A Field Guide to. Population Communication Services Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs

Transcription

1 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

2 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 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 ). ii A Fied Guide to Designing a Heath Communication Strategy

3 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

4 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

5 Tabe of Contents Acknowedgments... iii Using This Book... viii Introduction... 1 Chapter 1: Anaysis of the Situation 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 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 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

6 Chapter 4: Strategic Approach 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 Step 4: Determining Strategic Approach and Rationae Chapter 5: The Message Brief Step 1: Identifying the Key Fact Step 2: Identifying the Promise Step 3: Defining the Support Step 4: Describing the Competition for the Message Step 5: Deveoping the Statement of the Utimate and Lasting Impression That the Audience Wi Have After Hearing or Seeing the Message Step 6: Describing the Desired User Profie Step 7: Identifying the Key Message Points Chapter 6: Channes and Toos Step 1: Choosing the Channes That Are the Most Likey To Reach the Intended Audience Step 2: Determining Toos Step 3: Integrating Messages, Channes, and Toos Chapter 7: Management Pan Step 1: Identifying the Lead Organization and Coaborating Partners Step 2: Defining the Roes and Responsibiities of Each Partner Step 3: Outining How the Partners Wi Work Together Step 4: Deveoping a Timeine for Impementing the Strategy Step 5: Deveoping a Budget Step 6: Panning To Monitor Activities vi A Fied Guide to Designing a Heath Communication Strategy

7 Chapter 8. Evauation Pan Step 1: Identifying the Scope and Type of Evauation Step 2: Panning for Monitoring and Impact Assessment Step 3: Identifying the Evauation Design and Sources of Data Step 4: Taioring the Evauation to the Specific Situation Step 5: Deciding Who Wi Conduct the Evauation Step 6: Panning To Document and Disseminate Evauation Resuts Chapter 9. Summary Staying on Strategy The Strategy Test Why Ask Why? Strategy Summary Outine Strategy Review Appendices : Behavior Change Theories 2: Case Studies 3: Gossary 4: Bibiography A Fied Guide to Designing a Heath Communication Strategy vii

8 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

9 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

10 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

11 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

12 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

13 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

14 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

15 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

16 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

17 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

18 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

19 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

20 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

21 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

22 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.

23 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 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

24 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

25 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

26 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

27 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

28 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

29 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

30 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

31 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

32 The number of anemic pregnant women seen in antenata cinics in the eastern region is increasing by 2 percent per year. Measurements of incidence hep to estimate what the prevaence rate wi be in the future without any intervention. This information is usuay avaiabe from the MOH or from programs or projects deaing with the heath probem. The Severity of the Heath Probem Cosey reated to the extent of the heath probem is its severity, which is measured as: Mortaity, or the number of peope who die from the probem Morbidity, or the number of peope who are permanenty or temporariy disabed by the probem The cost of the probem to an individua, the individua s famiy, and society as a whoe The MOH usuay compies information about a specific heath probem s rates of mortaity and morbidity. Organizations advocating attention to a heath probem often compie information about its costs to individuas and society. When defining the severity of a heath probem, it is usuay hepfu to put the probem in perspective by comparing its effects to those of other common diseases. The data that you have gathered on the probem s extent and severity wi pay an important roe when you deveop your justification for spending resources to prevent and treat the probem. 22 A Fied Guide to Designing a Heath Communication Strategy

33 Desired Prevention and Treatment Behaviors Severa potentia behavior changes may be appropriate responses to a heath probem. Look beyond the factua information about the heath probem to truy understand the broader environmenta context. Pinpointing the desired behavior changes at the beginning of the panning process wi hep you and your team design an appropriate strategy. 1 To be sure that your team is panning to communicate appropriate prevention and treatment behaviors, tak with experts in the MOH, in the private sector, and in your organization, and ask whether the desired behavior is, for exampe, to: Improve dietary habits. Visit a cinic. Use a particuar product. In this area, ascertaining the views of the potentia audience is critica. Do they perceive the probem in the same way as the experts? What woud they ike to see happen to address the heath probem? Gaining understanding about the audience s perceptions may ead you to design communication interventions geared toward other groups, such as service providers or key infuentias. Simiary, taking to heath care providers may yied important insights about the heath probem that may infuence the strategy deveopment process. Such insight may aso demonstrate the need to conduct poicy advocacy or media advocacy to address the heath needs of the audience in a comprehensive way. Information Sources The information that you have gathered by identifying the extent and severity of the probem and the desired prevention and treatment behavior wi inform your communication strategy. Review exampe 1.1 beow, and then compete worksheet 1.1 to organize and summarize the information that you have coected. Note: For Worksheet 1.1 and for a worksheets in this book, use rea data whenever possibe. If the specific information requested in the worksheet is not avaiabe, compete the worksheet to the best of your abiity. A Fied Guide to Designing a Heath Communication Strategy 23

