Health

Making
Communication

Programs Work

U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES

Public Health Service • National Institutes of Health
National Cancer Institute
Preface

T
his book is a revision of the original Making Health
Communication Programs Work, first printed in 1989, which
the Office of Cancer Communications (OCC, now the Office
of Communications) of the National Cancer Institute (NCI)
developed to guide communication program planning. During the 25
years that NCI has been involved in health communication, ongoing
evaluation of our communication programs has affirmed the value of
using specific communication strategies to promote health and prevent
disease. Research and practice continue to expand our understanding
of the principles, theories, and techniques that provide a sound
foundation for successful health communication programs. The purpose
of this revision is to update communication planning guidelines to
account for the advances in knowledge and technology that have
occurred during the past decade.

To prepare this update, NCI solicited ideas and information from

various health communication program planners and experts (see
Acknowledgments). Their contributions ranged from reviewing and
commenting on existing text to providing real-life examples to illustrate
key concepts. In addition, the Centers for Disease Control and
Prevention (CDC) provided extensive input as part of the agency’s
partnership with NCI.

Although communicating effectively about health is an exacting task,

those who have the earlier version of this publication know that it is
possible. We hope the ideas and information in this revision will help
new health communication programs start soundly and mature
programs work even better.
Acknowledgments

Many health communication experts contributed to the revision of this book.

For their invaluable input, we would like to thank:

Elaine Bratic Arkin Health Communications Consultant

Cynthia Bauer, Ph.D. U.S. Department of Health and

Human Services

John Burklow Office of Communication and Public Liaison

National Institutes of Health

Lynne Doner Health Communications Consultant

Timothy Edgar, Ph.D. Westat

Brian R. Flay University of Illinois at Chicago

Vicki S. Freimuth, Ph.D. Office of Communication

Centers for Disease Control and Prevention

Joanne Gallivan, M.S., R.D. National Institute of Diabetes and Digestive

and Kidney Diseases

Karen Glanz, Ph.D., M.P.H. Cancer Research Center of Hawaii

Bernard Glassman, M.A.T. Special Expert in Informatics

National Cancer Institute

Susan Hager Hager Sharp

Jane Lewis, Dr.P.H. UMDNJ, School of Public Health

Terry Long National Heart, Lung, and Blood Institute

 Kathleen Loughrey, M.S., R.D. Health Communications Consultant

Susan K. Maloney, M.H.S. Health Communications Consultant

Joy R. Mara, M.A. Joy R. Mara Communications

John McGrath National Institute of Child Health and

Human Development

Diane Miller, M.P.A. National Institute on Alcohol Abuse and

Alcoholism

Ken Rabin, Ph.D. Ruder Finn Healthcare, Inc.

Scott C. Ratzan, M.D., M.P.A. Journal of Health Communication

U.S. Agency for International Development

Barbara K. Rimer, Dr.P.H. Division of Cancer Control and

Population Sciences
National Cancer Institute

Victor J. Strecher, Ph.D., M.P.H. University of Michigan

Tim L. Tinker, Dr.P.H., M.P.H. Widmeyer Communications

We would especially like to thank Elaine Bratic Arkin, author of the original book, whose knowledge of
health communication program planning made this revision possible, as well as Lynne Doner, whose
broad-based consumer research and evaluation expertise has enhanced the book’s content and quality.
Both have provided hours of review and consultation, and we are grateful to them for their contributions.

Thanks to the staff of the Office of Communications, particularly Nelvis Castro, Ellen Eisner, and Anne
Lubenow. And thanks to Christine Theisen, who coordinated the revisions to the original text.

This document was revised in coordination with the Centers for Disease Control and Prevention during
development of CDCynergy—a program-planning tool on CD-ROM.
Table of Contents

