strategies
correspondingly: one to convince caregivers to begin an immunization program
and the other to encourage them to bring the children in for the full course of
treatment.

Health communicators identified maternal mortality as a key problem and preg-
nant women as the potential audience for a message about antenatal care. Some
pregnant women may not go to a provider of antenatal care at all, while some
may not start going until the second or third trimester of the pregnancy. The first
audience may need to understand the advantages of going to a provider of
antenatal care. The second audience already understands the need for antenatal
care but may need to understand the advantages of antenatal care during the first
trimester.

57A Field Guide to Designing a Health Communication Strategy

2

2. When separate groups within an audience require different types of informa-
tion or motivation to promote behavior change, segment by information
needs and motivation.

Examples: Users at Different Stages of Behavior

����������� �

��
A potential audience for contraceptive use may be defined as
women of reproductive age. Within that group, however, young women may
want two or fewer children, and modern contraceptive methods may be a solu-
tion. On the other hand, older women with three or more children may want to
consider permanent contraceptive methods. Although both groups consist of
married women of reproductive age, their information needs are different.

An undifferentiated communication strategy may encourage women to choose
an inappropriate solution or may not give them a strong enough reason to seek a
FP method that best suits them. Segmenting the broader audience of married
women of reproductive age into those who wish to space out their pregnancies
and those who wish to limit the number of children that they have results in more
focused and appropriate communication strategies.

In many countries, a large proportion of adolescents are already sexually active,
and the desired behavior may be for them to use contraceptives to avoid un-
wanted pregnancies. For adolescents who are not sexually active, however, the
message may be to delay sexual activity. These different behavioral outcomes
require different messages and materials.

Materials that are highly visual with little text may be necessary for the less-literate
members of the audience, while fewer visual materials with more text may better
explain the communication messages to more literate members.

����������
Can a strategy appeal to rural women in the same way as urban
women? If not, consider segmenting these audiences to ensure that approaches
are appropriate for both of these groups. Consider whether most everyone in your
audience will respond to the same appeal and approach, even if the message and
desired behavior are similar.

Segmenting the Audience
The Romania Example

A women’s health communication strategy
was undertaken in Romania. Romania pro-
vided an unusual example of how formative
research was conducted to determine very
distinct audience segments, and then many of
these segments were collapsed into one
primary audience. Some of this segmentation
was given as part of the program. For example,
the original geographic program area was
concentrated in three judets, or counties.The
strategy designers knew from initial data that
there were differences in lifestyle between
rural and urban women and differences in
lifestyle between single and married women.
They also knew from past experience that they
would probably have to develop different
messages for each of these segments, so they
asked the research firm to gather data based
on these segments. Interestingly, the findings
showed that a need for more information
about modern FP methods was common to all
segments, and the desire to use modern
methods was equally great. In addition, mass
media were highly accessible by all
segments.The strategy designers realized that
they could conduct one campaign with clear
messages and reach all segments except
Roma women (a subset of Romanian women).
Their cultural differences and literacy levels
were so different from the others that it would
not have been cost-efficient to include this
group during this campaign phase

(Liskin & Yonkler, 1999).

58 A Field Guide to Designing a Health Communication Strategy

Literacy, language, and other considerations may indicate the need to develop
tailored materials for different groups within an audience, even if the basic mes-
sage and desired behavior change are similar. Is one set of messages enough to
effectively communicate with them all? If not, consider segmenting your audi-
ence according to who will need different kinds of materials.

Focusing on motivation means more than simply taking the same communication
materials and customizing them in a local language, using local models. It is a
matter of understanding particular motivations among the segmented audiences
and developing specific communication strategies to meet their needs.

3. When separate groups are likely to identify with different spokespersons,
segment by effective sources of information.

Example: People trust different sources of information

In many places, young people may respond to messages given by their peers
rather than to messages given by adults or providers. People may trust those who
can speak to them in their own language; people relate better to those who look
and sound like they do. Some people trust a neighbor’s advice more than that of a
health provider.

Although everyone’s preferences are individual, common preferences among
groups should be considered when selecting audience segments. If research from
the situation analysis shows that certain groups of people will respond better to
different messages or different sources, you may want to segment.

TIPS for Using the Audience
Segmentation Worksheets:
Once the team has decided to
segment the audience, use the
following worksheets to help
divide the audience into smaller
groups. This segmenting will
help communicate more
effectively by better focusing
the messages, communication
channels, and approaches.

To complete the worksheets,
list the potential audiences
identified in the situation
analysis in the first column
of the first worksheet.

Then answer the remaining
questions on each of the
worksheets. By the end of this
process, you and your team
should be able to define the
key audiences for the
communication efforts.

59A Field Guide to Designing a Health Communication Strategy

2
Example 2.1: Step-by-Step Audience Selection Worksheet
Instructions: Step 1: Identify Audience Segments. Based on your analysis of the
situation, identify potential audiences for your communication efforts. Name the
potential audiences in the first column in the following chart. For each audience,
identify possible segments (subgroups with traits that make them significantly
different from others in the larger group). A significant difference is one that will
require a different communication message or approach.

Example: Romania

60 A Field Guide to Designing a Health Communication Strategy

Worksheet 2.1: Step-by-Step Audience Selection
Instructions: Step 1: Identify Audience Segments. Based on your analysis of the
situation, identify potential audiences for your communication efforts. Name the
potential audiences in the first column in the following chart. For each audience,
identify possible segments (subgroups with traits that make them significantly
different from others in the larger group). A significant difference is one that will
require a different communication message or approach.

61A Field Guide to Designing a Health Communication Strategy

2

������
��
��
�
�
���
��
�������� ������
��
�����
��������

The need to prioritize is based on the answer to this question: Are enough re-
sources available to reach all the people identified as being affected by or at risk
of the health problem? If not, the team needs to decide which audience segments
should receive attention first.

A phased approach to audiences helps to build momentum for a communication
effort and to create in one segment of the audience the capacity to help others
who are at different stages of behavior change. The communication strategy may
start by addressing the audience that is easiest to reach, most receptive to hearing
the message, or at a stage where it is most likely to move to the next behavior
change stage.

An audience segment that already practices a behavior can be encouraged to
advocate the behavior to others. These “practitioners” become credible motivators
of the “intenders,” who will follow them through the stages of behavior change.
Worksheets 2.2.1, 2.2.2, and table 2.2.3 will help you and your team determine
whether to prioritize audience segments.

Example
In Ghana, a national strategy was developed to
increase the use of long-term FP methods—
specifically injectables, Norplant, intrauterine
device (IUD), TLs, and vasectomies. One of the
partners in the strategy, Engender Health
(formerly Association for Voluntary Surgical
Contraception [AVSC]), has a successful history
of working with “satisfied users” to help
promote the concept of long-term FP methods
to nonusers. However, there were so few
users of long-term contraceptives that the first
priority was to build a solid base of long-term
users who later could help promote the
concept to others. The strategy was to direct
the first phase of the campaign to users of
shorter term contraceptives who wanted to
widely space or limit their family size but who
were currently using the pill and condoms,
since they were already predisposed to use
modern FP methods. The partners realized
that there would be ongoing communication
to increase the number of pill and condom
users at the same time. Therefore, the priority
was as follows: Phase 1, build a base of
satisfied users by appealing to current users of
shorter term methods who would seek to use
longer term methods; and phase 2, work with
the now larger base of long-term users to have
them advocate to others about the benefit of
long-term methods.

62 A Field Guide to Designing a Health Communication Strategy

Example 2.2.1: Prioritize Audience Segments Worksheet
Instructions: Review your work in step 1, and identify potential audience seg-
ments. Segments should be audiences with common characteristics. Write the
names of potential audiences in column 1. Then answer the questions to help you
decide which audience segments to focus on.

Example: Romania

63A Field Guide to Designing a Health Communication Strategy

2

Worksheet 2.2.1: Prioritize Audience Segments
Instructions: Review your work in step 1, and identify potential audience seg-
ments. Segments should be audiences with common characteristics. Write the
names of potential audiences in column 1. Then answer the questions to help you
decide which audience segments to focus on.

64 A Field Guide to Designing a Health Communication Strategy

Example 2.2.2. Audience Prioritization Worksheet
Instructions: Using your answers from worksheet 2.2.1, rate each of your potential
audiences as described below.

Example: Romania

65A Field Guide to Designing a Health Communication Strategy

2

Worksheet 2.2.2: Audience Prioritization
Instructions: Using your answers from worksheet 2.2.1, rate each of your potential
audiences as described below.

66 A Field Guide to Designing a Health Communication Strategy

Example 2.2.3: Potential Audience Phasing Strategies Worksheet
Instructions: This chart shows three examples of potential audience phasing
strategies and the rationale for phasing. Your team needs to determine if re-
sources are available to achieve individual objectives for each of these audience
segments within the timeframe of the strategy. When possible, state the specific
time frame associated with each phase.

67A Field Guide to Designing a Health Communication Strategy

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Table 2.2.3: Potential Audience Phasing Strategies
Instructions: This chart shows three examples of potential audience phasing
strategies and the rationale for phasing. Your team needs to determine if re-
sources are available to achieve individual objectives for each of these audience
segments within the timeframe of the strategy. When possible, state the specific
time frame associated with each phase.

68 A Field Guide to Designing a Health Communication Strategy

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Step 3 identifies influential people in the primary audience’s social networks. The
goal is to mobilize these groups to influence the primary audience in favor of the
healthy behaviors. Chapter 1 discussed how to look for and list potential influenc-
ing audiences. After reviewing that material and the text below, use worksheets
2.3.1 and 2.3.2 to help your team work through this step.

To help you determine who influences the audience’s knowledge and attitudes
about the health problem, ask these questions:

� Who suggests ways that they can prevent or treat the health problem?

� Who influences their decision to seek assistance in preventing or treating the
health problem?

� Who influences their decision to try certain products or practice certain health
behaviors?

� Who influences their decision to continue or not to continue their new health
behaviors?

Describe these outside influences both in terms of such characteristics as age and
gender and in terms of their relationship to the primary audience. For example, are
they friends or relatives? Are they offering services or products to the audience?

69A Field Guide to Designing a Health Communication Strategy

2
Identify all providers of services and supplies to the primary audience. Identify
your own provider network and alternative providers. For example, does the
primary audience seek treatment from traditional healers? If so, these healers are
likely to have a strong influence on the audience. Does the audience seek services
from government clinics, nongovernmental outlets, or private clinics? When
identifying the audience’s health care providers, be as specific as possible. For
example, identify whether the people in the audience visit nurses or doctors. Note
if they visit the nearest provider or if they travel some distance to reach a preferred
provider. This information will help you select key providers.

To identify opinion leaders, ask program managers and community workers who
influences community opinions about health problems and who directs policy
decisions about health care matters. Interview these people about their views on
the health problem, and ask them for the names of other opinion leaders and
policymakers in the area.

As you list the influencers, estimate their degree of influence. For example, the
relationship between a client and a provider is a powerful one in influencing
health behaviors. Certain relatives, spouses and parents, are also strongly influen-
tial. When it comes to abstinence, for example, religious leaders or parents may
play an influential role, particularly among youth. Neighbors may have less influ-
ence. By estimating the degree of influence that others may have on the primary
audience, your team will be able to make more informed decisions on how to
spend communication resources to encourage advocacy by these groups.

Also, ask the influencers about their attitude toward the desired behavior. Know-
ing this will help determine how much of an investment the team will need to
make in promoting positive attitudes and advocacy among this group.

70 A Field Guide to Designing a Health Communication Strategy

Example 2.3.1: Identify Influencing Audiences Worksheet
Instructions: In column 1, write the names of the audiences you selected in step 2.
Then answer the questions.

Example: Romania

Worksheet 2.3.1: Identify Influencing Audiences
Instructions: In column 1, write the names of the audiences you selected in step 2.
Then answer the questions.

71A Field Guide to Designing a Health Communication Strategy

2

Example 2.3.2: Influencer Analysis Worksheet
Instructions: Write the name of the primary audience (the audience that you want
to encourage to practice a healthy behavior) above the table.

Example: Romania

Worksheet 2.3.2: Influencer Analysis
Instructions: Write the name of the primary audience (the audience that you want
to encourage to practice a healthy behavior) above the table.

In the first column, list the
groups who influence the
audience’s health behavior.

In the second column,
estimate how much
influence they have on the
primary audience (strong,
moderate, weak).

In the third column, state
what they are currently
influencing the audience
to do (or not to do).

In the fourth column,
describe what would be
likely to motivate them to
encourage the desired
behaviors.

In the fifth column,
describe what would be
likely to motivate them to
discourage the desired
behaviors.

In the sixth column,
describe their primary
sources of information for
influencing the primary
audience.

72 A Field Guide to Designing a Health Communication Strategy

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To help you and your team prepare a creative approach for effectively communi-
cating with the primary, secondary, and influencing audiences, step 4 shows how
to develop a description of each segmented audience to “paint a portrait.” In other
words, this step provides a way to “bring each audience to life.”

The purpose of painting the portrait is to fully understand the desires, wants, and
hopes of the intended audience, so that when you and your team develop mes-
sages, you can focus on that one person in the portrait rather than on a mass of
people. Start by looking at quantitative research as a foundation, and then layer
qualitative information on top of it.

As you describe each segment, consider psychographic variables as well as physi-
cal and socioeconomic data. Data collection sometimes includes the psychologi-
cal traits of audience members and can help in understanding such issues as self-
esteem, risk-taking tendencies, and fatalism. Analyze these characteristics to-
gether with socioeconomic data. Then, compose a profile of the audience that is
realistic and vivid.

This exercise will help you get inside the mind of the audience by painting a
portrait of one person in that audience. Think of the characteristics of the key
audience, and begin to paint a mental picture of a person that best represents that
audience. What is his or her name? Get a photo or picture that represents that
person. Describe him or her. If a woman, how old is she? What does she look like?
Where does she live? If she’s married, what is her husband like? How many chil-
dren does she have? Does she live with her mother-in-law? Does she live in a
village? Does she work? If so, what does she do? What are her media habits? Is
she more likely to watch television or listen to the radio? Develop a story about
the character. In the story, describe her behavior and some key attitudes about the
health behavior that the program is going to communicate to her. This “portrait”
won’t be solely based on facts, although the audience research you have gathered
will provide many factual details.

73A Field Guide to Designing a Health Communication Strategy

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Worksheet 2.4: Paint a Portrait of the Primary Audience

74 A Field Guide to Designing a Health Communication Strategy

Example: A Story from Ghana

Meet Kwame. He is a farmer living in Central Region and is 42 years of age. He has two wives
and five children ranging in age from 20 to 8. He lives a traditional Ghanaian rural lifestyle. He
spends his early morning tending his field and spends the late afternoon with his friends in the
chop bar. Although he considers himself to be a family man, he occasionally has extramarital
affairs. He cares about his children’s well-being and would like them to live a better life than he
does. He cares about his two wives because they raise his children. However, he is not at ease
in communicating with them about intimate matters, such as reproductive health. He assumes
that they know what to do. He is also more comfortable in having his wives talk to their
children about these matters. Kwame was a character that was created at a strategy develop-
ment workshop to represent men 35 years of age and older. One of the exercises in the
workshop was to set priorities among several health topics—one of them being male motiva-
tion—for a national population communication strategy. The typical audience segment initially
addressed for male motivation is men more than 35 years old. The exercise was a revelation
for workshop participants. When the participants started thinking like a 42-year-old rural farmer,
they realized that the concept of male motivation was totally alien to Kwame. And if Kwame
was asked to rank the importance of talking to his wives about reproductive health compared
to dealing with his adolescent children’s sexual behavior or the threat of HIV/AIDS, it was not a
priority. On the other hand, maternal and child health topics were important to him because he
cares about the health of his children and realizes that it is also important for his wives to stay
healthy and take care of them (Yonkler, 1998).

This exercise helped in two ways: (1) it put a face on the audience and helped to bring the
strategy to life; and (2) it helped the communicators realize that although they may spend all
day thinking of specific health topics, the audience doesn’t focus on them the way health
professionals do. It helped to put these issues in perspective.

75A Field Guide to Designing a Health Communication Strategy

2

Example 2.5: Summary of Audience Segmentation Decisions
Worksheet

Example: Uganda

Worksheet 2.5: Summary of Audience Segmentation Decisions
Instructions: In the first column of the summary worksheet, list the key audiences that
you will communicate with and the rationale for each. Then describe each audience
segment. In the third column, note the phasing strategy if this is applicable. Lastly,
describe the key influencers who will be reached and rationale for each group.

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Now that you have identified primary and influencing audiences, you are ready to
set the behavior change objectives for each audience segment.

76 A Field Guide to Designing a Health Communication Strategy

����������

Liskin, L. & Yonkler, J. (1999). The Romania Women’s Health Campaign Description.
Johns Hopkins School of Public Health, Population Communication Services.

Yonkler, J. (1998). National Population Communication Strategy Workshop.
Sogakope, Volta Region, Ghana.

77A Field Guide to Designing a Health Communication Strategy

3

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By the end of this chapter, the reader will understand how to
develop behavior change objectives that are SMART—specific,
measurable, appropriate, realistic, and time-bound—for each
audience segment, by completing the following steps:

Step 1: Stating the Behavior Change That Will Meet the
Audience’s Health Needs

Step 2: Stating How Much the Behavior Will Change

Step 3: Deciding the Timeframe Within Which the Expected
Change Will Occur

Step 4: Linking Behavior Change Objectives to Program
Objectives

Step 5: Identifying Indicators To Track Progress

78 A Field Guide to Designing a Health Communication Strategy

��������

Your friend, the architect, reviews the client’s needs and, within any inherent
limitations such as the size of the site where the school will be and the estimated
budget, establishes the objectives for designing the school. His overall objective is
to create spaces and areas that fit the needs of his audiences. Specific objectives
include creating:

� Classrooms that are large enough for the estimated number of students and
teachers, that have plenty of light, and that are conducive to learning.

� Rooms for teachers (a lounge), the principal (an office), and the entire student
body (an auditorium).

� Toilet facilities for boys and girls and for men and women.
� Play areas, perhaps indoors as well as outdoors.

Also, for all of these spaces, he will plan a network for the movement of his audi-
ences, flowing from outside to within the school; and within, from classroom to
classroom, to offices, to play areas, and to and from the toilet facilities.
At this point, the architect also establishes a preliminary schedule or timeline,
setting milestones or indicators that will measure progress towards completing
the building.

For you, too, the importance of setting clear objectives is paramount, and this
chapter shows you how to set them.

79A Field Guide to Designing a Health Communication Strategy

3

Behavior change objectives are short, clear statements of the intended effect of a
communication effort. Clear, concise behavior change objectives keep a commu-
nication program focused and on track. Objectives that are “on strategy” drive the
program forward and move it closer to the long-term vision of improved health.

This chapter provides guidance on developing behavior change objectives for
each audience segment. It discusses how to develop objectives that are congruent
with the needs and characteristics of the intended audience, as determined by
your analysis of the situation and audience segmentation. You will link the objec-
tives to the outcome or evaluation measures developed for the communication
program. To facilitate measuring the impact of the communication interventions,
you will identify indicators that will help measure progress toward objectives. The
use of clear objectives and indicators that track progress will benefit the strategic
communication effort, while simultaneously demonstrating the program’s contri-
bution to the overall health situation in a given community, region, or country.

The key to developing strategic behavior change objectives is keeping them
SMART (Piotrow, Kincaid, Rimon, & Rinehart, 1997). A SMART objective is:

Specific: The objective should say who or what is the focus of the effort and what
type of change is intended.

Measurable: The objective should include a verifiable amount or proportion of
change expected.

Appropriate: The objective should be sensitive to audience needs and prefer-
ences as well as to societal norms and expectations.

Realistic: The objective should include a degree of change that can reasonably be
achieved under the given conditions.

Time-bound: The objective should clearly state the time period for achieving
these behavior changes.

Example: Specific

Improve the knowledge of mothers of children
up to 5 years of age in three rural provinces of
Nicaragua about the benefits of hand washing
(2001).

Example: Measurable

Improve the knowledge of 80 percent of
mothers of children up to 5 years of age in
three rural provinces of Nicaragua so that hand
washing increases from 10 percent of the time
to 90 percent of the time.

Example: Appropriate

Improve the knowledge of 80 percent of
mothers of children up to 5 years of age in
three rural provinces of Nicaragua so that hand
washing increases from 10 percent of the time
to 90 percent of the time by explaining the
link between lack of proper hand washing and
diarrheal disease (research showed low levels
of understanding among the audience
concerning the link between proper hand
washing and prevention of diarrheal disease).

80 A Field Guide to Designing a Health Communication Strategy

Although you may sometimes find it difficult to craft an objective that fulfills each
of these requirements, this is the ideal format to follow. You and your team must
decide how to develop feasible behavior change objectives, based on your
audience’s situation and the information available to you.

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Based on the work discussed in chapter 2, you and your team should already have
a written description of the intended audience. Use this description to ensure
consistency throughout the development of the communication strategy. Each
audience segment may require a different behavioral change objective. You and
your team should be consistent in defining the objectives for each group or
audience segment.

Name the behavior that will change as a result of the audience hearing, seeing, or
participating in the strategic communication messages. Is the behavior change
ultimately going to impact the audience’s health needs? For example, washing
hands properly can reduce deaths due to diarrheal disease. Review the summary
of the analysis of the situation (worksheet 1.6), and note any behavior identified
as needing attention. At this point, you may need to clarify further the intended
audience’s behavior. If so, consider conducting some qualitative research to make
sure that the program is on the right track.

By following this step, you will ensure that the behavior change objectives are
specific and appropriate.

Example: Realistic

Improve knowledge of 80 percent of mothers
of children up to 5 years of age in three rural
provinces of Nicaragua so that handwashing
increases from 10 percent of the time to 90
percent of the time using a phased approach.

Example: Time-bound

Improve knowledge of 80 percent of mothers
of children up to 5 years of age in rural
Nicaragua so that hand washing increases from
10 percent of the time to 90 percent of the
time between January 2002 and January 2005.

81A Field Guide to Designing a Health Communication Strategy

3

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By completing step 2 you will ensure that the behavior change objectives are
measurable and realistic. To make a reasonable estimate about the amount of
behavior change that will occur, given the overall context of the program and the
resources available, consider:

� Barriers to change.
� Experiences of similar programs in the past.
� Conditions under which the communication will occur.
� How much behavior change is needed for the success of the program.

Barriers
Keep in mind the barriers to change that affect the intended audience. How
difficult will it be to get the attention of the audience? Are others actively trying to
convince the intended audience to adopt behaviors different from those that this
communication strategy will promote? Are there competing demands for the time
and actions of the audience? In general, adopting a new behavior is easier for
individuals than changing an existing behavior.

For example, a woman may decide that it is more urgent for her to spend time at
work than go to the clinic for an antenatal checkup. In this case, despite the best
communication efforts, she may not go to the clinic. Similarly, a family may have
limited financial resources available to treat health problems, and some other
health issue may take precedence over the one that you are promoting.
Keeping considerations such as these in mind will help ensure that expectations
for behavior change are realistic.

Prior Experiences
Examine available research data and reports that describe prior health communi-
cation campaigns related to the issue at hand. How were the behavior change
objectives stated? What changes were achieved? This information will help ensure
that the objectives are realistic and feasible.

Example

In Zambia, the Helping Each Other to Act
Responsibly Together (HEART) Campaign
(Serlemitsos, 2001) used mass media to
change norms related to risk reduction and
safer sex among youth ages 15–19. The main
objective was to promote healthy sexual
behaviors among young people by reinforcing
those behaviors that are safe while changing
the unsafe ones. Specifically, increases were
sought in:

� The number of youth who believed that
they could be at risk of HIV infection

� The number of females who had never
had sex and who continue to practice
abstinence

� The number of sexually active males who
formerly were occasional condom users
and who now will always use a condom

82 A Field Guide to Designing a Health Communication Strategy

Conditions Under Which the Communication Will Occur
Review how conditions under which the communication will occur might affect
results. Consider the portion of the analysis of the situation that examined:

� The “affordability” of behavior change.
� The availability and accessibility of services and products needed to practice

the desired behavior.
� Social, economic, and political factors.

Amount of Behavior Change Needed
Compare the amount of behavior change needed for the strategy to succeed and the
amount of behavior change that is manageable within the strategy’s timeframe. Can
the objectives be accomplished with available resources? Are there sufficient interper-
sonal, community-based, and mass media channels to reach the intended audience?
Will more demand be created than the program can fulfill? Discuss proposed objec-
tives with service delivery managers, and ensure that they will be able to provide
enough supplies and services to meet the expected increase in requests.

In Ghana a FP program generated significantly more demand for FP beyond initial
expectations—so much so that in the midst of the campaign the MOH’s clinics ran
out of oral contraceptives. Clients became frustrated when they discovered that
they could not receive what they had been motivated to get.

Give a numerical or percentage change expected. State the existing baseline
measure as well as an expected measure. Review available data and consult
research experts to determine a realistic goal for the expected change. For ex-
ample, revise an objective that says “increase the proportion of people practicing
the behavior to 20 percent” to “increase the proportion of people practicing the
behavior from 10 percent to 20 percent.”

If it is not possible to measure behavior change in precise terms, try to establish a
means of verifying that the audience’s behavior is at least following the general
trend that would support the aim of the communication program.

Refer to chapter 8, which discusses the issues involved in planning for evaluation,
and then revisit the objectives in this chapter to make sure that they are measurable.

83A Field Guide to Designing a Health Communication Strategy

3

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Identify the timeframe in which change will be achieved. Use timeframes that give
people enough time to change. Strategic communication objectives may be
stated in terms of months or years. Keep this long-term horizon in mind as you
develop your behavior change objectives.

A campaign will often have a shorter duration than an overall communication
program, and the timeframe established to achieve the behavior change objec-
tives will depend on this context. Sustained behavior change over time will clearly
not be achieved during a brief campaign period. Remember to set the timeframe
within the framework of the overall program.

The timing of the communication objectives may coincide with those of the rest
of the program. In some cases, however, it may be important to achieve results
before the program’s end. Ask if it will be necessary to generate demand earlier
in the program to ensure that products and services are fully utilized as soon as
they are available. Take into account such situations, and adjust timeframes
accordingly. You may find it helpful to link the program’s timing to existing data
collection schedules, such as the DHS. Such a link allows the health program to
gather baseline and monitoring information in a scientifically sound and cost-
effective manner.

At this point, you and your team should now have developed one or more behav-
ior change objectives that are SMART.

Example

In the Zambia HEART Campaign, the
behavior change objectives were initially
stated for the first phase of the campaign,
which ran from June to October 1999.

84 A Field Guide to Designing a Health Communication Strategy

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Your behavior change objectives should be likely to contribute directly to achiev-
ing program objectives. Behavior change objectives should always advance one
or more program objectives even if the program objectives do not include a
specific behavior change or communication component. Linking your change
objectives to the larger program objectives and goals strengthens your communi-
cation strategy.

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Indicators are the interim measures used to track progress toward achieving
objectives. Once you have fixed an indicator’s beginning point, or baseline value,
you can monitor it over time to see whether the intended behavior change is
being achieved. Looking at the work completed thus far, identify the interim
measures or indicators that will show the impact of the communication effort on
the behavioral characteristics leading to the behavior change desired.

Good indicators are (Bertrand & Kincaid, 1996):

� Valid: They measure the phenomenon that they are intended to measure.
� Reliable: They produce similar results when used more than once to measure

the same phenomenon.
� Specific: They measure only the phenomenon that they are intended to

measure.
� Sensitive: They reflect changes in the status of the phenomenon being studied.
� Operational: They are measurable or quantifiable with developed and tested

definitions and reference standards.

Example

Program Objective: Within
the next 2 years, decrease
the Total Fertility Rate (TFR)
among married women of
reproductive age from 5.9
to 5.3.

Behavior Change Objective:
Within the next 2 years,
increase from 1 percent to
10 percent the proportion
of the intended audience
who use a permanent
contraceptive method.

85A Field Guide to Designing a Health Communication Strategy

3

For example, increases in information seeking to understand how FP methods
work, increases in the frequency of communication between couples about FP,
increases in participation in community events related to FP, and increases in the
intent to adopt an FP method are all valid indicators when the behavior change
objective is to increase contraceptive use among a specific audience.
Indicators can also be used to assess changes at the community level (Figueroa,
Kincaid, Rani, & Lewis, 2002). For example, to track changes that lead to community
empowerment, you could analyze:

� Leadership
� Degree and Equity of Participation
� Information Equity
� Collective Self-Efficacy
� Sense of Ownership
� Social Cohesion
� Social Norms

Use the worksheet on the following page to summarize the behavior change
objectives that you have crafted.

86 A Field Guide to Designing a Health Communication Strategy

Example 3.1: Developing Objectives Worksheet

Example: Bolivia—Las Manitos I (Valente et al., 1996)

Project background: Bolivia’s National Reproductive Health Program was de-
signed to address high rates of infant and maternal mortality and to satisfy an
unmet demand for FP. The program also worked to improve the climate for FP and
to broaden the range of services offered to include a variety of reproductive
health services. A series of campaigns was designed and implemented over a
number of years, the first of which was called Las Manitos I.

87A Field Guide to Designing a Health Communication Strategy

3

Example: Bolivia—Las Manitos I (continued)

88 A Field Guide to Designing a Health Communication Strategy

Example 3.1: Summary of Behavior Change Objectives Worksheet

Example: Uganda

89A Field Guide to Designing a Health Communication Strategy

3

Example: Uganda (continued)

90 A Field Guide to Designing a Health Communication Strategy

Worksheet 3.1: Summary of Behavior Change Objectives

91A Field Guide to Designing a Health Communication Strategy

3

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This chapter has explained how to develop SMART objectives and has offered
country examples. You should now be able to develop behavior change objectives
for your program and move to the next step—deciding how to achieve these
objectives.