34 Exampe: Nicaragua (Informe de ) Project Background: In October 1998, Hurricane Mitch cut an unprecedented swath of destruction through the heart of Centra America, eaving thousands dead and biions of doars (USD) in damage. In Nicaragua, more than 800,000 peope suffered some degree of damage to their water suppy system due to the effects of the hurricane. Thanks to the rapid intervention by the Government of Nicaragua and generous internationa assistance, the country quicky entered a reconstruction phase. USAID/Nicaragua funded a water and sanitation component as a crucia piece of their Hurricane Mitch Reconstruction Project. Under this component, the Environmenta Heath Project (EHP) is responsibe for the construction and repair of the community water and sanitation infrastructure. The Mitch Project incuded a behavior change communication component to promote better hygiene and sanitation practices. A coaition of various partner organizations impemented the project, with the utimate goa of reducing the incidence of diarrhea diseases in the areas affected by Hurricane Mitch. This nationa effort was named the Bue Star Campaign, one of the most comprehensive diarrhea prevention programs undertaken at the nationa eve. The oca popuation understood the vaue of heath to the famiy, and the Bue Star symbo represented the dreams or goas of the audience to achieve a better quaity of ife. There were knowedge barriers, however, in that many peope did not understand the inks between bacteria on hands, handing of food, and the onset of diarrhea. Focusing on bocking the main pathways of diarrhea disease transmission, under the Bue Star Campaign, a number of interdependent components worked synergisticay to impement an effective diarrhea prevention program. 24 A Fied Guide to Designing a Heath Communication Strategy

35 Exampe 1.1: Heath Probem Anaysis Worksheet 1 Instructions: Identify up to three key heath probems that you might address. Use avaiabe data to estimate the prevaence, incidence, and severity of each probem. List the prevention and treatment methods recommended to the popuation by the program or organization with which you are working. Worksheet 1.1: Heath Probem Anaysis A Fied Guide to Designing a Heath Communication Strategy 25

36 Step 2 Determining Potentia Audiences TIPS: Practica Techniques for Anayzing the Situation 1. Read To coect quantitative and quaitative studies and reports pertaining to heath and communication, first contact the Ministry of Panning, MOH, and Ministry of Information. They may recommend other government agencies that can provide the type of information you want. Private organizations aso coect good quantitative data, but these surveys may be too costy or unavaiabe due to proprietary issues.ask for both pubished and unpubished documents, incuding interna reports, that cover the subjects in which you are interested, such as: Literature reviews Popuation-based surveys Service and saes statistics Focus-group discussion reports Evauation reports of other heath programs Anayses of heath care and heath deivery systems DHS and other househod surveys of knowedge, attitudes, and practices Inventories of communication materias avaiabe at cinic sites Census data Donors country reports Economic reports Poicy documents Workshop reports Management reports Supervisory reports Technica assistance reports Training needs assessments Interview records Service deivery records Action pans Progress reports Project evauations University papers Journa artices Get as many sampes of heath communication materias as you can for future reference. Printed materias, such as brochures and posters, are easy to transport, and you may be abe to obtain audio or videocassettes as we. If you don t know the anguage, ask for a written transation. The primary audience for a communication strategy wi usuay be the peope who are at risk of or who are suffering from a particuar heath probem. One exception to this is chidren, in which case their caregivers are usuay addressed as the key infuencing audience. To hep identify potentia audiences, review the avaiabe research about the extent of the condition or disease. Sources of this information incude the MOH, oca heath centers, and nationa heath surveys. Medica and pubic heath personne can expain how the probem spreads and can identify those at risk or affected by it. There may we be gaps in avaiabe information that wi require formative research or baseine studies before you can understand enough about potentia audiences to ceary articuate and describe who they are. Identify Common Audience Characteristics As you identify potentia audiences, group them according to common characteristics, such as age range, gender, occupation, residence, or number of chidren, as we as by ifestye and access to print, radio, and teevision media. Look for characteristics that differentiate the potentia audience from persons who are not at risk or do not have the heath probem. Make sure that your anaysis is gender-sensitive by considering the different gender roes and reationships among potentia audience members. How are the potentia audiences currenty behaving in reation to the concepts of gender equity and gender equaity? Aso ook at whether members of potentia audience groups have a high degree of perceived socia support, which can pay an important roe in an individua s abiity to change. Tabe 1.1 presents common group characteristics and exampes of audience groupings. Identify Behavior Change Stage For each audience, ook for information that identifies current heath behaviors compared with desired or recommended heath behaviors. How cose or far away are they from adopting the behaviors? One usefu approach is to categorize your potentia audience according to the PBC framework presented in the Introduction. 26 A Fied Guide to Designing a Heath Communication Strategy

