Working on Health Communication

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 Working on

Health
Communication
Nova Corcoran

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 © Nova Corcoran 2011
First published 2011

Apart from any fair dealing for the purposes of research or private
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sent to the publishers.

SAGE Publications Ltd

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 Contents

List of figures vii

List of tables ix
Author’s acknowledgements xi
Publisher’s acknowledgements xiii

Introduction 1

1 Planning campaigns 7

2 Frameworks and foundations 23

3 Starting the campaign process 41

4 Target groups 59

5 Channels of communication 77

6 Designing resources 99

7 Evaluation in practice 121

8 Overview: ten campaigns 141

Activity discussions 147

Glossary 159
References 163
Index 181

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 List of figures

0.1 A new model of communication 2

1.1 Nine-step planning model 11

1.2 Total Process Planning model 12
1.3 Precede-proceed planning model 15
1.4 Intervention Mapping planning model 19

2.1 The Health Belief Model 31

2.2 The Theory of Planned Behaviour 33
2.3 The Transtheoretical Model 35
2.4 Key variables in theoretical models 39

3.1 Rationale triangle 43

4.1 Checklist of possible questions to ask target groups 73

5.1 Drug driving: your eyes will give you away glasses 92

6.1 Poster from the 'Live with it' road safety campaign 104
6.2 Change4Life poster 106
6.3 Guidelines for using SMOG 111
6.4 Identifying and counting syllables 112
6.5 QUIT (2007) ‘Don’t’ overdo it’ poster 116

7.1 Five-stage evaluation cycle 126

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 List of tables

2.1 Example words that can be used when formulating objectives 25

2.2 Five objectives and their application to methods 27

4.1 Categories for planning culturally specific campagins using

Kreuter et al.’s (2003) five categories 65

5.1 Examples of the three channels of comunication 79

5.2 Information technology uses in health information 90

6.1 Summary of recommendations in the design of print-based resources 117

7.1 Examples of questions to ask in each stage of the evaluation process 129
7.2 Common subheadings used for media analysis 137

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 Author’s acknowledgements

Thank you to all the students at the University of East London, especially those
in the Communication and Health class for their enthusiasm and ideas.
I would like to acknowledge my contacts at Sage for orientating me in the
right directions. I would like to thank friends and family who supplied me with
ideas, sanity, time out, child-minding, food and proof reading. A special mention
goes to Ben Scott, Calvin Moorley, Joanne Middleton, Emma Halliday and my
parents. A big thank you to Ostyn and Huxley for keeping me grounded in the
real world and being such good sleepers. A final thank you goes to the Dockland
Light Railway service as all the time spent on their trains gave me my best ideas!

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 Publisher’s acknowledgements

Every effort has been made to trace all the copyright holders, but if any have
been accidentally overlooked the publishers will be happy to make the necessary
changes at the first opportunity.

Department for Transport for Figure 5.1: Drug driving: your eyes will give you
away glasses (DfT 2009).

Department for Transport for Figure 6.1: ‘Live with it’ (DfT 2009) road safety
campaign poster.

Department of Health for Figure 6.2: Change4Life (DH 2009) poster.

QUIT for Figure 6.5: QUIT (2007) ‘Don’t over do it’ poster.

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 Introduction

Campaigns are central to the development of public health interventions. There is

a growing dependence on campaigns as a primary strategy for public health
interventions (Kreps and Maibach 2009). All health promotion and public health
interventions include some form of communication (McKenzie et al. 2005) and
good communication is essential in the design of campaigns to promote health
or prevent ill health.
The notion of communication is changing and campaign designers are now
faced with a wealth of new media channels to use in their work. The popularity
of electronic media, such as social networking channels and internet-based
television, is encouraging practitioners to think creatively about campaign design.
Even campaigns in the political sphere are changing the way people think about
issues that impact on the communities in which they live. Abroms and Lefebure
(2009) note that in President Obama’s successful presidential election campaign,
use was made of a campaign website, a campaign TV channel (YouTube), social
network sites, mobile phones, and unofficial campaign materials (such as blogs and
students’ websites). The exposure levels achieved by the campaign were vast. For
example, by November 2008 1,700 videos of Obama had been uploaded to
YouTube and viewed over 18 million times. Abroms and Lefebure suggest Obama’s
political campaigns provide four possible lessons for health campaigns. They are:

•â•¢ consider new media such as social network sites, blogs, or Short Messaging Services (SMS) on
mobile phones;
•â•¢ encourage ‘horizontal’ communication, such as peer-to-peer and user-generated messages;
•â•¢ use new media for small acts of engagement (such as sending e-mails) that help to build
relationships;
•â•¢ use social media to facilitate, rather than replace, interpersonal grassroots work.

