A Fied Guide to Designing A Heath Communication Strategy A Resource for Heath Communication Professionas Popuation Communication Services Johns Hopkins Boomberg Schoo of Pubic Heath/Center for Communication Programs
Suggested Citation: O Suivan, G.A., Yonker, J.A., Morgan, W., and Merritt, A.P. A Fied Guide to Designing a Heath Communication Strategy, Batimore, MD: Johns Hopkins Boomberg Schoo of Pubic Heath/Center for Communication Programs, March 2003. Design: Ceciia Snyder for American Institutes for Research/Prospect Center This pubication may be reproduced without permission provided that the materia is distributed free of charge and that the Johns Hopkins Boomberg Schoo of Pubic Heath/Center for Communication Programs is acknowedged. Opinions expressed in this report are those of the authors and do not necessariy refect the views of the sponsoring agencies. Prepared by American Institutes For Research/Prospect Center and Johns Hopkins Boomberg Schoo of Pubic Heath/Center for Communication Programs, with primary support from the United States Agency for Internationa Deveopment under the Popuation Communication Services Project (DPE 3052 A 00 0014 00). ii A Fied Guide to Designing a Heath Communication Strategy
Acknowedgments As the fied of behavior change communication continues to evove, there is an ongoing need among poicymakers, communication professionas, and program staff for usefu toos to hep them appy their communication expertise in strategic and innovative ways. Since 1982, the Johns Hopkins University (JHU) Popuation Communication Services (PCS) project has provided assistance wordwide to hundreds of nationa, regiona, and oca organizations seeking to improve heath outcomes for specific audiences. JHU/PCS advocates creating a dynamic synergy between communication theory and practice to advance behavior changes in the areas of famiy panning (FP), reproductive heath, materna/chid heath, human immunodeficiency virus (HIV) acquired immunodeficiency syndrome (AIDS), and environmenta heath. The strategic communication process used by JHU/PCS can be extended beyond the ream of heath and can be appied to other issues reevant to deveoping countries, such as democracy and governance. Simiary, the behavior change communication framework empoyed by JHU/PCS can be appied to individua behavior change efforts or can be used to infuence community and socia norms. The purpose of this book is to share a set of steps and toos with those in the fied to hep ensure that behavior change communication efforts are deveoped strategicay with participation from a stakehoders, cear goas, segmented audiences, and effective messages based on sound research and credibe theory. The text is based on many years of experience in the fied and is suppemented with rea-word exampes and case studies. A Fied Guide to Designing a Heath Communication Strategy iii
Produced with support from the United States Agency for Internationa Deveopment (USAID), this Fied Guide was deveoped coaborativey by JHU/PCS and American Institutes for Research (AIR)/Prospect Center. The primary authors of the guide were Gae O Suivan and Joan Yonker of AIR/Prospect Center. Win Morgan of AIR/Prospect Center served as a coauthor. The book was designed by Ceciia Snyder with guidance from AIR/Prospect Center, and Jack Shea provided editoria expertise. Iustrations were provided by JHU s Media and Materias Cearinghouse and Where There is No Artist, by Petra Röhr-Rouendaa. The foowing coeagues at JHU/PCS provided information, exampes, case studies, and review comments for various sections of this book: Rob Ainsie, Jane Brown, Maria Eena Figueroa, Michee Heerey, Ron Hess, Larry Kincaid, Susan Krenn, Chery Lettenmaier, Gary Lewis, Ben Lozare, Morden Mayembe, Juan Caros Negrette, Patricia Poppe, Fitri Putjuk, Water Saba, Eizabeth Seremitsos, Mohammed Shahjahan, Caro Underwood, and Jim Wiiams. Phyis Tison Piotrow, Jose Rimon, and Gary Saffitz of JHU/PCS provided overa strategic direction, and their insights were very much appreciated. Specia thanks go to Aice Payne Merritt of the Johns Hopkins Boomberg Schoo of Pubic Heath/Center for Communication Programs (CCP), whose abe guidance, enduring patience, and coegia support made this book possibe. To request additiona copies of this book, pease compete the order form at the back of the book, and return it to JHU/CCP. Since this Fied Guide is designed to be a iving document that refects progress in the fied, users of this book are encouraged to provide feedback to JHU/CCP on how future versions can be improved to best serve program needs. Jane T. Bertrand, PhD, MBA Professor, Boomberg Schoo of Pubic Heath Director, Center for Communcation Programs Jose G. Rimon, II Project Director PCS Johns Hopkins Boomberg Schoo of Pubic Heath iv A Fied Guide to Designing a Heath Communication Strategy
Tabe of Contents Acknowedgments... iii Using This Book... viii Introduction... 1 Chapter 1: Anaysis of the Situation... 17 Step 1: Identifying and Understanding the Probem...20 Step 2: Determining Potentia Audiences...26 Step 3: Identifying Potentia 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 Infuencing 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 Wi Meet the Audience s Heath Needs...80 Step 2: Stating How Much the Behavior Wi Change...81 Step 3: Deciding the Timeframe Within Which the Expected Change Wi Occur...83 Step 4: Linking Behavior Change Objectives to Program Objectives...84 Step 5: Identifying Indicators to Track Progress...84 A Fied Guide to Designing a Heath Communication Strategy v