37 To deveop estimates of the stage of behavior change of the potentia audiences, review existing quantitative data, such as Demographic and Heath Surveys (DHS) and census data. Both sources may provide reevant information about the stage of behavior change of various groups of peope within a country s popuation. DHS generay ask about knowedge, attitudes, and practices reative to reproductive, materna, and chid heath. The atest DHS is generay avaiabe from your oca MOH or from the USAID office. If not, Macro Internationa, Inc., can provide copies of DHS reports for various countries.* Often the existing audience data are insufficient for making decisions reated to a communication strategy. You may need to work with research experts to design and impement a quantitative baseine survey that generates reiabe information about audience characteristics, behaviora issues, barriers to behavior change, etc. Simiary, it is often usefu to conduct quaitative research, such as focus groups, with potentia audience members to yied rich, descriptive information about the audience. Sometimes this is couped with one-on-one interviews with key stakehoders to get additiona insights. You and your team members wi need to make judgments about what preiminary research, if any, is required, and you shoud aso consider timing and budget issues when addressing this issue. In addition to reviewing forma studies, interview oca experts to get their opinions on the stage of behavior of the group in question. Aso, to gain additiona insight, tak with program personne who work with the potentia audience on a daiy basis. *Macro Internationa, Inc., Betsvie Drive, Caverton MD 20705, USA, phone: (301) , fax: (301) , emai: reports@macroint.com TIPS: Practica Techniques for Anayzing the Situation 2. Listen Another way to get the information you need to anayze the situation is to conduct interviews. Interviews wi hep you: Soicit the needs, views, and perspectives of those identified as stakehoders in the program, incuding the audience Identify potentia resources for assisting with heath communication Before conducting the interview, deveop an interview questionnaire to ensure that you ask a the questions you intend to ask. To hep compete your understanding of the situation, conduct interviews with representatives of at east five types of groups: Potentia audience members Agenda setters (poicymakers and researchers) Organizations providing heath services and products Media Donors and technica assistance organizations Potentia interviewees are any persons, groups, or entities that can shape the direction of a communication effort, provide vita resources, or serve as an impementing partner. Exampes of those to interview incude: Senior program managers within your program Directors of organizations providing reated heath services Representatives of reigious organizations in areas where heath probems exist Community eaders in areas where heath probems exist Directors of service deivery Directors of ogistics management Poitica eaders with a demonstrated interest in heath Potentia cients Traditiona heaers Directors of radio and teevision stations Journaists and editors of magazines and newspapers Donor representatives Representatives of ministries or directorates concerned with women s issues University representatives Cients of cinics offering heath services Cinic supervisors Service providers Internationa organizations working in heath A Fied Guide to Designing a Heath Communication Strategy 27 1

38 Tabe 1.1: Possibe Common Characteristics of Potentia Audiences (Schiffman & Kanuk, 1995) 28 A Fied Guide to Designing a Heath Communication Strategy

39 Identify Known Barriers to Behavior Change As you interview program workers, heath experts, community representatives, and members of the potentia audience, ask why they think the audiences are not adopting the desired heath behaviors. Often one of the main barriers to adopting behaviors is the fact that the audience is preknowedgeabe. In Bangadesh, for exampe, a situation anaysis for the Nationa Tubercuosis Contro Strategy reveaed that most peope, especiay in rura areas, did not know that treatment is provided free of cost from Government heath faciities. However, you and your team must aso consider barriers that go beyond awareness and knowedge. Look for barriers in the foowing categories to give you a more compete picture of the situation: TIPS: Practica Techniques for Anayzing the Situation 3. Observe As you trave the country, ask as many questions as possibe, and take ots of notes about what you see. Make sure that you spend time in rura areas as we as urban, and if there are strong regiona differences due to reigious or cutura traditions, try to visit different regions so that you obtain a baanced view of the country. Observe the foowing: Counseing sessions Group heath taks in cinics Community outreach efforts Presence of heath messages, materias, and activities in paces where intended audiences ive and work Observation is one of the best toos not ony to assess what is going on, but aso to note some of the strategies that seem to work best to reach a certain group of peope. For exampe: Do most mothers consut traditiona heaers about their chidren s heath? Wi a famiy use its scarce financia resources to pay for preventive heath care? 1 A Fied Guide to Designing a Heath Communication Strategy 29