Why Should You Use This Book? i

Introduction 1

The Role of Health Communication in Disease Prevention and Control 2

What Health Communication Can and Cannot Do 3

Planning Frameworks, Theories, and Models of Change 7

How Market Research and Evaluation Fit Into Communication Programs 8

Selected Readings 9

Overview: The Health Communication Process 11

The Stages of the Health Communication Process 11

Stage 1: Planning and Strategy Development 15

Why Planning Is Important 16

Planning Steps 16

Common Myths and Misconceptions About Planning 48

Selected Readings 50

Stage 2: Developing and Pretesting Concepts, 53

Messages, and Materials

Why Developing and Pretesting Messages and Materials Are Important 54

Steps in Developing and Pretesting Messages and Materials 54

Planning for Production, Distribution, Promotion, and Process Evaluation 86

Common Myths and Misconceptions About Materials Pretesting 86

Selected Readings 87

Stage 3: Implementing the Program 91

Preparing to Implement Your Program 92

Maintaining Media Relations After Launch 95

Working With the Media During a Crisis Situation 98

Managing Implementation: Monitoring and Problem Solving 98

Maintaining Partnerships 102

Common Myths and Misconceptions About Program Implementation 103

Selected Readings 104

 Stage 4: Assessing Effectiveness and 107

Making Refinements

Why Outcome Evaluation Is Important 108

Revising the Outcome Evaluation Plan 108

Conducting Outcome Evaluation 110

Refining Your Health Communication Program 121

Common Myths and Misconceptions About Evaluation 121

Selected Readings 123

Communication Research Methods 125

Types of Communication Research 126

Differences Between Qualitative and Quantitative Research Methods 126

Qualitative Research Methods 127

Quasi-Quantitative Research Methods: Pretesting Messages and Materials 141

Quantitative Research Methods 157

Additional Research Methods 161

Appendix A: Communication Planning 169

Forms and Samples

Appendix B: Selected Planning Frameworks, Social 217

Science Theories, and Models of Change

Appendix C: Information Sources 229

Appendix D: Selected Readings and Resources 235

Appendix E: Glossary 245

Why Should You Use This Book?

T
he planning steps in this book can help make any
communication program work, regardless of size, topic,
geographic span, intended audience, or budget. (intended
audience is the term this book uses to convey what other
publications may refer to as a target audience.) The key is reading all
the steps and adapting those relevant to your program at a level of
effort appropriate to the program’s scope. The tips and sidebars
throughout the book suggest ways to tailor the process to your
various communication needs.

If you have limited funding, you might

• Work with partners who can add their resources to your own
• Conduct activities on a smaller scale
• Use volunteer assistance
• Seek out existing information and approaches developed by
programs that have addressed similar issues to reduce
developmental costs

Don’t let budget constraints keep you from setting objectives, learning
about your intended audience, or pretesting. Neglecting any of these
steps could limit your program’s effectiveness before it starts.

This book describes a practical approach for planning and

implementing health communication efforts; it offers guidelines, not
hard and fast rules. Your situation may not permit or require each step
outlined in the following chapters, but we hope you will consider each
guideline and decide carefully whether it applies to your situation.

To request additional copies of this book, please visit NCI’s Web site
at www.cancer.gov or call NCI’s Cancer Information Service at
1-800-4-CANCER (1-800-422-6237).
 INTRO
Introduction

In This Section:
• The role of health communication in disease prevention and control
• What health communication can and cannot do
• Planning frameworks, theories, and models of change
• How research and evaluation fit into communication programs

Questions to Ask and Answer:

• Can communication help us achieve all or some of our aims?
• How can health communication fit into our program?
• What theories, models, and practices should we use to plan
our communication program?
• What types of evaluation should we include?
The Role of Health Communication in products and determine the channels that
Disease Prevention and Control deliver them to the right intended audiences.

There are numerous definitions of health Since this book first appeared in 1989,
communication. The National Cancer the discipline of health communication has
Institute and the Centers for Disease Control grown and matured. As research has
and Prevention use the following: continued to validate and define the
effectiveness of health communication, this
The study and use of communication book has become a widely accepted tool
strategies to inform and influence for promoting public health. Healthy People
individual and community decisions 2010, the U.S. Department of Health and
that enhance health. Human Services’ stated health objectives for
the nation, contains separate objectives for
Use the principles of effective health health communication for the first time.
communication to plan and create initiatives Meanwhile, the availability of new
at all levels, from one brochure or Web site technologies is expanding access to
to a complete communication campaign. health information and raising questions
Successful health communication programs about equality of access, accuracy of
involve more than the production of information, and how to use the new tools
messages and materials. They use most effectively.
research-based strategies to shape the

2
 INTRO

What Health Communication Can • Produce sustained change in complex

and Cannot Do health behaviors without the support of a
larger program for change, including
Understanding what health communication components addressing health care
can and cannot do is critical to services, technology, and changes in
communicating successfully. Health regulations and policy
communication is one tool for promoting or • Be equally effective in addressing all
improving health. Changes in health care issues or relaying all messages because
services, technology, regulations, and policy the topic or suggested behavior change
are often also necessary to completely may be complex, because the intended
address a health problem. audience may have preconceptions about
the topic or message sender, or because
Communication alone can: the topic may be controversial