Chapter 4: Strategic Approach... 93 Step 1: Reviewing the Key Issue or Probem, Audience Segments, and Objectives...95 Step 2: Determining Long-Term Identity and Positioning Strategy of the Behavior...96 Step 3: Exporing Strategic Aternatives...110 Step 4: Determining Strategic Approach and Rationae...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: Deveoping the Statement of the Utimate and Lasting Impression That the Audience Wi Have After Hearing or Seeing the Message...131 Step 6: Describing the Desired User Profie...132 Step 7: Identifying the Key Message Points...133 Chapter 6: Channes and Toos... 139 Step 1: Choosing the Channes That Are the Most Likey To Reach the Intended Audience...141 Step 2: Determining Toos...153 Step 3: Integrating Messages, Channes, and Toos...162 Chapter 7: Management Pan... 165 Step 1: Identifying the Lead Organization and Coaborating Partners...167 Step 2: Defining the Roes and Responsibiities of Each Partner...170 Step 3: Outining How the Partners Wi Work Together...172 Step 4: Deveoping a Timeine for Impementing the Strategy...173 Step 5: Deveoping a Budget...176 Step 6: Panning To Monitor Activities...179 vi A Fied Guide to Designing a Heath Communication Strategy
Chapter 8. Evauation Pan... 193 Step 1: Identifying the Scope and Type of Evauation...195 Step 2: Panning for Monitoring and Impact Assessment...197 Step 3: Identifying the Evauation Design and Sources of Data...208 Step 4: Taioring the Evauation to the Specific Situation...215 Step 5: Deciding Who Wi Conduct the Evauation...216 Step 6: Panning To Document and Disseminate Evauation Resuts...217 Chapter 9. Summary... 221 Staying on Strategy...222 The Strategy Test...224 Why Ask Why?...225 Strategy Summary Outine...226 Strategy Review...229 Appendices... 1-1 1: Behavior Change Theories 2: Case Studies 3: Gossary 4: Bibiography A Fied Guide to Designing a Heath Communication Strategy vii
Using This Book The purpose of this strategic communication Fied Guide is to provide practica guidance to those who are in a position to design, impement, or support a strategic heath communication effort. The emphasis of the guide is on deveoping a comprehensive, ong-term approach to heath communication that responds appropriatey 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 aso based on the recognition that communication, to be effective, must not be treated as a spare whee, used ony when the efforts start to fater or fai, but as a steering whee that can serve as a basis for making informed choices. Strategic communication is coaborative and participatory in nature, foows a sound decisionmaking process based on science, and creates sustainabe efforts that improve heath outcomes. The guide has three primary audiences: Program managers in deveoping countries who are responsibe for designing and impementing heath programs. Communication speciaists who are responsibe for designing and executing heath communication strategies and for deveoping materias and messages. Poicymakers and representatives of funding agencies who determine the eve of support for heath communication strategies and the degree to which communication efforts are integrated into other heath program initiatives. viii A Fied Guide to Designing a Heath Communication Strategy
A program manager shoud find this book hepfu in understanding the context within which communication professionas design and impement heath communication strategies. Program managers may find that issues identified in the course of deveoping one heath communication strategy have an impact on other heath programs on which they are working. For a communication speciaist, this book wi provide a comprehensive set of practica toos and steps to guide efforts to improve heath among specific popuations. Each chapter provides worksheets, exampes, and tips to hep the reader appy the concepts and processes described. For a poicymaker, this book wi demonstrate the roe that strategic communication can pay in addressing compex heath probems. It wi aso emphasize the need to continuousy appy strategic communication principes to achieve ongterm behavior change objectives. * The process of designing a heath communication strategy is participatory in nature. Typicay, a team of individuas wi be invoved in designing the strategy. The communication speciaist is often the primary staff person responsibe for creating the process in which a stakehoders, incuding the beneficiaries, participate in designing the strategy. The communication speciaist works in cose coaboration with the other stakehoders and team members, which at the nationa or subnationa eve may incude a variety of pubic and private sector agencies, such as the Ministry of Heath (MOH), service deivery groups (e.g., cinics, doctors offices, nurse-midwife associations), cients or audience members, advertising agencies, research organizations, pubic reations (PR) firms, and other technica consutants with reevant expertise. As you read this book, keep in mind that it is designed to be a catayst for your own creative thinking. The steps and worksheets provided are fexibe guideines that you can and shoud adapt to fit your own particuar situation. The emphasis is on practica tips and advice as we as on exampes to iustrate how to appy * The term behavior change is used in this book in a broad sense. It incudes reinforcing existing behaviors, when desired, or deveoping new behaviors when they do not exist. A Fied Guide to Designing a Heath Communication Strategy ix
Icon Key: Icons wi appear throughout the fied guide to hep you with the process of deveoping a communication strategy. Exampe Worksheet Tip the concepts in rea-ife situations. The book contains summary sheets at the end of each chapter that are designed to be compied and used together in writing a heath communication strategy. It is important to note, however, that designing a strategy is not a inear process. Strategy deveopment is iterative in nature, and you wi ikey have to revisit decisions made eary in the process as more information becomes avaiabe and as you gain additiona insight from and about the audience. To aid you in deveoping a strategy, the fied guide offers iustrative exampes, worksheets, tips and other specia features that can be easiy identified through the use of icons. In addition, every chapter ends with a Uganda communication strategy summary statement that capsuizes the chapter s main points. The Uganda summary exampe can be identified through its own icon. We hope that after you have read this book, you wi have found it a usefu too that heps design and impement heath communication efforts that are truy strategic. Checkist Questions to ask yoursef Important note Uganda summary exampe x A Fied Guide to Designing a Heath Communication Strategy