40 Understanding the barriers to change even those that may be beyond the abiity of communication to change is important for making strategic communication decisions. This knowedge wi hep you estimate the degree of change that can be achieved within a given timeframe. Identify Key Infuencers After you have identified your potentia audiences, find out who infuences their heath behaviors. Tak with program managers who work in the community as we as community workers who visit the audience reguary. Review reevant research findings. Make informa visits to communities and homes. Tak with members of the potentia audience and community eaders about the heath probem. Review exampes 1.2a and 1.2b, and then compete worksheets 1.2a and 1.2b. 30 A Fied Guide to Designing a Heath Communication Strategy

41 Exampe 1.2a: Potentia Primary Audiences Worksheet Instructions: Identify groups of peope with common characteristics who are suffering from or at risk of the heath probem. Compete the tabe for each potentia audience. 1 Exampe: Nicaragua Worksheet 1.2a: Potentia Primary Audiences Instructions: Identify groups of peope with common characteristics who are suffering from or at risk of the heath probem. Compete the tabe for each potentia audience. A Fied Guide to Designing a Heath Communication Strategy 31

42 Exampe 1.2b: Potentia Infuencing Audiences Worksheet Instructions: Identify groups of peope with common characteristics who potentiay can infuence audiences for your communication efforts. Compete the tabe for each potentia primary audience. Exampe: Nicaragua Worksheet 1.2b: Potentia Infuencing Audiences Instructions: Identify groups of peope with common characteristics who potentiay can infuence audiences for your communication efforts. Compete the tabe for each potentia audience. 32 A Fied Guide to Designing a Heath Communication Strategy

43 Step 3 Identifying Potentia Communication Resources 1 Step 3 in anayzing the situation is to gain an understanding of the communication environment, incuding current heath communication activities and avaiabe resources. Chapter 6, Channes and Toos, provides a guide for seecting the channes that your team wi use to convey the message to the intended audience. The focus here is on identifying and assessing potentia resources that can hep you carry out a communication program. Heath communicators define communication channes broady as a deivery system for messages to reach intended audiences. They have categorized them as interpersona, community-oriented, and mass media. The atter two channes are particuary effective when the goa is to change community or cutura norms. Interpersona channes focus on either one-to-one or one-to-group communication. One-to-one channes incude peer to peer, spouse to spouse, and heath cinic worker to cient. An exampe of one-to-group communication may be a community-based outreach worker meeting with a women s cooperative. Interpersona channes use verba and nonverba communication. Community-oriented channes focus on spreading information through existing socia networks, such as a famiy or a community group. This channe is effective when deaing with community norms and offers the opportunity for audience members to reinforce one another s behavior. Mass-media channes reach arge audiences. They are particuary effective at agenda setting and contributing to the estabishment of new socia norms. Formats range from educationa to entertainment and advertising, and incude teevision, radio, and print media, such as magazines, newspapers, outdoor and transit boards, the Internet, and direct mai. TIPS: Information Coection Methods The foowing types of formative research and PLA wi provide you with essentia information to guide your strategy decisions. Stakehoders Meetings To access different dimensions of a strategy s potentia impact on peope and their environments, you can use many stakehoder techniques. For exampe, tak with program managers, community heath workers (CHWs), cinic staff, and community eaders about the situation. When possibe, gather together those who have an interest in or contro over addressing the probem to have them share insights on causes and contributors to the probem. Whie interviewing them or hosting a meeting, find out what they are doing now to address the probem, and why. Ask them to hep you identify key strategic communication issues. Gender Anaysis In the context of participatory deveopment, gender anaysis heps you to understand how gender differences affect access to resources and the participation of women in deveopment activities. Such an anaysis wi hep you to take appropriate measures to ensure that women are not excuded. Ideay, gender anaysis shoud not be a separate participatory method but shoud be integra to a participatory methods. (continued on foowing page) A Fied Guide to Designing a Heath Communication Strategy 33