Chapter 4 discusses this process, which involves developing a strategic approach.

92 A Field Guide to Designing a Health Communication Strategy

����������

Bertrand, J. T. & Kincaid, D. L. (1996). Evaluating Information-Education-Communi-
cation (IEC) Programs for Family Planning and Reproductive health. Final Report
of the IEC Working Group, the EVALUATION Project. Chapel Hill: Carolina Popula-
tion Center, University of North Carolina at Chapel Hill.

Communication Strategy to Conserve/Improve Public Health, October 1999 –
September 2001 (2001). Johns Hopkins University/Center for Communication
Programs.

Figueroa, M. E., Kincaid, D. L., Rani, M., & Lewis, G. (2002). Communication for social
change: A framework for measuring the process and its outcomes. The Rockefeller
Foundation and Johns Hopkins Center for Communication Programs.

Piotrow, P. T., Kincaid, D. L., Rimon, J. G. I., & Rinehart, W. (1997). Health Communica-
tion: Lessons from Family Planning and Reproductive Health. Westport, CT: Praeger
Publishers.

Serlemitsos, E. (2001). Zambia Heart Program. Lusaka: Johns Hopkins School of
Public Health, Center for Communication Programs.

Valente, T. W., Saba, W. P., Merritt, A. P., Fryer, M. L., Forbes, T., Pérez, A., & et al. (1996). La
Salud Reproductiva Está en Tus Manos: Impacto de la Camapaña del Programa
Nacional de Salud Reproductiva de Bolivia. Baltimore: Johns Hopkins School of
Public Health, Center for Communication Programs.

93A Field Guide to Designing a Health Communication Strategy

4

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By the end of this chapter, the reader will know how to develop
an overall strategic approach for a health communication
program by completing the following steps:

Step 1: Reviewing the Key Issue or Problem, Audience
Segments, and Objectives

Step 2: Determining Long-Term Identity and Positioning
Strategy Of The Behavior

Step 3: Exploring Strategic Alternatives

Step 4: Determining Strategic Approach and Rationale

94 A Field Guide to Designing a Health Communication Strategy

��������

Using the knowledge gained in analyzing the situation, thinking about the client’s
needs, and setting objectives, your friend the architect develops his strategic
approach for building the school. He decides how he wants the students, teachers,
administrators, and parents to feel about their school: a serious enclosure for
learning but also a friendly space and, in some areas, a play space. He may sketch
out how the various classrooms, offices, lounges, and meeting areas will look,
where the visitor areas, playrooms, and bathrooms will be, and how these will
relate to the entire building, inside and out. He also decides on the overall look or
impression that the school will give. For a school in a city, his approach will be to
design the spaces and use building materials that fit into a cityscape.

As part of developing his strategy, he reviews the different approaches available
to him for meeting his objectives and determines which options he will choose.
He may reaffirm earlier decisions or refine them to ensure that when completed
the school will fulfill its purpose of providing a functional and attractive learning
center for a long time.

So too, you need to develop a specific strategy that links all the elements of your
proposed communication efforts.

95A Field Guide to Designing a Health Communication Strategy

4

In addition to being familiar with the health areas to be addressed and the needs
and wants of the audience, you and your team, having determined the behavior
change objectives, have to describe how the communication efforts are going to
meet these objectives. In other words, together, you develop the overarching
direction that dictates and guides the choice of the tactical tools that the team will
use to achieve the objectives.

The strategic approach is one of the most important elements in a communication
strategy. It drives the rest of the program. It ensures synergy, consistency, and
coordination among stakeholders and partners. It enables the team to picture how
all the elements will fall into place. Think of it this way: What is the communication
strategy going to look like? How is it going to work? What shape will it take? Your
health communication team’s efforts to develop a strategy will lead to a strategic
approach statement, which is different from the objectives. Objectives are specific
and measurable and tell you what needs to be achieved. The strategic approach is
descriptive and tells you how the objectives will be achieved.

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Review the summary sheets developed for chapters 1 through 3 to understand the
key issue or problem, the defined primary and secondary audience segments, and
the behavioral objectives. At this point, the team is faced with an array of possible
approaches to achieve objectives, but some may be better ways than others. You
and your team should ensure that you develop the most appropriate strategic
approach by looking at all the options.
Before proceeding to explore strategic alternatives and to determine your strate-
gic approach and its rationale, you will need to understand the communication
concepts of long-term identity and positioning, so that you can determine these
components for your program.

Example

To meet the objective of increasing the use of
primary health care facilities, a strategy can
take many directions:

1. Focus on the facilities themselves, and
develop a communication strategy that
emphasizes quality services (provided that
these facilities can deliver quality ser-
vices).

2. Concentrate on the audience, and
develop messages related to each of the
health services being offered at these
facilities.

3. Package these health services together
under a healthy lifestyle approach, and
focus on “wellness” as a way for audiences
to utilize these facilities.

All three approaches may be reasonable ways
to achieve the objective. Each option describes
a particular direction and will affect the choice
of messages to be delivered, the channels to
be used, and, in many ways, the management
of the overall program. Obviously it will not be
feasible to implement all three approaches.
You probably do not have the resources or the
manpower to follow through with all ap-
proaches. The best strategy is to focus on one
approach that appears to be the most appropri-
ate based on the knowledge and behavior
stage of the audience, the level of services
being offered, and the access of the audiences
to different communication channels. Focus
demands sacrifice.

96 A Field Guide to Designing a Health Communication Strategy

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In the evolving world of strategic health communication, planners are focusing
more energy on two closely interrelated and sometimes overlapping components:
(1) the behavior’s long-term identity (sometimes referred to as “the brand”) and (2)
positioning the behavior.

Long-Term Identity
As the members of the intended audience perceive and respond to the health com-
munication effort to change behavior, they create in their minds a perception that
becomes a behavior’s long-term identity. In the course of such perception, the audi-
ence builds an image or an idea of the behavior. This image exists only in the minds of
the intended audience and is, for them, an identity for the behavior. At best, it is clear,
distinct, and easily recognized, and it shows the behavior’s benefits as desirable.

Example: Physical fitness is a good example of a behavior that has a long-term
identity. For some, the identity is a positive one. When people who are predis-
posed to exercising regularly think of the term “physical fitness,” they may make
the following positive associations: it is good for you; it helps keep you slim; it
helps prevent heart disease; it gives you energy. On the other hand, some people
may have negative associations: it is too time-consuming; it is not enjoyable; it is
too much work; it takes too much discipline. Positive or negative, the behavior
itself has a set of associations that may immediately come to mind when the
term “physical fitness” is mentioned, and any of those associations reinforce a
long-term identity to an audience member.

A long-term identity or brand:

� Provides a visual signature or brand mark (symbol, name, design, colors, or
combination of these) that is attached to products, services, or behaviors.

� Fosters a relationship of trust, reliability, and exclusivity between the behavior
and the audience.

97A Field Guide to Designing a Health Communication Strategy

4

� Adds value to the basic product, service, or behavior.
� Provides some kind of psychological payoff to the audience.
� Simplifies the problem of differentiation between other like products, services,

or competing behaviors.
� Possesses personality traits, which will allow the audience to form a relation-

ship with the brand (Smith, Berry, & Pulford, 1997).

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labeled with the name of the product, service, or behavior. Then store all the
features, benefits, and thoughts in that box. People keep these boxes in their
minds. Everything that comes to mind about that product becomes part of its
long-term identity. One of the very important components of this identity is the
emotional connection that is established between the audience and the product,
service, or behavior.

Example: Coca-Cola is a good example. It is more than a beverage among
many other beverages. Coke enjoys a special relationship with people all over
the world based on the long-term identity that it has built over many years.
Some of Coke’s attributes can be shared with other beverages. For example,
people know that Coke offers a refreshing taste; it always tastes the same, and
is always within an arm’s reach—accessible. However, other beverages can
make that same claim in many places. In addition, blind taste tests have
shown that many people actually prefer the taste of Pepsi (Allen, 1994). It
doesn’t matter. Coke is still the number one brand in the world (2000). The
reason is the emotional connection between the audience and the brand, a
connection built over many years through a long-term identity system that the
company developed and nurtured with its customers on a consistent and
ongoing basis. The company accomplished this connection through ongoing
advertising, excellent packaging, distribution, merchandising, and PR, among
other things, over a long period of time. Coke, the brand, has become a trust-
worthy friend. Coke purchasers depend on this brand to provide satisfaction.

98 A Field Guide to Designing a Health Communication Strategy

Long-term identities or brand images can work well with products, services, and
behaviors. Here are some examples:

Products
Many car brands have built up long-term identities to ensure a loyal customer
base. Mercedes-Benz is an example of a luxury car that conjures up many positive
images not only among luxury car customers, but also among the general public.
The reason for this is simple. Although people may not currently be able to afford
a Mercedes, they still link the brand name with positive associations. Perhaps
someday they may be able to afford the car, or at least they aspire to owning the
car. While there are many other car brands in the luxury car category and while all
of them provide the same functions and amenities, the Mercedes brand image is
strong enough to be at the top of people’s list when naming luxury cars.

Intel, the microprocessor chip manufacturer, has spent a great deal of money over
many years, to support its brand name. It insists that computer manufacturers use
the Intel logo on any personal computer they make that uses one of its products
and then pays part of the manufacturers’ ad campaign when the Intel logo is
featured. The Intel brand image lends credibility to the computer manufacturer,
while reinforcing its own brand image with each ad exposure. Plus an active ad
campaign demonstrating product benefits supports all of these efforts and further
embeds the value of the Intel name to the consumer. Intel’s brand image is strong
enough to demand higher prices for computers that offer “Intel Inside” than
computers that offer competing chip manufacturers (Aaker, 1996).

Services
American Express (Amex) offers credit for purchases, as does Visa and MasterCard.
While Visa and MasterCard offer credit through banks and other organizations,
Amex offers credit directly through its organization and for a fee that is often
higher than the other credit card companies. Plus Amex cardholders cannot pay
over time. They have to pay in full every month for the previous month’s charges if
they hold the typical green Amex card. Considering the ease of getting a bank
credit card, the (sometimes) lower fees or (on occasion) no fees, and the flexibility
in paying off charges, why are there 42.7 million Amex cardholders (2002)? The
answer is that Amex has promoted its “Members Only” brand image consistently

99A Field Guide to Designing a Health Communication Strategy

4

over time to its two distinct audiences—the cardholder customers and the retail-
ers, hotels, airlines, and restaurants that accept Amex at their establishments. Both
audiences trust, rely on, and have a relationship with Amex and the easily identifi-
able green credit card.

The Egypt Gold Star campaign was the “first nationwide FP communication
strategy in a developing country focused on promoting quality of care and posi-
tioning government clinics as a source of high-quality care (Piotrow, Kincaid,
Rimon, & Rinehart, 1997).” Over several phases, the Gold Star program branded
clinics that passed a 101-item checklist of quality improvement indicators in two
consecutive quarters, with a Gold Star to certify to both potential clients and
providers that these clinics met the requirements of better service. The Gold Star
logo was used throughout the clinic and in all campaign materials and was pro-
moted heavily in the media. This logo came to represent the clinics’ long-term
identity of quality service.

Behaviors
Long-term identities for behaviors are not as well documented and are not usually
thought of in this way. However, in the United States the use of seat belts in cars
has become so ubiquitous that it is hard to realize that it has only become a
common behavior within the last 12 years (National Highway Traffic Safety Ad-
ministration, 1999). It took a combination of public service advertising, policy
advocacy, and role modeling to instill this behavior. Now most States have seat
belt laws requiring the use of seat belts by anyone sitting in the front seat of an
automobile. And all car manufacturers are required to include seat belts in both
front and back seats. Does the use of seat belts have a long-term identity? The
answer is to read any newspaper article or watch any television news program
that announces a fatal car accident. One of the key pieces of information will be
whether the passenger or driver was wearing a seat belt.

The same can be true for behavior change in health communication. Communica-
tion efforts can build long-term identities with clients by promoting products,
services, and behaviors that are “trusted to consistently deliver excellence, and
perceived by customers to be both relevant and distinctive (Shore, 2001).”
A long-term identity or brand consists of tangible and intangible components.

100 A Field Guide to Designing a Health Communication Strategy

The tangible components consist of the functional benefits of the product, such as
what the product does, and any special identification markings (logo or name).
The intangible components consist of the emotional benefits of the product, such
as trust, reliability, added value, and quality of differentiation.

The same concept can be used in behavior change communication. For example, a
client can continue to use and think positively about modern FP methods because
modern methods offer the functional benefit of reliability and the emotional
benefit of giving clients a feeling of security and confidence.

People have certain attitudes and beliefs about products, services, and behaviors,
and store bits of information about them in their heads. These attitudes and beliefs
may be positive, negative, or a combination of both. For example, while some
people think positively about the term “family planning” and may practice FP,
others may associate the term with side effects or find that FP runs counter to their
cultural beliefs. Developing a long-term identity program can help frame the way
that people think about behaviors by fulfilling a need, fostering positive attitudes,
and at the same time diminishing negative attitudes and beliefs. The long-term
identity, if managed properly and continually, will help to build an ongoing
positive and trusting relationship between intended audiences and the behavior.

Your challenge is to help shape every aspect of a communication strategy to foster
the development and maintenance of the behavior’s long-term identity in the
minds of the intended audience. Your job is to help give the behavior its identity
and meaning, thus providing a framework for those who work with the strategy to
build in the minds of the audience a perception of the behavior’s worth. The
challenge is to develop a strong identity, a successful communication strategy,
awareness in the community, and loyalty in the intended audience.

Although long-term identity (or brand) is usually associated with products and
services, the term is not yet a common term associated with behaviors. However,
the long-term identity process can help organize and frame an entire health
program. A key concept is to name the behavior. In Ghana, to increase demand for

What can long-term identity do for a
health program?

Long-term identity:

� Integrates the health program and all its
efforts. It is the glue that holds together
the program’s broad range of activities and
functions, all designed to build relation-
ships with the intended audience.

� Provides for consistent, effective commu-
nication over the long term.

� Encourages the audience to maintain the
behavior by predisposing the audience to
accept messages favorably and to remain
loyal to the program’s activities.

� Differentiates the program’s product or
services from those of other programs..

� Attracts people involved in health care,
such as medical personnel and
policymakers, to participate in and support
the program.

101A Field Guide to Designing a Health Communication Strategy

4

FP, the long-term identity was named “Life Choices.” FP was not just a health
program to reduce unwanted pregnancies but was seen as a tool enabling audi-
ences to achieve their personal life goals. See the example on this page of nam-
ing an antismoking effort directed to U.S. teenagers as “truth.”

Positioning
Behavior change communicators use positioning to determine the best approach
to motivate audiences to change or adopt a specific behavior. Once communica-
tors have determined the objectives for an audience and have developed a long-
term identity, they need to think about how they are going to position the behav-
ior to achieve the objectives and maintain the long-term identity. Closely inter-
twined with the long-term identity, positioning establishes in the minds of the
audience an image of the desired behavior that helps the audience remember it,
learn about it, act upon it, and advocate for it. If the long-term identity is every-
thing an audience knows and feels about the product, service, or behavior, then
positioning is the promotional image that is intentionally communicated to an
audience. An effective position:

� Resonates with the audience.
� Differentiates from the competition.
� Stands out as better than the known alternatives.
� Provides a benefit that is worth the cost or effort.

To succeed in our overcommunicated society, a company must
create a position in the prospect’s mind, a position that takes into
consideration not only a company’s own strengths and weak-
nesses, but those of its competitors as well . . . IBM didn’t invent
the computer. Sperry Rand did. But IBM was the first company to
build a computer position in the mind of the prospect.

—(Ries & Trout, 1981).

Example: The “Truth” Program

In the United States, the tobacco control program is
an ongoing effort that has resulted in a marked
decrease in the use of tobacco. However, smoking
among young people has increased. Once people
start to smoke in their teenage years, they become
addicted to tobacco, and it becomes more difficult for
them to stop smoking as they reach adulthood.

The American Legacy Foundation funded a program
to develop a culture of “not smoking” among young
people. To accomplish this goal, the foundation and its
communication partners developed a long-term
identity program (or branding program) to treat not
smoking as a “brand,” by managing the program in
the same way that a manufacturer manages a
branded product. They first conducted considerable
research to gain insight about their audiences and
then segmented their audiences by specific attitudes.

They studied 3,000 teens in middle school and high
school and learned about their health behaviors,
worries, dreams, values, self-descriptions, and social
connectedness. They learned that teens are open to
smoking and that initiation begins when they are in the
5th, 6th, and 7th grades. Teens who were open to
smoking are more likely to use drugs and alcohol and
are less future-oriented. Their dreams are of becoming
rich, being a hero, having a great car, and getting even
with people who may cross them. A key insight about
them was their desire to assert control and their
willingness to engage in a variety of risky behaviors to
assert control (taking control away from parents,
teachers, and other authority figures). Control was
expressed by “need states,” such as rebellion, taking
risks, fitting in, being independent, self-expression, and
feeling respected. Tobacco satisfies all of the need
states in the minds of these teenagers. In other words,
the use of tobacco was seen as a tool of control.

(continued on next page)

102 A Field Guide to Designing a Health Communication Strategy

Positioning: In the context of strategic design, positioning means presenting
an issue, service, or product in such a way that it stands out from other compa-
rable or competing issues, services, or products, and it is appealing and per-
suasive. Positioning creates a distinctive and attractive image, a perpetual
foothold in the minds of the intended audience (Piotrow, Kincaid, Rimon &
Rinehart, 1997).

The commercial marketing sector uses the term “positioning” in a competitive
environment to set or position one product against another. If one car is the
“luxury” car, such as Cadillac, then another car is the “economy” car, such as
Hyundai. If Clairol shampoo offers manageable hair that is easy to control, then
L’Oreal shampoo gives you lustrous, shiny hair. Positioning helps to communicate
to the audience a unique appealing difference designed to give the product an
edge over the competition.

Positioning helps determine the overall strategic approach. “Positioning suggests
how these changes (desired behavior changes) can be presented to the intended
audience in the most persuasive fashion. . . . From a communication standpoint,
positioning may be the key element because positioning determines the way that
people will perceive the product/service/behavior, how they will remember the
communication activities, and to what extent those will prompt action” (Piotrow,
Kincaid, Rimon & Rinehart, 1997).

Think of positioning as a way to deliver PUNCH to the strategy. Positioning:

Is always Positive.
Is always Unique.
Develops a Niche in the minds of the audience.
Is always Competitive.
Always Helps the audience by delivering a benefit.

Example: The “Truth” Program

(continued from previous page)

Another key insight was that if the program wants to
take tobacco away from this audience, it must replace
the behavior with something else that fulfills the need
states and provides control. Therefore, the program had
to give teens knowledge (about not smoking), a
motivation (give them a way to rebel and take risks), and
power (put control in their hands). At the same time, the
program had to deconstruct myths, lies, and deceptions
about tobacco.

The strategy was to package “not smoking” as a brand to
give teens something that they would want to affiliate
with, a “badge” standing for rebelling, taking risks, being
independent, self-expression, and respect. The result was
the “truth” program. This program positioned tobacco
companies as villains by providing evidence from ongoing
litigation that tobacco companies knew that smoking was
addictive and harmful while continuing to promote their
products to young people. By providing the “truth” about
the companies, the campaign gave young people some-
thing to rebel against—the big, authoritative tobacco
companies who were trying to harm them. Messages were
designed that put teens in control and allowed them to
help expose big tobacco companies for what they are. Teen
advocacy groups were organized to help expose these
“truths.” These groups enabled teens to rebel and fit into a
group at the same time. They were able to gain respect and
be socially connected. Designing messages, organizing
groups, conducting the research, and monitoring and
evaluating the program were all made part of the long-
term identity system or branding system. This program has
been successfully building a relationship between the
audience (teenagers) and the brand (“truth”). The State of
Florida reports that the truth “campaign resulted in high
rates of recall, significant changes in attitudes/beliefs, and
reduced rates of smoking behavior among youth.

(Sly, Heald, & Ray, 2001)

103A Field Guide to Designing a Health Communication Strategy

4

Positioning creates the memorable cue for the audience to know why they should
adopt a behavior. It forms the basis for communication tactics: advertising, promo-
tion, packaging, publicity, special events, IPC, community-based communication,
and advocacy programs. It shapes the development of messages and the selection
of channels. It ensures that messages will be consistent and that each communica-
tion effort or activity will reinforce other activities for a cumulative effect.

Many corporations use symbols to further identify their brand to the public. Below
are two examples of very familiar corporate logos.

Many health programs have successfully used positioning. In the Zambia HEART
Program, for example, one of the campaign efforts focused on delaying initiation
of sexual activity. A positioning statement was developed, “Virginity is something
to be proud of”, and the campaign slogan used was, “Virgin Power-Virgin Pride”.

Figure 4.1 shows a variety of positioning strategies used in different countries,
together with the logos that served as communication tools to symbolize the
position (Piotrow, Kincaid, Rimon & Rinehart, 1997).

Many health programs have successfully used positioning. In Zambia for example,
one of the aspects of the HEART campaign addressed the benefits of abstaining
from sexual activity for adolescent girls. Girls feel a lot of peer pressure to engage
in sex as a way to prove their love to a boy. They also believe that a boy should be
asking for sex if he really loves the girl. Girls say they want to maintain their
abstinent status, so they need support to feel that this is a behavior to be proud of.
The positioning statement of the campaign was, “Virginity is something to be
proud of” and the campaign slogan was, “Virgin Power-Virgin Pride”.

Figure 4.1 shows a variety of positioning strategies used in different countries,
together with the logos that served as communication tools to symbolize the
position (Piotrow, Kincaid, Rimon & Rinehart, 1997).

104 A Field Guide to Designing a Health Communication Strategy

Figure 4.1: Various Positioning Strategies
By focusing on a unique characteristic, strategic position-
ing gives a FP/reproductive health program a memorable
identity, occupying a niche in the minds of the public and
providers. A well-designed symbol can help position a
service, product, idea, or program.

Keep in mind that positioning is about perception, and
even if the audience thinks about a behavior or a compet-
ing behavior in an incomplete or even somewhat incorrect
way, audience perception is the reality that health commu-
nicators must face. Knowing and listening to the audience
helps the health communicator position the program to
meet the needs of the intended audience segments.

Strategic communicators understand that reality is based
on what the audience believes and not only on what the
health communicators think is appropriate. Reality is also
based on what the audience is willing to hear or see and
not only on what the health communicators want them to
know. Understanding this audience insight helps commu-
nicators to position (or reposition) in the minds of the
audience a behavior that, if communicated consistently,
will be sustained.

Steps to Developing a Position
The first key step in developing a position is for you to
know where the audience is currently going for its health
products and services and how the audience is currently
behaving.

105A Field Guide to Designing a Health Communication Strategy

4

For example, is the audience going to public facilities, to private providers, and to
traditional healers, or is it not going anywhere? Instead of breastfeeding, is the
audience using bottled milk or giving its babies solid food earlier than recom-
mended? For HIV/AIDS prevention, are sexually active young men not protecting
themselves? Do they have multiple partners?

It is important to know what the audience is doing; it is just as important to know
why the audience is doing it. Most people behave a certain way because they
derive a benefit from that behavior. So you have to understand why they are
doing it and what they get out of it before you can position a behavior against it.
Another way of looking at this approach is to “identify the competition.” So the
first questions to ask are, “What is the audience doing now? And why?”

The second key step is to determine what the positive behavior can realistically
deliver that the audience will perceive as a benefit. This step may require addi-
tional audience research. Start by reviewing and following these basic steps:

� Analyze the program’s capabilities, and identify differences from other pro-
grams (from “Analysis of the Situation”).

� Analyze the audience’s perceptions of the product, service, or behavior (from
“Analysis of the Situation” and “Audience Segmentation”).

� List the audiences and their characteristics (from “Audience Segmentation”).

� Match product, service, or behavior characteristics to audience needs and
wants.

� Explore positioning alternatives.

� Develop a positioning statement.

106 A Field Guide to Designing a Health Communication Strategy

Refer to the following examples and worksheet 4.1 in completing these steps.

Examples of Positioning

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107A Field Guide to Designing a Health Communication Strategy

4

When reviewing several positioning possibilities, use this checklist to help deter-
mine the one that is most appropriate.

Checklist: Questions To Ask About the Position:

1. Does it resonate with the audience?
2. Will it endure?
3. Does it differentiate from the competition? Does it represent something better

or different that is valued?
4. Does it represent a feasible strategy? Can the program deliver the promise or

benefit?
5. Does it support the program view?
6. Does it represent a clear vision?
7. Can people in the involved organizations clearly articulate the position?
8. Does it stimulate innovative communication activities?

Developing a Positioning Statement
A positioning statement describes how the behavior will be placed in the minds of
the audience. It is not a catchy slogan. Positioning statements help writers develop
catchy slogans, but they are not the slogans themselves. A positioning statement is
not to be included in communication materials that go to audiences. It will, how-
ever, provide direction for the strategic approach and subsequent messages.

Commercial Positioning Statements*
� Apple Computer—”Easy to use”
� BMW—”Exceptional performance”
� Federal Express—”Guaranteed next-day delivery”
� Visa—”Accepted everywhere”
� Volvo—”Safety”

The next step is to explore strategic alternatives to find one that makes the most
sense based on the position that you and your team have selected.

*http://faculty.cox.smu.edu/~rsethura/mktg6301/course_files/positioning_lec4.ppt

108 A Field Guide to Designing a Health Communication Strategy

Worksheet 4.1: Positioning Statement Worksheet
Instructions: Develop one or two sentences describing as succinctly as possible the
position for the product, service, or behavior. Make sure to include the name of the
product, service, or behavior, the unique difference that sets it apart from the
competition, and the benefit to the audience. Keep in mind that this is not a
slogan. The positioning statement is the forerunner to a slogan—to be used to
inform the creative team as they develop a slogan.

Example: Gold Star: Egypt

q

109A Field Guide to Designing a Health Communication Strategy

4

Worksheet 4.1: Positioning Statement
Instructions: Develop one or two sentences describing as succinctly as possible the
position for the product, service, or behavior. Make sure to include the name of the
product, service, or behavior, the unique difference that sets it apart from the
competition, and the benefit to the audience. Keep in mind that this is not a
slogan. The positioning statement is the forerunner to a slogan—to be used to
inform the creative team as they develop a slogan.

110 A Field Guide to Designing a Health Communication Strategy

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Again, the comparison with the work of an architect is helpful. In building a
house, the architect has many options. He knows the number of bedrooms and
toilets his client needs; he knows that the house must contain a living room, a
kitchen, closets, and perhaps other rooms that have already been determined.
Yet, he still has many choices. Should he design a three-story house or one that
has rooms all on one level? Should the house have bedrooms facing east, west,
south, or north? Where on the property should the house be situated—at a
distance from the road or closer to the road but with a large backyard? An
experienced architect explores alternatives using his mathematical and logical
skills as well as his creative talent to come up with the best design possible. The
same is true of the communication strategy team. Since many ways to solve a
communication problem exist, the best way to move forward is to make a list of
possible solutions and then start eliminating options.

Table 4.1 on the following pages lists examples of strategic alternatives, with
advantages and disadvantages for each one. Review this table to become familiar
with the many different approaches available.

Table 4.1: Some Strategic Approach Alternatives
This list is by no means all-inclusive. The key for you and your team is to find the
alternatives that best represent the needs already identified by thought and
discussion. Review table 4.1 (page 111) to help you list strategic alternatives, and
use checklist 4.1 (page 113) to review strategic approach considerations. Then use
worksheet 4.2 (page 116) to write down your ideas.

111A Field Guide to Designing a Health Communication Strategy

4

Table 4.1: Some Strategic Approach Alternatives

112 A Field Guide to Designing a Health Communication Strategy

Table 4.1: Some Strategic Approach Alternatives (continued)

113A Field Guide to Designing a Health Communication Strategy

4

Checklist 4.1: Strategic Approach Considerations

114 A Field Guide to Designing a Health Communication Strategy

Example Worksheet 4.2: Developing Strategic Alternatives

Objective: Women ages 18–29 will use short-term FP methods to space their
children.

115A Field Guide to Designing a Health Communication Strategy

4

Example Worksheet 4.2: Developing Strategic Alternatives
(continued)

116 A Field Guide to Designing a Health Communication Strategy

Worksheet 4.2: Developing Strategic Alternatives

117A Field Guide to Designing a Health Communication Strategy

4

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Every strategic approach requires an accompanying rationale. Writing a rationale
enables you to recognize the suitability of the approach and to identify any flaws
that it may have. In addition, you and your team may have to present and defend
this approach on many occasions, and a well-thought-out rationale will serve as a
sound basis for justifying your approach.

Worksheet 4.3: Summary of Strategic Approach and Rationale
Example: Uganda

Example: Approach and Rationale

In Bangladesh, the Smiling Sun smiles over
health clinics all over the country. One can
travel around and see a Smiling Sun sign in
urban areas as well as rural areas. The Smiling
Sun is a symbol for warm and caring services
provided by clinics that are a part of the
National Integrated Population and Health
Program (NIPHP); the NIPHP is a collaborative
effort of rural health clinic NGOs managed by
Pathfinder, urban health clinic NGOs managed
by John Snow, Inc. (JSI), and the Bangladesh
Center for Communication Programs (BCCP),
with funding from USAID. The major objective
was to offer integrated health services with
improved quality for a small fee through well-
trained and well-stocked NGO clinics through-
out Bangladesh. The strategic approach was to
use the health clinic as the major source of
information and services and set out to
position these clinics as offering attentive,
warm, and caring providers—something that
all clinics within the NGO network could
deliver and something that research showed
audiences demanding. This helped to differen-
tiate them from private clinics and govern-
ment health facilities. The strategy included a
long-term identity program that helped to
position the clinics as offering warm and caring
providers (worth the small service fee) through
a branding campaign that referred to the
Smiling Sun (Paribark Shastho) Clinic. Promo-
tional tools included radio and television spots,
badges worn by providers, signboards, bill-
boards, and other support materials. In
addition, the Smiling Sun logo was integrated
into all brochures, pamphlets, and provider
materials.