Introduction By the end of this introduction, the reader wi understand: The components of a communication strategy outine Why the word strategic is important in heath communication The importance of having a vision The Process of Behavior Change (PBC) framework and the P Process The definition and characteristics of strategic heath communication As you embark on the process of deveoping a heath communication strategy, you wi need to have a framework in mind to hep organize the information gathered. The foowing outine ists the components that shoud be incuded in an integrated, mutiyear, mutiphased communication strategy. The eements in this outine wi be discussed in detai in the foowing chapters. You wi note that the communication strategy outine does not exacty match the chapter tites and chapter subheadings. This discrepancy is intentiona, as the communication strategy outine is intended to be a synthesis of the strategic design process, whie the chapters incude detaied steps to foow at each stage of the process. A Fied Guide to Designing a Heath Communication Strategy 1
Communication Strategy Outine I. Anaysis of the Situation A. Purpose (Heath situation that the program is trying to improve) B. Key Heath Issue (Behavior or change that needs to occur to improve the heath situation) C. Context (Strengths, Weaknesses, Opportunities, and Threats [SWOT] that affect the heath situation) D. Gaps in information avaiabe to the program panners and to the audience that imit the program s abiity to deveop sound strategy. These gaps wi be addressed through research in preparation for executing the strategy E. Formative Research (New information that wi address the gaps identified above) II. Communication Strategy F. Audiences (Primary, secondary and/or infuencing audiences) G. Objectives H. Positioning and Long-Term Identity I. Strategic Approach J. Key Message Points K. Channes and Toos III. Management Considerations A. Partner Roes and Responsibiities B. Timeine for Strategy Impementation C. Budget D. Monitoring Pan IV. Evauation Tracking Progress and Evauating Impact 2 A Fied Guide to Designing a Heath Communication Strategy
Overview Consider, for exampe, the way an architect and a buider work together to produce a buiding for their cient. Suppose, for exampe, that a city in your country needs a new primary schoo. The Ministry of Education is the cient. The Ministry staff consut with an architect and discuss the overa characteristics of the need: the number of students expected, the number of different casses, the ocation of the schoo, and aocated budget and timeframe for competing the project. The key stakehoders work together as a team to carify what is needed. The architect then anayzes the situation further, for exampe, specifying the number of casses, the estimated number of boys, girs, teachers, and administrators, the number of foors the schoo shoud have, the number of offices for staff, and the pacement of haways and stairways. The architect deveops a strategic design for the schoo, a design that meets the specified needs and is at the same time feasibe in terms of cost, materias, and abor. TIP: As you read this book, ook for your friend the architect at the beginning of each chapter. His or her roe in designing the schoo wi hep you understand the ideas expained in the chapter. In other words, the architect interprets data as we as the cient s needs and creates a unique master pan, specifications, and detaied bueprints. The architect is a strategic designer who works with his cient to ensure that the cient s input is taken into account. The buider s roe is simiar to that of an impementer, who deveops a tactica pan to execute the strategy and ideas in the architect s bueprint, whie staying within the budget and meeting deadines. He or she impements through a team of subcontractors: engineers, eectricians, pumbers, carpenters, and designers. Without an overa strategy, a master pan, and detaied bueprints for the workers to foow, the finished buiding might ook more ike a house than a schoo. A Fied Guide to Designing a Heath Communication Strategy 3
Why the Emphasis on Strategic in Heath Communication? Strategic design is the hamark of successfu heath programs. Over the past 20 years, heath communicators have come to reaize that coaborativey designed, impemented, and evauated heath communication strategies wi hep achieve the goa of improving heath in a significant and asting way by empowering peope to change their behavior and by faciitating socia change. Sound communication strategies provide coherence for a heath program s activities and enhance the heath program s power to succeed. Strategic communication is the program s steering whee, guiding it towards its goas. Strategic communication is aso the gue that hods the program together or the creative vision that integrates a program s mutifaceted activities. Prior to this era of strategic design, heath communication in the 1960s was argey characterized as the medica era. It operated under the assumption that, If we buid it they wi come. This medica monoogue mode is often represented by the image of a physician ecturing or taking to patients. The 1970s recognized the need to reach beyond the cinics. Borrowing mainy from the agricutura extension mode, fied work was mosty supported by print materias and visua aids. Mass media impact was considered modest due to imited reach. This period was mainy described as the fied era, moving from monoogue to diaogue (Rogers, 1973). The 1980s saw the proiferation of socia marketing with a move from nonpaying cients to customers who ask and pay for services, and the use of integrated marketing communication approaches borrowed from the commercia sector. This period may be caed the socia marketing era. Heath communication in the 1990s to the present has evoved into what may be caed the strategic era, characterized by mutichanne integration, mutipicity of stakehoders, increased attention to evauation and evidence-based programming, arge-scae impact at the nationa eve, more pervasive use of mass media, and a communication process in which participants ( senders and receivers ) both create and share together (Rimon, 2001). 4 A Fied Guide to Designing a Heath Communication Strategy