44 TIPS: Information Coection Methods (continued from previous page) Loca Leve Information Gathering and Panning This technique focuses primariy on oca peope s views, how they perceive their conditions and their ives, and how to change them. Two methods predominate: Focus Group Discussions Have a trained focus group moderator discuss the heath probem with a few groups of between 6 and 12 members of your potentia audiences for 1 or 2 hours. Find out about their perspectives on the probem, incuding possibe causes and contributors. Find out about the group s sources of information and infuence as we as their eves of knowedge, beiefs, and attitudes. Interviews with potentia audience members Informay interview those who are potentia audiences for your effort. Visit with both those currenty affected and those at risk. Ask them about their perspectives on the heath probem. Try to interview both those who are aready practicing behaviors that promote heath and those who are not. Observation Visit paces where reated heath suppies and services are offered. Observe how easy or difficut it is for cients to access a provider. Observe severa cient/ provider interactions, aowing that your presence wi change the interaction somewhat. Observe the conditions within which they are exchanging information. Make notes about your observations. Ongoing Communication Activities A wide variety of communication channes is avaiabe. Your chaenge is to find those that can reach the potentia audiences that you have identified. Three approaches can hep: Describe communication efforts aready going on through the identified communication channes and media. Tak to other peope who have conducted communication campaigns in the country. This approach is a good starting point for identifying oca partners and for understanding the obstaces and opportunities invoved in oca communication efforts. Categorize these activities according to the channes described above. Remember to: Look for media use surveys of potentia audiences. DHS can be a hepfu resource here. In addition, many countries survey media use by the popuation. Ask advertising agencies if a media survey is avaiabe. Interview program managers at organizations communicating with your audiences. They can give you a good idea about what has worked and what has not. Visit the communities where your audience ives, and make an inventory of existing media channes. Describe the sizes and types of the audience that they reach. One approach to identifying the key communication channes is to interview the program managers of existing heath projects. As you identify the activities, note the gatekeepers the individuas or organizations responsibe for each activity. Note the main channes and formats used by these organizations. Focus on their messages as we as the intended audience. This activity wi give you an understanding of the messages aready being communicated and the extent to which they were we received. 34 A Fied Guide to Designing a Heath Communication Strategy

45 Communication, Organizationa, and Professiona Resources In addition to identifying heath-reated programs and activities, identify the organizations and professionas who are heping to carry them out. Ask these peope questions ike the foowing: 1 Who has experience producing heath education materias? Which are the top advertising firms in the area? Who can produce teevision and radio programs? Which organizations provide training to service providers and community workers? Are there networks or associations of communication organizations? If so, what is their membership and scope? Compete worksheets 1.3.a, 1.3.b, and 1.3.c to hep summarize your findings. A Fied Guide to Designing a Heath Communication Strategy 35

46 Exampe 1.3a: Heath Communication Channes Worksheet Instructions: Identify heath communication channes in your area by name and type as we as the type of audiences reached. Exampe: Nicaragua Worksheet 1.3a: Heath Communication Channes Instructions: Identify heath communication channes in your area by name and type as we as the type of audiences reached. 36 A Fied Guide to Designing a Heath Communication Strategy

47 Exampe 1.3b: Current Heath Communication Worksheet Instructions: Identify reevant communication efforts in your area. 1 Exampe: Nicaragua Worksheet 1.3b: Heath Communication Efforts Instructions: Identify reevant communication efforts in your area. A Fied Guide to Designing a Heath Communication Strategy 37

48 Exampe 1.3c: Heath Communication Assistance Worksheet Instructions: Identify organizations or individuas who can hep you carry out a communication initiative. Exampe: Nicaragua Worksheet 1.3c: Heath Communication Assistance Instructions: Identify organizations or individuas who can hep you carry out a communication initiative. 38 A Fied Guide to Designing a Heath Communication Strategy

49 Step 4 Assessing the Environment 1 The fourth step in anayzing the situation is to assess key aspects of the environment where the strategy wi be impemented. Sometimes a heath issue requires promotion of a behavior and does not invove a product or service (i.e., breastfeeding). In other instances the heath probem requires products that are easiy accessibe (i.e., soap for hand washing). Sti other heath issues require an interaction with the heath service deivery system (i.e., immunization). These considerations shoud be carified as part of the process of assessing the environment. Heath Service and/or Product and Behavior Support Assessing the avaiabiity, accessibiity, affordabiity, and acceptabiity of services, products, and behaviors wi ead to knowedge of the capacity of service providers and suppy outets to hep the communication effort. Avaiabiity Consut with personne and ogistics managers in the programs that the communication effort wi be promoting. Ask them to estimate their current capacity and current demand. Key questions incude: Can they increase their capacity to meet increased demand? TIP: Make note of the products, services, or behaviora supports that are offered to hep peope adopt the heathier behavior you wi be promoting and which organizations are offering the products and services. How quicky can they respond to stockouts and understaffing? Wi they be abe to hande additiona cients? Wi enough suppies be avaiabe, and wi these suppies be avaiabe on a reguar basis? Ask yoursef if you wi be creating expectations that existing services cannot meet. If so, you shoud consider whether promoting the desired behavior is counterproductive. A Fied Guide to Designing a Heath Communication Strategy 39