118 A Field Guide to Designing a Health Communication Strategy

Worksheet 4.3: Summary of Strategic Approach and Rationale

+�)�������
Chapters 5 and 6 will explain how to use the strategic approach to design specific
message points and to choose appropriate channels and tools. The messages and
channels selected should support and reinforce the positioning and strategic
approach developed in this chapter.

119A Field Guide to Designing a Health Communication Strategy

4

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��
Aaker, D. A. (1996). Building Strong Brands. New York: The Free Press.
American Express Company Quarterly Earnings Report, First Quarter 2002. (2002).
Additional Financial Information (PDF) [On-line].

Allen, F. (1994). Georgia Trend. (12 ed.) (Vols. 9) (pp. 55). ISSN: 0882-5971.
World’s Most Valuable Brands (2000). Interbrand [On-line]. Available:
www.interbrand.com

National Highway Traffic Safety Administration (1999). Fourth report to Congress.
Effectiveness of occupant protection systems and their use. Washington, DC: U.S.
Department of Transportation.

Piotrow, P. T., Kincaid, D. L., Rimon, J. G. I., & Rinehart, W. (1997). Health Communica-
tion: Lessons from Family Planning and Reproductive Health. Westport, CT: Praeger
Publishers.

Ries, A. & Trout, J. (1981). Positioning. The Battle for Your Mind. New York: McGraw-
Hill.

Shore, D. A. (2001). Creating brands people know and trust. Cambridge, MA:
Harvard University.

Sly, D. F., Heald, G. R., & Ray, S. The Florida “truth” anti-tobacco media evaluation:
Design, first year results, and implications for planning future state media evalua-
tions. Tobacco Control 10, 9-15. 2001.

Smith, P., Berry, C., & Pulford, A. (1997). Strategic Marketing Communications. Lon-
don: Kogan Page.

120 A Field Guide to Designing a Health Communication Strategy

121A Field Guide to Designing a Health Communication Strategy

5

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By the end of this chapter, the reader will understand the purpose
of a message brief and how to summarize the strategic rationale
for why the messages are being developed. In addition, the reader
will learn how to complete the message brief worksheet by:

Step 1: Identifying the Key Fact That, if Addressed, Will Lead
to the Desired Behavior Change

Step 2: Identifying the Promise to the Audience That Will
Motivate It To Adopt the Behavior

Step 3: Defining the Support for the Promise That Summarizes
Why the Audience Should Believe the Promise

Step 4: Describing the Competition for the Message

Step 5: Developing the Statement of the Ultimate and Lasting
Impression That the Audience Ideally Will Have After
Hearing or Seeing the Message

Step 6: Describing the Desired User Profile: How Does the
Intended Audience Perceive Someone Who Uses The
Product or Service Being Promoted

Step 7: Identifying the Key Message Points That Will Be Included
in All Communication Delivered by the Partners Who
Will Implement the Strategy

122 A Field Guide to Designing a Health Communication Strategy

��������

To ensure that the strategic approach is clear to the builder and then to the
workforce, your friend the architect develops detailed sketches, plans, and
ultimately his blueprints. By following these blueprints, the subcontractors
implement the architect’s strategic approach: the electricians install the wiring, the
plumbers install the pipes and ventilation system, the carpenters build the frame,
and all of the team members work together to execute the strategy.

The message brief that you will learn about in this chapter performs much the
same function as the architect’s blueprints: it puts on paper exactly what you want
your creative collaborators to accomplish.

123A Field Guide to Designing a Health Communication Strategy

5

You and your team have completed much of the groundwork for developing a
health communication strategy. Using solid communication theory, research find-
ings, and analytical thinking, you and your colleagues, such as health workers and
other stakeholders, have isolated the problem and have analyzed the situation and
all the factors that impact communication. You have also identified the primary and
secondary audience segments, defined the behavior change objectives, and de-
signed a well-orchestrated strategic approach. The positioning statement, along
with the strategic approach, provides direction and guidance for identifying a
central theme for the overall communication strategy. From this, you will move to
the step of developing a message brief for each component of the strategy.

A message brief is a document that the communication team develops and shares
with experts at an advertising agency, PR agency, creative writers and designers, or
any other organization or person involved in message development. The creative
experts use the message brief as a springboard for developing creative concepts.
Remember, it is the job of these experts to develop creative materials. The strategic
health communication team outlines “what” the messages need to say. The cre-
ative experts determine the execution—”how” the messages will be designed. The
more precise the message brief is, the more likely it is that the communication will
be effective. A “tight” message brief leaves nothing to interpretation and is inca-
pable of being misunderstood. A well-crafted message brief allows the creative
experts to explore a variety of approaches, as opposed to a loosely worded brief
that confuses the creative experts and leaves them wondering what the client
really wants and needs.

To communicate effectively with the intended audiences, the communication
team needs to design messages that are (1) on strategy, (2) relevant, (3) attention-
getting, (4) memorable, and (5) motivational. The message brief in this chapter
presents a way to summarize for the creative experts what we know about the
health issue and the communication needs of the audience. The message brief
also outlines the key fact that will lead to the desired behavior change and the
promise or benefit for the intended audience that ideally will motivate it to adopt
the change. Communication team members then define the support for the
promise and develop a statement of the ultimate and lasting impression that the
audience will take away from the message.

124 A Field Guide to Designing a Health Communication Strategy

Finally, the communication team describes the perception that the intended
audience associates with the user of the product, service, or behavior. The desired
output from this chapter is a simple, brief document that completely describes
what the message needs to accomplish.

Message Design
Message design cuts across all communication channels, such as IPC, community-
based activities, and mass media. The more the messages reinforce each other
across channels, the higher is the probability of effective impact. Strategic health
communicators craft key message points that are consistent and relevant for all
channels and tools. This consistency and relevance contribute to the overall
effectiveness of the communication strategy by ensuring that, for example, the
service provider, the community mobilizer, and the actor featured in a radio an-
nouncement all reinforce the same key message points. This approach does not
mean that planners create only one message for all these venues. It does mean
that they identify the key points that are to be made in every message that is
communicated to the audience, no matter which channel or tool is used.

Message Brief Outline
There are many variations of the message brief tool. They are all designed to
generate creative concepts and messages. In the field of commercial advertising,
the “creative brief” is used for this purpose. In the context of this book, the message
brief is suggested as a useful means of gaining insight into the audience, which is
one of the keys to designing messages that will resonate with audiences. Complet-
ing the message brief outline will provide you and your team with a simple docu-
ment that describes what the message should say and do.

The message brief has two principal parts: a strategy component and a mes-
sage development component. For the sake of completeness, the entire out-
line is presented here, even though worksheet 5.1, “Strategic Component,” was
completed by following the steps in chapters 1 through 4.

To focus on the message development component, complete the steps in
worksheet 5.2.

125A Field Guide to Designing a Health Communication Strategy

5

Worksheet 5.1: The Message Brief Outline—Strategic Component
Instructions: Summarize from the work already completed.

Example: FriendlyCare—A Network of FP Clinics in the
Philippines (FriendlyCare Communication Plan…2000)

126 A Field Guide to Designing a Health Communication Strategy

Worksheet 5.1: The Message Brief Outline—Strategic Component
Instructions: Summarize from the work already completed.

127A Field Guide to Designing a Health Communication Strategy

5

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You and your team will likely identify a central theme for the communication
strategy. In keeping with this broad theme, you will complete a message brief for
each component of the strategy and will ensure that all of the messages reinforce
one another. The following step, “Identifying the Key Fact,” is critical to developing
a well-crafted message brief for a particular strategy component.

Strategic communicators look for the key factor or the single most important fact in a
health problem or situation that, if addressed in the communication effort, will most likely
lead to the desired behavior change. The key fact may be an obstacle or an opportunity.
Selection of the single most important fact is key because a message is only effective if it
addresses a single problem. The process of selecting the key fact forces the strategist to
look for the relevance and importance that will make the message stand out.

From the information gathered in the analysis of the situation, you and your team
need to identify the key fact. It crystallizes what you know about the problem and
the opportunities for solving the problem. As planning progresses, you can expect
to observe a number of facts that might shape the creative work. The key fact can
suggest the need to:

� Eliminate a problem that the audience has with the product or idea.
� Correct an erroneous or incomplete perception that the audience may have.
� Reinforce or extend a benefit that the program delivers.
� Strengthen the reason for greater use of the product or an unexpected way to

use the product or service.
� Fill a void.

Examples of Key Facts

� People of lower socioeconomic status in
the Philippines believe in FP but perceive
that they have nowhere to go for advice.

� Men in Tanzania do not know the advan-
tages of using condoms. In addition,
condoms are known to diminish sexual
pleasure. Therefore, condom use in
Tanzania is low.

� Although there is high interest in learning
more about HIV/AIDS in Lagos, Nigeria,
young men and women do not feel at risk
and do not fully understand the implica-
tions of their high-risk behavior.

128 A Field Guide to Designing a Health Communication Strategy

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Step 2 is to identify the promise or benefit to the members of the intended audi-
ence that will motivate them to change their behavior. (See behavior change
objectives defined in chapter 3.) The purpose of this step is to select a promise that
is most persuasive to the primary audience. The promise is a clear benefit that the
audience will understand after receiving the message. The promise should serve to
differentiate the message from communication about other products, services, or
behavior. It should convey a benefit like “happy, strong adolescents” or “your
babies will live longer and healthier and will be stronger” and not a product
attribute like “a modern, hormonal method of contraception.” An attribute should
be used only when it communicates and supports the consumer benefit.

Put another way, the promise is the specific audience benefit that the health
communicator wants the audience to associate most readily with the objective or
proposed behavior change. For example, the promise of feeling secure and pro-
tected from contracting HIV or other STDs by using a condom is a clear benefit to
the audience of adopting a particular behavior. The promise is a consumer-end
benefit whose appeal is usually based on emotion and is consistent with the
attributes of the product, service, and/or behavior. Although a product, service, or
behavior may deliver more than one benefit, it is important to highlight a single
benefit. Expecting the audience to associate the promise with more than one
benefit may confuse the audience and may reduce the impact of the message.

A promise need not be tied directly to a product, service, or behavior. In many
cases, enduring promises have the feeling that the product, service, or behavior is
for a certain kind of person or a certain kind of experience. This approach is par-
ticularly relevant when competing products, services, or behaviors are perceived
to be similar in nature.

Finding the promise that will resonate with the audience is one of the most chal-
lenging tasks in developing a communication strategy because it relies on having
a clear understanding of the intended audience. Identifying the promise may

Examples of Promise Statements

� A successful campaign for Nike athletic shoes used
the tag line “Just do it” (Advertising theme
lines…2002). The tag line appeared on television
and in print but was never used with a voice-over.
Nike’s strategy was to let viewers interpret the
message themselves, while showing diverse
women and men leading active lifestyles. A
lifestyle in which the audience could realize their
goals was the promise; the Nike shoes served as a
support for the promise.

� In the FriendlyCare project, the promise tells the
consumer that at FriendlyCare, he or she is going to
find a friend and a partner who is an expert in
planning and caring for his or her family.

� A cancer prevention program wanted to increase the
number of consumers (Lefebvre et al., 1995) who eat
at least five servings of fruits and vegetables per day.
Promise statements that were relevant and motiva-
tional to the intended audience were identified,
including “Eating five servings of fruits and vegetables
a day will keep me young,” “Serving more fruits and
vegetables will make me a better parent,” and “Eating
more fruits and vegetables will help me lose weight.”
A traditional public health approach might have
promised consumers that by adopting the 5-A-Day
behavior they would reduce their risk of cancer, but
pretesting showed these other promise statements to
be more persuasive and relevant.

129A Field Guide to Designing a Health Communication Strategy

5

require additional formative research beyond what was undertaken in the analy-
sis of the situation. Many different methods to uncover this information exist. For
different ways of gaining insightful information on determining benefits, it is best
to work with a research firm with experience in communication.

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Step 3 is to define the supporting statements that summarize why the audience
should believe the promise. The support statements are based on research find-
ings that have been analyzed to understand what will make the message credible
to the audience. The reasons for the audience to believe the message may be
factual or emotional. In the message brief, the support statements summarize why
the promise is beneficial to the audience and why the promise outweighs any
obstacles to using the product or service or any barriers to adopting the behavior.

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Even if the audience understands, relates to, and is motivated by the message,
there may be other factors that limit the audience’s ability to adopt the proposed
behavior. For example, social norms that limit a woman’s ability to use FP methods
may inhibit her desire to go to a clinic and determine which method would be
best for her. In many countries, HIV/AIDS is still considered a social taboo, and
many at-risk individuals are intimidated from seeking testing, counseling, or
treatment because they are afraid of the consequences in their communities.

Most people behave the way that they do because they derive a benefit from that
behavior. In the case of the woman in the FP example above, the benefit to her of
not going to the clinic may be good relations with her husband and extended
family members. For those who do not seek HIV/AIDS testing, counseling, or

Examples of Support Statements:

Factual: Condoms prevent the transmission of
disease 99.9 percent of the time. All doctors
recommend their use.

Emotional: By using condoms, you’ll be less
fearful of contracting a disease that will make
you sterile, reduce your quality of life, or even
kill you.

Both: In Egypt, the Clinical Services Project
(CSI) Project promoted its FP services as,
“Distinguished Service at an Affordable Price.”
The factual support points were that the clinics
had modern equipment and were affordable,
accessible, clean, and comfortable. The
emotional support point was that the clinics
were recommended by clients who had
experienced their services.

130 A Field Guide to Designing a Health Communication Strategy

treatment, the benefit may be the protection of the individual’s status and reputa-
tion within the community. It is critical to understand the reasons behind the
competition when crafting new messages.

Competition for the message also exists in the more traditional sense, where a
consumer has a choice of where to go to obtain health services or where to pur-
chase health products. For organizations that are promoting their own clinics or
brands of products, for example, the audience will evaluate the communication
message in relation to other alternatives available to them. Often the challenge in
analyzing the competition is to translate a relative advantage into an absolute
advantage.

This notion of competition links back to the positioning statement developed in
chapter 4, “Strategic Approach.” Remember that an effective position must differ-
entiate itself from the competition. A positioning statement helps to communi-
cate to the audience a unique appealing difference designed to give the product
or service an edge over the competition.

Chapter 4 also notes that positioning creates the memorable cue for the audience
to know why it should adopt a specific behavior. This idea is also contained in step
3 of chapter 5, “Define the Support.” Remember that the support statement should
state why the message promise will benefit the audience and why it will outweigh
obstacles to using the product or service or to adopting the behavior.

You will encounter a number of places in the strategic design process where the
concept of competition comes into play. You and your team need to be consistent
in how you articulate what the competition is and why the audience should act
on your message as compared to other messages.

131A Field Guide to Designing a Health Communication Strategy

5

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The ultimate and lasting impression of the message is what people retain after
seeing it or hearing it, that is, the full range of thoughts, feelings, and attitudes
about the product, service, or behavior proposed in the message. In other words, it
is the “take-away” of the message, including its call to action.

The overall impression is not a slogan but the belief and feeling that the audience
should get from the communication. The take-away message may be explicit or
implicit and may be communicated verbally or nonverbally. You should strive for
a multifaceted but single-minded impression that will contribute to creating a
powerful message brief. Such a message will communicate the identity of the
strategy, paint a picture in the audience’s mind, and help to build a long-term
identity for the product, service, or behavior.

Example

Promise statement: FriendlyCare is my
partner and friend in planning and caring for
my family.

Overall impression statement: FriendlyCare
clinics can provide me and my family with
high-quality, affordable, caring services like
those that I would expect to get at much more
expensive facilities.

132 A Field Guide to Designing a Health Communication Strategy

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You and your team need to identify the important personality characteristics that
the audience associates with the use of the product or service or with the change
in behavior. Every message makes a statement about the kind of people that the
audience perceives as using the product or service or performing the behavior.

You, the strategist, must think like the audience and ask:

� What is the profile of someone who would use the product or service or who
would adopt the behavior?

� Do others want to emulate these users?
� What is it about the users that makes others aspire to be like them?
� Are these users perceived as smart, concerned for their families, modern, and

responsible?

Example

In Nigeria, a campaign to promote an HIV/AIDS
hotline used the mass media to communicate
with young men and women, ages 15–24,
living in the Lagos metropolitan area (Nigeria
HIV/AIDS Creative Brief, 2001). The campaign’s
objective was to have young adults discuss
HIV/AIDS openly and knowledgeably. The HIV/
AIDS hotline was intended to inform the
audience about this topic.

Based on research, the strategy team decided
that the desired user profile was young men
and women who were “in the know” or
knowledgeable about HIV/AIDS. The commu-
nication messages and materials reinforced
this desired user profile by showing charac-
ters who were confident and respected by
their peers and were communicated by
dialogue as well as body language in the
communication materials.

133A Field Guide to Designing a Health Communication Strategy

5

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Now you are ready, based on steps 1 through 6, to identify the key message points
that will be included in all communication delivered by the partners who will
implement the strategy. The key message points will be delivered in different
ways based upon the work that the advertising agency or other communication
experts develop. A message point can be a core theme, such as the “Life Choices”
(Campaign materials…2001) concept in Ghana. A message point can also be used
specifically as an advertising slogan or as a counseling message or can be built
into community-based activities.

All messages, regardless of how they are delivered or by whom, should consis-
tently contain the same core information. Medical staff in clinics, counselors,
pharmacy staff, field workers, and any other partners in the communication effort
should reinforce the key message points.

Example

In Ghana, the key message point of the “Life
Choices” campaign was that FP is a means to
achieving your goals in life. The campaign
highlighted the relationships among decisions
couples make about when to use FP, which
methods to use, how many children they want,
how far apart the children will be spaced, and
how these decisions affect the life goals that
these couples have set for themselves.

A wide variety of channels and tools was used
to communicate the “Life Choices” messages.
All of these channels and tools built upon the
same key message points and reinforced one
another. At the community level, for example,
meetings were held at which satisfied users of
FP discussed how their reproductive health
decisions have allowed them to pursue various
goals in life. A PR plan provided trained
spokespersons who appeared on television
and radio to discuss how FP has helped them
achieve their goals. Service providers were
trained to reinforce the notion of life choices
with their clients. These service providers
understood that they were not merely
providing FP services but were key actors in
enabling clients to reach their life goals.

TIP: Follow the seven C’s of effective
communication (Williams, 1992) when
developing messages:

1. Command attention.
2. Cater to the heart and head.
3. Clarify the message.
4. Communicate a benefit.
5. Create trust.
6. Convey a consistent message.
7. Call for action.

134 A Field Guide to Designing a Health Communication Strategy

Example 5.2: Sample Message Brief Worksheet

Example: FriendlyCare—Summary of Message Brief Outline—
Message Development Components

135A Field Guide to Designing a Health Communication Strategy

5

Example 5.2: Summary Message Brief Worksheet
Example: Uganda

136 A Field Guide to Designing a Health Communication Strategy

Worksheet 5.2: Summary Message Brief

137A Field Guide to Designing a Health Communication Strategy

5

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The message brief helps you and your team to develop messages that are on
strategy, relevant, attention-getting, memorable, and motivational. The content of
the message brief is consistent with the information gathered in the analysis of
the situation, audience segmentation, behavior change objectives, and strategic
approach phases of the strategy design process. If you find the process of devel-
oping the message brief confusing or problematic, your strategic approach may
need to be revisited.

The key message points identified as a result of the message brief consist of the
essential themes that should be included through all communication channels
used by any of the strategy partners. Once you have completed the steps outlined
in chapter 5, you are ready to study chapter 6, where you will analyze and select
the communication channels and tools that will help you deliver the key message
points.

138 A Field Guide to Designing a Health Communication Strategy

$������#��

Advertising themelines and advertising materials (2002). (pp. 158). Portland,
Oregon: Wieden & Kennedy Advertising.

Campaign materials for Life Choices Family Planning program (2001). Accra,
Ghana: Lintas Advertising designed for JHU/CCP and Ghana Social Marketing
Foundation.

Friendly Care Communication Plan (unpublished) (2000). Manila: Friendly Care
Marketing Division.

Lefebvre, R. C., Doner, L., Johnston, C., Loughrey, K., Balch, G., & Sutton, S. M. (1995).
Use of database marketing and consumer-based health communication in mes-
sage design: An example from the Office of Cancer Communications’ “5 A Day for
Better Health” program. In E.Maibach & R. Parrott (Eds.), Designing health mes-
sages: Approaches from communication theory and public health practice (pp.
158). Newbury Park, CA: Sage Publications.

Nigeria HIV/AIDS Creative Brief (unpublished) (2001). Lagos: Johns Hopkins School
of Public Health, Center for Communication Programs.

Williams, J. R. (1992). The Seven C’s of Effective Communication. Baltimore, MD:
JHU/CCP presentation materials.

139A Field Guide to Designing a Health Communication Strategy

6

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By the end of this chapter, the reader will be able to identify
channels and tools for communicating the message by:

Step 1: Choosing the Channels That Are the Most Likely To
Reach the Intended Audience:

� Evaluate the best strategic approach for the
channel mix.

� Evaluate each channel’s capacity to reach the
audience in the most cost-efficient manner.

� Select a lead channel and supporting channels,
with a rationale for each.

Step 2: Determining Tools

Step 3: Integrating Messages, Channels, and Tools

140 A Field Guide to Designing a Health Communication Strategy

��������

Your friend the architect, of course, does not actually build the school. He chooses
a general contractor and, through him, subcontractors to do the job. For the
architect, these skilled technicians serve as channels for him to achieve his objec-
tives. In turn, these technicians use the tools of their trades to build the school: the
carpenter uses his saws, hammer, and nails; the electrician strings wires and con-
nects them to the main source of electricity and to outlets; the plumber uses his
wrench to install and connect pipes.

Similarly, you will use channels and tools to reach your intended audiences, and
this chapter shows you how to choose the tools and how to integrate them.

141A Field Guide to Designing a Health Communication Strategy

6

You will spend the bulk of your communication budget on creating materials and
placing them in the most suitable channels and on using the most appropriate tools
for communicating to audiences. This chapter will help you select the communication
channels and tools that are most likely to move the strategic approach forward in the
most cost-efficient manner.

In chapter 1, you listed the available communication channels and the audiences best
reached by these channels (worksheet 1.3a). In subsequent chapters, you identified the
primary and secondary audiences, set behavior change objectives, determined the
overarching strategic approach, and developed key message points. Now it’s time to put
these pieces together by matching audience profiles with the channels of communication.

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Before you can decide what materials to produce, you must first decide what
communication channels will best reach the intended audience. Health commu-
nicators have defined communication channels as modes of transmission that
enable messages to be exchanged between “senders” and “receivers.”

The various types of communication channels are:

� Interpersonal Channels, which include one-to-one communication, such as
provider to client, spouse to spouse, or peer to peer.

� Community-Based Channels, which reach a community (a group of people
within a distinct geographic area, such as a village or neighborhood, or a
group based on common interests or characteristics, such as ethnicity or
occupational status). Forms of community communication are:
— Community-based media, such as local newspapers, local radio stations,

bulletin boards, and posters.
— Community-based activities, such as health fairs, folk dramas, concerts,

rallies, and parades.
— Community mobilization, a participatory process of communities identify-

ing and taking action on shared concerns.

142 A Field Guide to Designing a Health Communication Strategy

� Mass Media Channels, which reach a large audience in a short period of time
and include:

— Television
— Radio
— Newspapers
— Magazines
— Outdoor/Transit Advertising
— Direct Mail
— The Internet

f

143A Field Guide to Designing a Health Communication Strategy

6

144 A Field Guide to Designing a Health Communication Strategy

To start developing a channel strategy, write down opportunities (or openings) for
sending your message during a typical day in the life of your audience. The
example below, together with worksheet 6.1, identifies the various opportunities
for exposure.

Example 6.1: A Typical Day in the Life of the Intended Audience
Worksheet
Instructions: Fill out this chart to track a typical day in the life of the intended
audience, which should include home, workplace, and leisure time activities. This
information should be readily available through consumer-based research and by
speaking with potential members of the audience. Indicate where opportunities
exist for audience members to be exposed to communication channels.

145A Field Guide to Designing a Health Communication Strategy

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Worksheet 6.1: A Typical Day in the Life of the Intended Audience
Instructions: Fill out this chart to track a typical day in the life of the intended
audience, which should include home, workplace, and leisure time activities. This
information should be readily available through consumer-based research and by
speaking with potential members of the audience. Indicate where opportunities
exist for audience members to be exposed to communication channels.

Compare the above worksheet with worksheet 1.3a developed in chapter 1 that
listed available communication channels. Are there matches between the list of
available channels and the typical day? If so, you should concentrate on these
channels. Circle the channels that you might use.

146 A Field Guide to Designing a Health Communication Strategy

Evaluate the Best Strategic Approach for the Channel Mix
Your next decision is to decide the focus of the channel mix. What is the best way
to reach the intended audience, based on the objectives in chapter 3? Should you
focus on building reach, building frequency, or maximizing both?

Build Reach Quickly
Do you want to reach as many different people in the audience segment as
quickly as possible? If so, the channel mix will be based on reach. This approach
means that the lead channels selected are ones that can reach a large number of
people in a short period of time. In some countries, television is considered such a
medium. In other countries, it is radio. Community events can reach a large num-
ber of people within a community, but the frequency of message exposure is
limited to the timeframe of the event and to the number of events planned for a
community.

Emphasize Frequency
Should the channel mix be one that steadily conveys a message to build recall
over a long period of time? If so, emphasize frequency, and use a medium that
may not reach as many people quickly but is affordable enough to repeat mes-
sages regularly over an extended period of time. Radio in many countries is a
good example of a channel that helps to build frequency. Radio advertising is
relatively inexpensive, and radio spots can be repeated over and over during a
campaign. IPC at a health clinic is a way to build frequency by ensuring that
different levels of health providers reinforce the messages and by repeating the
messages at each provider visit.

Combine Reach and Frequency
To build reach, but not at the expense of minimizing frequency, consider using an
equal combination of these approaches. You will reach a large number of people
on an ongoing basis. In some counties, a combination of television, radio, commu-
nity events, and IPC is a way to build both reach and frequency at the same time.

TIP: If you are not sure whether
rating surveys are available in your
country, check with an advertising
agency. If surveys are not available,
consider collaborating with other
organizations to fund a survey.

Definitions

These definitions may be helpful, especially
when working with advertising agencies.

Reach: The number or percentage of members of a
defined audience segment that will be exposed to
a message at least once. Reach helps to build
momentum quickly.

Frequency: The average number of times that one
person is exposed to a message. Frequency helps
ensure message penetration.

Gross Rating Points: In broadcast media, the
combination of reach and frequency is measured as
Gross Rating Points. Ratings are the percentage of a
specified audience segment that is viewing or
listening to a particular program at a specific time.
The accumulation of ratings (based on the number
of television or radio spots bought in these time
periods) equals total Gross Rating Points. The
percentage of reach multiplied by average fre-
quency also gives total Gross Ratings Points. “Gross
Impressions” is the term used when this is given in
actual numbers instead of percentage points.

147A Field Guide to Designing a Health Communication Strategy

6

Evaluate Each Channel’s Capacity To Reach the Audience in
the Most Cost-Efficient Manner
A good channel mix balances a variety of factors, such as the size of the audi-
ence reached and the cost of reaching this audience. To compare each channel
on a cost-efficiency basis, divide the cost of placing the message by the audi-
ence reached.

Example 6.2: Evaluating Each Communication Channel
Worksheet
Instructions: Fill in the type of channel, the audience reached, and the esti-
mated cost in the first three columns. In column 4, estimate the cost per
thousand. In column 5, rate the channel’s credibility. Check the boxes that
offer both efficiency and credibility.

Example: Nicaragua1

Example

The cost of a television spot is divided by the audience reached (in
thousands) using the latest television program ratings data. The result
will give you a cost-per-thousand to use for comparison purposes.

If a television program reaches 400,000 women ages 18–35
and if the cost of a television spot on the program is $500, the
cost per thousand is $1.25.

You can do the same calculation for a magazine ad. Divide the
cost of a page in a magazine by readership (in thousands) to
obtain a cost per thousand. Cost-per-thousand comparisons
are used to compare one television station with another, to
compare one medium with another, and to compare one
communication channel with another. Mass media will clearly
reach more people more often in a less costly way on a cost-
per-thousand basis. Conducting such an evaluation helps
justify the use of different channels.

148 A Field Guide to Designing a Health Communication Strategy

Worksheet 6.2: Evaluating Each Communication Channel
Instructions: Fill in the type of channel, the audience reached, and the estimated
cost in the first three columns. In column 4, estimate the cost per thousand. In
column 5, rate the channel’s credibility. Check the boxes that offer both efficiency
and credibility.

149A Field Guide to Designing a Health Communication Strategy

6

The Multichannel Approach
Research has demonstrated that a multichannel approach has a better chance of
changing behavior than a single channel approach (Piotrow, Kincaid, Rimon, &
Rinehart, 1997). In addition, a multichannel approach, especially an approach that
uses mass media, can achieve objectives more quickly. Using several channels
enables you to reach more people and to reach people in different environments
with more frequency. The combination of multiple channels also offers a synergy
to the campaign and gives it more impact. It is important for the primary audience
as well as for other secondary and influencing audiences, who will most likely be
exposed to these same messages. This exposure will, in turn, help to reinforce in
them the necessity of supporting the campaign.