The new, strategic era of communication is distinguished by severa other important characteristics: Previousy separate services are more integrated. It is becoming more common to find a variety of services, such as famiy panning (FP), materna and chid heath, and sexuay transmitted disease (STD) treatment and prevention offered at the same ocation. Integration is aso occurring among communication channes. Mass media, community-based, and interpersona channes are being used strategicay to reinforce one another and maximize impact. The roe of the eectronic media is becoming more prominent. New technoogies are being added to the communication mix to reach more peope in innovative ways. Decentraization has shifted contro and decisionmaking from the centra government to oca communities. A mutipicity of stakehoders is invoved at every step in the strategic communication process. Audience segmentation is becoming more sophisticated, which aows for more taiored messages to audiences. A recognition that househods and communities are producers of heath and pay a different roe in improving heath than does the heath service deivery system. Increased attention to evauation and evidence-based programming is providing much-needed data upon which to base decisions (Rimon, 2001). Strategic Vision The overarching component of a strategicay oriented heath communication program is a powerfu, we-articuated, ong-term vision. A Fied Guide to Designing a Heath Communication Strategy 5
Exampe The Coaition for Heathy Indonesia envisioned heathy individuas, famiies, and communities in a heathy nation. By 2010, their mission at the individua/househod eve is that individuas and househods (2000): Are receiving heath-reated messages through mutipe channes. Are knowedgeabe about persona and pubic heath probems, are knowedgeabe of types and sources of services to prevent diseases and promote heath, and wi be motivated to adopt heathy behaviors and practices. Understand their rights to a heathy environment and to a basic package of accessibe, affordabe, quaity heath services. Are participating in socia, cutura, reigious, and other associations that incude heath information, promotion, and advocacy on their agendas. Are exhibiting heathy behavior and avoidance of heath risk. Every program needs a ong-term vision. It can empower peope because it shows what is important. It can stimuate 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 a stakehoders. It is inspirationa and concrete, suggests what peope need to do, and engages participants. The strategic vision shoud paint a menta picture of a desired scenario in the future. It shoud refect the core vaues and beiefs shared by team members, such as the concept of peope acting as producers of their own heath. A good strategic vision focuses not on the size of the probem at hand but on the possibiity of sharing in the creation of a better future. [I have a vision of a society where] Nontechnica, everyday peope are abe to easiy use technoogy. Steve Jobs, Chairman, Appe 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 ony those who are poor or cannot afford to pay. Work with us to make this vision a reaity. Dr. Haryono Suyono, Chairman of the Indonesian Nationa Famiy Panning Coordinating Board (BKKBN), 1986 Good strategic visions are aso practica and set the team s sights on what is considered possibe. Visions considered to be beyond the ream of possibiity are often disregarded as a eader s fancifu dreams. A dream that is not thought possibe to achieve in rea ife is ignored. 6 A Fied Guide to Designing a Heath Communication Strategy
Successfu eements of strategic visions: Buid on the core strengths of the program. Reinforce a program s history and cuture whie striving to achieve new goas. Carify 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, kinde excitement, and foster commitment and dedication? If it does, then the strategic vision can provide severa benefits, incuding: Empowering the team to work toward a common goa because the vision shows what is important. A vision stimuates teamwork because it shows what everyone needs to do. Inspirationa visions energize program activities, giving them new strength upon which to draw when impementing strategies. Heping team members determine priority actions in reation to the program. A vision heps peope focus on attaining certain outcomes and on acting in ways that wi achieve those outcomes. When a cear vision is in pace, it concentrates power by avoiding arguments about whether to do something or not. Caiming the future. A vision suppies a caing for team members, creating meaning for their work and a justifiabe pride. By comparing the present with a desired future, a vision creates a usefu tension between what exists now and how the team woud ike the word to be. It heps peope recognize barriers to achieving the desired state or condition by vividy describing the desired state and making it seem attainabe. Effective communication efforts deveop vision statements, with the participation of stakehoders and beneficiaries, to set forth the direction that the team shoud foow and to define ceary and succincty how the communication activities wi affect the broader program environment. Sometimes a program mission statement is aso deveoped to transate the overa thrust of the strategic vision into more management-oriented goas and objectives. The vision statement shoud be A Fied Guide to Designing a Heath Communication Strategy 7