50 It is aso important to conduct a competitive anaysis to understand the broader environment and to identify potentia barriers to success. First, designate whether you wi be promoting a product, service, or behavior. Then, within the chosen category, ist a of the competitors that you know about. For exampe, when promoting a behavior such as breastfeeding, the competition may consist of socia pressure not to breastfeed, as we as baby formua sod through commercia channes. See chapter 5, The Message Brief, for additiona information about competition considerations when deveoping messages. Accessibiity Where services or suppies are apparenty avaiabe, ask whether those who need them can get them. For exampe, in some countries where contraceptives are readiy avaiabe, sexuay active, unmarried women cannot get access to them because of cutura or ega restrictions. Determining the eve of accessibiity before starting a specific campaign is crucia. Affordabiity Ask if the primary audience can afford the services and suppies. Think beyond monetary cost. How much does it cost in time and effort to get the service or item? If someone has to take a day off from work to get it, how much does this ose them in wages? Understanding potentia constraints ike these wi hep you design a more effective strategy. Acceptabiity Ask how sociay acceptabe it is to get and use the product or item. In some countries, for exampe, it is sociay unacceptabe for a woman to purchase condoms, even for her husband. In other countries, certain contraceptives are unacceptabe because they require a woman to touch her genitas. Interview service providers and users about these issues to find out if barriers exist to promoting certain behaviors. Review the questions and findings about these four issues with the program managers who are responsibe for service deivery and distribution of products. Find out if there are any current service or suppy issues. Consider visiting severa service deivery sites to test avaiabiity and severa suppy outets to test accessibiity. 40 A Fied Guide to Designing a Heath Communication Strategy

51 Socia, Economic, and Poitica Conditions Socia, economic, and poitica conditions can imit heath communication. Crime, unempoyment, poverty, and socia upheava a affect heath behavior. Consut program managers about socia conditions that may impact their abiity to promote heath issues. Read about current affairs. Ask about pending egisation that may affect the effective promotion of heath behaviors. Make note of other deveopment issues that wi be competing for resources and the attention of your audiences. 1 Based on the foowing exampes, compete the corresponding worksheets. Exampe 1.4a: Heath Service and Product Support Worksheet Instructions: Identify services and products that hep peope prevent or treat the heath probem. Indicate the avaiabiity, accessibiity, acceptabiity, and affordabiity of each one. Exampe: Nicaragua A Fied Guide to Designing a Heath Communication Strategy 41

52 42 A Fied Guide to Designing a Heath Communication Strategy Worksheet 1.4a: Heath Service and Product Support Instructions: Identify services and products offered in your area for heping peope prevent and treat the heath probem. Briefy describe each according to its avaiabiity, accessibiity, acceptabiity, and affordabiity.

53 Exampe 1.4b: Socia, Economic, or Poitica Conditions Instructions: Identify any major infuences that may affect your abiity to communicate effectivey. 1 Exampe: Nicaragua Worksheet 1.4b: Socia, Economic, or Poitica Conditions Instructions: Identify any major infuences that may affect your abiity to communicate effectivey. A Fied Guide to Designing a Heath Communication Strategy 43

54 TIP: Avoid writing a ong ist of SWOT. Prioritize your ist, and incude ony those that you beieve wi have a major impact on your communication strategy. Step 5 Summarizing Strengths, Weaknesses, Opportunities, and Threats The next step is to summarize what you have earned to form a foundation for your communication strategy. Many strategic panners use the SWOT framework: Strengths, Weaknesses, Opportunities, and Threats. Summarizing Key Strengths and Weaknesses Review the resources that you contro, and ist key strengths and weaknesses in your abiity to communicate effectivey. Invove your coeagues in creating this ist. Review financia, human, and technoogica resources that can be devoted to the communication initiative. Summarizing Key Opportunities and Threats Simiary, ask the foowing questions: What key opportunities are there for improving heath through communication? What threatens the abiity to improve heath through communication? Based on the foowing exampe, compete the corresponding worksheet to summarize your findings. 44 A Fied Guide to Designing a Heath Communication Strategy