Achieve a Seamless Channel Mix
The ideal multiple channel mix is one that reaches a large proportion of the
audience segment efficiently. Messages delivered through these channels must
be consistent and reinforce each other. This means, for example, that messages on
television are consistent with messages delivered at health clinics.

The strategist should understand how the audience responds to each channel, so
that the message is seamless. For example, when adolescents are at a village
concert sponsored by a social marketing company, the messages that they are
exposed to are reinforced with materials they receive through peer counselors
and ones they hear on the radio.

Example

In Kenya, an FP campaign called Haki Yako used radio,
community mobilization, and IPC, with radio being the
lead channel. The conclusion in the Information,
Education, and Communication (IEC) Field Report
(December 1996) was that “using several communica-
tion channels . . . reached three-fourths of the adult
population of Kenya. In fact, the overlapping coverage
of various media increased the level of exposure and
had a reinforcing effect on those exposed.”
(Kim, Lettenmaier, & et al., 1996)

Example

In the United States, the Department of Agriculture
(USDA) School Meals Initiative for Healthy Children is a
comprehensive plan that aims to ensure that children
eat healthy meals at school. USDA established Team
Nutrition as a way to ensure that schools are able to
provide healthy meals to children and to motivate them
to eat more healthful foods. The goals of Team Nutrition
include eating less fat, eating more fruits, vegetables,
and grains, as well as eating a variety of foods. A
nutrition education program was delivered through the
media, in schools, and at home, to build skills and
motivate children to make healthful choices. The
program was evaluated to determine the impact of
multiple channels, and evaluation showed that the
degree of behavior change was directly related to the
number of channels that students reported being
exposed to (Lefebvre, Olander, & Levine, 1999).

150 A Field Guide to Designing a Health Communication Strategy

Select a Lead Channel and Supporting Channels, With a Rationale
for Each
You must determine which channel will be the lead channel and which ones will
serve as supporting channels. Just as a locomotive pulls the other cars on a train,
the lead channel will be the “engine” that pulls the other channels with it. Think
about your worksheets as you answer the following questions:

� Which channel will reach the largest proportion of the intended audience?
� Which channel will fit the message brief most appropriately?
� Which channel will achieve the greatest impact?

Although a mass medium may reach more people, it may not always make sense
to choose it as a lead channel.

Use the following worksheet to determine the lead channel and supporting
channels. Write a rationale for each channel.

Example

In Bangladesh, the lead channel was
“jiggasha,”* a Bangla term used to signify a
community social networking meeting,
because this was the channel capable of
reaching women of reproductive age at a
place where they would be most receptive
and responsive to the messages. “Jiggasha”
was reinforced by radio broadcasts and
print materials.

* “A Bangla term, which means ‘to inquire,’ was
selected by the Bangladeshi staff to represent the
community network approach because it implies the
active participation of village women in obtaining
health and FP information, counseling, and supplies.”

(Kincaid, 2000)

151A Field Guide to Designing a Health Communication Strategy

6

Example 6.3: Summary of Communication Channels Selected
Worksheet

Example: Ghana’s “Life Choices”
In Ghana, a demand generation strategy for FP was designed to encourage the use
of modern contraceptives among several audience segments: young sexually active
unmarried adults, young married adults who wanted to space the number of chil-
dren that they planned to have, and more mature married adults who wanted to
limit the number of children that they had. Since the strategic approach was to
associate FP with the ability to achieve life goals and since the messages were
designed to focus on specific characters, television became the lead channel to help
deliver the story of each character’s life goal and subsequent FP choice.

152 A Field Guide to Designing a Health Communication Strategy

Example 6.3: Summary of Communication Channels Selected
Worksheet

Example: Uganda

Worksheet 6.3: Summary of Communication Channels Selected

153A Field Guide to Designing a Health Communication Strategy

6

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Suppose you want to visit your relatives in another town. You have many ways of
getting to the town. You can go by river and take a ferry or hire a small boat. You
can go by rail and take the express train or the local train. You can go by road and
take a taxi, take a bus, or drive your own car. The river, rail, and road serve as the
route to get you from one place to the other—they serve as the channel. The ferry,
small boat, train(s), taxi, bus, or car serve as the tools that you will take to access the
channel. It is the same with communication channels and tools. For example,
television and radio are mass media channels, while advertising and publicity are
tools. Channels enable you to reach the audience, while tools are what you use on
those channels.

Tools are the tactics used to send messages through the channels and include
advertising, publicity, entertainment education, advocacy, community participa-
tion, provider training, events management, and private partnership development.

A communication strategy team has a bag of tools or a toolkit to choose from. The
challenge is to choose the best combination of tools to follow the strategic ap-
proach and achieve the objectives.

Your team needs to understand how the tools work, what tools will work best to
achieve objectives, and when to use them. Advocacy, for example, can help to
establish an environment that supports a behavior before an audience is exposed
to messages. A campaign of advocacy to religious leaders in Jordan paved the
way for an adolescent reproductive health campaign. A mass media advertising
and PR campaign can help dispose policymakers to support a policy change. In
Romania, the launching of a nationwide multichannel campaign on women’s
health was the impetus for the MOH to move ahead with a program to ensure that
providers of FP were being compensated for their work.

Eight Tools of Strategic Communication:
Definitions and Examples

1. Advocacy: a set of tools used to create a shift
in public opinion and mobilize necessary
resources and forces to support an issue,
policy, or constituency.

2. Advertising: a set of tools to inform and
persuade in a controlled setting through paid
media, such as television, radio, billboards,
newspapers, and magazines.

3. Promotion: a set of tools for providing added
incentives to encourage the audience to
think favorably about a desired behavior or to
take some intermediate action that will lead
toward practice of the desired behavior, such
as coupons, free samples, contests, sweep-
stakes, and merchandising.

4. IPC Enhancement: a set of tools that can
enhance personal interaction between clients
and providers, including discussions within and
outside the clinic. It includes not only training the
information providers, but also enhancing the
place where the communication takes place.

5. Event Creation and Sponsorship: developing
and/or sponsoring events for the purpose of
calling attention to and promoting a desired
behavior, such as a news conference,
celebrity appearance, grand opening, parade,
concert, award presentation, research
presentation, or sporting event.

6. Community Participation: a set of tools for
helping a community to actively support and
facilitate the adoption of a desired behavior.

7. Publicity: the use of nonpaid media communi-
cation to help build audience awareness and
affect attitudes positively.

8. Entertainment vehicles, such as television or
radio programs, folk dramas, songs, or games,
provide entertainment combined with
educational messages.

154 A Field Guide to Designing a Health Communication Strategy

The major questions to ask are:

� What tools do we need to support the strategic approach?
� How will they be used?
� Why should these tools be used?
� How will these tools fit into the overall picture?
� How will these tools work together?

Other questions to ask are:

� Do our partners have the ability to manage these tools?
� Do we have the resources to finance these tools?

If advertising, for example, is a viable option, it is best to hire an advertising agency
to handle materials development and media placement. (See “How To Select and
Work With an Advertising Agency.”) For more on managing tools, see chapter 7.

155A Field Guide to Designing a Health Communication Strategy

6

Table 6.2: Eight Tools: Advantages, Disadvantages, and Appropriate Uses

156 A Field Guide to Designing a Health Communication Strategy

Table 6.2: Eight Tools: Advantages, Disadvantages, and Appropriate Uses (continued)

157A Field Guide to Designing a Health Communication Strategy

6

Table 6.2: Eight Tools: Advantages, Disadvantages, and Appropriate Uses (continued)

158 A Field Guide to Designing a Health Communication Strategy

Examples of Channels and Tools
Table 6.3 shows the relationship between channels and tools and some of the
materials used for each category. For example, mass media as a channel is a way to
transmit messages. However, messages can be conveyed through designing fully
produced programs, paid advertising spots, or news items as a result of a publicity
campaign. All of these tools are using the same channels of communication but
require different skills and/or organizations (advertising agencies, PR firms, pro-
duction companies) to help you implement them.

159A Field Guide to Designing a Health Communication Strategy

6

Table 6.3: Relationship Between Channels and Tools

Review the example for worksheet 6.4, and then fill in the worksheet to select the
tools that you will use.

160 A Field Guide to Designing a Health Communication Strategy

Example 6.4: Summary of Tools Selected Worksheet

Example: Nigeria’s Democracy and Governance Communication
Strategy
A communication effort was developed with the objective of encouraging Nige-
rian citizens of voting age to become involved in civic affairs and especially to
work within existing groups that may already belong to advocate for social
change. A combination of tools was used to encourage Nigerians to get involved.

Example 6.4: Summary of Tools Selected Worksheet

Example: Uganda

161A Field Guide to Designing a Health Communication Strategy

6

Worksheet 6.4: Summary of Tools Selected

162 A Field Guide to Designing a Health Communication Strategy

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The advantage of strategic communication is that the planning process allows
you to see a whole picture of how to use messages, channels, and tools to maxi-
mize communication efforts, as described in the following example.

Example: A Nutrition Campaign on
Breastfeeding

The intended audience is young mothers and
the key issue is to encourage exclusive
breastfeeding for the first 6 months of a child’s
life. The strategic approach is to convince
pregnant women during the antenatal period
that they should exclusively breastfeed their
newborn child. The message is based on the
woman’s desire to keep the baby healthy
during infancy. Channels are IPC, community
communication, and radio. Tools used are
training providers to counsel pregnant women
during antenatal visits, IPC materials to support
counseling efforts and reinforce positive
behavior at the provider site, group meetings
at marketplaces on market days, and an
entertainment education radio program that
focuses on nutrition. All of the efforts men-
tioned are planned together, so that messages
are consistent and reinforce each other, while
the timing of all efforts falls within the same
period for maximum impact.

163A Field Guide to Designing a Health Communication Strategy

6

Example: Integrating Channels and Tools

The Zambia Integrated Health Program (ZIHP) was designed to move forward the implementation
of health reform in selected districts in the country. It focused on the needs of various audiences
and offered specific integrated packages of health services to each audience. ZIHPCOMM was
designed to communicate to the four basic audiences: women, men, caretakers of children, and
youth, and focused on four technical areas: malaria, HIV/AIDS, integrated reproductive health, and
child health and nutrition. ZIHPCOMM had three major objectives: to increase demand for popula-
tion, health, and nutrition interventions; to change knowledge and attitudes about health behaviors;
and to increase knowledge about when and where to go for services. Within ZIHPCOMM, sets of
interventions were developed that corresponded to different communication channels. The Better
Health Campaign became the mass media application and included radio and television messages
about health behaviors. The Neighborhood Health Committee package became the community
partnership component that included training of CHWs and print materials to support their training
and ongoing community work. A radio program provided distance education to support commu-
nity partners. This became the glue for the whole community partnership package. It provided
updates on the health interventions as well as the community mobilization techniques.

The interpersonal intervention package complemented the mass media and community interven-
tion packages. The package included a set of clinic-based activities, including counseling kits,
training materials, and other clinic support materials, such as posters, wall paintings, and leaflets. All
of the elements of the interpersonal package contributed to enhancing the experience that clients
and patients have at the clinic for any of the health-related areas: FP services, maternity services,
child health care, reproductive tract infections, or other HIV-related services.

The Better Health Campaign, the Neighborhood Health Committee package, and the clinic package
complement each other to ensure that all levels of the system receive appropriate materials with
consistent messages from a credible source. Each package is flexible enough to accommodate
changing program foci yet offers a consistency and a credibility that increases the level of impact.

����������
You are getting closer to developing an implementation plan. You have an
overarching strategic approach, key message points, and now a channels and
tools mix. The next step is to determine how to manage this strategy, that is, who
will implement the strategy, who will collaborate, how this effort will be coordi-
nated, what timeframe to use, and what financial resources you will need.

164 A Field Guide to Designing a Health Communication Strategy

����������

Greenberg, R. H., Williams, J. R., Yonkler, J. A., Saffitz, G. B., & Rimon II, J. G. (1996). How
to select and work with an advertising agency: Handbook for population and
health communication programs. Baltimore: Johns Hopkins School of Public
Health, Center for Communication Programs.

Kim, Y. M., Lettenmaier, C., & et al. (1996). Haki Yako: a client provider information,
education and communication project in Kenya. (Rep. No. 8). JHU/CCP: IEC Field
Report.

Kincaid, D. L. (2000). Social Networks, Ideation, and Contraceptive Behavior in
Bangladesh: a Longitudinal Analysis. Social Science and Medicine, 50, 215-231.

Lefebvre, R. C., Olander, C., & Levine, E. (1999). The impact of multiple channel
delivery of nutrition messages on student knowledge, motivation and behavior:
results from the Team Nutrition Study, Innovations in Social Marketing Conference.
Montreal, Canada.

Piotrow, P. T., Kincaid, D. L., Rimon, J. G. I., & Rinehart, W. (1997). Health Communica-
tion: Lessons from Family Planning and Reproductive Health. Westport, CT: Praeger
Publishers.

165A Field Guide to Designing a Health Communication Strategy

7

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By the end of this chapter, the reader will understand the
importance of management for strategic health communication
and the elements of successful management by completing the
following steps:

Step 1: Identifying the Lead Organization and Collaborating
Partners

Step 2: Defining the Roles and Responsibilities of Each Partner

Step 3: Outlining How the Partners Will Work Together

Step 4: Developing a Timeline for Implementing the Strategy

Step 5: Developing a Budget

Step 6: Planning To Monitor Activities

166 A Field Guide to Designing a Health Communication Strategy

��������

The architect, the builder, and the subcontractors constitute the team that will
build the school. Together, the architect and the builder manage the project: they
draw up agreements for working together, determine a schedule, and prepare a
budget. Specifically, they will determine how and when the team members—
engineers, electricians, plumbers, painters, and decorators—will do their work. In
addition, the architect and the builder specify how they will monitor progress and
plan for solving problems and maintaining quality control.

Likewise, you will need to manage all the elements of your communication efforts,
most importantly your coworkers and any collaborating agencies. This chapter
will show you how to develop a management plan.

167A Field Guide to Designing a Health Communication Strategy

7

Successful management requires leadership, clearly defined roles and responsibili-
ties, close coordination and teamwork between all the participants, and adherence
to a timeline and budget. This chapter explains the strategic considerations inherent
in each of these elements and discusses how to develop a management plan.

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To distinguish the lead organization from collaborating partners, start by identify-
ing the key functional areas and skills that need to be in place to carry out the
strategy. Typically, these roles include management coordination, policy, research,
advertising, media planning and placement, PR, community-based activities,
training, monitoring, and evaluation. Some of these may not apply to the particu-
lar communication strategy at hand, and often functions not listed above may be
relevant. Plan only for those roles that are appropriate to the situation.

The Lead Organization
The group designated as the lead organization is often responsible for the overall
coordination of the strategy design and implementation. Within this organization,
one manager is typically designated as the contact person through whom all infor-
mation should flow. The contact person often makes sure that all activities are on
strategy, within budget, and on schedule and that all partners are involved and kept
up-to-date. This organization will write the management plan, coordinate with
other groups to implement the plan according to an agreed-upon timeline and
budget, and keep the management plan on track. The lead organization is usually
responsible for obtaining all necessary approvals for activities. It often serves as a
focal point for issuing status reports and for alerting other groups to problems and
issues that require attention. This organization should always have a clear, “big
picture” notion about why various activities are taking place and how these activi-
ties interrelate. Also, this group should work collaboratively with other partners in
establishing clear timelines that include decisionmaking approval points. The lead
organization often helps build the capacity of the collaborating partners through
the day-to-day work of implementing the communication strategy.

168 A Field Guide to Designing a Health Communication Strategy

Potential Collaborating Partners
For Policy Matters. Facilitating the implementation of the strategy according to
plan may require policy changes, either in the public or private sector. For ex-
ample, perhaps the local government has never before allowed mention of pre-
scription contraceptives on television, or perhaps a privately owned radio station
is reluctant to allow programming that includes references to STDs. To change
such obstacles may require various advocacy tactics at the highest levels. Roles
may include individuals with appropriate influence serving on an advisory board
or coordinating committee that oversees the communication effort. This ap-
proach will ensure that a management mechanism is in place to deal with policy
obstacles.

For Research, Monitoring, and Evaluation. If there is a research component in the
strategy or if there are plans for monitoring and evaluation, several options exist
for choosing who will carry out the research. Although expertise may exist within
the lead organization, staff members are often committed to other responsibilities
and may not be able to get information as quickly as required. Chapter 8 contains
several suggestions for identifying research firms and provides additional infor-
mation on this topic. Once the research partners are selected, make sure that they
have all of the background information they need and that they have a chance to
meet with all partners.

For Advertising. An in-house group rarely has the skills and experience to de-
velop and implement a comprehensive communication campaign that includes
creative materials development, production, media buying, and other advertising
agency functions. Experience has demonstrated the advantage—almost always—
of having the lead organization select and contract with an advertising agency to
carry out this work (Greenberg, Williams, Yonkler, Saffitz, & Rimon II, 1996).

For Media Placement. The advertising agency will typically take care of buying
media time and ensuring that messages are delivered according to the media
plan. If the advertising agency is unable to provide this service, you may have to
engage an individual or company whose specialty is media buying.

169A Field Guide to Designing a Health Communication Strategy

7

For PR. PR is another area that the advertising agency may or may not be able to
manage. Depending on the country, the scope of the communication strategy, and
the level of PR expertise within the country, you may find it worthwhile to engage
a PR agency or consultant to help implement the strategy. PR staff work with high-
level decision-makers at the lead organization and other collaborating agencies
to train these individuals as spokespersons and to prepare them in the event that
the program comes under criticism. This type of work requires strategic manage-
ment decisions and close collaboration with other partner agencies.

For Community-Based Activities. Although a communication strategy may not
necessitate working with community-based groups to ensure smooth implemen-
tation, engaging the services of a grassroots organization can sometimes be
helpful in disseminating messages to the intended audience. In other instances,
the program may benefit by enlisting support from women’s groups, health
groups, or local opinion leaders. Identify the community-based activities that are
key to the strategy, and then decide whether it is appropriate to forge a collabora-
tive partnership with community members or whether it is preferable to subcon-
tract to one or more organizations for this purpose. See the resource book titled
How to Mobilize Communities for Health and Social Change, published by JHU/
PCS in collaboration with Save the Children, for ideas about how to work with
communities.

For Training. Identify any areas where gaps in skill or knowledge might prevent
the management team from achieving the objectives of the strategy. For example,
if the strategy includes developing a campaign to promote clinic use, the plan
may need to provide for the training of clinic workers to increase their counseling
skills prior to launching the campaign. Decide which training needs are most
critical and whether you can justify the costs of meeting those needs in light of the
overall budget.

Example

The HEART Campaign in Zambia is managed by
a Design Team consisting of about 10 different
people representing different organizations.
Given the focus in this campaign on promoting
safer sex among young people, HEART is
guided by a Youth Advisory Group (YAG), which
is comprised of 35 young people from 15
youth-serving organizations around the
country. The YAG developed the behavior
change objectives and message points for
each audience segment. Strong linkages were
developed among all of the partners in the
campaign. These partnerships proved to be
critical when controversy arose and the
television spots were pulled off the air. The
youth representatives were able to come
together quickly and present a united front in
expressing their objection to the cessation of
the television spots. This spontaneous and
unified response on the part of the young
people enabled the Design Team to effectively
negotiate for the reintroduction of the
campaign, which occurred within 2 months of
the ads being stopped.

170 A Field Guide to Designing a Health Communication Strategy

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Once the lead organization and collaborating partners have been identified, the
next step is to delineate respective roles and functions to ensure successful imple-
mentation of the program. As these roles are determined, try to establish ways of
working that will benefit the partner organizations as well as support the communi-
cation strategy. For example, a group of health professionals may be willing to
advocate for government support of the strategy because that will help them forge
closer ties with host country officials. Partner organizations must derive a benefit
from participating in the strategy; otherwise, they are unlikely to collaborate.

Use worksheet 7.1 to help you map out how the participating groups will work
together.

Example 7.1: Identify Key Functional Areas and Skills Required
Worksheet

Example: Country X

171A Field Guide to Designing a Health Communication Strategy

7

Worksheet 7.1: Identify Key Functional Areas and Skills Required

172 A Field Guide to Designing a Health Communication Strategy

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Write a brief memorandum of understanding (MOU) for all parties to sign outlin-
ing how day-to-day management will be handled. Summarize who the players
are, what their functional roles will be, and how they will coordinate their activi-
ties. To get started, answer the following questions:

� Will there be an advisory body consisting of the collaborating partners?
� Will the advisory body meet on a regular basis?
� What decisionmaking authority will the advisory body have?
� Will the lead organization handle day-to-day coordination and provide the

collaborating partners with regular written updates of activities?

Many different ways of managing and coordinating exist, and it is important to
select a set of tools that makes sense for all of the partners involved. For example,
if the partners are not located in the same geographic area, you may find it more
practical to rely more on telephone calls and written reports than face-to-face
meetings. Keep the management guidelines simple, and revisit them regularly to
see if you need to change them.

For examples of how to delineate roles and responsibilities, see the sample man-
agement descriptions for the Ghana Long-Term Family Planning Methods IEC
Campaign and the regional West Africa project known as SFPS at the end of this
chapter.

173A Field Guide to Designing a Health Communication Strategy

7

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If the communication strategy is to be implemented in phases, establish a timeline
that shows when the major activities of each phase will take place and where the
key decision points are. Since communication efforts are usually tied to service
delivery, training, and other areas, it is important to create a timetable with appro-
priate linkages to these other functions.

Several commercial software programs designed to aid in project management
decisions are available, or it may be sufficient to use a simple grid format on a
piece of paper. The focus should remain strategic—that is, identify only the major
milestones at this point. A detailed management implementation plan should
follow later.

Use the timeline as a guide to ensure that implementation activities stay on track.
Make adjustments as needed, and be sure to communicate the status of activities
to all relevant partner organizations.

To help develop your timeline, review worksheet example 7.2, and then complete
worksheet 7.2.

174 A Field Guide to Designing a Health Communication Strategy

Example 7.2: Timeline Worksheet

Example: Country X Phase 1 Timeline—as of January 1, 2003

175A Field Guide to Designing a Health Communication Strategy

7

Worksheet 7.2: Timeline

176 A Field Guide to Designing a Health Communication Strategy

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Developing a budget ensures that you have available the financial resources that
you need to carry out your communication strategy in all its parts. Although the
strategy team may use several different approaches for developing a budget, one
of two situations usually prevails and will drive the process:

� The amount of funding is fixed, and the strategy team must allocate these funds
across all activities for a finite time period and must justify these allocations.

� The team conducts an analysis of the situation, identifies the intended audi-
ences, sets objectives, and then obtains funding commitments from one or
more sources to continue designing the communication strategy and to
implement it. In this instance, opportunities for leveraging funds from other
organizations or programs are usually also explored.

To estimate the actual amount of funding needed for each category in the budget,
you should research comparable costs in your country and obtain quotations
from contractors for services, such as research and advertising. Review worksheet
example 7.3, and complete worksheet 7.3 to guide you and your team in develop-
ing your budget.

177A Field Guide to Designing a Health Communication Strategy

7

Example 7.3: Budget Worksheet

Example: Country X
This example provides an illustrative Year 1 budget (January through December). As
such, there is no funding allocated for evaluation. The media launch is projected for
November of Year 1.

178 A Field Guide to Designing a Health Communication Strategy

Worksheet 7.3: Budget

179A Field Guide to Designing a Health Communication Strategy

7

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Monitoring is an important, but often overlooked, function in strategy execution. A
good management plan contains a clear process for tracking the implementation of
campaign activities. For example, how will you know if clinic materials, such as
handouts, are in all of the appropriate places and are being distributed to the in-
tended audience? How will you determine whether community events have oc-
curred according to the strategy? Who will track the advertising to make sure that it
is aired or published on schedule? Who will be responsible for ensuring a continu-
ous supply of campaign materials? Who will collect client service statistics?

You and your team will want to avoid situations such as the one in which a large
number of posters were printed and then were stored indefinitely in a warehouse
because no instructions had been given to the health clinics about why the
materials were important and how the clinics should use them.

You and your team should plan to monitor such activities. Decide what organiza-
tion will be responsible for each activity. For example, your advertising agency
will likely conduct media tracking; the lead organization or one or more collabo-
rating partners may perform other monitoring tasks.

Example

In Zambia, phase 2 television spots for
the HEART Campaign were not aired in
adherence to the media plan, which
resulted in television spots discussing
condom use among young people being
shown during the news hour when
families typically watch television
together. Incorrect broadcasting of the
spots contributed to an already sensitive
environment in which certain Govern-
ment, religious, and community leaders
had expressed concerns about the
appropriateness of mass media messages
directed at young people that dealt with
sex and condom use.

180 A Field Guide to Designing a Health Communication Strategy

Conclusion
A good management plan includes a clear description of the roles and responsi-
bilities of the partners involved, a realistic timeline, a feasible budget, and a de-
scription of monitoring tasks. It takes strong leadership, organizational skills, and
collaboration to work in a team environment that builds local capacity and gener-
ates effective communication strategies.

When developing a practical management plan, remember these guidelines:

� Keep management tasks simple. Refer to the strategy’s behavior change
objectives, and ensure that management activities support these objectives.
Stop doing what does not need to be done, and focus on getting results.

� Empower people by offering effective leadership, training and retraining of
staff, and job aids or tools to help staff do their jobs well.

� Improve the organizational climate by setting forth clear plans, strengthening
the commitment to excellence, and building capacity through structural and
systems improvement.

� Monitor progress, make changes when necessary, and provide feedback in a
timely manner to those who need it.

Use worksheet 7.4 to summarize who will be involved, what roles each partner will
play, the timeline, estimated budget, and monitoring functions. Next, read chapter
8 to understand the key issues in planning for evaluation.

181A Field Guide to Designing a Health Communication Strategy

7

Example 7.4: Summary of Management Plan Considerations
Worksheet

Example: Country X

182 A Field Guide to Designing a Health Communication Strategy

Example 7.4: Summary of Management Plan Considerations
Worksheet

Example: Uganda

183A Field Guide to Designing a Health Communication Strategy

7

Worksheet 7.4: Summary of Management Plan Considerations

184 A Field Guide to Designing a Health Communication Strategy

Sample Management Plans
The following descriptions of management roles and responsibilities use different
formats, yet they are each valid ways to depict how specific tasks will be managed.
As with all components of a good strategic communication strategy, there are
different approaches that can be used, and strategic designers should use their
creativity, technical skills, and cultural sensitivity to ensure that the management
plan developed is appropriate for the situation.

Sample Management Plan I
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Background: A workshop held in Achimota, Ghana, in May 1996, brought all of the
stakeholders together for the purpose of developing a national communication
strategy to encourage the use of long-term FP methods. The lead organization
was the MOH of Ghana. Collaborating agencies were:

� National Population Council (NPC)
� Planned Parenthood Association of Ghana (PPAG)
� Ghana Registered Midwives Association (GRMA)
� Ghana Social Marketing Foundation (GSMF)
� Lintas Advertising
� Cooperating agencies (CAs), such as JHU/PCS and Engender Health, formerly

known as the AVSC
� USAID
� Religious organizations

Project Implementation: Workshop participants decided to set up a coordinating
committee of key organizations: MOH, AVSC, JHU/PCS, NPC, PPAG, GRMA, and
GSMF. In addition, they issued a request for proposals from advertising agencies to
develop creative materials and handle media placement. Lintas won the contract.

(Yonkler, 1997)

185A Field Guide to Designing a Health Communication Strategy

7

Sample Management Plan I (Continued)

The coordinating committee approved materials developed by Lintas and coordi-
nated regional launches in 5 of the country’s 10 regions. Each organization had re-
sponsibility for a specific aspect of the strategy: AVSC trained providers, MOH con-
tracted with the ad agency and was the main liaison, NPC coordinated the regional
launches, PPAG trained local drama groups to provide entertainment education
programs, GRMA trained midwives, and GSMF disseminated brochures and posters.

Campaign Roles of Each Coordinating Committee Member

� MOH/Health Education Unit (HEU)

– Serves as the contact point for Lintas Advertising.
– Provides liaison with Lintas and the IEC Campaign Committee.
– Issues request for services (RFS).
– Approves budgets and tracks payments.
– Monitors timetables to ensure that work is on schedule.
– Provides input to Lintas and assists Lintas in getting input from other

committee members.
– Helps set up meetings between Lintas and the IEC Campaign Committee.
– Assists with the regional incentive campaign.
– Participates on the training subcommittee.
– Distributes client materials and provider materials to public health facilities.

� Lintas

– Develops, designs, and produces print materials, such as posters, client
leaflets, question-and-answer brochures, press kits, campaign slogans, and
regional campaign kits; radio spots and four to six radio programs for
regional use; PR services, such as assistance with launch events and media
training for key spokespeople; and other creative materials.

– Submits status reports, budgets, and conference reports in a prompt fashion.
– Makes MOH/HEU aware of adjustments in schedules and budgets.
– Prepares cost estimates.
– Obtains competitive bids for production activities.

186 A Field Guide to Designing a Health Communication Strategy

– Documents and completes invoices.
– Develops media schedules, when appropriate.
– Recommends radio stations, timing, number of spots, costs, and rationale.
– Trains journalists, correspondents, and other media personnel.

� Engender Health (formerly AVSC)

– Furnishes input on provider training, provider sites, and expert lists; updates
committee and agency on sites.

