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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

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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

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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 tha

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