• Increase the intended audience’s Communication Can Affect Multiple

knowledge and awareness of a health Types of Change
issue, problem, or solution
• Influence perceptions, beliefs, and Health communication programs can
attitudes that may change social norms affect change among individuals and also
• Prompt action in organizations, communities, and society
as a whole:
• Demonstrate or illustrate healthy skills
• Reinforce knowledge, attitudes, • Individuals—The interpersonal level is the
or behavior most fundamental level of health-related
• Show the benefit of behavior change communication because individual
• Advocate a position on a health issue behavior affects health status.
or policy Communication can affect individuals’
• Increase demand or support for awareness, knowledge, attitudes, self-
health services efficacy, skills, and commitment to
• Refute myths and misconceptions behavior change. Activities directed at
• Strengthen organizational relationships other intended audiences for change may
also affect individual change, such as
Communication combined with other involving patients in their own care.
strategies can: • Groups—The informal groups to which
people belong and the community settings
• Cause sustained change in which an they frequent can have a significant
individual adopts and maintains a new impact on their health. Examples include
health behavior or an organization adopts relationships between customers and
and maintains a new policy direction employees at a salon or restaurant,
• Overcome barriers/systemic problems, exercisers who go to the same gym,
such as insufficient access to care students and parents in a school setting,
employees at a worksite, and patients and
Communication cannot: health professionals at a clinic. Activities
aimed at this level can take advantage of
• Compensate for inadequate health care or these informal settings.
access to health care services

Making Health Communication Programs Work 3

• Organizations—Organizations are groups Communication Programs Can Include
with defined structures, such as Multiple Methods of Influence
associations, clubs, or civic groups. This
category can also include businesses, Health communicators can use a wide range
government agencies, and health insurers. of methods to design programs to
Organizations can carry health messages fit specific circumstances. These
to their constituents, provide support for methods include:
health communication programs, and
make policy changes that encourage • Media literacy—teaches intended
individual change. audiences (often youth) to deconstruct
• Communities—Community opinion media messages so they can identify the
leaders and policymakers can be effective sponsor’s motives; also teaches
allies in influencing change in policies, communicators how to compose
products, and services that can hinder or messages attuned to the intended
support people’s actions. By influencing audience’s point of view
communities, health communication • Media advocacy—seeks to change the
programs can promote increased social and political environment in which
awareness of an issue, changes in decisions that affect health and health
attitudes and beliefs, and group or resources are made by influencing the
institutional support for desirable mass media’s selection of topics and by
behaviors. In addition, communication shaping the debate about those topics
can advocate policy or structural changes • Public relations—promotes the inclusion
in the community (e.g., sidewalks) that of messages about a health issue or
encourage healthy behavior. behavior in the mass media
• Society—Society as a whole influences • Advertising—places paid or public service
individual behavior by affecting norms and messages in the media or in public spaces
values, attitudes and opinions, laws and to increase awareness of and support for
policies, and by creating physical, a product, service, or behavior
economic, cultural, and information • Education entertainment—seeks to
environments. Health communication embed health-promoting messages and
programs aimed at the societal level can storylines into entertainment and news
change individual attitudes or behavior programs or to eliminate messages that
and thus change social norms. Efforts counter health messages; can also include
to reduce drunk driving, for example, seeking entertainment industry support for
have changed individual and societal a health issue
attitudes, behaviors, and policies through
• Individual and group instruction—
multiple forms of intervention,
influences, counsels, and provides skills to
including communication.
support desirable behaviors
Multistrategy health communication • Partnership development—increases
programs can address one or all of support for a program or issue by
the above. harnessing the influence, credibility, and
resources of profit, nonprofit, or
governmental organizations

4 Introduction
 INTRO

CHARACTERISTICS OF EFFECTIVE HEALTH COMMUNICATION CAMPAIGNS

Certain attributes can make health communication campaigns more effective.

Use the guidelines in this section to plan your campaign.