These lessons suggest that traditional health campaigns need to be reconceived in

light of the availability of new media and people’s communication preferences.
‘Communication’ refers to the exchange of information, thoughts, or feelings
between individuals or groups (The Communications Network 2008). Such
exchanges take place through channels of communication. These channels may
be grouped into four categories, namely, (1) intrapersonal; (2) interpersonal;
(3) organizational; and (4) community. These are hierarchical in nature, with

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 2 Working on Health Communication

Top down practitioner-led

communication

Person

Information-seeking Side-to-side
behaviours horizontal sharing
of messages

Bottom-up user-generated

Figure 0.1â•… A new model of communication

Source : Adapted from Thackery and Neiger (2009).

interpersonal (one-to-one communication) reaching the smallest number of

people and community reaching the whole population.
Current research suggests that combining both interpersonal or intrapersonal
communication with communication at organizational or community level is more
effective than using mass media alone – a point that we discuss further in Chapter 5.
The changing nature of communication implies that older (sequential)
communication models consisting of: (1) a sender; (2) a message; and (3) a receiver
are no longer appropriate. This is in part because they do not include a mecha-
nism for feedback (or responding to that feedback) and partly because of the
changing nature of communication. Today, the health communication process is
multi-directional as the general population actively seeks information from the
immediate, accessible formats. Thackery and Neiger (2009) have therefore pro-
posed a new model of communication, as shown in Figure 0.1.
This model assumes that communication may be expert-generated, i.e. from
top down (as in traditional models of communication), or user-generated, i.e
bottom up, or side-to-side (i.e. horizontal). The population actively seeks infor-
mation and this becomes part of this communication cycle. Although Thackery
and Neiger suggest the application of this model in social marketing, this model
is also appropriate for health campaigns.
Other authors emphasize the importance of horizontal sharing of information
(Abroms and Lefebure 2009). Traditional media is often considered a one-way
source (Gray et al. 2005) but health communication campaigns should no longer
rely on such models. They need to consider their target audiences and the con-
text in which they live their lives. The continual nature of communication is

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 Introduction 3

often ignored by campaigns: the Department of Health notes that campaigns are
often ‘inconsistent, uncoordinated and out of step’ (DH 2004: 21) with the lived
experience of their target audiences.
There are a number of reasons why campaigns may fail to be effective. Atkin
notes that in some campaigns audience members are lost because messages can
be ‘offensive, disturbing, boring, stale, preachy, confusing, irritating, misleading,
irrelevant, uninformative, useless, unbelievable or unmotivating’ (2001: 51). This
is also true for the whole campaign process. If planning models are confusing,
target groups irrelevant, materials useless, or evaluations misleading, then com-
munication campaigns are doomed to failure. The design, implementation, and
evaluation of a communication campaign can be challenging and practitioners
may need to develop a number of new skills to ensure that they can design and
execute effective, suitable, appropriate campaigns.
A number of important factors are involved in the design of behaviour change
campaigns at population, community and individual level (NICE 2007). These
include planning interventions carefully, taking into account the wider contexts
of communities, and evaluating work. In addition, needs assessments, acknowl-
edging social and cultural contexts, specifying theory and models for delivery,
considering barriers to change, noting time scales and setting out evaluation
plans are all essential in the planning of any campaign. We also need to consider
material design, message formulation and methods of delivery. There are some
similarities in the NICE (2007) guidelines to recommendations first noted by
Myhre and Flora (2000) and reiterated by Noar et al. (2009). The authors note
that formative research, segmentation of audiences, targeted message design,
effective channels for communication, high message exposure and evaluation
are principles that should be followed in campaigns.