55 Exampe 1.5: SWOT Anaysis Worksheet Exampe: Nicaragua 1 Worksheet 1.5: SWOT Anaysis A Fied Guide to Designing a Heath Communication Strategy 45

56 Now you are ready to summarize what you have earned from anayzing the situation by competing worksheet 1.6, Situation Summary. When you reach chapter 9 of the book, you wi combine worksheet 1.6 with seven other summary worksheets (one each for chapters 2, 3, 4, 5, and 7 and two summary worksheets for chapter 6, Channes and Toos ). Taken together, this set of summary worksheets wi provide the information and guidance that you need to write a heath communication strategy. Exampe 1.6: Situation Summary Worksheet Instructions: Review the worksheets that you have competed. Refer to them to compete the foowing summary of your situation. Exampe 1: Nicaragua 46 A Fied Guide to Designing a Heath Communication Strategy

57 Exampe 1.6: Situation Summary Worksheet Instructions: Review the worksheets that you have competed. Refer to them to compete the foowing summary of your situation. 1 Exampe 2: Uganda (Communication Strategy ) At the end of this chapter and at the end of most chapters, you wi find a summary worksheet. The 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. Project Background: The ong-term and permanent methods (LTPMs) of FP were highy underutiized in Uganda. Permanent methods incude tuba igation (TL) and vasectomy. The ong-term method used in this exampe is Norpant. Despite strong FP campaigns and a survey among new FP acceptors that noted an increase in the desire to space or imit births atogether, the use of LTPMs remained significanty ow. In 1997, the DISH project conducted a survey of nine districts and found that ony 4 percent of married women were using TL, ess than 0.26 percent of married women were using Norpant, and no men reported using vasectomy. When asked why, cients cited many reasons for the LTPMs not being more widey used, incuding inaccessibe and unreiabe services, ack of awareness, fears and misconceptions about the methods, and poor quaity services. The DISH II project, aong with the MOH and other partners, deveoped a strategy to expand the avaiabiity and to improve the quaity of these services through connected activities reated to training and supervision of medica personne, provision of equipment and suppies, and targeted behavior change communication messages for the different audience segments. A Fied Guide to Designing a Heath Communication Strategy 47

58 48 A Fied Guide to Designing a Heath Communication Strategy Exampe 1.6: Situation Summary Worksheet (Uganda)

59 Worksheet 1.6: Situation Summary Instructions: Review the worksheets that you have competed. Refer to them to compete the foowing summary of your situation. 1 A Fied Guide to Designing a Heath Communication Strategy 49

60 Concusion This chapter has given you the necessary toos to anayze your situation. By now, you shoud be we on your way to: Identifying and understanding the probem Determining potentia audiences Identifying potentia communication resources Assessing the environment where you wi be communicating Summarizing the key 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 Once these five steps are competed, you are ready to move on to step 2 of the P Process strategy design. 50 A Fied Guide to Designing a Heath Communication Strategy

61 References 1 Communication Strategy to Conserve/Improve Pubic Heath, October September 2001 (2001). Johns Hopkins University/Center for Communication Programs. Informe de Resutados de a Encuesta de Linea de Base para a Campaña La Estrea Azu (2001). (pp. 24). Johns Hopkins University/Center for Communication Programs. Schiffman, L. G. & Kanuk, L. L. (1995). Consumer behavior. Engewood Ciffs, NJ: Prentice-Ha. A Fied Guide to Designing a Heath Communication Strategy 51

62 52 A Fied Guide to Designing a Heath Communication Strategy

63 Chapter 2 Audience Segmentation By the end of this chapter, the reader wi be abe to compete the audience segmentation process by competing the foowing steps: 2 Step 1: Step 2: Step 3: Step 4: Determining Audience Segments Prioritizing Audience Segments Within the Strategy Identifying Infuencing Audiences Painting a Portrait of the Primary Audience A Fied Guide to Designing a Heath Communication Strategy 53