– Participates on the training subcommittee.
– Serves as one of the key informants for Lintas creative staff in developing

question-and-answer brochures.
– Trains and works with satisfied clients—several from each region—to

appear on radio and television shows, hold press interviews, and
participate in community activities.

– Helps with regional launch events.

� PPAG

– Helps with community mobilization efforts
– Manages small grants programs with local drama groups.
– Provides training in IEC counseling.
– Participates on the training subcommittee.
– Refers clients to service sites when appropriate.
– Assists with the distribution of print materials.

� NPC

– Coordinates regional campaigns.
– Sets up meetings with regions.
– Assists in providing input on provider training; updates committee and

agency on latest activities.
– Serves as one of the key informants for Lintas in developing question-and-

answer brochures.
– Helps with regional launch events.
– Helps coordinate the training of media personnel.

187A Field Guide to Designing a Health Communication Strategy

7

Sample Management Plan I (Continued)
– Serves as the resource for regional activities, collects materials from each

region, and serves as the liaison between agency and regional committees.
– Assists with the regional incentive campaign
– Coordinates training and counseling materials.
– Coordinates the activities of the training subcommittee.
– Assists MOH/HEU with the day-to-day management and scheduling of ad

agency materials development.

� GSMF

– Distributes posters and client leaflets to pharmacies, hairdressers, barber shops,
and other retail outlets, either through merchandise runs or through sales
representatives in four regions (Greater Accra, Eastern Region, Central Region,
and Western Region); uses another form of distribution in Ashanti Region.

– Assists with launch event funds.
– Assists MOH/HEU as needed with the creative and media development process.
– Refers clients to service sites.

� JHU/PCS

– Guides the coordinating committee and ensures adherence to the strategy.

� GRMA

– Assists with the distribution of print materials.
– Refers clients to service sites.
– Participates on the training subcommittee.

� MOH/MCH–FP

– Participates on training subcommittee.
– Assists MOH/HEU with resource mobilization.
– Refers clients to service sites.
– Coordinates and disseminates the list of service provider sites to other

organizations.

188 A Field Guide to Designing a Health Communication Strategy

Sample Management Plan II
Management Approach for the SFPS Project

Background: Declining resources forced USAID to close nearly half of its bilateral
missions in West and Central Africa (WCA). At the same time, health officials
recognized that major public health problems in the region were common to the
region and transnational in nature. Efforts to address some of the most pressing
health concerns in WCA were no longer effective when carried out only through
isolated country programs. Programs could be more cost-effective when imple-
mented on a regional basis.

In 1995, USAID authorized a Family Health and AIDS program in West and Central
Africa (FHA–WCA). With an 8-year timeline, FHA–WCA is responsible for achieving
regional impact on FP, HIV/AIDS prevention, and child survival through a combi-
nation of country-level and regional programming.

The main implementing program of FHA–WCA is the SFPS project. This project
does not use the traditional model of prime contractor with subcontractors but
rather an innovative procurement and management approach that created equal
partners who share responsibility for program management, coordination, and
implementation. SFPS consists of five separate cooperative agreements between
USAID and five U.S. private voluntary organizations: JHU/CCP, Johns Hopkins
Program for International Education in Reproductive Health (JHPIEGO), Popula-
tion Services International (PSI), Tulane University, and most recently Family Health
International (FHI). JHU/CCP works in the area of behavior change communica-
tion. JHPIEGO specializes in service delivery, training, and finance and administra-
tion. PSI is a social marketing organization that sells health products through the
private sector. Tulane’s role is to conduct operations research and to monitor and
evaluate activities. FHI provides support in the area of HIV/AIDS.

Project Implementation: The cornerstone of collaboration between the project’s
partners is its Unified Management Team (UMT), which consists of professional
staff members from each partner agency and is based in Côte d’Ivoire. Team

(Shereikis & Wyss, 2000)

189A Field Guide to Designing a Health Communication Strategy

7

Sample Management Plan II (Continued)

members meet regularly to ensure that the various activities are in harmony with
the objectives defined in the results package and the overall vision for SFPS. All of
the partners work together to prepare the annual work plan, and each organiza-
tion is responsible for preparing its own budget.

The core UMT consists of the Chiefs of Party (COPs) from each of the collaborating
agencies. A MOU provides details regarding how the team approaches issues,
such as deciding on program priorities, coordinating component activities, and
developing work plans. The MOU specifies that, to help facilitate consensus
building, to promote collaboration, and to coordinate program activities across
organization lines, the JHPIEGO COP will serve as the team leader (TL). The MOU
includes specific directions regarding how the consensus decisionmaking process
shall work. Similarly, communication systems and procedures are outlined in the
MOU, and provisions are included for collaborating with other donor agencies.

Decisions typically requiring consensus among UMT members include any deci-
sions with funding implications for individual CAs, initiatives outside the work
plan, revision of project strategies or the results package, and decisions with
political or corporate implications. All decisions are resolved within the UMT
without requiring outside mediation. This attests to the strong collaborative spirit
of the UMT, which has ensured close collaboration among CAs without compro-
mising clinical and behavior change communication expertise.

190 A Field Guide to Designing a Health Communication Strategy

The UMT is supported by three collateral units that enhance the project’s opera-
tional coherence:

� Leadership Unit—This unit has a TL responsible for articulating and keeping
up the program vision, coordinating program activities, and facilitating con-
sensus building.

� Finance and Administration Unit—This unit is responsible for budgeting and
disbursement of joint operational costs in the Abidjan office and the four
country offices.

� Monitoring and Evaluation Unit—This unit has a regional monitoring and
evaluation coordinator who works closely with each country office, program
information manager to monitor and assess the progress and performance of
SFPS.

SFPS uses a performance-based management approach tied to a results frame-
work for its main project areas: FP, child survival, HIV/AIDS, and capacity building.
For each result, intermediate results and indicators are set. Performance is as-
sessed and reported semiannually to USAID. A consistent project-reporting
mechanism and review schedule help the team to focus on project objectives and
keep track of progress. Every quarter, progress on activities is reported to USAID
against milestones preset in the project work plan for each component.

191A Field Guide to Designing a Health Communication Strategy

7

����������

Greenberg, R. H., Williams, J. R., Yonkler, J. A., Saffitz, G. B., & Rimon II, J. G. (1996). How
to select and work with an advertising agency: Handbook for population and
health communication programs. Baltimore: Johns Hopkins School of Public
Health, Center for Communication Programs.

Shereikis, M. & Wyss, S. (2000). A regional model for successful health intervention
in a low resource environment. (2nd ed.) (pp. 227). Abidjan, Cote d’Ivoire: SFPS
Working Paper.

Yonkler, J. (1997). Ghana long term family planning management plan (unpub-
lished). Accra, Ghana.

192 A Field Guide to Designing a Health Communication Strategy

193A Field Guide to Designing a Health Communication Strategy

8

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By the end of this chapter, the reader will understand the
importance of evaluation for strategic health communication
programs and the key elements of monitoring and impact
assessment by completing the following steps:

Step 1: Identifying the Scope and Type of Evaluation

Step 2: Planning for Monitoring and Impact Assessment

Step 3: Identifying the Evaluation Design and Sources of
Data

Step 4: Tailoring the Evaluation to the Specific Situation

Step 5: Deciding Who Will Conduct the Evaluation

Step 6: Planning To Document and Disseminate Evaluation
Results

194 A Field Guide to Designing a Health Communication Strategy

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When conceptualizing a design for a new school, your friend the architect must
think ahead to how the teachers, students, and staff will actually use the school. At
every stage of the planning and execution of the building process, he and his
team must consider the impact of the school design on the ability of the users to
maximize its utility.

Similarly, evaluation plays a key role in a communication strategy because
without it no one can judge whether the strategy was either applied or effec-
tive. Planning for evaluation occurs from the very beginning of the strategy
design process. Ideally, an evaluation plan is generated in participatory fash-
ion with input from various stakeholders, such as program staff, community
groups, research experts, and donor organizations. The communication spe-
cialist does not need to be an expert in research methodology but does need
to play an active role in developing the evaluation plan to ensure that it
focuses on the appropriate communication issues.

195A Field Guide to Designing a Health Communication Strategy

8

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Determining the appropriate scope and type of evaluation that is both needed
and possible is a key element in strategic design. At the basic level, evaluation
serves the purposes of:

� Finding out whether the implementation activities spelled out in the work
plan were actually carried out (process evaluation or monitoring)

� Determining whether the objectives set forth in the strategy (see chapter 3)
were achieved (impact assessment).

Evaluation, like research, must be addressed at the beginning of any strategic
communication project. The initial definition of strategic communication
objectives guides every stage of evaluation. Thus, an objective of changing
individual behavior requires an evaluation that will measure individual be-
havior over time; a policy objective of passing specific legislation will require a
means to determine whether or what part of that legislation became law; and
an objective of stimulating community activism will require from the start
measures or indicators of community activism.

The evaluation design must focus on the intended unit of analysis as well as
expected changes. Therefore, those who carry out the evaluation should ideally
participate in helping to set SMART objectives in such a way that those objectives
and the process of achieving them can be accurately and precisely measured
throughout the project.

At a more complex and strategic level, evaluation should also:

� Assess the adequacy of the strategy selected
� Highlight areas of high and low impact
� Identify not only individual or community behavior change, but also measure

population-based health and social outcomes, such as birth and death rates,
education levels, and voting registration

TIPS for an Effective Evaluation Design:

1. Evaluation must be introduced, under
stood, and planned from the start of a
program and must be based on the
program objectives. It cannot be a last
minute addition. To measure change, it
is essential to have baseline data before
an intervention takes place as well as
postinterventiondata.

2. Program evaluators need to assist
program personnel in articulating
objectives in measurable terms consis-
tent with behavior change theory and
in using research methodologies that
are practical and appropriate to the
situation.

3. Evaluations should avoid overly sweep-
ing claims of impact from pre- and
postdata alone. Cross-sectional data
can document correlation between
variables but not causality.

4. The use of different types of data and
more extensive analysis can strengthen
the probability that a specific commu-
nication intervention caused a measur-
able change in behavior or contributed
an identifiable amount to the change.

196 A Field Guide to Designing a Health Communication Strategy

� Highlight ways to improve the program
� Measure cost-effectiveness per person reached or per any measure of behavior

change

Without a documented evaluation, policymakers, program planners, funders, and
participants will not know what happened, why, when, or with what effect. Within
a few years, for all practical purposes, a program that is not evaluated will not have
existed.

The following chart summarizes the ways that evaluation can be used in public
health programs.

Selected Uses for Evaluation in Public Health Practice by Category
of Purpose

Gain Insight
� Assess needs, desires, and assets of community members.
� Identify barriers and facilitators to service use.
� Learn how to describe and measure program activities and effects.

Change Practice
� Refine plans for introducing a new service.
� Characterize the extent to which intervention plans were implemented.
� Improve the content of educational materials.
� Enhance the program’s cultural competence.
� Verify that participants’ rights are protected.
� Set priorities for staff training.
� Make midcourse adjustments to improve patient/client flow.
� Improve the clarity of health communication messages.
� Determine whether customer satisfaction rates can be improved.
� Mobilize community support for the program.

197A Field Guide to Designing a Health Communication Strategy

8

Selected Uses for Evaluation in Public Health Practice by Category
of Purpose (continued)

Assess Effects
� Assess skills development by program participants.
� Compare changes in provider behavior over time.
� Compare costs with benefits.
� Find out which participants do well in the program.
� Decide where to allocate new resources.
� Document the level of success in accomplishing objectives.
� Demonstrate that accountability requirements are fulfilled.
� Aggregate information from several evaluations to estimate outcome effects

for similar kinds of programs.
� Gather success stories.

Affect Participants
� Reinforce intervention messages.
� Stimulate dialogue, and raise awareness regarding health issues.
� Broaden consensus among coalition members regarding program goals.
� Teach evaluation skills to staff and other stakeholders.
� Support organizational change and development.

(Centers for Disease Control and Prevention, 1999)

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Chronologically, once objectives have been established, evaluation must address:

� First, monitoring of program activities and outputs
� Second, impact assessment

Each of these types of evaluation requires different action and skills.

198 A Field Guide to Designing a Health Communication Strategy

Monitoring
Monitoring requires attention to process, performance, and, to a lesser extent,
outcomes:

� Process monitoring—Here evaluators must measure whether activities
occurred with the planned frequency, with the planned intensity, with the
appropriate timing, and as directed to reach the intended audience. Ideally,
monitoring begins at the start of the program activities and continues
throughout the length of a program or campaign. Retrospective monitoring is
less reliable than ongoing monitoring.

� Performance monitoring—The quality, quantity, and distribution of commu-
nication outputs must be closely followed. For example, were the expected
number of posters printed and distributed to the designated locations? Were
the expected number of health care providers or others trained in the proper
use of communication materials? Did all members of the management and
communication team carry out their functions as planned? Were the quality
and volume of the outputs, whether posters, serial dramas, or community
events, at the expected and desired levels? In what ways did the performance
of the management team meet expectations and work plan requirements?
These measures of both process and performance monitoring should be as
specific and as quantitative as possible, since it would be impossible to deter-
mine the success of the strategy if, in fact, it was not carried out as planned.

� Outcome monitoring—Here the evaluation focus shifts from activities and
actions back toward original objectives. If the objectives were increased
attendance at certain specific clinics, increased purchase of certain products, or
increases/decreases in a specified behavior, such as partner reduction or
condom use, to what extent did these changes take place? During the monitor-
ing process, extensive surveys may not be possible, but onsite observation and
interviews are important to ensure that expected outcomes are beginning to
take place. Unintended outcomes, different from those identified as original
program objectives, would immediately call for close attention, feedback to
program directors, and, if necessary, changes in either implementation or
strategy.

199A Field Guide to Designing a Health Communication Strategy

8

In short, monitoring is essential to be sure that the program is being carried out as
planned and that no unintended, unforeseen, or unexpected events or shifts are
taking place. Whether the planned activities are in fact responsible for producing
whatever changes may be observed (for example, the question of causality)
usually cannot be determined at this stage during the progress of a campaign.

Impact Assessment
More difficult, but essential for any large-scale communication strategy, is some
form of impact assessment. Impact assessment seeks to answer the question “Did
the communication strategy achieve the specified objectives?” Impact assess-
ment then goes on to look at the difference that the strategy made in the overall
program environment.

Indicators
As discussed in chapter 3, the first step in impact evaluation is to determine the
indicators you will use to determine whether your objectives have been achieved.
Examples of individual-level indicators for the behavior change communication
strategies include (Bertrand & Escudero, 2002):

� Percent of audience with a specific attitude (toward a product, practice, or
service)

� Percent of audience who believe that their spouses, friends, relatives, and
community approve (or disapprove) of a product, practice, or service

� Percent of non-users who intend to adopt a certain practice in the future
� Percent of audience who are confident that they can adopt a particular behavior

At a broader social level, the indicators listed below can be used to measure social
change. Some of these indicators are measured qualitatively and others are more
appropriately measured through quantitative techniques:

200 A Field Guide to Designing a Health Communication Strategy

Indicators of Social Change

� Leadership
� Degree and equity of participation
� Information equity
� Collective self-efficacy
� Sense of ownership
� Social cohesion
� Social norms

For detailed explanations of these terms and for guidance on how these indicators
can be used within an integrated model of communication for social change, see
(Figueroa, Kincaid, Rani, & Lewis, 2002).

A key issue in impact assessment is the research design or plan for the evaluation,
which must be determined early in the project. Traditionally and particularly in
biomedical research, the so-called Gold Standard for impact assessments is an
experimental design in which individuals or communities are randomly assigned
to be involved or not to be involved in a specific intervention. After the interven-
tion is complete, the difference between those involved in the intervention and
those not involved determines the impact of the project.

Experimental Design
Experimental design is not feasible for many communication programs and
certainly is not appropriate for large-scale communication projects. The major
problems that arise in applying experimental design to strategic communication
are as follows:

� The control group and the experimental group must be the same in all key
characteristics that might influence the outcome.

� No differing events or activities, apart from project activities, must take place
among either those exposed or those in the control group.

� There must be no contamination or shared activities or information between
the control and the experimental group.

201A Field Guide to Designing a Health Communication Strategy

8

Not only is it almost impossible on a large scale to select comparable communities,
but also, and even more important in communication projects, it is almost impos-
sible to prevent contamination from one audience to another. Since the goal of an
effective communication project is to disseminate information, ideas, and advice, a
strong communication project will almost inevitably spread beyond its original
boundaries. The only types of strategic communication projects that can be
considered for an experimental design are those that relate to facilities that may
be widely dispersed geographically or geographic areas that are not close to one
another but otherwise similar—both unlikely possibilities. In other words, while
experimental design is valuable—and indeed essential—in evaluating the impact
of drug treatments on individuals where individuals are randomly assigned and
do not know their own status, experimental design is not conceptually appropri-
ate for most strategic communication interventions.

Quasi-Experimental Designs
A substitute for a pure experimental design in some communication projects is a
quasi-experimental design in which a randomized selection of control and inter-
vention groups does not take place. Instead, an effort is made to identify both
control and intervention areas or units that are as comparable as possible and to
limit the strategic communication program to certain areas while measuring
changes in both areas. Even in such quasi-experimental designs, problems fre-
quently arise as to the similarity of the controls, differing events in different areas,
and, above all, contamination between the two groups. The degree of exposure is
a key element of most communication programs, and unlike interventions consist-
ing of specific drug treatments, exposure is determined not by the provider but
rather by the reactions of the audience. Therefore, it is clear that exposure to a
strategic communication intervention cannot be controlled in the same way in
which exposure to a new or experimental medication can be controlled by dis-
pensing physicians. Therefore, even at best, quasi-experimental designs with
measurements before and after intervention may not be convincing.

202 A Field Guide to Designing a Health Communication Strategy

Use of Statistical Analysis To Account for Population Differences and
Contamination
Since exposure to strategic communication cannot be managed as accurately as
exposure to different medications, various statistical techniques can be used to
compensate for differences in control and intervention populations and, to a
lesser degree, for contamination, that is, exposure in the control group and
nonexposure in the experimental group. Weighting one or another population to
be similar can control these differences. Various other forms of analysis can be
used after pre- and postdata are collected.

One commonly used technique is bivariate analysis, in which researchers deter-
mine whether there is a correlation between two variables by examining the
strength and directions of the relationship. For example, in a positive relationship,
if the value of one variable increases, so does the value of the second variable. In a
negative relationship, as the value of one variable increases, the value of the
second variable decreases. However, bivariate analysis does not assume a causal
relationship between the two variables.

Regression analysis is used when one or more variables are assumed to predict or
explain changes in another variable. When multiple variables are used to predict
the dependent variable, regression analysis allows the impact of each variable to
be evaluated separately, holding all other variables constant. For example, analy-
sis of a communication campaign might determine that audience receptivity to a
message (the dependent variable) can be predicted by measuring related vari-
ables, such as the believability of the message and media weight.

203A Field Guide to Designing a Health Communication Strategy

8

Establishing a Causal Relationship
In all strategic communication programs and in almost all evaluations of the impact
of a communication program, skeptics may question the degree to which communi-
cation alone contributed to changing behavior. To strengthen the causal inference
that the communication project was indeed responsible for the behavior changes
measured, programs should seek to establish eight key points. From the start of the
evaluation, therefore, data must be collected relating to each of these points (JHU/
CCP, 2001).

� Evidence of a change in the desired behavior from time 1 to time 2. See
graph 1, below, for an illustration of a change in behavior that took place after
a hypothetical campaign.

� Evidence that the change occurred during or after the intervention took
place. Graph 1 also indicates that the change clearly occurred after the strate-
gic communication took place. A major issue in evaluating changes in behav-
ior following communication interventions is selectivity bias in the audience.
Were those who recalled the material previous users, already predisposed, or
self-selected to respond to that issue? This cannot be measured in a single
survey that offers only cross-sectional data. However longitudinal surveys,
which analyze the same or very similar groups over time and ask about current
practice, can identify more clearly which came first: certain knowledge, experi-
ence and attitudes, or exposure to the strategic communication.

Graph 1

204 A Field Guide to Designing a Health Communication Strategy

� Evidence that greater change occurred among those exposed to the strate-
gic communication campaign than among those not exposed. A strategic
communication program should document from the start how many and what
segments of the population were exposed to the communication intervention,
so that their behavior change, if any, can be compared with and hopefully will
exceed that of those who were not exposed to the campaign. One problem in
determining exposure is that exposure may be direct by actually seeing,
hearing, or participating in a communication intervention, or exposure may be
indirect through discussions with others who have been directly exposed. In
order to include such indirect exposure to campaigns, specific data may be
collected on IPC relating to strategic programs as well as, for example, direct
viewership of a television serial. Graph 2, below, illustrates the difference in the
use of modern contraceptive methods between (1) those directly exposed to a
radio program, (2) those who heard the radio messages from peers, and (3)
those who did not hear messages from either the radio or their peers.

Graph 2

205A Field Guide to Designing a Health Communication Strategy

8

� Evidence of scientific plausibility. To strengthen claims that a strategic com-
munication program caused behavior change, it is important to build cam-
paigns upon an appropriate theory of behavior change and to document not
only the final results, but also the intermediate or other preliminary steps to
such behavior change. For example, if knowledge and approval of a specific
practice declined, while at the same time the practice itself seemed to increase,
this would cast validity upon the findings. Graph 3, below, illustrates how
collecting data on intermediate indicators, based upon a theory of behavior
change from knowledge to approval to practice, lends further validity to the
inference that a strategic communication program caused the change.

Graph 3

206 A Field Guide to Designing a Health Communication Strategy

� Control of confounding variables. To ensure that any changes observed were
the result of the communication intervention rather than some external event,
such as opening or closing of facilities, increases or decreases in price, changes
in weather, civil disorder, political change, or other factors, it is essential to
control to the degree possible for such confounding variables. To control for
such variables means to identify those variables at the start, to collect data
regarding those variables to the extent possible, and to weigh the final analy-
sis accordingly. Graph 4, below, shows the relationship between new cases of
malaria and a decrease in rainfall, given the context of an antimalaria cam-
paign that occurred during the same time period. The graph suggests that
reduced rainfall rather than the campaign may be the major cause of the
decline in new malaria cases.

Graph 4

207A Field Guide to Designing a Health Communication Strategy

8

� Evidence of a dose response. One type of measurement derived from medical
and clinical studies that can often strengthen causal inference regarding the
impact of communication activities is the use of dose response measurements.
It is hypothesized that increased exposure to communication will increase the
likelihood of behavior change. Therefore, measurement of exposure should
consider exposure not as a “yes” or “no” variable but rather as a cumulative
variable in which the extent of exposure, either to different interventions or
repeatedly to similar interventions, can be collected and evaluated. Graph 5,
below, indicates how a typical dose response effect might operate.

Graph 5

208 A Field Guide to Designing a Health Communication Strategy

� Evidence of magnitude and direction of changes. Clearly the greater the
behavior change in the desired direction, the more convincing is the case that
the communication intervention was effective.

� Evidence of replicability. The final test of causality in scientific experimenta-
tion is the ability to replicate results by other investigators and/or in other
projects. While this may not always be possible in communication interven-
tions, every effort should be made to repeat interventions and to evaluate to
confirm the validity of initial data. To the extent that interventions are de-
signed along similar lines and with comparable research designs, the existence
of a number of different studies increases the inference that a specific inter-
vention not only was effective in one setting, but also can be effective in
different settings. The ability to predict future results is a key element in causal
inference. To the extent that multiple studies confirm a similar result, this
replication adds to the validity of the individual studies.

In short, impact analysis in the field of communication will always be controversial
and may be questioned by skeptics. For that very reason, it is important that the
evaluation of strategic communication programs seeks to document impact and
to strengthen causal inference in as many different ways as possible.

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When considering how the evaluation of a communication effort should be
designed and which sources of data will be used, it is helpful to keep the concep-
tual framework to the left in mind.

This framework can be adopted to fit other health behaviors in addition to the
adoption of a FP method. The variables in this framework can be analyzed in
different ways to measure changes at the individual, program, and outcome levels.
It is important to note that the audience’s process of weighing the personal risks
and benefits of adopting the behavior and the audience’s perception of commu-
nity norms impact an individual’s decision whether to pursue the proposed
behavior change.

209A Field Guide to Designing a Health Communication Strategy

8

Levels of Measurement
The evaluation of strategic communication depends upon the collection of data
at different levels relevant to the objectives of the program. The two major levels
of measurement for communication evaluation data are:

� Population-based
� Program-based

Population-based measurement is useful in tracking initial, intermediate and
long-term outcomes. For example, surveys among the intended audience
measure self-reported exposure, knowledge, attitudes, emotions and other factors
that are often precursors to behavior change (known as initial outcomes). Surveys
can also track changes in behavior or practice over the life of a project (i.e., inter-
mediate outcomes). These intermediate outcomes in turn influence the long-term
outcomes related to health status, such as fertility or mortality rates. The following
example on Zimbabwe measured both initial and intermediate outcomes. The
one from Bolivia also included the long-term outcome of infant mortality.

Example: Promoting Sexual Responsibility Among Young People in Zimbabwe

In 1997–98, a multimedia campaign promoted sexual responsibility among young people in
Zimbabwe while strengthening their access to reproductive health services by training providers.
Baseline and followup surveys, each involving approximately 1,400 women and men ages 10–24,
were conducted in 5 campaign and 2 comparison sites. Logistic regression analyses were conducted
to assess exposure to the campaign and to assess its impact on young people’s reproductive health
knowledge and discussion, safer sexual behaviors, and use of services. The results showed that the
campaign reached 97 percent of the youth audience. Awareness of contraceptive methods in-
creased in campaign areas. As a result of the campaign, 80 percent of respondents had discussions
about reproductive health—with friends (72 percent), siblings (49 percent), parents (44 percent),
teachers (34 percent), or partners (28 percent). In response to the campaign, young people in
campaign areas were 2.5 times as likely as those in comparison sites to report saying no to sex, 4.7
times as likely to visit a health center, and 14.0 times as likely to visit a youth center. Contraceptive
use at last sex increased significantly in campaign areas (from 56 percent to 67 percent). Launch
events, leaflets, and dramas were the most influential campaign components. The more components
that respondents were exposed to, the more likely they were to take action in response.

(Kim, Kols, Nyakauru, Marangwanda, & Chibatamoto, 2001)

210 A Field Guide to Designing a Health Communication Strategy

Example: Bolivia’s National Reproductive Health Program

In Bolivia, a series of carefully designed and well-executed reproductive health campaigns contrib-
uted significant improvements in the health status of Bolivian mothers and their children. (See
appendix 3—Bolivia Case Study.) From 1994 to the present, the National Reproductive Health
Program has implemented a strategic communication effort to address specific audience needs
using a variety of communication channels. This program has been research-driven, and the key
outcome results—an increase in contraception use and a reduction in infant mortality—are noted in
graph 6, below.

(The Johns Hopkins University Center for Communication Programs, 1999)

Graph 6

211A Field Guide to Designing a Health Communication Strategy

8

Program-based measurement depends upon the collection of service statistics,
sales data, client exit interviews, interviews or observations within clinic or service
settings, and possibly a review of organizational and management factors relevant
to program performance.

Types of Data Needed
In assessing communication programs, it is important to collect different types
of data. Since communication affects individuals, groups, and communities, it is
important to gather quantitative and qualitative information as well as information
relevant to the appropriate unit of analysis.

Example: Length of Counseling Sessions and the Amount of Relevant
Information Exchanged: A Mystery Client Study in Peruvian Clinics

Time constraints have been implicated in FP providers’ inability to offer comprehensive counseling
to their clients. It is important for providers to know whether lengthening counseling sessions
increases the amount of relevant information imparted to clients. Using the mystery client tech-
nique, 28 women were trained to pretend to solicit an effective method and to opt for the injectable
contraceptive at 19 clinics in urban areas from a national sample of MOH facilities in Peru. Each clinic
was visited on different days by 6 of these “simulated clients,” for a total of 114 cases. For each visit,
the woman recorded on a 46-item checklist the topics discussed by the provider and estimated the
duration of the counseling session. Providers dedicated anywhere from 2–45 minutes to counseling.
The amount of information given that was relevant to the client’s choice significantly increased, by
43 percent, when the session length went from 2–8 minutes to 9–14 minutes. However, further
improvements in the amount of useful information exchanged were trivial and nonsignificant when
session lengths extended beyond 14 minutes. At any duration, many pieces of information that
should have been exchanged were not exchanged. Offering a wide range of contraceptive options
took up most of the consultation time and was highly correlated with session length. Discussion of
the chosen method’s side effects and screening for contraindications did not vary by session length.
The study concluded that counseling sessions longer than 14 minutes confer little advantage in
terms of effective counseling for women who choose the injectable. It is important that providers
use the available time more efficiently, that they be more practical in assessing clients’ needs, and
that they avoid providing too much information about irrelevant methods. They should focus on the
method chosen by the client and address that specific method in greater depth.

(León, Monge, Zumarán, García, & Ríos, 2001)

212 A Field Guide to Designing a Health Communication Strategy

� Quantitative data. These data can be derived from surveys, service statistics, or
sales data and involve active measures to gather information from individuals,
communities, sites, or facilities in sufficient quantity, quality, and relevance for
further analysis. None of these are easy to collect or without problems.
– Surveys—The most common form of quantitative data with respect to

strategic communication and behavior change is derived from surveys
among randomly selected individual respondents. Surveys are a complex,
highly specialized form of operational research that require implementa-
tion by experts.