Define the communication campaign goal effectively:

• Identify the larger goal
• Determine which part of the larger goal could be met by a communication campaign
• Describe the specific objectives of the campaign; integrate these into a campaign plan

Define the intended audience effectively:

• Identify the group to whom you want to communicate your message
• Consider identifying subgroups to whom you could tailor your message
• Learn as much as possible about the intended audience; add information about beliefs,
current actions, and social and physical environment to demographic information

Create messages effectively:

• Brainstorm messages that fit with the communication campaign goal and the
intended audience(s)
• Identify channels and sources that are considered credible and influential by the
intended audience(s)
• Consider the best times to reach the audience(s) and prepare messages accordingly
• Select a few messages and plan to pretest them

Pretest and revise messages and materials effectively:

• Select pretesting methods that fit the campaign’s budget and timeline
• Pretest messages and materials with people who share the attributes of the
intended audience(s)
• Take the time to revise messages and materials based upon pretesting findings

Implement the campaign effectively:

• Follow the plans you developed at the beginning of the campaign
• Communicate with partners and the media as necessary to ensure the campaign
runs smoothly
• Begin evaluating the campaign plan and processes as soon as the campaign
is implemented

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

Workstation, available at http://ctb.lsi.ukans.edu/tools/CWS/socialmarketing/outline.htm.
Accessed March 7, 2002.

Making Health Communication Programs Work 5

THEORIES GUIDE ACTION TO INCREASE MAMMOGRAPHY USE

Fox Chase Cancer Center, in cooperation with area managed care organizations, designed
a program that was based on key elements of the health belief model to encourage women
to have regular mammograms. Selected women received educational materials explaining
that virtually all women are at risk for breast cancer, regardless of the absence of
symptoms, and that risk increases with age (susceptibility). The materials stressed that
early detection brings not only the best chance of cure but also the widest range of
treatment choices (benefit). Women received a letter stating their physician’s support (cue
to action) and a coupon for a free mammogram (to overcome the cost barrier). Those who
did not have a mammogram within 90 days received different forms of reminders (cues to
action). In the most intensive reminder, a telephone counselor called selected women to
review their perceptions about susceptibility, benefits, and barriers. Program evaluation
showed that mammography use increased substantially.

The Fox Chase program also applied social learning theory in developing interventions to
encourage physician support of mammography and to improve clinical breast
examinations (CBEs). The planners examined the environmental and situational factors
that might affect physician behavior and tried to change the low expectations of
physicians about the benefits of breast screening. The interventions included
observational learning by watching an expert perform a CBE, an opportunity to increase
self-efficacy by practicing CBE with the instructor, and the use of a feedback report and
CME credits to reinforce physician skills.

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

diffusion of innovations model. Community analysis showed that women who were early
adopters (leaders) already had a heightened awareness of the value of mammography. To
reach middle adopters, the program mobilized the social influence of the early adopters by
using volunteers who had breast cancer to provide mammography information. The
program also provided highly individualized educational strategies linked to social
interaction approaches to reach late adopters. A social marketing framework influenced
the program’s planning approach, and media materials incorporated the health belief
model to promote individual behavior change.

Note. From “Audiences and Messages for Breast and Cervical Cancer Screenings,” by B. K. Rimer,
1995, Wellness Perspectives: Research, Theory, and Practice, 11(2), pp. 13–39. Copyright by University
of Alabama. Adapted with permission.

6 Introduction
 INTRO

Communication programs can take (See Appendix B for an overview of some

advantage of the strengths of each of the other relevant theoretical models.) Social
above by using multiple methods. A program marketing concentrates on tailoring
to decrease tobacco use among youth, for programs to serve a defined group and is
example, could include: most successful when it is implemented as

• Paid advertising to ensure that youth are

exposed to on-target, unfiltered NATIONAL OBJECTIVES FOR RESEARCH
motivational messages AND EVALUATION
• Media advocacy to support regulatory or
The Health Communication chapter of
policy changes to limit access to tobacco
Healthy People 2010, the nationwide
• Public relations to support health promotion and disease
anti-tobacco attitudes prevention agenda, identifies increasing
• Media literacy instruction in schools the proportion of health
to reduce the influence of the communication activities that include
tobacco industry research and evaluation as one of six
• Entertainment education and advocacy objectives for the field for the next
to decrease the depiction of tobacco use decade (objective 11-3). This objective
in movies focuses attention on the need to make
• Partnerships with commercial enterprises research and evaluation integral parts of
(such as retail chains popular initial program design. Research and
among youth) to spread the evaluation are used to systematically
anti-smoking message obtain the information needed to
refine the design, development,
Using multiple methods increases the need implementation, adoption, redesign,
for careful planning and program and overall quality of a
management to ensure that all efforts are communication intervention.
integrated and consistently support program
goals and objectives.