a brief but compeing description of how the heath situation or condition wi ook after the communication activities have successfuy reached their concusion. This statement shoud become the cataytic force or organizing principe for a subsequent strategic communication activities carried out by the team. A Framework for Strategic Design Many theoretica modes 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 successfuy in the fied of heath communication for many years. Process of Behavior Change The PBC framework recognizes that behavior change and thus communication intended to infuence behavior change is a process. Peope usuay move through severa intermediate steps in the behavior change process (Piotrow et a., 1997). In addition, there is typicay a correation between increases in behaviors, such as partner-to-partner diaogue about reproductive heath and subsequent use of reproductive heath methods. Furthermore, this framework suggests that peope at different stages constitute distinct audiences. Thus, they usuay need different messages and sometimes different approaches, whether through interpersona channes, community channes, or mass media. An audience can generay be described as: Preknowedgeabe Is unaware of the probem or of their persona risk. Knowedgeabe Is aware of the probem and knowedgeabe about desired behaviors. Approving Is in favor of the desired behaviors. Intending Intends to personay take the desired actions. Practicing Practices the desired behaviors. Advocating Practices the desired behaviors and advocates them to others. 8 A Fied Guide to Designing a Heath Communication Strategy
It is important to understand where the audience is in reation to these eements before embarking on a strategy. Progress from one eement to the next increases the probabiity of behavior change and continuation. Pubic poicy and communication strategies infuence both individua and coective change, estabishing new community norms and, over time, providing support for stronger and more effective poicies and programs. The PBC can pay an important roe in creating an enabing environment to support new behaviors. Advocacy is a key eement in this process and can hep make the desired behavior sustainabe. The PBC framework can work effectivey together with a comprehensive project design and impementation approach known as the Processes and Principes of Heath Communication the P Process (Piotrow et a., 1997). The P Process was deveoped in 1983 and is depicted by the figure on the right. The P Process steps are: 1. Anaysis Understand the nature of the heath issue and barriers to change: isten to potentia audiences; assess existing program poicies, resources, strengths, and weaknesses; and anayze communication resources. 2. Strategic Design Decide on objectives, identify audience segments, position the concept for the audience, carify the behavior change mode to be used, seect channes of communication, pan for interpersona discussion, draw up an action pan, and design for evauation. 3. Deveopment, Pretesting, Revision, and Production Deveop message concepts, pretest with audience members and gatekeepers, revise and produce messages and materias, and retest new and existing materias. 4. Management, Impementation, and Monitoring Mobiize key organizations; create a positive organizationa cimate; impement the action pan; and monitor dissemination, transmission, and reception of program outputs. 5. Impact Evauation Measure impact on audiences, and determine how to improve future projects. 6. Panning for Continuity Adjust to changing conditions, and pan for continuity and sef-sufficiency. A Fied Guide to Designing a Heath Communication Strategy 9
For amost two decades, the P Process has provided a soid framework that is easiy appied to strategy deveopment, project impementation, technica assistance, institution buiding, and training. This framework is used coaborativey as a guide by the various stakehoders invoved in designing and impementing strategic heath communication programs. Severa quaities of the P Process make it a very usefu too for program panning and impementation: It is systematic and rationa. It is continuay responsive to changing environments and can be adapted to new research findings and data. It is practica for fied appications at a eves. It is strategic in setting and pursuing ong-term objectives. When foowed in sequence, the six steps of the P Process are hepfu in deveoping 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 eve of strategic decisionmaking that is required. The focus is on designing, not impementing, a program. Appying Step 2 of the P Process to design a communication strategy wi aso require using information obtained from conducting an anaysis of the situation. Simiary, the strategic design process wi require thinking ahead to issues invoving the other steps of the P Process. Definition and Characteristics of Strategic Heath Communication Strategic communication is based on a combination of: 1. Data, ideas, and theories integrated by 2. A visionary design to achieve 3. Verifiabe objectives by 4. Affecting the most ikey sources and barriers to behaviora change, with the 5. Active participation of stakehoders and beneficiaries (Piotrow & Kincaid, 2001) 10 A Fied Guide to Designing a Heath Communication Strategy
In other words, strategic communication takes advantage of science and facts, in addition to ideas and concepts, to set forth a ong-term vision and reaistic behavior change objectives to address a heath issue. The vision and objectives are deveoped through diaogue with the intended audience and various stakehoders. In the diaogue process, both the senders and receivers are affected, moving toward mutua adjustments and convergence. A bending of science and art is essentia to crafting a sound strategy. Specific Characteristics For communication to be strategic, it shoud be: 1. Resuts-oriented. The utimate proof that a strategic communication effort is effective ies in heath outcomes. Research shoud be designed to gauge increases in audience knowedge, approva, and adoption of heathy behaviors. Equay important is increasing the capacity of oca 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 reevant theory. It begins with formative research and adequate data to define a specific heath probem, identify feasibe soutions, and describe the intended audience. This approach reies on the heath sciences to make sure that the content and context of a strategic communication effort are correct. For exampe, in Brazi a series of focus groups was conducted with potentia audience members to identify the sexua practices of street chidren, in an effort to determine the risk of contracting HIV/ AIDS. Resuts of the focus groups were compied and anayzed according to severa variabes, such as number of partners, type of partners (e.g., same sex, commercia sex workers), type of sexua contact (e.g., ora, ana, vagina), frequency, and reasons for the occurence of the sexua activity. This anaysis formed the basis for deveoping a communication strategy that was designed to reduce HIV/AIDS transmission among Braziian street chidren. A Fied Guide to Designing a Heath Communication Strategy 11