� Service Statistics—Collection of service statistics may appear as a relatively
easy task to be undertaken by visiting various facilities. In practice, however,
service statistics have usually proved less satisfactory than surveys conducted
by experienced survey researchers. Problems in the use of service statistics
include:

1. Different degrees of accuracy and completeness in maintaining
service statistics

2. Different definitions of terms, such as initiation and continuation, as
well as change in practices by different facilities

3. Illegible or incomprehensible records
4. Inaccessible records
5. Gaps in key data

Improvement of service statistics through management information systems is a
continuing goal which might simplify the evaluation of some strategic communi-
cation programs, but it remains an ideal rather than an actuality in most countries.

� Sales Data—Collection of sales data can be an important element, particularly
in the evaluation of social marketing programs. Some questions to be answered
include:

Consider the following questions when
planning for a survey:

1. What geographic areas will be surveyed? This is
usually determined by policymakers, donors, and
project managers.

2. What individuals, based on demographic or other
characteristics, will be surveyed? This will be influ-
enced by the audience and objectives selected in the
strategic plan.

3. How many people will be included in the survey to
assure the statistical significance of expected
results? This usually requires a compromise between
academic rigor in achieving the desired power and
significance and the available financial, personnel,
and time resources.

4. How will random selection of those to be surveyed
within a population be achieved? Can existing census
frames provide basic population data? What techniques
will be used for random selection? This procedure of
random selection is actually more important than the
number surveyed and requires expert guidance. A
useful reference for this purpose is: Sudman, S. (1976).
Applied Sampling. NY: Academic Press.

5. What will be the content and length of the survey?
This is clearly a major question and will also require
compromise between the need for data and the
practical constraints concerning interviewee time
and resources.

6. What will be the number and timing of the surveys?
Will surveys be conducted at the beginning and the
end of a project or at specified midterm intervals?
This question is also closely related to budget
resources and to the length of the program.

7. How will the analysis of survey results be con-
ducted? Here the skills of both local and interna-
tional experts can be blended to achieve the most
useful results.

213A Field Guide to Designing a Health Communication Strategy

8

1. At what point (wholesaler, distributor, retailer) will data be collected?
2. How will price and packaging differences be recorded?
3. How will free promotional materials be distinguished from sales materials?
4. How can substitution effects be taken into account when a lower priced

product displaces a higher priced one?

� Qualitative Evaluation
Essential at the start of any project in order to understand the problem, the audi-
ence, and the overall situation, qualitative research can also play an important role
throughout the project both in monitoring and in evaluating impact. The major
roles for qualitative research in program evaluations include:

– Helping to evaluate activities and products as they are disseminated
– Helping to explain how and why impact was achieved

Qualitative evaluation can be subtle, intuitive, and highly revealing when sensi-
tively carried out, using ethnographic and unobtrusive measures.

Key qualitative methods that can be used for evaluation are:

1. Focus group discussions—Group discussions among homogeneous
individuals led by a trained moderator can reveal community as well as
individual values and prejudices, emotional intensity, points of controversy,
and customary language used or “audience verbatims.”

2. Interviews—Interviewers can tease out both information and emotional
reactions by interviewing influentials, key informants, or typical audience
members. Open-ended questions, followup to responses, and in-depth
pursuit of significant issues as gathered through interviews can provide a
wealth of valuable qualitative information.

214 A Field Guide to Designing a Health Communication Strategy

3. Observation—Whether in person or through videotapes or even audio-
tapes, observation can provide an immediate insight into the reaction of
an audience or client to specific types of communication or to recom-
mended products and behaviors. Reproductive health programs offer less
opportunity for direct observation than childcare and family health pro-
grams, but the observation of clinical practices or direct observation of
those attending events or performances can provide valuable feedback.

4. Diaries—These can be useful in literate societies or among literate profes-
sionals to record immediate day-by-day actions and reactions, to monitor
ongoing activities, to capture a full history of events, and to understand
better a PBC as it actually takes place over time.

� Combination—Quantitative and Qualitative Evaluation
Evaluations that are both convincing as to causal effects and useful for future
programming combine quantitative and qualitative measures. Quantitative
evaluations can determine how much change took place and even how much
change can be specifically attributed to different communication interventions.

Qualitative evaluation is essential to frame the appropriate questions from which
to derive quantitative data, to ensure the correct language so that the audience
understands what is being asked, and to measure the intensity of emotions and
certainty surrounding particular responses. Qualitative evaluation, above all, seeks
to explore why and how change has taken place and to provide insights that can
be useful in refining and improving future interventions. On the other hand,
quantitative evaluation focuses on how much change has occurred.

215A Field Guide to Designing a Health Communication Strategy

8

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On a theoretical level, the most useful evaluation will be tailored to the specific
communication strategy and situation under consideration, which means it will
reflect the conceptual behavior change model that was used to design the pro-
gram initially; it will focus on the intended audience for the specific program; it
will measure the extent of exposure to the various different media used in the
program (whether radio, television, community meetings, IPC and counseling, or
other channels of communication), and it will link findings closely to the objec-
tives, positioning, and implementation of the program.

On a practical level, the design of the evaluation should be consistent with both
the scope of the program and the availability of human, financial, and physical
resources. A national multimedia program, which is the form taken by many
strategic communication programs, calls for national surveys, selected service site
statistics, and a combination of appropriate quantitative and qualitative measures
from different areas. A small local intervention may benefit from an experimental/
control design and may seek unobtrusive program measures rather than surveys
to measure its impact. Basically, the scope of the evaluation must be consistent
with the availability of budgetary resources. Evaluation costs can range from as
little as 10 percent of a project size to, in rare cases, two or three times the size of
the original project if research concerns are primary. Such evaluations can be
misleading, however, if a weak, less costly intervention is evaluated through a
strong research process. Results may often be negative. A general rule is that
evaluation should amount to about 20 percent of project costs. Very small projects
may justify no evaluation at all, since adequate resources are not available. Large
projects justify a larger expenditure for evaluation, since the need for comprehen-
sive feedback is greater.

216 A Field Guide to Designing a Health Communication Strategy

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Perennial debates have occurred around the issue of whether evaluation should
be performed in-house by researchers closely linked to the program designers or
whether evaluation should be independent, carried out by external experts who
have had little prior connection and no financial benefit from the program.

Whereas external evaluators lend an aura of authority and objectivity to an
evaluation, the extensive knowledge and close connection between program
objectives and evaluation designs suggests that evaluators should become
intimately familiar not only with the program, but also with the environment and
audience. Without working extremely closely with program staff, it is difficult for
evaluators to ask the right questions, probe for the right interpretation, and make
practical recommendations for project improvement.

Overall, therefore, a collaborative evaluation in which skilled evaluators work
closely with program planners and managers but establish their own independent
and rigorous scientific standards for measurement is the ideal situation. Moreover,
in most countries because of language issues and because of the need to develop
local expertise, data collection is carried out under contract by local market re-
searchers or other survey firms. Such firms must recognize the value and integrity
of the data, must respect rules for the protection of human subjects, and must carry
out initial independent analyses. Their work, however, can be assisted and some-
times guided to a more sophisticated level with the assistance of researchers and
evaluators who developed the original research design. Collaboration between
implementers and researchers, with each party recognizing the separate and
partially independent roles of the other, is the best combination to evaluate a
strategic communication program.

217A Field Guide to Designing a Health Communication Strategy

8

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The final stage for any evaluation should be a full documentation and report on
the results. Evaluators who leave a few tables behind and do not write up or
distribute results have not fulfilled their responsibilities. “Results” include insights
and lessons learned in addition to data and tables. Since a program that is not
evaluated and documented ceases to exist in the public mind after a very short
time, this documentation is essential. A good evaluation should be clearly re-
ported to at least three different audiences, each in appropriate ways:

1. To participants and the public—Basic data can be shared orally with commu-
nity leaders, all others involved in the program itself, and the general public.
Data can be explained in local media, and brief summaries can be provided to
all who worked on the program and, to the extent possible, to those exposed
to the intervention.

2. To donors—Whether government leaders, international agencies, or private
foundations, donors are entitled to an honest and comprehensive report on
the impact of projects that they have funded. Even where donors may appear
busy and preoccupied, strategic communication programs have an obligation
to present results. Presenting results can be done through meetings, to which
national and local press are invited; through discussion groups, in which
donors can participate; through reports that are released to the press; and
through special media events particularly designed to call attention to evalua-
tion results. Reports to donors should be accurate and clear and should give
considerable attention to discussing not only the data, but also the implica-
tions of the data for future programming and other related activities.

218 A Field Guide to Designing a Health Communication Strategy

3. To the professional field—For professionals in the communication field and
in whatever substantive field may be involved, peer-reviewed articles, presen-
tations at professional meetings, book chapters, and even textbooks are
essential to document important findings. Results for the professional and/or
academic field need to describe in detail both the nature of the strategic
communication interventions carried out and the methodologies used to
collect and analyze the evaluation data. Where communication strategies
suggest new directions or alter previous concepts or understandings, such
innovations should be clearly highlighted and well defended. Communication
to peers in the field should provide sufficient information, so that others are
encouraged and are able to replicate the program wherever circumstances
warrant.

Strategic communication calls for strategic evaluation to be considered from the
very beginning of the strategy design process. A strategic evaluation not only
must include a full and adequate documentation of the process used, the objec-
tives achieved, the impact, and where possible the cost-effectiveness of the pro-
gram, but also guidelines and recommendations for improvement in future
programs.

219A Field Guide to Designing a Health Communication Strategy

8

����������

Bertrand, J. T. & Escudero, G. (2002). Compendium of indicators for evaluating
reproductive health programs, MEASURE Evaluation Manual Series. (Rep. No. 6).

Centers for Disease Control and Prevention (1999). Framework for Program Evalu-
ation in Public Health.

The Johns Hopkins University Center for Communication Programs. (1999).
Bolivia’s Lilac Tent: A First in Health Promotion. Communication Impact!, 5.

The Johns Hopkins University Center for Communication Programs. (2001). Charts
and graphs.

Figueroa, M. E., Kincaid, D. L., Rani, M., & Lewis, G. (2002). Communication for social
change: A framework for measuring the process and its outcomes. The Rockefeller
Foundation and Johns Hopkins Center for Communication Programs.

Kim, Y. M., Kols, A., Nyakauru, R., Marangwanda, C., & Chibatamoto, P. (2001). Promot-
ing sexual responsibility among young people in Zimbabwe. International Family
Planning Perspectives, 27(1), 11-19.

León, F. R., Monge, R., Zumarán, A., García, I., & Ríos, A. (2001). Length of counseling
sessions and the amount of relevant information exchanged: A study in Peruvian
clinics. International Family Planning Perspectives 27(1), 28-33 & 46.

Sudman, S. (1976). Applied Sampling. NY: Academic Press.

220 A Field Guide to Designing a Health Communication Strategy

221A Field Guide to Designing a Health Communication Strategy

9

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By the end of this summary, the reader will understand:

� The importance of staying on strategy.

� How to take the “Strategy Test” for future programs

� Why it is so important to ask, “Why?”

222 A Field Guide to Designing a Health Communication Strategy

Staying on Strategy
Congratulations. You have completed the crucial steps for designing a communi-
cation strategy. You have:

� Learned how to analyze the health situation, the audience data, and the
communication environment, with an eye toward identifying the most impor-
tant problems for you to address through communication.

� Learned how to segment potential audiences so that you can efficiently and
effectively design communication activities to help change behavior.

� Learned the importance of setting SMART objectives.
� Reviewed potential strategic approaches until you have settled on one best

suited for achieving these objectives.
� Developed a message brief to help guide creative professionals in designing

messages that will be most receptive to audiences while achieving the objectives.
� Identified the most appropriate channels and tools for communicating with

the intended audience.
� Created a management plan that maximizes each partner’s capability in a

coordinated way.
� Planned for evaluation activities to monitor and measure outcomes and to

fine-tune future communication efforts.

What you have accomplished so far, however, is not the end of the process. It is
just the beginning. Designing the strategy is the second stage of the “P” Process.
The subsequent stages involve producing materials, implementing the strategy,
working with professional firms, and monitoring the implemented communica-
tion effort. Although the actual implementation may not exactly mirror the strate-
gic design detail by detail, the essence of the strategy should always be apparent
in all activities and materials. This is called staying on strategy.

Staying on strategy means that when an opportunity arises that seems like a really
good idea but may not be geared for the intended audiences, or help achieve the
strategic objectives, or contain key benefits for the audience, or add to the long-
term identity of the communication plan, then maybe the idea is not as good as it
seemed.

223A Field Guide to Designing a Health Communication Strategy

9

This dilemma is common to many communication managers. Many good ideas
and opportunities arise, and seizing the moment may often work to the program’s
advantage. Also, you don’t want the strategy to be so rigid that you are unrecep-
tive to any new idea that is not exactly part of the original strategy design. But not
all of the opportunities that come your way fit the strategy well. A good measure
of whether a new idea is worth pursuing is to give it the Strategy Test.

The Strategy Test
New opportunities and ideas may come to your attention at times during the
course of the effort. They can come from an outside source, such as the television
producer in the example on this page. They can also come from your partners,
other staff members, or yourself. The questions in table 9.1 on the following page
constitute a simple test that you can use to measure the viability of a new idea or
opportunity that comes to your attention once the strategy has been designed.
The questions follow the “Communication Strategy Outline” that you first saw in
the “Introduction” to this book. Answering the questions will help you ensure that
everything developed and produced within the communication effort contributes
to accomplishing the strategy.

Example

A television producer calls you and wants you to help
produce a television serial drama for adolescent girls on
better hygiene. It sounds like a great idea. It will reach
young women and will be geared toward giving them
sound advice in an area that may not be addressed
anywhere else. The television program will cost
$70,000 to produce and air and will require three
technical experts for approximately 6 months. Should
you do it? The question to ask is, “Is it on strategy?”
Have adolescent girls been identified as an important
audience segment in the strategy design? Has poor
hygiene been identified as a key problem? Will
spending the $70,000 to develop this television
program and using the three technical experts take
needed resources away from the ability to implement
the strategic approach set forth in the communication
effort? In other words, is it worth the trade-off between
producing this new and innovative program and doing
more of the work required to help accomplish the
objectives set forth in the strategy?

224 A Field Guide to Designing a Health Communication Strategy

Table 9.1: The Strategy Test

225A Field Guide to Designing a Health Communication Strategy

9

Ideally, there should be no “no” answers to the above questions. This criterion,
however, may be unrealistic. If there is a “no” answer to one or more of the above
questions, you may be able to change something about the new idea to get it on
strategy.

Another part of the strategy is to test yourself as a reviewer.

Why Ask “Why?”
A good strategy demonstrates not only what is being done, to whom, and how it
will be done, but also why. All statements at every stage of a strategy should
provide a clear rationale. Therefore, the most important question that a strategist
can ask when developing or reviewing a communication strategy is, “Why?”

� Why is this the most important problem?
� Why are urban men ages 18–24 the primary audience?
� Why are you expecting to convince 25 percent of adolescents to visit health

care clinics?
� Why are you designing a logo when all the partner organizations have their

own logo?
� Why is it important to emphasize the friendliness of providers?
� Why use television when 70 percent of the households do not own television

sets?
� Why produce newspaper ads when the intended audience does not read

newspapers?
� Why do you need a poster?
� Why use community participatory activities when you are implementing a

national program?
� Why evaluate all women when the intended audience is rural women ages

20–49?
� “WHY?”

You should ask “why?” at every step of the strategic communication development
process and at every level of design. Asking “why?” ensures that everyone and
everything stays on strategy.

Example

A donor has given your organization additional
resources to reach a specially targeted audience
segment that has not been identified in the
communication effort. Through good formative
research about this specified audience segment
(understanding the audience problems and
recognizing opportunities), you might be able to
fold this segment into the strategic approach, use
existing communication channels, and alter
slightly existing message and materials. So, you
can easily integrate this segment into the
communication effort even if it is not part of the
original strategic design and even if the effort is
already in the implementation stage.

226 A Field Guide to Designing a Health Communication Strategy

Strategy Summary Outline
The final step in designing a communication strategy is to prepare an instant
picture of the strategy that you and your team have developed. You obtain this
picture by filling in worksheet 9.1, the “Communication Strategy Summary Out-
line.” Complete this outline by reviewing the summary worksheets that you
prepared at the end of each chapter in this book. This exercise will provide you
with a logical, well-thought-out, step-by-step approach to how your communica-
tion strategy will help solve the targeted health problem.

227A Field Guide to Designing a Health Communication Strategy

9

228 A Field Guide to Designing a Health Communication Strategy

Worksheet 9.1: Communication Strategy Summary Outline

229A Field Guide to Designing a Health Communication Strategy

9

Strategy Review
Table 9.2 is a checklist to help you ensure that the communication strategy is
completely integrated into the health program. As mentioned at the beginning of
the book, strategic communication is the steering wheel that guides the rest of the
health program. This checklist helps to ensure that the steering wheel is working
successfully.

Table 9.2: Checklist

230 A Field Guide to Designing a Health Communication Strategy

This checklist should help you determine how successful it will be to carry out the
communication effort. The higher the score, the easier it will be to implement the
strategy and the more effective the strategy should be in achieving objectives. If
you achieve a middle range, it may mean that there are areas that require atten-
tion before the communication effort can be implemented, unless part of your
strategy is to increase audience demand to help improve these weaker areas.

Using your scores as a basis, you and your team should decide what you need to
improve before going forward with the implementation.

Conclusion
Strategy development is an ongoing process. Changes in the political environ-
ment or communication arena may have significant implications for the strategic
approach. Think of your communication strategy as a “working document” that
evolves based on audience, environment, and communication factors. Review
your strategy at least once a year to ensure the viability and appropriateness of
the factors that originally determined the strategy.

A great deal of thought and hard work goes into helping to fulfill a vision. The
immediate benefit is working within a team, helping to orchestrate an effort that
takes many partners, reaches many people, and, when done well, plays an integral
role in changing behavior. In the long term, just like the work of our friend the
architect, strategic planning is an important step in helping to fulfill the vision. In
his case, it is seeing the completion of a building that encloses space for educating
children that is safe, easily accessible, and pleasant. In your case, it is knowing that
your strategic design is contributing to a health program that will help make
society healthier and safer.

1-1A Field Guide to Designing a Health Communication Strategy

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2-1A Field Guide to Designing a Health Communication Strategy

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Table of Contents

I. Background Information
II. The DISH Integrated Communication Strategy
III. Management Considerations
IV. Evaluation and Continuity Issues

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2-2 A Field Guide to Designing a Health Communication Strategy

I. Background Information

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The DISH project, in partnership with the Uganda Ministry of Health (MOH) and
the District Health Services of 12 participating districts, embarked on a
multiphased initiative to improve the health and well-being of men, women, and
children in Uganda. The goal of the DISH project was to reduce TFRs and the
incidence of HIV infection by increasing the availability and utilization of inte-
grated reproductive, maternal, and child health services by both public and pri-
vate service providers. The project initially focused on FP and HIV/AIDS preven-
tion—core issues with which project planners had the most experience and a
strong research base. As the project unfolded, it highlighted additional, related
family health topics.

The DISH project began its first 5-year phase in 1994 and its second 3-year phase in
1999. DISH II built on the successes achieved during the first 5 years of DISH I and
continued to work with the Ministry of Health and District Health Services to
promote improved quality, availability, and utilization of reproductive, maternal,
and child health services and to improve public health attitudes, knowledge, and
practices.

The DISH project featured a series of strategically designed, interrelated behavior
change communication campaigns on various reproductive, maternal, and child
health topics. The campaigns directed potential clients to health facilities for
information and services and encouraged changes in individual health attitudes
and behavior. These communication campaigns were designed to promote,
complement, and reinforce simultaneous DISH project components to train nurses
and midwives to provide integrated maternal, child, and reproductive health
services (clients can get a full range of services during the same visit, often from
the same health worker); train doctors and medical assistants in the syndromic
management of STDs; expand HIV counseling and testing services; and provide
training in logistics and management information systems.

2-3A Field Guide to Designing a Health Communication Strategy

This case study discusses the development of the overall communication strategy
that guided the DISH communication campaigns. DISH was administered by
Pathfinder International. Collaborating partners were the JHU/CCP, the University
of North Carolina Program in International Training in Health (INTRAH), and E.
Petrich and Associates. The project was funded by the U.S. Agency for Interna-
tional Development.

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Almost half of the Ugandan population is under 15 years of age, with total fertility
averaging about 7 children (Uganda Ministry of Finance and Economic Planning
and Macro International, 1995: Uganda Demographic and Health Survey, 1996b).
Fertility rates have stayed stable for the last 15 years. “A tradition of early child-
bearing has led both to a young population and to high fertility; 60 percent of
Ugandan women have their first babies before they are 20 years old” (Uganda
Ministry of Health and Institute for Resource Development (IRD)/Macro Systems,
Inc., 1988/1989: Uganda Demographic and Health Survey, 1989). Modern contra-
ceptive use is low, with a 2.5 percent prevalence, and birth intervals are short, with
about half less than 2 years apart.

In addition to its high fertility rate, Uganda has one of the highest rates of HIV in
the world. When the DISH project was initiated, as many as 1.5 million people
were HIV positive, perhaps 1 in 5, with substantially more young women infected
than men. Surveillance at some urban clinics suggested infection rates ranging
from 7.5 percent in small towns to around 30 percent in Kampala and highly
endemic areas of the southwest.

Widely believed to be cofactors in the transmission of AIDS, STDs were and still
remain ubiquitous in Uganda. A 1990 review revealed that 19 percent of more
than 108,000 outpatient visits were STD-related. In 1991, 26 hospitals reported
more than 254,000 cases of STDs, about 60 percent of which were thought to be
syphilis and gonorrhea. Fifteen to 25 percent of women attending routine ante-
natal care in sentinel surveillance sites were infected with syphilis.

2-4 A Field Guide to Designing a Health Communication Strategy

In 1995, the maternal mortality ratio in Uganda was one of the highest in the world
at approximately 550 deaths per 100,000 live births. More than two-thirds of
deliveries took place outside health facilities without assistance from a qualified
health worker. In addition, in 1995 about one-third of Ugandan children were
stunted by the age of 3 years. Although breastfeeding was ubiquitous, most
mothers introduced fluids or other solids before the recommended 4–6 months.

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Against this backdrop, the DISH project defined its goal as reducing the incidence
of HIV and other STDs, increasing the prevalence of modern contraceptives, and
improving care before, during, and after childbirth (Promoting reproductive
health in Uganda: Evaluation of a National IEC program, 1996a). As with other
integrated communication campaigns, preliminary planning began with an
analysis of Strengths, Weaknesses, Opportunities, and Threats—also known as a
SWOT analysis. Conducting a SWOT review can provide information about and
insights into existing resources and information, potential weaknesses that could
undermine the campaign if not addressed, threats or barriers to success that must
be addressed in program development, and campaign opportunities. Through a
SWOT analysis, for instance, project planners may identify ways to build on suc-
cesses in similar, earlier campaigns, discover the types of critically needed services
and information that clients most want, or identify current networks or partner-
ships that can contribute to the program’s reach or effectiveness.

1. Strengths
While DISH required addressing multiple issues, it was able to build on the
experience and knowledge gained from previous FP programs. Uganda
initiated FP activities in 1957, with the establishment of the Family Planning
Association of Uganda (FPAU), an affiliate of the International Planned Parent-
hood Federation.

In 1987, the Government of Uganda established a population secretariat as
part of the Ministry of Planning and Economic Development. In addition,
more than 30 multilateral and bilateral donors and international NGOs sup-
ported health and population activities of various sizes and scope in Uganda.

2-5A Field Guide to Designing a Health Communication Strategy

There was also a precedent of communication program success in the repro-
ductive health arena. Prior to the DISH project, the MOH carried out a project
to increase the use of modern FP methods among married couples in urban
areas of eastern, central, and southwestern Uganda. The multimedia effort
entailed the development and widespread dissemination of IEC materials.

Survey data gathered in a precampaign and postcampaign household survey
showed that the campaign had reached the majority of respondents and had
influenced the behavior of many audience members. More than half of the
population could identify the Yellow Flower symbol, which represented FP
nationally. HIV/AIDS communication efforts were also widespread, and most
adults knew the modes of transmission and consequences of HIV/AIDS. The
HIV prevalence rates had already begun to decline at the start of the DISH
project.

2. Weaknesses
In the communication area, there was a general lack of quality IEC materials for
staff to use to promote FP, to explain the various FP methods to clients, and to
share with AIDS clients in counseling. HIV/AIDS messages predominantly
instilled the fear of AIDS and offered only abstinence and faithfulness as
solutions; neither of which were practical for adolescents.

FP services were limited mostly to urban areas, but more than 80 percent of the
population resided in rural areas. Many providers were poorly informed,
provided incorrect information about FP, and did not discuss HIV/AIDS preven-
tion with their clients. The health infrastructure required to support a broad
behavior change communication campaign was weak.

Uganda’s health provider network was characterized in many areas, especially
rural areas, by limited availability of health services, inadequately trained
personnel in the areas of FP and maternal health (MH), and shortages of
trained staff, drugs, laboratories, supplies, and related equipment for STD
services. Moreover, MH, STD, and FP services were not generally provided in an
integrated fashion, and limited planning and management capability
thwarted efforts to anticipate client needs and deliver services accordingly.

2-6 A Field Guide to Designing a Health Communication Strategy

3. Opportunities
Despite the low level of contraceptive use in Uganda, the UDHS indicated that
the potential need for FP was great. While 39 percent of currently married
women wanted another child within 2 years, 33 percent wanted to space their
pregnancies for at least 2 years, and another 19 percent wanted no more
children. “This [meant] that 52 percent of currently married women in the
surveyed area may require FP services either to limit or space their births.
Furthermore, 35 percent of the women who had a birth in the 12 months prior
to the survey indicated that their last birth was either unwanted or mistimed”
(Uganda Ministry of Health and IRD/Macro Systems, Inc., 1988/1989: Uganda
Demographic and Health Survey, 1989).

Studies indicated a generally positive attitude towards FP among women who
knew about FP. “Seventy-one percent of currently married women knowing
about FP approve of FP use by couples. Only 26 percent of married women
think that their husband approves of FP use by couples. One-third of women
do not know their husbands attitudes” (Uganda Ministry of Health and IRD/
Macro Systems, Inc., 1988/1989: Uganda Demographic and Health Survey,
1989). In the Uganda baseline survey, “over 90 percent of respondents agreed
that FP has positive impacts on mother’s health, children’s education, the
family’s standard of living, and society at large” (Kiragu, Nyonyintono,
Sengendo, & Lettenmaier, 1993).

At the start of the DISH project, AIDS was almost universally known, there was
already a large condom social marketing program in place, a STD reference
laboratory had been established, and the MOH had developed protocols and
guidelines for syndromic STD management. The Government was also very
supportive of HIV/AIDS/STD prevention efforts.

4. Threats or Barriers
There were serious barriers to contraceptive use and safe sex practices in
Uganda. As of 1994, the dominant television and radio stations, which were
controlled by the Government, would not allow contraceptive product
promotion. In addition, there was strong opposition to condom use by the
religious community.

2-7A Field Guide to Designing a Health Communication Strategy

Contraceptive use in Uganda was low. DHS indicated, “Only 6 percent of all
women and 5 percent of currently married women reported using a contra-
ceptive method at the time of the interview . . . 21 percent of all women and 22
percent of currently married women have used a method at some point in
their lives” (Uganda Ministry of Health and IRD/Macro Systems, Inc., 1988/1989:
Uganda Demographic and Health Survey, 1989).

The most common reasons for nonuse of contraception cited by women who
were exposed to the risk of pregnancy but did not want to get pregnant
immediately are fear of side effects, prohibition by religion, lack of knowledge,
and disapproval by partner. There was also a lack of knowledge about modern
contraceptive methods, and many women did not know where to obtain
contraceptives. Low rates of contraceptive use may also be related to the
belief by many women that a large family is the ideal—”sixty percent of
women report 6 or more children as the ideal number” (Uganda Ministry of
Health and IRD/Macro Systems, Inc., 1988/1989: Uganda Demographic and
Health Survey, 1989).

Polygyny is still a common practice in Uganda, with 33 percent of currently
married women reporting that their husband has other wives. However, “the
relationship between polygyny and fertility is not straightforward. There is a
tendency for women in polygynous unions to compete with co-wives in
number of children, so as to have the largest share of family property. In this
respect, the desire to have as many sons as possible is likely, and polygyny may
be one of the factors that sustains high fertility” (Uganda Ministry of Health
and IRD/Macro Systems, Inc., 1988/1989: Uganda Demographic and Health
Survey, 1989).

Barriers to adopting safe sex practices and to seeking diagnosis and treatment
of STDs include inadequate knowledge about maternal-fetal HIV transmission,
misperceptions of personal risk, negative attitudes towards condoms, and
absence of perceived community support for condom use. In addition, youth
had a fatalistic attitude toward HIV/AIDS, believing that there was little that
they could do to protect themselves.

2-8 A Field Guide to Designing a Health Communication Strategy

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DISH project designers faced significant gaps in knowledge about how men
and women make reproductive health decisions throughout Uganda as well
as other African nations.

Research was needed into how reproductive decisions and their outcomes are
negotiated within sexual unions. Little was known about how a woman’s life
circumstances may affect her achievement of reproductive and health goals or
what types of roles men play in reproductive decisions (Blanc et al., 1996).

“Relatively little is known about the processes by which decisions about
reproductive matters are made. While both partners in a sexual union may
express the same fertility preferences . . . survey data do not indicate what
factors may influence fertility preferences . . . which partner’s preferences
carried the greatest weight, and to what extent other people influenced the
decision” (Blanc et al., 1996).