This book

This textbook provides a practical guide to communication campaigns and their

design, implementation, and evaluation. It covers areas recommended by NICE
(2007) and Noar et al. (2009) alongside other key areas in health campaigns. If
communication campaigns can be planned, implemented and evaluated care-
fully, the likelihood of an effective campaign is much higher. To help you
achieve this aim, this book examines which steps need to be taken in the design
of communication campaigns and the best way to undertake these.
This book has a strong academic focus. Its approach aims to help practitioners
gain practical theoretical knowledge, by using a mixture of activities and case
studies. In addition, the final chapter includes case studies of health campaigns
to give examples of current good practice in communication.
The book is divided into eight chapters. The chapters aim to take into account
the range of areas that practitioners will encounter when designing, implementing

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 4 Working on Health Communication

and evaluating communication campaigns. Each chapter includes a number of

activities and case studies. The activity discussions are found at the back of this
textbook and are designed to give the reader examples of model answers for
these activities. There is also a glossary at the end of the book. All terms in the
glossary have been highlighted in italic in the text on their first appearance, and
the symbol appears in the margin.

Outline of content
Chapter 1 identifies the role of planning models in the design of campaigns. It
considers a range of models that can be used to plan campaigns in practice. This
chapter includes both basic and complex planning models, as well as examples
of these planning models in practice.
Chapter 2 considers the foundations of campaigns. This includes formulating
aims and objectives, identifying stakeholders and establishing the role of theo-
retical models in planning campaigns. A selection of theoretical models are
discussed to illustrate the importance of theory in campaign design.
Chapter 3 examines the factors involved in the campaign design process, such
as researching health issues and identifying settings and locations for cam-
paigns. It also discusses the writing of campaign rationales and the collection of
data to inform campaign planning.
Chapter 4 analyses the target groups in the campaign context. Target groups’
social and psychological characteristics such as age, sex, ethnicity, culture and reli-
gion are considered alongside questions concerning knowledge, attitudes, beliefs
and values. Ways to tailor information to different target groups are also considered.
Chapter 5 examines communication channels in campaigns. This includes the role
of interpersonal, intrapersonal, organizational and community channels of commu-
nication. Ways to utilize mass media and electronic media are also discussed.
Chapter 6 outlines the steps to be taken when designing a print-based resource.
This chapter works through eight steps in the design process and considers the
role of readability, typography, interactive features and visuals. This chapter also
considers the design of messages and message framing.
Chapter 7 considers the role of evaluation. It highlights the evaluation cycle
of process, impact and outcomes evaluation. It considers formative evaluation
and cost evaluation. Consideration is also given to evaluation techniques that are
specifically linked to media such as monitoring activities and media analysis as
well as unconventional ways of evaluating.
Chapter 8 provides a summary of the main themes and recommendations of
this textbook. It also provides an outline of ten campaigns in order to assist prac-
titioners in the design, implementation and evaluation of their own campaigns.
This book draws on journals and communication information sources from
around the world. The areas it draws on are being constantly updated (for example,

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 Introduction 5

information technology and new media), where reliance on current information

is essential. It is hoped that, by using sources from journals and existing health-
related organizations, this textbook will provide practitioners with an up-to-date
compendium of ideas and practices to assist in the design, implementation and
evaluation of health-related communication campaigns.

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 1
Planning campaigns

Planning is essential to ensure success in health campaigns. This chapter will

highlight the role of planning in the design of health campaigns and consider
why planning is integral to success. This chapter will identify four planning
models: (1) the nine-step model; (2) the Total Process Planning Model;
(3) PRECEDE-PROCEED; and (4) Intervention Mapping. These are taken from
various disciplines connected to health and can be applied to health cam-
paigns. This chapter will evaluate these models and consider how they can
work in a practical context.

This chapter aims to:

•â•¢ explore the rationale for using planning models in campaign planning
and design
•â•¢ identify a selection of planning models that can be used in the design of
campaigns
•â•¢ apply theoretical aspects of planning models to health communication
practice

Planning

Planning can contribute to a health campaign by helping to:

•â•¢ identify the main problem and solution;

•â•¢ identify the correct approach;
•â•¢ ensure effective resource use and allocation;
•â•¢ avoid unwanted outcomes.