Strategic communication aso depends upon appropriate socia science modes or theories of behavior change, which might incude: * Stages of change/diffusion theories Cognitive theories Emotiona response theories Socia process and infuence theories Mass media theories 3. Cient-centered. A cient-centered approach requires starting with an understanding from the cient s point of view of what the heath needs are. Discussions with the potentia audience provide insights about those heath needs and the barriers to meeting the expressed needs. Through research, especiay quaitative research and participatory earning approaches (PLA), members of the intended audience can hep shape appropriate messages and can offer insights for other communication-reated decisions that need to be made. A cient-centered approach aso impies understanding strategic changes that can affect the baance of power, incuding the gender baance of power, in service programs. For exampe, encouraging greater community participation, aowing cients to choose their own methods and treatment, or having cients set the program priorities for heath services are ways to strengthen a cientcentered approach. 4. Participatory. Strategic communication promotes participatory decision making by stakehoders and beneficiaries in a stages of the P Process, incuding panning, impementation, and evauation. It is critica to invove the key stakehoders at the inception of the strategy design process. Buiding a sense of ownership wi hep ensure that the strategy wi be impemented in a meangingfu way. See the resource book tited How To Mobiize Communities for Heath and Socia Change pubished by Johns Hopkins Boomberg Schoo of Pubic Heath/CCP in coaboration with Save the Chidren for further information on this topic. 12 A Fied Guide to Designing a Heath Communication Strategy *See Appendix 1, Behavior Change Theories, for more information.
5. Benefit-oriented. The audience must perceive a cear benefit in taking the action promoted by the communication effort. This characteristic is cosey associated with the ong-term identity and with the notion of positioning, which is discussed in chapter 4. 6. Service-inked. Heath promotion efforts shoud identify and promote specific services, whether through heath care deivery sites, providers, brand name products, or ways to increase access to services and products. This approach reinforces the concept of individua sef-efficacy or the abiity to resove a probem onesef and aso supports the concept of coective sef-efficacy or the abiity of a community to assert its wi. 7. Mutichanneed. Effective strategic communication uses a variety of means. Communication strategies often integrate interpersona communication (IPC), community-based channes, and various media to create a dynamic, two-way exchange of information and ideas. Additionay, research has shown that often the effectiveness of messages being understood and acted upon increases with the number and type of channes used to disseminate them. This is sometimes caed the dose effect. Like a good carpenter who knows when to use a hammer or a chise, an effective communicator does not argue whether mass media is better than IPC. Each too has a roe, and the communicator uses the too or combination of toos that is most appropriate for the situation. 8. Technicay high quaity. The strategic heath communicator works with competent agencies and individuas to: Design high-quaity communication messages and materias. Produce professionay designed materias. Ensure that community-based activities are appropriate and we done. Strengthen counseing skis. A Fied Guide to Designing a Heath Communication Strategy 13
Investing resources wisey to design effective strategies and materias at the outset wi utimatey be more economica than cutting corners and producing a campaign that conveys a substandard image. Simpy put, quaity costs ess. Another important point to remember is that focus demands sacrifice. Strategic communication is specific in what it attempts to accompish and does not try to be a things to a peope. 9. Advocacy-reated. Advocacy occurs on two eves: the persona/socia eve and the poicy or program eve. Persona and socia advocacy occurs when current and new adopters of a behavior acknowedge their change and encourage famiy members and friends to adopt a simiar behavior. For exampe, individuas who have quit smoking often advocate to other smokers that they shoud quit. Poicy or program advocacy occurs when the advocacy is aimed at change in specific poicies or programs. Seeking to infuence behavior aone is insufficient if the underying socia factors that shape the behavior remain unchanged. Behavior change objectives wi address individua behavior, but poicies, aws, strategies, and programs may aso need to be infuenced, so that they support sustained behavior change. The two eves of advocacy reinforce one another. 10. Expanded to scae. It is easy to ensure the effectiveness of a communication intervention when appied to a sma viage or district. The rea chaenge is whether the intervention can effect change on a much wider scae beyond a viage or the usua piot areas. Communication strategies can be scaed up to reach ever-arger popuations and areas. In genera, mass media interventions are easier to scae up than community or interpersona interventions. The atter two can be costy to scae up and can be difficut to monitor. 14 A Fied Guide to Designing a Heath Communication Strategy