Additional research was needed into how the position of women influenced
their ability to negotiate the outcomes that they desired. In settings where
HIV/AIDS is prevalent, social norms “and their relationship to reproduction—
and particularly to the use of condoms—are complex and evolving. Explicit
consideration of gender inequality is thus an important component of the
study of reproductive outcomes” (Blanc et al., 1996).

Little information about adolescent sexual practices, beliefs, and knowledge
was available. There was also a lack of understanding about reasons for poor
utilization of MH services and about the quality of reproductive health, MH,
and FP services.

1. Formative Research
Formative research prior to the DISH project development involved the
review of existing qualitative and quantitative research findings. In
addition, each individual campaign developed for the DISH project
included audience research to determine attitudes, knowledge, concerns,
and beliefs related to a wide variety of reproductive health issues(Family
Planning Association of Uganda (FPAU), 1992).

Chart A2.1:Focus Group and In-Depth Interview Findings and
Campaign Message Recommendations—1995

��������� Married men and women who do not use modern FP
methods but do not want to become pregnant now

� Respondents relied most heavily on the safe period to prevent
pregnancy. However, they had an incomplete understanding of
when the safe period was.

Recommendation: Since birth spacing is already practiced through use
of the safe period, promote FP as “an easier way to space your births.”

� Most of the nonusers were aware of what modern methods are
available but had little in-depth knowledge about any of the methods.

Recommendation: Find every opportunity to provide details about
how the methods work, their reliability, and safety.

� Most of the nonusers had heard mostly negative things about
modern methods.

Recommendation: Dispel rumors and misinformation about the
modern methods through testimonials by satisfied users, statements
by medical experts and other authorities, and presenting correct
information about the various methods.

� Most nonusers felt that there was a complete lack of community
support for using modern methods.

Recommendation: Build links between nonusers and those who
support the use of modern contraceptives: satisfied users, educated
youth, and health care workers.

� Most of the couples had talked about HIV/AIDS in impersonal
terms. When they got to the issue of condom use and faithfulness
in their own marriages, however, talking became difficult.

Recommendation: Model husband and wife communication in which
the difficult issues of personal behavior change are confronted.

� Knowledge, attitudes, and practices concerning FP and HIV/AIDS
differed greatly among married women, married men, and
unmarried youth.

Recommendation: Design separate messages for unmarried youth,
married women, and married men.

(continued)

2-9A Field Guide to Designing a Health Communication Strategy

Available quantitative research used to develop the program included at least
two surveys: UDHS 1988/1989 and Uganda Baseline Survey: Key Findings 1993.
The former survey provided data on the background characteristics of survey
respondents, marriage and exposure to the risk of pregnancy, current fertility
levels and trends, contraceptive knowledge and use, fertility preferences, and
mortality and health. The latter survey provided information on knowledge,
attitudes, and beliefs about family size; knowledge of FP methods; use of FP;
attitudes and approval of FP; sources of FP information; and exposure to mass
media. The data from these two quantitative surveys, as well as data from the
1995 DHS, are used throughout this case study.

In 1995, formative research was conducted through focus groups and in-depth
interviews in six districts in Uganda. This qualitative research examined current
knowledge, beliefs, and practices concerning HIV/AIDS and FP among men
and women ages 15–35. The results were used in formulating the DISH Inte-
grated Communication Strategy.

The research objectives were to:

� Learn what motivated current FP users to adopt modern methods.
� Identify myths and misconceptions about FP and HIV/AIDS.
� Determine the barriers to discussion between partners regarding FP, HIV/

AIDS, and condom use.
� Explore the reasons why people are not using modern FP methods despite

their desire to delay or stop childbearing.

Key findings from this research are summarized in chart A2.1 (Glass,
Gamurorwa, Loganathan, & Lettenmaier, 1995).

(continued)
Chart A2.1:Focus Group and In-Depth Interview Findings

and Campaign Message Recommendations—1995

����������Married men and women who currently use modern
FP methods

� Most of the men thought that they had controlled the entire
process of FP decisionmaking.

Recommendation: Men’s statements and photos need to be
included in FP materials, even if they are designed for women.

� Most of the users were spokespeople for FP in their communities.
Recommendation: Use testimonials by satisfied users to
convince others.

� Users were tenacious in their commitment to FP. They all
had experienced some challenges (side effects or adverse
community opinion) and had persevered.

Recommendation: Be honest in print materials and counseling
about the potential temporary adverse effects of modern
methods—it will not deter people from using these methods.

� For both male and female users, the reasons for their use
had to do mostly with economic issues. Women also
mentioned health reasons behind their decisions to use.

Recommendation: Use economic messages in promoting male
motivation and both economic and health messages when
reaching women.

(continued)

2-10 A Field Guide to Designing a Health Communication Strategy

II. The DISH Integrated Communication Strategy

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The original objective of the IEC component of the DISH I project was to increase
the utilization of basic reproductive health services and to encourage personal
behavior that improves personal health. The IEC component worked hand in
hand with the training and service delivery components under which health
services were offered. At the beginning of the project, FP services were already
available in about 50 percent of health facilities in the project area.

In 1995, DISH project planners held a strategy design workshop with representa-
tives from organizations active in reproductive health and with District Health
Services personnel from the DISH I project districts. During that workshop, partici-
pants reviewed research in Uganda about reproductive heath topics, including
MH, FP, HIV/AIDS, and other STDs.

Based on that meeting and the overall objectives of the IEC component of DISH
(see chart A2.2), they developed a 5-year IEC message strategy. They decided that it
would not be possible to produce materials and activities about all five topics
simultaneously; instead, messages and topics would be added in stages.

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The DISH project launched a total of seven campaigns between 1995 and 1999.
(See table A2.1 for an overview of the DISH project Integrated Communication
Campaigns 1995–1999.)

Persons 12–45 years old residing in the 10 DISH districts, both rural and urban,
regardless of their level of education, were the intended audience for DISH mes-
sages. Each DISH campaign sought to communicate with a segment of the target
audience most likely to need and be receptive to the campaign’s messages. Dur-
ing the 5-year DISH project, communication campaigns targeted the following
audience segments:

(continued)
Chart A2.1:Focus Group and In-Depth Interview Findings

and Campaign Message Recommendations—1995

����������Unmarried Youth

� More than one sexual partner was the norm, and most felt
that the different partners could serve different purposes.

Recommendation: Show adolescents that they are putting
themselves at risk for HIV/AIDS by having more than one sexual
partner at a time or by changing partners frequently.

� Most of the youth knew that they were at risk for AIDS, but
they did not feel that they could do anything about it.

Recommendation: Design messages to convince youth that
they can do something to protect themselves from HIV/AIDS,
rather than convincing them that they are at risk.

� Peer pressure to have sex in this age group was overwhelming.
Recommendation: Communication should help adolescents to
resist peer pressure and to decide for themselves.

� The only modern methods of FP that adolescent respon-
dents had used were pills or condoms. They had very little
knowledge about other methods.

Recommendation: Develop materials that explain the variety of
FP methods available in Uganda.

2-11A Field Guide to Designing a Health Communication Strategy

� HIV/AIDS Prevention for Youth: Males ages 15–19
� FP: Women ages 18–35 in rural areas who were nonusers of modern FP but did

not want children right away
� Family Health Logo: All IEC segments
� Maternal Health: Sexually active women ages 16–35 in rural areas who did

not plan to attend antenatal care clinics at least 3 times during pregnancy
� Sexually Transmitted Diseases: Men ages 18–35 in both rural and urban areas

in stable sexual relationships who also had other partners but did not consis-
tently use condoms

� HIV Counseling and Testing: Men living in rural areas who were in sexual
relationships and had not had an HIV test

� Breastfeeding and Infant Nutrition: Rural mothers ages 18–35

The campaigns were designed to be implemented in three stages: first promoting
existing FP services and addressing HIV/AIDS prevention among youth; next
focusing on STDs and MH services, to coincide with training activities and to
enhance the provision of these services; and then promoting HIV testing and
counseling services as they became more widely available. At each stage, the
team would design specific research-based strategies and media and materials
plans. While each stage focused on a different service or issue, it simultaneously
promoted the issues of the previous campaign. At any one time since 1997, as
many as four separate communication campaigns were going on simultaneously.
(See chart A2.4, Communication Impact, October 1999, Number 6.)

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The DISH project initially promoted FP services at the sign of the Yellow Flower
logo, a well-established symbol for FP. In 1997, the project assisted the MOH in
designing, distributing, and publicizing the rainbow-over-the-yellow-flower
symbol to identify health facilities offering a full range of family health services,
including FP, antenatal and postnatal care, immunizations, STD management, and
HIV counseling. An important factor behind the design of the family health logo
was the indication that a facility offered STD treatment, as well as other family
services, so that clients seeking STD treatment did not feel stigmatized. All materi-
als developed advised couples to visit health facilities with the Yellow Flower or
rainbow over the Yellow Flower, for information and services (Katende, Bessinger,
Gupta, Knight, & Lettenmaier, 2000).

2-12 A Field Guide to Designing a Health Communication Strategy

Reinforcing the visual identity of the family health logo was the slogan “Family
Health Made Easy,” promoting the campaign’s promise that those who go to a
facility that displayed the family health logo would receive a variety of family
health services from trained providers.

In addition to the logo, the project developed a creative concept to link the
various campaigns together. The creative concept was, “It’s easy. 1–2–3.”

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The overall objectives of the project are summarized in Chart A2.2.

Chart A2.2: Overall IEC Objectives

Example

For instance, for the STD campaign, the audience
would hear something like,You can avoid HIV
infection by properly treating STDs. It’s as easy as 1–
2–3—Stop, Treat, and Destroy.

1. If you have an STD, STOP having sex, or use a
condom while on treatment.

2. TREAT yourself as well as all your sexual partners
at a health facility with the rainbow symbol.

3. DESTROY the disease completely by completing
all your medication, even if symptoms have
disappeared.

For more information, visit a health facility where you
see the logo.

Example

For the MH campaign, the concept was “To Have a
Healthy Baby, Have a Healthy Pregnancy.” It’s as easy
as 1–2–3:

1. Visit a health facility for antenatal care as soon as
you know that you are pregnant.

2. Go at least three times for antenatal care.
3. Return to the health facility if you have any

problems.

For antenatal care, visit any health facility with the
rainbow over the Yellow Flower.

2-13A Field Guide to Designing a Health Communication Strategy

The timeline for implementing the strategy unfolded in 3 stages over a period of 5
years:

Stage I (Years 1 and 2). FP services were already available, and the Yellow Flower
logo was already established. HIV was a serious problem, and prevention did not
depend on improved services. Thus, the two topics of FP and HIV were introduced
during the first stage while training, renovations, and equipment procurement
were underway.

Stage 2 (Years 3 and 4). It was anticipated that training, equipping, and renovat-
ing facilities would have progressed enough to make STD and MH services more
widely available by the third year. So it was decided to add messages directing
people to these services during the second stage.

Stage 3 (Year 5). HIV testing and counseling were not available in all 10 districts
until the final year of the project. It was thus decided to add messages directing
people to facilities and services for HIV-related health issues during the third
phase.

2-14 A Field Guide to Designing a Health Communication Strategy

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If you are informed and educated about healthy reproductive and sexual behavior
and utilize Integrated Health Services, you can have better health.

1. Support Points
You can have better health by:

STAGE 1: Practicing Safer Sex to Prevent AIDS
� Condoms
� Abstinence
� Delaying sex
� Remaining faithful to one partner
� Nonpenetrative sex

STAGE 1: Using modern FP methods to avoid unwanted pregnancies
� Safe
� Effective
� Reliable
� Widely available where you see the Yellow Flower

STAGE 2: Having STDs properly diagnosed and treated
� Location of services
� Dispelling misconceptions

STAGE 2: Adopting appropriate health care before, during, and after pregnancy
� Antenatal care
� Delivery assistance
� Postnatal care
� Location of services

STAGE 3: Learning your HIV serostatus and acting responsibly
Positioning: Convenience.

2-15A Field Guide to Designing a Health Communication Strategy

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The campaigns included a mix of mass media, community-based, and interpersonal
channels. Mass media used included television, radio (such as the weekly “Choices” radio
program, which won the 1998 Global Media Award for Best Radio Program on Popula-
tion Issues), and print. Community activities included drama performances, video shows,
village meetings, soccer matches, special World Cup promotions during the event (June–
July 1998), and bicycle rallies. Interpersonal channels included training; client counseling
materials, such as flip charts and cue cards; and Group Africa experiential marketing road
shows. All materials were produced in three or four different languages for the different
audiences.

III. Management Considerations

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DISH I was administered by Pathfinder International in close collaboration with the
Ugandan Government’s MOH. Collaborating partners were the JHU/CCP, INTRAH, and E.
Petrich and Associates. Responsibilities of partners were as follows:

� Pathfinder International: Project management, monitoring, and evaluation; health
management and information systems (HMIS); contraceptive logistics support; and
community-based programs

� JHU/CCP: IEC
� INTRAH: Training and clinical services
� E. Petrich and Associates: Health financing

District-level IEC campaign plans were designed and implemented by the District
Health Services, in collaboration with NGOs, community-based organizations, and
other Government departments active in each district. The District Health Educators
(DHEs) were the overall coordinators of the district campaign plans. DISH I provided
grants to each District Health Service to implement the activities in its plans.

Implementation was carried out by a District Action Committee formed by the
DHE and comprised of representatives from various organizations and depart-
ments active in health activities in the district. DISH project IEC coordinators
provided technical assistance to the District Action Committees and DHEs to
design and implement their action plans and provided the supportive print and
audiovisual materials for use during their activities.

2-16 A Field Guide to Designing a Health Communication Strategy

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The DISH project was funded by the U.S. Agency for International Development.
Innovative administrative mechanisms were developed to place responsibility for
funds management and much decisionmaking at the district level. These funds
helped defray the cost of local district community mobilization activities. This
decentralization of project management through the empowerment of district-
level personnel resulted in a strong sense of project ownership and active support
by the local population. At the same time, financial resources were used centrally
to develop nationally distributed media products for print, radio, and television.

IV. Evaluation and Continuity Issues

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The project monitored and evaluated the impact of counseling and IEC on knowl-
edge, attitudes, and practices and used this information to improve district-level
IEC interventions. IEC monitoring built on the DISH project Management Informa-
tion System. Midterm and final evaluations examined sources of clients referred
for MH, FP, STD, and HIV services as well as examining time-series analyses of client
visits to DISH centers before, during, and after campaign interventions.

DISH designed campaign monitoring and evaluation plans for each campaign, in
addition to the periodic community- and facility-based surveys and DHS. Most of
these evaluations involved client exit or entry interviews at a sample of health
facilities. For the “Safe Sex or AIDS” campaign for youth, baseline and intervention
surveys were conducted with youth to evaluate exposure and impact. For the FP,
MH, STD, family health logo, and HIV campaigns, interviews were conducted with
FP, antenatal, STD, and HIV clients at selected facilities during the campaign to
determine their exposure to campaign interventions and their reactions to cam-
paign messages and materials. Small-scale studies were also conducted to mea-
sure the impact of specific interventions, such as the “Choices” and “Straight Talk”
radio programs and the video “Time To Care: The Dilemma.”

1. Results
The Uganda DISH Evaluation Surveys in 1999 collected information to assess the
reproductive health situation in DISH districts and the effectiveness of DISH
project activities. “The 1999 DISH Evaluation Survey gathered information from

2-17A Field Guide to Designing a Health Communication Strategy

1,766 women ages 15–49, 1,057 men ages 15–54, and 292 health facilities and 186
pharmacies and drug stores in 11 of the 12 districts in Uganda served by the DISH
project, covering 30 percent of Uganda’s population” (Katende et al., 2000).

The evaluation survey found that from 1995 to 1999, media exposure to FP IEC
messages increased significantly for men and women. By 1999, the majority of
men and women had heard radio advertisements about FP, antenatal care, exclu-
sive breastfeeding, STD prevention, and HIV testing and counseling. In 1999, three-
quarters of men and women reported exposure to the Yellow Flower FP logo and
the rainbow-over-the-Yellow-Flower family health logo (Katende et al., 2000).

During the same time period, survey respondents reported a marked increase in
the use of modern contraception. Survey data presented a strong and consistent
association between women’s and men’s exposure to DISH-sponsored FP IEC
messages and increased use of modern contraceptives. In addition, between 1995
and 1999, the proportion of men and women not already practicing FP who
intended to use a modern contraceptive in the next 12 months increased signifi-
cantly (Katende et al., 2000).

Survey data also found that exposure to other family health topics led to in-
creased knowledge. During the first 4 years of the DISH project, there were signifi-
cant increases for men and women in knowledge about use of condoms for STD
and HIV prevention. Between 1997 and 1999, a significant increase in men’s and
women’s knowledge of a place to obtain STD treatment occurred. In addition, a
significant increase in the proportion of men and women ever tested for HIV
occurred between 1997 and 1999. Among those not yet tested for HIV, nearly two-
thirds of men and women expressed a desire to be tested in 1999 (Katende et al.,
2000).

DISH IEC activities also appeared positively associated with increased knowledge
of pregnancy complications among men and women in 1999. In addition, be-
tween 1997 and 1999, the proportion of mothers who could name at least three of
four obstetric complications increased significantly. In 1999, the majority of men
and women surveyed also reported hearing messages about child nutrition and

2-18 A Field Guide to Designing a Health Communication Strategy

breastfeeding. Based on 1999 data, women’s knowledge of 6 months as the ideal
duration for exclusive breastfeeding appeared significantly associated with DISH
IEC activities (Katende et al., 2000).

Some of the key findings and recommendations can be found in chart A2.1.

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Since 1995, the DISH project has launched multimedia campaigns on various
health topics. The project implemented two campaigns between 1995 and 1997—
one promoting FP services at the sign of the Yellow Flower logo and a simulta-
neous “Safer Sex or AIDS” campaign which encouraged safer sex practices among
youth to prevent HIV transmissions. In 1997, the project developed the rainbow-
over-the-Yellow-Flower symbol to identify health facilities providing integrated
family health services.

With the new symbol in place, the project launched two new campaigns in 1998
directing couples to the rainbow logo for antenatal care and STD treatment. The
MH campaign promoted early and repeated antenatal care during pregnancy and
recognition of four warning signs of serious obstetric problems. The STD cam-
paign educated men to treat STDs properly. Both campaigns were launched in
March 1998 and were at their highest level of intensity with both community-
based and mass media messages until November 1998, when all but the radio
spots were discontinued.

In March 1999, the DISH project introduced two new campaigns—one promoting
newly established HIV counseling and testing services and the other renewing
efforts to increase contraceptive use. Both campaigns employed a combination of
community-level, print, and electronic media.

In June 1999, the project launched a final campaign promoting exclusive
breastfeeding for the first 6 months of life and the appropriate introduction of
complementary foods thereafter. Messages were disseminated through radio and
print materials.

2-19A Field Guide to Designing a Health Communication Strategy

Table A2.1: Overview of DISH Project Integrated Communications Campaign, 1995–1999

2-20 A Field Guide to Designing a Health Communication Strategy

Table A2.1: Overview of DISH Project Integrated Communications Campaign, 1995–1999 (continued)

2-21A Field Guide to Designing a Health Communication Strategy

Table A2.1: Overview of DISH Project Integrated Communications Campaign, 1995–1999 (continued)

2-22 A Field Guide to Designing a Health Communication Strategy

Table A2.1: Overview of DISH Project Integrated Communications Campaign, 1995–1999 (continued)

2-23A Field Guide to Designing a Health Communication Strategy

Table A2.1: Overview of DISH Project Integrated Communications Campaign, 1995–1999 (continued)

2-24 A Field Guide to Designing a Health Communication Strategy

����������

Blanc, A. K., Wolff, B., Gage, A. J., Ezeh, A. C., Neema, S., & Ssekamatte-Ssebuliba, J.
(1996). Negotiating Reproductive Outcomes in Uganda. Calverton, MD: Macro
International Inc. and Institute of Statistics and Applied Economics (Uganda).

Family Planning Association of Uganda (FPAU) (1992). Family Planning: We cannot
use what we do not understand! Qualitative research on family planning in
Uganda. Kampala, Uganda and Baltimore: FPAU and Johns Hopkins University,
Population Communication Services.

Glass, W., Gamurorwa, A., Loganathan, R., & Lettenmaier, C. (1995). Family planning
and HIV/AIDS knowledge, attitudes and practices in six districts in Uganda. Results
of focus group discussions and in-depth interviews. Kampala, Uganda: Uganda
DISH Project.

Katende, C., Bessinger, R., Gupta, N., Knight, R., & Lettenmaier, C. (2000). Uganda
Delivery of Improved Services for Health (DISH) Evaluation Surveys: 1999 MEA-
SURE Evaluation Technical Report Series No. 6. Chapel Hill: Carolina Population
Center, University of North Carolina at Chapel Hill.

Kiragu, K., Nyonyintono, R., Sengendo, J., & Lettenmaier, C. (1993). Family planning
needs in Uganda: key findings from a baseline survey of selected urban and peri-
urban areas. Kampala, Uganda and Baltimore: Family Planning Association of
Uganda and Johns Hopkins University, Population Communication Services.

Promoting reproductive health in Uganda: Evaluation of a National IEC program
(1996a). (Rep. No. 7). Baltimore: The Johns Hopkins School of Public Health Center
for Communications Programs: IEC Field Report.

2-25A Field Guide to Designing a Health Communication Strategy

Uganda Ministry of Finance and Economic Planning and Macro International,
1995: Uganda Demographic and Health Survey (1996b). Entebbe, Uganda and
Calverton, MD: Uganda Ministry of Finance and Macro International.

Uganda Ministry of Health and Institute for Resource Development (IRD)/Macro
Systems, Inc., 1988/1989: Uganda Demographic and Health Survey (1989). Entebbe,
Uganda and Columbia, MD: Uganda Ministry of Health and IRD/Macro Systems.

2-26 A Field Guide to Designing a Health Communication Strategy

2-27A Field Guide to Designing a Health Communication Strategy

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Table of Contents

I. Overview
II. Key Characteristics That Made Las Manitos

a Success
III. Analysis of the Situation
IV. Communication Strategy
V. Management Considerations
VI. Evaluation
VII. Staying on Strategy
VIII. Conclusion

Attachment 1—List of Information, Education, and
Communicaton Subcommittee Members

2-28 A Field Guide to Designing a Health Communication Strategy

I. Overview

Through the efforts of many public and private sector partners working
collaboratively together, the National Reproductive Health Program (NRHP) in
Bolivia was able to alter significantly the environment surrounding reproductive
health in the country. The NRHP helped meet the needs of Bolivian couples and
families by providing high-quality reproductive health information and services
in a strategic way. This case study highlights the experience of Las Manitos I, which
was the first large-scale campaign conducted under the auspices of the NRHP with
technical assistance provided by the JHU/PCS. Follow-on campaigns are ad-
dressed briefly in this case study within the context of long-term strategy imple-
mentation.

II. Key Characteristics That Made Las Manitos a Success

Unfolded in Stages Over Time
The organizers of the NRHP understood the value of developing a continuous
series of carefully calibrated campaigns that moved from cautious advocacy to
countrywide action. The overall strategic approach developed by the NRHP was
to develop a more positive environment surrounding reproductive health in
Bolivia. A major emphasis was empowering women to take care of their own
health and the health of their children. This effort was implemented by develop-
ing national level political support, training of key stakeholders in communication
techniques, carefully segmenting audiences, and using innovative mass media
activities.

The strategic approach unfolded in stages over time, expanding to additional
audiences, geographic regions, health issues, and communication channels in a
coordinated fashion. Each element of the strategic approach reinforced the work
that had been done previously and added a new depth of understanding about
the needs of the audience.

2-29A Field Guide to Designing a Health Communication Strategy

Multimedia Approach
Las Manitos I used mass media as the lead channel, which was supported by
community and interpersonal channels of communication. The media campaign,
which was the first of its kind in Latin America, was launched by the Bolivian
President and Secretary of Health, who appeared in the first television spots.

Given the high penetration of television and radio and given the reasonable price
of airtime in Bolivia, the Las Manitos I campaign primarily used mass media to
disseminate key messages to the audience, which enabled the organizers to
accomplish a quick and broad reach of the campaign messages. Specifically, 11
television and 44 radio spots were used to allow for maximum reach and fre-
quency during the initial 7-month campaign.

Interpersonal channels focused on training service delivery providers and on
providing them with a wide variety of materials to use with their clients. Materials
included flip charts, reference manuals, method posters, reproductive health
brochures, and individual method flyers.

Linkages to Reproductive Health Services
A training curriculum was also developed for use by institutions in training repro-
ductive health providers in IPC skills. In preparing for the mass media campaign, a
set of integrated print materials was produced, and training activities were imple-
mented that assisted clinic staff in counseling, informed clients on methods, and
promoted reproductive health services.

The campaign’s logo and tag line, “Reproductive Health—It’s in Your Hands” were
used to identify where services were provided. The logo appeared, for example, on
the doors of hospitals and clinics where reproductive health services were offered.

Interinstitutional Coordination Among Stakeholders
The Las Manitos I campaign was carried out under the auspices of the NRHP. The
NRHP built linkages with various organizations through its National Coordinating
Commission. Four subcommittees were established, with an initial membership of
28 institutions. These groups focused on the issues of services, research, training,

2-30 A Field Guide to Designing a Health Communication Strategy

and IEC. The members of the different subcommittees represented various Gov-
ernment agencies and NGOs. Therefore, strong ownership of the NRHP was devel-
oped within various groups and sectors of society from the beginning of this effort.

Use of Research at Every Stage
The success of a campaign depends in great measure on the amount of research
on which it is based. Planning for evaluation occurred from the very beginning of
the strategy design process, thereby allowing researchers to work with the pro-
gram staff throughout the process of campaign planning and development. Both
quantitative and qualitative research methodologies were used to inform deci-
sions and to track progress and outcomes.

Researchers tested the acceptability of words, phrases, and concepts surrounding
reproductive health and FP issues that would help determine the future position-
ing of the campaign. After the first messages were drafted, additional research
was conducted to pretest the comprehension, attraction, acceptability, and rel-
evance to the audience of the different messages.

Research also played a role during the management and monitoring phase of the
campaign to ensure that the materials were being properly distributed and broad-
casted. This was accomplished by distribution reports completed by the NGOs, in the
case of the print materials, and by reports from a media agency in the case of televi-
sion and radio broadcasting. The monitoring led to some important adjustments in
the broadcasting strategy and served as a reassurance to the NGO members that the
distribution of the materials they had being working so hard to produce were, in
fact, efficiently disseminated and helpful to the intended audience.

Finally, research was also conducted to evaluate the campaign impact and help to
guide the strategic approach of the next campaign.

Reproductive Health Focus Instead of Family Planning
The positioning of FP within the greater context of reproductive health was very
effective in attracting attention and encouraging acceptance of campaign mes-
sages. The reproductive health approach also received political support. Unlike FP
per se, reproductive health was not a controversial topic in Bolivia. Rather it was a

2-31A Field Guide to Designing a Health Communication Strategy

major part of the Government’s strategy to reduce maternal mortality and to
improve child survival, and allowed for easy expansion of the approach to other
geographic areas.

Unified Image of Reproductive Health Services
The success of the Bolivia campaign also relied on the creation of a unified image
of reproductive health services. One of the main tools to help create this image
was the design and positioning of a common logo that allow for identification of
places where reproductive health services and information were available as well
as an identification sign for all the materials and activities related to the Bolivian
reproductive health program. In addition to providing a corporate image to the
program, the shared logo helped to boost the feeling of teamwork among the
NRHP stakeholders.

The logo, together with the lilac color, and the tag line “Reproductive Health Is in
Your Hands” were used systematically in all materials and at the clinic level to
build the program’s identity and to establish the Las Manitos brand.

III. Analysis of the Situation

Context
Prior to the 1990s the climate for FP services was not favorable in Bolivia. In fact, in
1977 the Bolivian Government banned the provision of FP services by public
institutions and closed the only NGO provider of these services. In 1982, a new
Government explicitly banned the provision of FP services by NGOs. In this con-
text, few FP efforts had been implemented prior to 1990, despite the high level of
unmet need for FP services.

The turnaround began in 1986 with an advocacy and service promotion campaign
to promote the private-sector organization Centro de Orientacion Familiar (COF),
which was providing FP services in three Bolivian cities. About 700 policymakers
and influential citizens attended 10 discussion meetings on the pros and cons of FP,
especially the benefits for maternal and child health. Participants were very sup-
portive of increasing services and advocacy. The positive experience of the 1986
campaign was instrumental in paving the way for the national strategy of the 1990s.

2-32 A Field Guide to Designing a Health Communication Strategy

In 1990, the Bolivian Government and the U.S. Agency for International Develop-
ment (USAID)/Bolivia signed the first bilateral agreement on reproductive health
under the name National Reproductive Health Program. The NRHP was created to
bring together stakeholder efforts directed toward the creation and promotion of
healthy reproductive practices and increased acceptance of modern FP methods.
At the inception of Bolivia’s NRHP the country’s population was 7.2 million, with
almost half of the population concentrated in 7 urban areas. Bolivia also had the
highest rate of maternal mortality in the Western Hemisphere, with 416 deaths per
100,000 live births during 1984–1989. Six out of 10 deaths of women in their
reproductive years were related to pregnancy and delivery. Thirty-eight percent of
these deaths were due to abortions.

The evolution of NRHP is depicted in Figure A2.1. As part of the third and largest
phase of the program, the NRHP designed and implemented several campaigns
between 1994 and 1997, three of them under the name “Las Manitos.” This case
study focuses on the strategic elements that made Las Manitos a success.