Planning Frameworks, Theories,

and Models of Change

Sound health communication development

should draw upon theories and models that
offer different perspectives on the intended
audiences and on the steps that can
influence their change. No single theory
dominates health communication because
health problems, populations, cultures, and
contexts vary. Many programs achieve the
greatest impact by combining theories to
address a problem. The approach to health
communication we use in this book is based
on the social marketing framework.

Making Health Communication Programs Work 7

a systematic, continuous process that is Evaluation should be built in from the start,
driven at every step by decision-based not tacked on to the end of a program.
research, which is used as feedback to Integrating evaluation throughout planning
adjust the program.* and implementation ensures that you:

Why Use Theories and Models? • Tailor messages, materials, and activities
to your intended audience
Although theories cannot substitute for • Include evaluation mechanisms (e.g.,
effective planning and research, they offer include feedback forms with a
many benefits for the design of health community guide)
communication programs. At each stage of • Define appropriate, meaningful,
the process outlined in this book, theories achievable, and time-specific
and models can help answer key questions, program objectives
such as:
Evaluating your program’s communication
• Why a problem exists efforts enables you to:
• Whom to select
• What you need to know about the • Understand what is and is not working,
population/intended audience before and why
taking action • Improve the effort while it is under way
• How to reach people and make an impact and improve future efforts
• Which strategies are most likely to • Demonstrate the value of the program to
cause change interested parties such as partners,
funding agencies, and the public
Reviewing theories and models can suggest • Help program staff see how its work
factors to consider as you formulate your affects the intended audiences
objectives and approach, and can help you
determine whether specific ideas are likely In this book, we address appropriate
to work. Theories and models can guide evaluation activities for each stage; see the
message and materials development, and Communication Research Methods section
are also useful when you decide what to for a description of the different types of
evaluate and how to design evaluation tools. research and evaluation that support each
stage of the health communication
How Market Research and Evaluation process. See Appendix A for sample
Fit Into Communication Programs forms and instruments.

Conducting market research is vital to

identifying and understanding intended
audiences and developing messages and
strategies that will motivate action.
Evaluations conducted before, throughout,
and after implementation provide data on
* From Theory at a Glance: A Guide for Health Promotion
which to base conclusions about success or Practice (NIH Publication No. 97-3896), by the National
failure and help to improve current and Cancer Institute, 1995. Bethesda, MD. In the
future communication programs. public domain.

8 Introduction
 INTRO

Selected Readings National Cancer Institute. (1993). A picture

of health (NIH Publication No. 94-3604).
Andreasen, A. (1995). Marketing social Rockville, MD: U.S. Department of Health
change: Changing behavior to promote and Human Services.
health, social development, and the
environment. San Francisco: Jossey-Bass. Rimer, B. K. (1995). Audiences and
messages for breast and cervical cancer
Backer, T. E., Rogers, E. M., & Sopory, P. screenings. Wellness Perspectives:
(1992). Designing health communication Research, Theory, and Practice, 11(2),
campaigns: What works. Thousand Oaks, 13–39.
CA: Sage.
Siegel, M., & Doner, L. (1998). Marketing
Bandura, A. (1986). Social foundations of public health: Strategies to promote social
thought and action: A social cognitive theory. change. Gaithersburg, MD: Aspen.
Englewood Cliffs, NJ: Prentice-Hall.
U.S. Department of Health and Human
Centers for Disease Control and Prevention. Services. (2000). Healthy people 2010 (2nd
(2001). CDCynergy 2001 [CD-ROM]. Atlanta. Ed.; in two volumes: Understanding and
improving health and Objectives for
Glanz, K., Lewis, F. M., & Rimer, B. K. improving health.). Washington, DC: U.S.
(Eds.). (1997). Health behavior and health Government Printing Office.
education: Theory, research, and practice
(2nd ed.). San Francisco: Jossey-Bass.

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

glance: A guide for health promotion
practice (NIH Publication No. 97-3896).
Bethesda, MD: National Cancer Institute.

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

Middlestadt, S. E. (Eds.). (1997). Social
marketing: Theoretical and practical
perspectives. Mahwah, NJ: Erlbaum.

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

promotion planning: An educational and
ecological approach (3rd ed.). Mountain
View, CA: Mayfield.

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

Designing health messages: Approaches
from communication theory and public
health practice. Thousand Oaks, CA: Sage.

Making Health Communication Programs Work 9