11. Programmaticay sustainabe. 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 pace at the organizationa eve, among eaders, and with the donor community, to ensure that strategic communication efforts achieve ong-term impact. 12. Cost-effective. Strategic communication seeks to achieve heathy outcomes in more efficient and cost-effective ways. Strategy designers must aso examine costs by the type of intervention, to try to achieve the optima mix of activities and channes. Concusion A sound and effective heath communication strategy shoud be based on an overarching vision of what needs to be achieved to address a particuar heath issue. The strategy shoud be integrated, have a ong-term focus, shoud be responsive to individua behavior change needs, and shoud maximize the potentia for change on a broader societa eve. Frameworks such as the PBC and the P Process for project design and impementation are usefu toos to guide the process of deveoping heath communication strategies that get resuts. A combination of science, facts, vision, stakehoder buy-in, and audience participation is essentia for success. A Fied Guide to Designing a Heath Communication Strategy 15
References Coaition for Heathy Indonesia Strategy Document (2000). (pp. 8). Piotrow, P. T., Kincaid, D. L., Rimon, J. G. I., & Rinehart, W. (1997). Heath Communication: Lessons from Famiy Panning and Reproductive Heath. Westport, CT: Praeger Pubishers. Piotrow, P. T. & Kincaid, D. L. (2001). Strategic Communication for Internationa Heath Programs. In Rice and Atkin (Ed.), Pubic Communication Campaigns (3 rd ed., pp. 251). Sage Pubications. Rimon, J. G. I. (2001). Behavior Change Communication in Pubic Heath. In Beyond Diaogue: Moving Toward Convergence. Managua, Nicaragua: Presented at the United Nations Roundtabe on Deveopment Communication. 16 A Fied Guide to Designing a Heath Communication Strategy
Chapter 1 Anaysis of the Situation 1 By the end of this chapter, the reader wi be abe to conduct an anaysis of a particuar heath probem by competing the foowing steps: Step 1: Step 2: Step 3: Step 4: Step 5: Identifying and Understanding the Probem Determining Potentia Audiences Identifying Potentia Communication Resources Assessing the Environment Summarizing the Strengths and Weaknesses of the human, technoogica, and financia resources avaiabe as we as the Opportunities for and Threats to effective heath communication in the current environment. A Fied Guide to Designing a Heath Communication Strategy 17
Overview After a preiminary meeting with the cient, the next step of your friend the architect is to meet his cient, the Ministry of Education, at the site of the proposed schoo to ook over the situation, anayze it, and make some preiminary observations. This anaysis wi hep shape his pan for designing the schoo. Working with the key stakehoders, the architect wi refine many of these initia findings over time. For exampe, the architect ooks over the buiding site, notes whether it is fat or hiy, notes whether it is covered with trees or open space, and decides whether heavy machinery can easiy access the area. In other words, he identifies any probems, and he notes their extent and the difficuty or ease with which they can be overcome. He aso begins to think of how teachers, students, and parents wi view this space. He thinks about their needs, such as natura ight for the cassrooms, air circuation, and ampe room for sports activities and games. With a mind to avaiabe resources, he examines the infrastructure to ensure that water and eectricity are readiy avaiabe. He begins to think about engaging a buider who has experience buiding a schoo and who has access to the kinds of subcontractors who wi do their jobs most efficienty, for exampe, engineers, eectricians, pumbers, carpenters, interior designers, and andscapers. In much the same way, as you and your team begin the process of designing your heath communication strategy, your first undertaking is the anaysis of the situation. 18 A Fied Guide to Designing a Heath Communication Strategy
This chapter offers guidance, practica toos, and approaches to hep your team work through the five steps of deveoping an anaysis of the situation. At the end of this chapter and at the end of most chapters, you wi find a summary worksheet. The Deivery of Improved Services for Heath (DISH) project in Uganda is used throughout this book to provide a comprehensive exampe showing how these summary worksheets are to be competed. When compied as a set, the information in these summary worksheets wi provide a concise overview of the key strategic considerations upon which you wi base your strategy. Once you and your team have competed the anaysis of the situation, you wi have a more informed basis for proceeding to the next stages of strategy deveopment. Deveoping a heath communication strategy demands in the first pace that you understand a the factors that may have an impact on communication efforts. Such an understanding, known as the anaysis of the situation, serves as the guide for a communication activities. Heath communicators use the anaysis of the situation to observe, gather, organize, and assess reevant factors. These factors incude the nature and extent of the probem, audience characteristics, avaiabe resources, and the communication environment. Thus, athough the anaysis of the situation is not technicay a part of step 2 of the P Process, which is the concern of this book, its importance warrants incusion here of the information that wi hep you work through step 2. The term anaysis of the situation can be defined and used in many different ways. In the context of this Fied Guide, the term anaysis of the situation refers to the process of anayzing factors reated specificay to the deveopment of