Figure A2.1. Evolution of Bolivia’s NRHP

2-33A Field Guide to Designing a Health Communication Strategy

Program Goals
Based on the consensus obtained in the workshops of 1989 and having identified
the lead institutions on the subject, USAID provided funds for the creation of a
comprehensive national program on reproductive health. A large number of
private and public sector stakeholders, in addition to a series of technical assis-
tance agencies, participated in the design and implementation of the NRHP.

The NRHP’s goal was to improve the health of Bolivian families through (1) pro-
moting healthy reproductive practices, (2) improving the provision of services, and
(3) increasing acceptance of modern FP methods.

Key Problem
The key problem influencing the development of the strategy was the combina-
tion of substantial unmet need for FP services and high rates of infant and mater-
nal mortality. Low rates of knowledge about FP methods and lack of information
about their use contributed to limited use of contraceptives.

According to the NRHP communication baseline survey conducted in 1994 at the
start of Las Manitos, 30.9 percent of urban women were using modern contraceptive
methods, with the condom the most popular method (11.6 percent), followed by the
intrauterine device (IUD) (8.9 percent), and oral contraceptives (4.7 percent). Aware-
ness of the most common modern methods was relatively high, with combined
spontaneous and assisted recall of the pill, IUD, and condoms exceeding 75 percent.

The 1994 DHS showed that 17.7 percent of women in union (urban and rural) were
using modern methods of contraception in Bolivia. This figure had increased from
12.2 percent according to the 1989 DHS, but in 1994 there were still many couples
with unmet needs for FP. The 1994 DHS showed that 67.6 percent of women in
union did not want to have any more children (excluding women who were
sterilized). While fertility in 1994 was 4.8, the DHS revealed that most women ages
15–49 desired a total of 2.5 children.

2-34 A Field Guide to Designing a Health Communication Strategy

As of 1994, 48 percent of Bolivian women who gave birth never received prenatal
care, and 58 percent of births took place in homes, usually without the assistance
of a health worker. Both fertility and infant mortality rates were higher in Bolivia
than in most other Latin American countries. While the overall infant mortality
rate was about 80 deaths per 1,000 births, the rate in some rural regions was almost
twice that.

Information Gaps and Formative Research Findings
In addition to epidemiological information concerning fertility in different age
groups (extracted from DHS), campaign strategists needed to learn more about
current knowledge, attitudes, and practices regarding reproductive health as well
as media habits of the intended audience. This information was gathered through
quantitative and qualitative studies. In 1994, prior to the design of the strategy, a
baseline household survey was conducted among 2,256 men and women in 7
urban areas. This survey measured the intended audience’s knowledge, attitudes,
and practices regarding reproductive health as well as their media habits.

To gain a qualitative perspective of the situation, a series of 16 focus groups was
conducted in 1994 with members of the potential audience to clarify issues re-
lated to understanding of key terms and to gain insight concerning barriers to use
of modern FP methods. The focus group discussions revealed that:

� Participants associated reproductive health with a broader range of services.
� FP had negative connotations.
� Misunderstandings and misinformation existed relative to knowledge about

specific FP methods.

The participants thought that the phrase “reproductive health” was vague and that
it alluded to women’s health issues, not men’s. However, when compared to “family
planning,” which was seen as narrow in its definition, “reproductive health” was
associated with a wider variety of services. Another important insight gained from
the focus groups was that a clear and positive definition could be attached to the
term “reproductive health,” whereas strong negative beliefs and barriers were
already attached to the term “family planning.”

2-35A Field Guide to Designing a Health Communication Strategy

The formative research also revealed concerns that women had regarding their
ability to control their own reproductive health and to positively influence the
health of their children. A number of religious, cultural, and educational barriers
were identified as primary causes of this self-doubt. The religious concern was
that the Catholic Church did not approve of modern FP methods. One cultural
issue was that some men feared that if their partners used these methods they
might develop other sexual relationships. Another cultural concern related to the
discomfort that some men had regarding their partners being seen by a male
physician. The major educational barrier was a lack of knowledge among both
men and women concerning reproductive health issues.

IV. Communication Strategy

The Las Manitos I campaign was launched in 1994 in the four largest cities. It was
the first audience-based communication effort developed under the NRHP.

Audience
The intended audience for the Las Manitos I campaign strategy consisted of
individuals and couples between the ages of 18 and 35 living in urban and peri-
urban areas. They represented the middle and lower socioeconomic groups,
which comprised the urban majority and constituted a population of approxi-
mately 500,000 people. The campaign was implemented in the four urban areas of
La Paz, El Alto, Santa Cruz, and Cochabamba.

Objectives
A number of behavior change objectives were developed for the Las Manitos I
campaign, which ran from May through November of 1994. Desired changes
were to:

� Introduce the NRHP logo to achieve recall by 64 percent of the intended
audience.

� Explain the benefits of reproductive health, so that within a period of 3
months, 41 percent of the intended audience mentions at least one benefit.

� Inform at least 33 percent of the intended audience about the availability of
reproductive health services and how to obtain them.

2-36 A Field Guide to Designing a Health Communication Strategy

� Have at least 26 percent of the intended audience show a favorable attitude
toward reproductive health services.

� Have at least 7 percent of the intended audience seek information and/or
services by visiting health centers.

Indicators were used to verify that the campaign strategy was having the in-
tended effect. Examples of these indicators were to:

� Have at least 17 percent of the intended audience talk about reproductive
health themes with their spouses.

� Have at least 13 percent of the intended audience show intent to seek, in the
near future, information and services provided by health centers.

Strategic Approach
The strategic approach of the Las Manitos I campaign was to empower women
and men to take action to meet their reproductive health needs through the
innovative use of advocacy and mass media channels.

To emphasize Government support of the Las Manitos I campaign, the President of
Bolivia, Gonzalo Sanches de Lozada, delivered a keynote address to launch the
effort. The President proclaimed reproductive health as the cornerstone of his 3-
year “Plan for the Accelerated Reduction of Maternal and Perinatal Mortality.” The
inauguration of Las Manitos I represented the first time that the Government of
Bolivia had ever prioritized FP and reproductive health on the national agenda in
the history of the country.

Over time, a long-term identity was forged, in which women and men understood
Las Manitos to represent a way to improve the health of children and mothers
through birth spacing, FP, prenatal and postnatal care, breastfeeding and preven-
tion of abortions.

The positioning statement for Las Manitos I can be described as:
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2-37A Field Guide to Designing a Health Communication Strategy

The NRHP ensured that the positioning of Las Manitos I reinforced the goals of the
Government of Bolivia in the areas of maternal and child health. By offering
information and services on a wide array of health issues, Las Manitos was able to
support the President’s initiatives to offer a range of services to improve the health
of Bolivian families.

Key Message Points
In developing appropriate and effective messages, the Las Manitos I campaign
had to overcome both cultural misperceptions about FP and opposition from
conservative sectors to respond to the audience’s perceived health needs.

Three sets of messages were designed and disseminated over the course of the
campaign. The first set of messages explained the overall concept of reproductive
health, which was not well understood initially by the audience. The Las Manitos
logo was also introduced and featured prominently in all spots, and information
was provided informing the audience where to go to obtain services.

In the second set of messages, specific information about particular FP methods
was disseminated. Additional reproductive health concepts were also explained,
including breastfeeding, prenatal and postnatal care, and the dangers of abortion.
Factual information was shared in an attempt to educate the audience and to
correct misperceptions. The messages also highlighted the benefits to the user of
adopting these behaviors.

In the third round, the messages included testimonials from satisfied users to rein-
force the benefits to women and men of taking charge of their reproductive health;
in particular, the testimonials reinforced the positive effects of practicing FP.

Las Manitos I also aired a spot on the dangers of abortions and the importance of
using FP methods to prevent unwanted pregnancy. Since one of the leading
causes of maternal death in Bolivia was abortion, the Minister of Health requested
that a spot emphasizing the potential risks of abortion be integrated into the mass
media campaign. This was the first television spot aired in Latin America to men-
tion this important health issue.

2-38 A Field Guide to Designing a Health Communication Strategy

Throughout the campaign, pretesting and audience research were conducted to
ensure that the messages were meaningful, appropriate, understood, and motiva-
tional. Special attention was given to language considerations as well.

Channels and Tools
Las Manitos I used mass media as the lead channel, which was supported by
community and interpersonal channels of communication. Due to the low cost of
radio production and broadcasting in Bolivia, the campaign was able to produce
the number of spots required by the country’s diverse population. Specifically, 11
television and 44 radio spots were used to allow for maximum reach and fre-
quency during the initial 7-month campaign. To reach as much of the intended
audience as possible, the radio spots were adapted to the indigenous languages
of Aymara and Quechua. In addition, the Spanish versions were recorded in two
linguistic norms—Coya and Camba.

At the community level, a series of four audiocassettes was developed for use on
1,000 city and interstate buses. Each cassette was 1 hour in length and included
reproductive health messages complemented by popular music, a jingle, and jokes.

Interpersonal channels focused on training service delivery providers and providing
them with a wide variety of materials to use with their clients. Materials included flip
charts, reference manuals, method posters, reproductive health brochures, and
individual method flyers. Print materials were used by all of the NRHP service deliv-
ery partner organizations and were adapted to the specific needs of their clinics.
Clinic staff were trained in the use of the materials prior to initiation of the mass
media campaign. A series of clinic videos for clients was also developed that cov-
ered the topics of breastfeeding, FP methods, and spousal communication.

V. Management Considerations

Partner Roles and Responsibilities
The NRHP had four technical subcommittees specialized by function: services,
research and population policies, training, and IEC. Each of these committees was
comprised of technical representatives of the participating public and private
institutions. They met regularly each month and also met on an as-needed basis.

2-39A Field Guide to Designing a Health Communication Strategy

Members of these committees also met in minicommittees or working groups to
execute a specific activity (e.g., printed materials, videos, campaign strategy).
Despite the voluntary nature of this effort, the subcommittees worked very inten-
sively and were instrumental in the success of the campaign. They participated in
all phases of campaign development, shared the responsibility for the distribution
of print materials, and acted as intermediaries with the Ministry of Health, other
Government agencies, the church, and other key influentials. These partners also
publicly advocated for the benefits of the campaign in different meetings and
events.

The NRHP IEC Subcommittee was responsible for the campaign strategy design,
implementation, and evaluation. This group primarily provided strategy oversight,
direction, advocacy, and endorsement. The Ministry of Health was an active
member of the IEC Subcommittee and also publicly endorsed the final campaign.
The members of the subcommittee elected their own President and Secretary. The
President served as the lead advocate in support of the campaign. A list of the IEC
Subcommittee members is found in attachment 1.

Timeline
To lay the proper foundation for the Las Manitos I mass media campaign, prior to
the campaign launch a number of training workshops were held with members of
the IEC Subcommittee. Through these workshops, subcommittee members gained
skills in developing health communication campaigns. The training covered
audience research, message design, campaign development and implementation,
pretesting and posttesting, and evaluation techniques.

Earlier, successful communication outreach efforts also played a role in laying the
foundation for Las Manitos. A series of four 1-hour long audiocassettes had been
developed beginning in 1986 and used extensively by intracity buses. The tapes
covered many areas of reproductive health and FP methods. The response was so
great for these audiocassettes that intercity bus drivers demanded that they also
receive the audiocassette series.

The success of the Las Manitos I campaign, which aired from May–November 1994,
provided the momentum for follow-on campaigns over the next several years.

2-40 A Field Guide to Designing a Health Communication Strategy

Monitoring
The 7-month Las Manitos I mass media campaign was monitored primarily
through media plan tracking. The advertising agency provided monthly televi-
sion rating reports, and the distribution of the materials was verified through the
IEC NGOs. This gave the campaign organizers the ability to monitor the reach and
penetration of the campaign messages among the intended audiences.

VI. Evaluation

The success of the Las Manitos I campaign was measured after the campaign
ended with a second cross-sectional national probability sample survey of house-
holds in urban areas conducted in November 1994. Modifications of the baseline
questionnaire were made to include specific questions measuring impact based
on message exposure and message recall.

Results indicated that the campaign reached more than 85 percent of the in-
tended audience and met all of the stated behavior change objectives. Recogni-
tion of the Las Manitos logo was high; 94 percent of respondents were able to
identify the logo. There was a significant increase in the proportion of the audi-
ence that knew about specific preventive health care measures. Among respon-
dents in the four main cities, knowledge increased from 19 to 28 percent.

While awareness and IPC were found to be fairly high in the baseline survey and
while attitudes were quite favorable, an increase in these measures was still
achieved according to the followup survey. In the four main cities, method aware-
ness increased from 84 percent in the baseline to 88 percent among those exposed
to campaign messages. As for actual method use, new FP adopters in the four
main cities increased from 5.4 percent of respondents in the baseline to 8.6 per-
cent in the followup survey.

Indicators had been developed to track progress in reaching the objectives. One
indicator looked at increased partner communication about reproductive health
issues. The followup survey showed slight increases in partner communication
among respondents, but these changes were not statistically significant. This
finding implied that more refined measures of partner communication were
needed for future evaluation efforts.

2-41A Field Guide to Designing a Health Communication Strategy

The other indicator examined respondents’ intent to seek reproductive health
information and services in the future. The change in the percentage of respon-
dents who sought information on reproductive health was not statistically signifi-
cant. Some of the intended audience may have “skipped” the information-seeking
step and moved directly to the intention to use or actual adoption of a FP method.
However, intention to use or continuation of method use increased significantly
between the baseline and followup surveys for respondents in the four main
cities. The percentage of men who responded “definitely yes” when asked if they
would begin or continue using a method in the next 6 months increased from 25
to 53 percent.

The evaluation design allowed project managers to assess the impact of the
campaign, measure changes, and determine their significance.

VII. Staying on Strategy

The Las Manitos I campaign was extended to seven medium-sized cities from
October 1995 to January 1996. In 1996, a second campaign was developed to
build on the experience of Las Manitos I. The focus of this campaign, which was
implemented in all urban areas, supported the Government’s goal of reducing
maternal mortality. In addition, since this campaign was linked to a contraceptive
social marketing campaign, the slogan “Reproductive Health Is Closer to You” was
developed to reinforce the fact that contraceptives were now available at tradi-
tional and nontraditional outlets, and the health centers were not the only provid-
ers of reproductive health services or commodities.

Specific objectives of Las Manitos II were to:

� Expand the audience to reach more young adults and more couples living in
urban areas.

� Emphasize the importance of preventing the spread of STDs and AIDS by
using condoms.

� Reinforce the benefits of using specific contraceptive methods to prevent
reproductive health problems, such as unwanted pregnancy and abortion.

2-42 A Field Guide to Designing a Health Communication Strategy

Compared to the February 1994 baseline survey, the August 1996 survey analyzing
the Las Manitos II campaign showed the following percentage changes among
members of the intended audience:

In 1997, recognizing the significant unmet need in rural areas for reproductive
health information and services (modern method prevalence in rural areas was
6.9%), the NRHP developed a strategy called the Lilac Tent (Carpa Lila) to em-
power rural communities to learn more about reproductive health issues. A
combination of mass media, community-based channels, and IPC is used to attract
the intended audience, which is predominantly young adults, and to provide
information in an educational and entertaining manner.

The Lilac Tent uses a community participation process to identify who should be
trained as facilitators. Radio station producers are trained and given educa-
tional programming materials, and other community stakeholders, such as
teachers and health workers, are also given training and materials. In the first
year of the Lilac Tent, a total of 495,362 people were reached. Of these, 196,105
participated in community-based events, and 299,257 were reached through
local radio and print.

2-43A Field Guide to Designing a Health Communication Strategy

VIII. Conclusion

The experience, lessons learned, and research results generated by Las Manitos I
were used to refine the NRHP strategic approach over time. The IEC Subcommittee
membership continued to grow to 45 organizations (as of 1998), and the group
remained active in shaping messages to meet the needs of audiences in wider
geographic areas, including rural communities. Additional audiences, such as
young adults, were also identified as having significant needs for reproductive
health information and services. Subsequently, there were two television series
aimed at youth as well as a life skills curriculum for use in the classroom.

Due to the collaboration of many stakeholders and an unyielding focus on the
needs of the couples with unmet needs, the rate of modern contraceptive method
use has steadily increased in Bolivia from 7 percent in 1989 to 17.5 percent in 1998.
This success is due in large measure to the vision and commitment of the NRHP
and to the role that Las Manitos played.

Figure 2.

2-44 A Field Guide to Designing a Health Communication Strategy

Lessons Learned
Las Manitos I broke new ground in Bolivia by highlighting a sensitive issue in a
public, educational, and motivational way. In addition, for the first time in Bolivia
high-level Government officials appeared in some of the Las Manitos television
spots to reinforce the Government’s support of reproductive health.

Between 1991 and 2000, significant changes occurred in community norms. The
use of modern FP methods became more openly discussed, accepted, and preva-
lent. Las Manitos started a movement that showed, with a series of well planned
campaigns over time, that substantial changes in community norms can occur. For
example, in 1993–1994, traditional methods were more prevalent than modern
methods. By 1999, this ratio had been reversed.

Las Manitos played the role of a catalyst and provided momentum for other
health initiatives in Bolivia. Las Manitos also established an enabling environ-
ment that empowered other groups to speak out in support of reproductive
health efforts.

2-45A Field Guide to Designing a Health Communication Strategy

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The 10 founding members of the subcommittee were:
Ministerio de Salud (MINSA)
Fundación San Gabriel (FSG)
Caja Nacional de Salud (CNS)
Unidad de Políticas de Población del Ministerio de Planificación (UPP)
Centro de Orientación Familiar (COF)
Protección a la Salud (PROSALUD)
Centro de Investigación, Educación y Servicios (CIES)
USAID
JHU/CCP
FAMES

Additional subcommittee members at various points in time included:
IPAS
Educación en Población/UNFPA
AVSC
Family Care International (FCI)
FHI
Freedom from Hunger
Fuerzas Armada de Bolivia (FFAB)
Programa de Salud Reproductiva (GTZ)
JHPIEGO/SMN
Mothercare
OPS/OMS
Focus/Pathfinder
Population Council
Proyecto Comunitario de Salud Integral (PROCOSI)
Proyecto contra el SIDA
PSI
Save the Children
Sociedad Boliviana de Ginecología (SBG)

2-46 A Field Guide to Designing a Health Communication Strategy

Winay
UNFPA
UNICEF
Viceministerio de Genero
AYUFAM
Ilustre Alcaldia Municipal de La Paz
Viceministerio de Educación Alternativa
SERVIR
CROF
Centro de Investigación Social, Tecnología Apropiada y Capacitación
CISTAC
Cruz Roja Boliviana

2-47A Field Guide to Designing a Health Communication Strategy

����������

Annual Reports of Population Communication Services/Population Information
Program, 1993-1997. Baltimore: The Johns Hopkins University School of Hygiene
and Public Health, Center for Communication Programs.

Communication Impact (1999). (Rep. No. 5). The Johns Hopkins University
Bloomberg School of Public Health, Center for Communication Programs.

Dagron, A. G. (2001). Making waves: Stories of participatory communication for
social change. The Rockefeller Foundation.

Mercado, E. (1995). Historical summary of the Bolivian national reproductive
health coordinating committees. USAID.

Merritt, A. P. (1992). Family planning goes public. Integration, 41-43.

Merritt, A. P., et al. (2002). Bolivia case study, reproductive health is launched
nationally: A first for Latin America. Johns Hopkins Bloomberg School of Public
Health/Center for Communication Programs.

Second DHS survey in Bolivia shows improving health indicators (1995). Demo-
graphic and Health Surveys Newsletter, 7(2), 5.

Partnerships that Work! (1996). The Johns Hopkins University/Population Commu-
nication Services.

2-48 A Field Guide to Designing a Health Communication Strategy

Valente, T. W., Saba, W. P., Merritt, A. P., Fryer, M. L., Forbes, T., Perez, A., & Beltran, L. R.
(1996). Reproductive Health is in Your Hands: Impact of the Bolivia National
Reproductive Health Program Campaign. (IEC Field Report Number 4). Baltimore:
The Johns Hopkins School of Public Health Center for Communications Programs.

Valente, T. W. & Saba, W. P. (2001). Campaign exposure and interpersonal communi-
cation as factors in contraceptive use in Bolivia. Journal of Health Communication,
6, 303-322.

Valente, T. W. (2002). Evaluating health promotion programs. Oxford University
Press.

1-2 A Field Guide to Designing a Health Communication Strategy

1-3A Field Guide to Designing a Health Communication Strategy

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Theories of Communication Impacts on Behavior
Over the last 50 years, social scientists have advanced various theories of how
communication can influence human behavior. These theories and models
provide communicators with indicators and examples of what influences behav-
ior, and offer foundations for planning, executing, and evaluating communication
projects (Piotrow, Kincaid, Rimon, & Rinehart, 1997). Theories particularly relevant
to health communication include the following:

Ideation Theory (Kincaid, Figueroa, Storey, & Underwood, 2001). This theory
(Cleland, 1985; Cleland et al., 1994; Cleland and Wilson, 1987; Freedman, 1987; Tsui,
1985) refers to new ways of thinking and the diffusion of those ways of thinking
by means of social interaction (Bongaarts and Watkins, 1996) in local, culturally
homogeneous communities. Recent sociodemographic literature has identified
ideation and social interaction as important determinants of fertility decline. This
perspective amounts to a shift from macrolevel structural explanations to
microlevel decisionmaking explanations of demographic change.

Stage/Step Theories. Diffusion of innovations theory (Ryan and Gross, 1943)
traces the process by which a new idea or practice is communicated through
certain channels over time among members of a social system. The model
describes the factors that influence people’s thoughts and actions and the process
of adopting a new technology or idea (Rogers, 1962, 1983; Ryan and Gross, 1943,
1950; Valente, 1995). The input/output persuasion model (McGuire, 1969)

1-4 A Field Guide to Designing a Health Communication Strategy

emphasizes the hierarchy of communication effects and considers how various
aspects of communication, such as message design, source, and channel, as well as
audience characteristics, influence the behavioral outcome of communication
(McGuire, 1969, 1989). Stages of change theory, by psychologists J.O. Prochaska,
C.C. DiClemente, and J.C. Norcross (1992), identifies psychological processes that
people undergo and stages that they reach as they adopt new behavior. Changes
in behavior result when the psyche moves through several iterations of a spiral
process—from precontemplation through contemplation, preparation, and action
to maintenance of the new behavior (Prochaska et al., 1992).

Cognitive Theories. Theory of reasoned action, by M. Fishbein and I. Ajzen, speci-
fies that adoption of a behavior is a function of intent, which is determined by a
person’s attitude (beliefs and expected values) toward performing the behavior
and by perceived social norms (importance and perception that others assign the
behavior) (Fishbein and Ajzen, 1975). Social cognitive (learning) theory, by A.
Bandura, specifies that audience members identify with attractive characters in
the mass media who demonstrate behavior, engage emotions, and facilitate
mental rehearsal and modeling of new behavior. The behavior of models in the
mass media also offers vicarious reinforcement to motivate audience members’
adoption of the behavior (Bandura, 1977, 1986).

Social Process Theories. Social influence, social comparison, and convergence
theories specify that one’s perception and behavior are influenced by the percep-
tions and behavior of members of groups to which one belongs and by members
of one’s personal networks. People rely on the opinions of others, especially when
a situation is highly uncertain or ambiguous and when no objective evidence is
readily available. Social influence can have vicarious effects on audiences by
depicting in television and radio programs the process of change and eventual
conversion of behavior (Festinger, 1954; Kincaid, 1987, 1988; Latane, 1981;
Moscovici, 1976; Rogers and Kincaid, 1981; Suls, 1977).

1-5A Field Guide to Designing a Health Communication Strategy

Emotional Response Theories. Theories of emotional response propose that
emotional response precedes and conditions cognitive and attitudinal effects.
This implies that highly emotional messages in entertainment (see chapter 4)
would be more likely to influence behavior than messages low in emotional
content (Clark, 1992; Zajonc, 1984; Zajonc, Murphy, and Inglehart, 1989).

Mass Media Theories. Cultivation theory of mass media, proposed by George
Gerbner, specifies that repeated, intense exposure to deviant definitions of “reality”
in the mass media leads to perception of that “reality” as normal. The result is a
social legitimization of the “reality” depicted in the mass media, which can influ-
ence behavior (Gerbner, 1973, 1977; Gerbner et al., 1980).

1-6 A Field Guide to Designing a Health Communication Strategy

����������

Kincaid, D. L., Figueroa, M. E., Storey, D., & Underwood, C. Communication and
behavior change: The role of ideation. Johns Hopkins University Bloomberg
School of Public Health, Center for Communication Programs. 2001.

Piotrow, P. T., Kincaid, D. L., Rimon, J. G. I., & Rinehart, W. (1997). Health Communication:
Lessons from Family Planning and Reproductive Health. Westport, CT: Praeger
Publishers.

3-1A Field Guide to Designing a Health Communication Strategy

Activity
A specific event or action.

Campaign
Goal-oriented attempt to inform, persuade, or motivate behavior change in a well-
defined audience. A campaign provides benefits to the individual and/or society,
typically within a given time period, by means of organized communication
activities.

Channels
Three categories of communication channels are interpersonal, community, and
mass media. Interpersonal channels include one-to-one communication. Com-
munity channels reach a group of people within a distinct geographic area or
reach a group that shares common interests or characteristics. Community-based
media, community-based activities, and community mobilization are all forms of
community channels. Mass media channels, which can reach large audiences
quickly, include television, radio, newspapers, magazines, outdoor/transit advertis-
ing, and direct mail.

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3-2 A Field Guide to Designing a Health Communication Strategy

Community Mobilization
A process through which action is stimulated by a community itself, or by others,
that is planned, carried out, and evaluated by a community’s individuals, groups,
and organizations on a participatory and sustained basis to improve health. In
addition to improving health, the community mobilization process also aims to
strengthen the community’s capacity to address its health and other needs in the
future. A participatory process of communities identifying and taking action on
shared concerns.

Formative Research
Research studies conducted during the initial stages of program and message
development. Includes reviews of existing research studies, pretesting concepts and
messages, or trying out a program on a small scale before full implementation.

Gender Equality
The same status, rights, and responsibilities for women and men.

Gender Equity
The quality of being fair and right. Addresses imbalances. A stage in the process
of achieving gender equality.

Indicator
An interim measure used to track progress toward achieving objectives.

Intervention
A health communication implementation that takes place within a given time.

Key Influencers
Influential people in the primary audience’s social network, such as friends, rela-
tives, religious leaders, and traditional healers.

Long-Term Identity
A unique set of associations that represent what the product, service, or behavior
stands for in the minds of the audience.

3-3A Field Guide to Designing a Health Communication Strategy

Media Advocacy
The strategic use of mass media to advance a social or political policy initiative.
Attempts to reframe community-based public dialogue and to increase support
from the public in general and community policy and decision-makers in specific
for public health policies.

Outcome Evaluation
A type of evaluation that determines whether a particular intervention had the
desired impact on the intended audience’s behavior, that is, whether the interven-
tion made a difference in knowledge, skills, attitudes, beliefs, behaviors, and health
outcomes. Also called impact or summative evaluation.

Positioning
In the context of strategic design, positioning means presenting an issue, service,
or product in such a way that it stands out from other comparable or competing
issues, services, or products and is appealing and persuasive. Positioning creates a
distinctive and attractive image, a perpetual foothold in the minds of the intended
audience.

Program
A plan or system under which action may be taken toward a goal. In the context of
this book, “program” refers to a broad health-related effort with long-term goals,
perhaps national in scope, usually generated or at least endorsed by the govern-
ment. A health program may include various projects and strategies focusing on
issues, such as health care service delivery, service provider training, commodity
supply, clinic infrastructure, communication, and research. Examples are FP, HIV/
AIDS, integrated health services, and child immunization.

Project
A specific plan or design scheme. In the context of this book, “project” refers to a
subset of a health program in which a portion of the program is implemented,
such as a specific child immunization project under a broader maternal and child
health program. Other projects under this program might focus on breastfeeding,
nutrition, and prenatal and postnatal care, for example.

3-4 A Field Guide to Designing a Health Communication Strategy

Public Policy Advocacy
The effort to influence public policy through various forms of persuasive com-
munication. Public policy includes statements, policies, or prevailing practices
imposed by those in authority to guide or control institutional, community, and
sometimes individual behavior.

Segmentation
This process involves dividing the audience into smaller groups of people who
have similar communication-related needs, preferences, and characteristics. Each
audience segment requires tailored messages that will be meaningful to the
audience members.

Segmentation entails subdividing an overall population into similar subgroups in
order to better describe and understand each subgroup, predict behavior, and
formulate the appropriate messages and programs to meet specific needs.

Social Capital
The resources embedded in social relations among persons and organizations
that facilitate cooperation and collaboration in communities.

Strategic Approach
Describes the overarching direction that guides the choice of messages, channels,
tools, management components, and indicators to achieve desired goals.

Strategic Communication
A process based on a combination of data, ideas, and theories integrated by a
visionary design to achieve verifiable objectives by affecting the most likely
sources and barriers to behavior change, with the active participation of stake-
holders and beneficiaries.

3-5A Field Guide to Designing a Health Communication Strategy

Strategic Communication Tools
The various tactics used to conduct messages through the channels. They
include advocacy; advertising; promotion; IPC enhancement, event creation and
sponsorship, community mobilization; publicity; and entertainment vehicles,
such as television or radio programs, folk dramas, songs, or games that provide
entertainment and educational messages simultaneously.

Strategy
A careful plan or method; the art of devising or employing plans toward a goal.

In the context of this book, a “strategy” is the health communication strategy that
includes subsections describing the situation, the audience, behavior change
objectives, the strategic approach, key message points, channels, management
and evaluation plans.

3-6 A Field Guide to Designing a Health Communication Strategy

4-1A Field Guide to Designing a Health Communication Strategy

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