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 8 Working on Health Communication

Practitioners need to ensure that, in any campaign, both the main problem and its
solution are identified. Russell et al. (2003) suggest that if the problem is not
described accurately, then factors including the inability to identify an alternative
solution may not be possible. Tones and Green (2004: 109) suggest that ‘the overall
purpose of systematic planning is to identify goals and the most effective means of
achieving them’. Planning therefore can ensure success. Godin et al. (2007), in their
review of the planning process in STI and HIV campaigns, emphasize that planned
campaigns are more likely to be successful. Planning not only helps to organize
theories and ideas, but also ensures correct identification of a problem and a solution.
Approaches vary between campaigns. Planning assists the selection of the
most appropriate approach. For example, an accident prevention campaign
aimed at young children will use a different approach to a campaign that aims to
increase knowledge in adults of an infectious disease. There is no single general
campaign that can be applied to all health issues or all target groups. There can
be considerable differences between campaigns, especially in relation to appli-
cability and transferability of theory into practice (Wang et al. 2005; Corcoran
2007b; see also Chapter 2). Evidence from research in one campaign may not
translate well into practice in another campaign.
Planning also helps to ensure that resources are used effectively. Douglas et al.
(2007) indicate that failure to demonstrate a planned approach can mean there is
a risk that your topic will not be given priority, and thus funding or resources
may be allocated elsewhere. They also note that systematic planning can ensure
resources are used effectively. From the budget-holders’ or stakeholders’ per-
spectives, planning ensures value for money and minimizes misdirected time,
spending and resources. Planning is essential in ensuring any problems identi-
fied are addressed in the preliminary phases to try and eliminate factors such as
misdirected messages, or administration failures.
One of the problems of campaigns is the risk of unexpected or unintended
consequences, for example, a campaign may run out of resources. Moreover,
there is some evidence to suggest that campaigns may have a boomerang effect
(for an example, see the section on fear appeals in Chapter 6). In addition, some
authors suggest campaigns can have unintentional, negative, impacts. Lee
(2007) indicates that some sexual health promotion misses its audience with
men who have sex with men, possibly in part due to the advertising imagery
used having unintended consequences. Effective planning may help to reduce
this risk, especially through the application of planning models.

Activity 1.1:â•… Unplanned outcomes

You have been working on a campaign to reduce high dietary fat intake in a group
of overweight young teenagers. The main messages link appearance and feeling
good with eating less fat.
1 What possible positive effects could this campaign have and what possible
negative effects could this campaign have on the target group?

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 Planning campaigns 9

Planning models

Planning need not be static, rigid or fixed. It does, however, need to be systematic
(Douglas et al. 2007). Health communication is generally based on systematic
planning models drawn from health promotion and public health practice. It can
be argued that working to a planning model may restrict creativity and imagina-
tion in the campaign process, but on the contrary, planning models help ensure
that the imaginative and creative process is developed as appropriately as pos-
sible. Horst et al. (2009) indicate the importance of adapting campaign planning
to prevailing conditions. For example, their project changed elements of the
original project in response to new information regarding drug toxicity,
decreases of workload, and the changing realities of HIV care. A practitioner
therefore needs to view planning as an adaptable process that is flexible enough
to change to meet the changing realities of day-to-day health practice.
Effective planning may be based on a variety of models. ‘Models are the
means by which structure and organization are given to the planning process’
(McKenzie et al. 2005: 15). This is not to say that a planning model is rigid and
inflexible, but is more a framework that ensures everything you want to happen
actually does happen. Although campaigns can take place without a planning
model to guide them, the risk of the campaign not meeting outcomes, going over
budget or not anticipating avoidable factors is then much higher.

Activity 1.2:â•…Stages in the planning process

1 If you were going to pre-plan a health communication campaign to promote the

wearing of a seatbelt in a car, what key planning steps would you need to
include? Think broadly from the conception of the campaign to the very end of
the campaign.

Planning models typically follow a series of steps in a logical order. These

sequential steps vary somewhat between different planning models. McKenzie
et al. (2005) propose that these steps are: understanding and engaging, assessing
needs, setting goals and objectives, developing a campaign, implementing the
campaign and evaluating the campaign. Other common steps in a planning
model include examining the evidence base, identifying budget and resources
and identifying methods. The steps included in planning models are usually
represented in diagrammatic forms – usually circular or linear – to enable the health
practitioner to work towards their desired outcomes.

Choosing a model

In small-scale campaigns a basic planning model will suffice. Practitioners can

then choose to add other planning tools (see Chapters 2 and 3) to their own

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