a communication strategy. One resut of conducting an anaysis of the situation is an understanding of the gaps in your knowedge base that wi need to be fied in order to move ahead with the strategy deveopment process. A quantitative measure of the current situation as it reates to the audience is typicay conducted in the form of a baseine survey. Additiona insights are often gained by using quaitative techniques, such as focus groups. The Tips on Information Coection Methods in this chapter provide brief descriptions of some of the more commony used TIPS: Do s and Don ts To Keep in Mind as You Anayze Your Situation Do s Deveop a cear outine before gathering information. It wi hep keep you focused on the important issues. Ensure that the anaysis wi inform the decisions of strategic components (identification of audiences, objectives, etc.) that wi be made ater in the process. Set a timetabe for the process, and stay within the parameters of the timetabe. Read, isten, and observe many sources of information. No singe source of information wi provide you with a the information that you need. Keep your summary statements as objective as possibe. Keep a notebook for jotting down ideas for strategy or tactics. Aso, keep a ist of chaenges and opportunities that arise from reviewing the data. Your notebook and the ist wi give you a head start in writing the pan. Document your progress by making note of your key sources of information, so that you can refer to them in future discussions. 1 A Fied Guide to Designing a Heath Communication Strategy 19
quaitative techniques. As you work through the steps in this chapter, keep a ist of the gaps and questions that you wi need to answer through formative or preiminary research. Even under the best of circumstances, it is unikey that you wi have a compete set of data to inform your decisions. The process of designing a heath communication strategy is part art and part science. You wi have to make judgments throughout the process to decide how much importance to assign a particuar issue as we as to decide which approaches and strategies wi work best. Step 1 Identifying and Understanding the Probem TIPS: Do s and Don ts To Keep in Mind as You Anayze Your Situation Don ts Do not write objectives and strategies as part of the anaysis of the situation. Keep your anaysis as factua as possibe. Appending objectives and strategies tempts you to adjust the anaysis to fit the proposed strategy and objectives. Do not give up if you cannot find the information that you need. Ca on contacts, visit ibraries, and consut coaborating organizations. The answers are there, but you wi not aways have data to substantiate every finding. At times you wi have to rey on the views of knowedgeabe individuas and your own observations, in addition to research data, as you begin to understand the situation. The first step in conducting the anaysis is to identify and understand the specific heath probem that wi be the focus of the proposed communication effort. Consider the heath probem in the context of the overa strategic vision. To define an effective communication strategy, you wi need to compare the shared vision with your understanding of the present situation, and you wi need to understand why there is a difference between the two. Usuay in a nationa heath communication strategy and especiay when heath programs and services are integrated, a number of different probems wi be identified that need attention. This series of probems is often deat with over time using phasing or sequencing techniques, ayering of service deivery and communication channes to ensure maximum coverage, and custering of heath behaviors to promote integration. However, it is important to identify the key probem reated to each heath behavior incuded in the strategy and to craft appropriate objectives and messages for each of these probems. The key to a successfu heath communication strategy is to focus on one specific probem at a time. Addressing too many probems at one time or too genera a probem often creates messages that confuse or overwhem the audience, imiting the impact of the communication. 20 A Fied Guide to Designing a Heath Communication Strategy
In some cases, you wi not need to identify the probem. An existing strategy may aready point to what needs to be done, whether as directy reated to an overa program objective (see chapter 3, step 4) or, ideay, as reated to the overa strategic vision, articuated by key eaders and poicymakers. However, if the probem is aready identified, it is important to verify that it is sti vaid. You want to avoid beginning with a preconceived notion about the probem that may be based on od information, poitica concerns, or imited understanding of stakehoder perceptions. 1 Understanding the Heath Probem Understanding the heath probem means having a cear perception of its extent and severity as we as of the behaviors that wi prevent and treat the probem. In the course of gaining such an understanding, you wi become famiiar with the avaiabe sources of information about the probem. The Extent of the Heath Probem Estimating the extent of a heath probem is a factor in deciding how to communicate about it. Look for two key measures of extent: prevaence and incidence. These measures are commony avaiabe through the MOH. Prevaence measures the proportion usuay, the percentage of peope in a defined popuation who have the probem at a given time. For exampe: Last year, 65 percent of a sex workers in the northern region had gonorrhea. This month, 30 percent of a pregnant women in the eastern region between the ages of 18 and 25 years were anemic. Since prevaence is constanty changing, pubic heath practitioners use the most recent measurement in combination with incidence to estimate the extent of the probem. Incidence measures the rate of new cases of a particuar heath probem per thousand peope in the popuation. For exampe: The number of cases of gonorrhea in the northern region is increasing by 10 percent per year. A Fied Guide to Designing a Heath Communication Strategy 21