64 Overview In the forefront of the architect s mind at every stage of design are the audience and the audience s needs. In our exampe of designing a schoo, the audience incudes students of different sexes and ages, teachers, parents, administrators, and visitors. Because of its different needs and depending on the actua situation, the architect may segment the audience into these groups. He aso considers the needs of peope who wi infuence the intended audience, such as officias from the Ministry of Education and other government officias. For each segment he creates a menta picture to ensure that he pans and designs cassrooms, a ibrary, auditoriums, offices, and pay areas in accordance with the needs of each segment. Simiary, you and your team may need to segment your audience to design the most effective and efficient strategy for communicating with it. 54 A Fied Guide to Designing a Heath Communication Strategy

65 The term audience segmentation means dividing and organizing an audience into smaer groups of peope who have simiar communication-reated needs, preferences, and characteristics. Heath communicators segment audiences to achieve the most appropriate and effective ways to communicate with these groups. As discussed in Chapter 1, heath communicators identify severa potentia audiences for the communication strategy. Each audience consists of peope who wi directy benefit from the desired behavior changes. Your task is to determine the audiences on which to focus communication efforts. 2 This chapter provides four steps as a guide for carrying out the segmentation process to determine the primary, secondary, and infuencing audiences. Foowing these steps wi ead to the decisions and descriptions that wi form the core of the audience portion of your communication strategy. Step 1 Determining Audience Segments The first question for you to resove is whether you need to segment the audience at a. If the potentia audience as a whoe can be effectivey reached through the same set of channes and receive the same set of messages, you do not need to segment. In most cases, however, the audience wi benefit from being segmented, and your communication activities wi be more effective. Indeed, heath communicators have found that to most effectivey promote behavior change, they need to segment the audience and design severa different customized messages, appeas, or cas to action. The question of avaiabe resources aso infuences your audience segmentation decisions. The costs invoved in deveoping and executing separate communication efforts for severa groups may outweigh the benefits. If resources are imited but segmenting the audience is warranted, it may be appropriate to focus on either fewer segments or to ook for ways to everage funds with other programs. Review the guideines on the next page, and compete worksheets 2.1 and 2.2 to hep you reach audience segmentation decisions. A Fied Guide to Designing a Heath Communication Strategy 55

66 Guideines To Hep Determine When It May Be Usefu To Segment an Audience It may be usefu to segment audiences in the foowing cases: 1. When it is usefu to separate users of a product from nonusers or peope who practice a behavior from peope who do not practice the behavior, segment accordingy. Exampes: Users and Nonusers Messages to men who have never used a condom wi be different from those who have used a condom but not on a reguar basis. The former group requires information on the advantages of condom use. The atter may require more research on why they do not use condoms reguary, and any effective communication pan must design messages to address their concerns. The same is true for chid immunization. Immunization programs often address famiies to get their chidren immunized, as if the caregivers were thinking of this subject for the first time. In many countries, however, the probem is that famiies aren t making sure that their chidren get the required number of immunizations. Based on these different behavior stages nonpracticing and practicing communicators segment the audience and deveop the communication strategies correspondingy: one to convince caregivers to begin an immunization program and the other to encourage them to bring the chidren in for the fu course of treatment. Heath communicators identified materna mortaity as a key probem and pregnant women as the potentia audience for a message about antenata care. Some pregnant women may not go to a provider of antenata care at a, whie some may not start going unti the second or third trimester of the pregnancy. The first audience may need to understand the advantages of going to a provider of antenata care. The second audience aready understands the need for antenata care but may need to understand the advantages of antenata care during the first trimester. 56 A Fied Guide to Designing a Heath Communication Strategy

67 2. When separate groups within an audience require different types of information or motivation to promote behavior change, segment by information needs and motivation. Exampes: Users at Different Stages of Behavior Information needs: A potentia audience for contraceptive use may be defined as women of reproductive age. Within that group, however, young women may want two or fewer chidren, and modern contraceptive methods may be a soution. On the other hand, oder women with three or more chidren may want to consider permanent contraceptive methods. Athough both groups consist of married women of reproductive age, their information needs are different. An undifferentiated communication strategy may encourage women to choose an inappropriate soution or may not give them a strong enough reason to seek a FP method that best suits them. Segmenting the broader audience of married women of reproductive age into those who wish to space out their pregnancies and those who wish to imit the number of chidren that they have resuts in more focused and appropriate communication strategies. In many countries, a arge proportion of adoescents are aready sexuay active, and the desired behavior may be for them to use contraceptives to avoid unwanted pregnancies. For adoescents who are not sexuay active, however, the message may be to deay sexua activity. These different behaviora outcomes require different messages and materias. Materias that are highy visua with itte text may be necessary for the ess-iterate members of the audience, whie fewer visua materias with more text may better expain the communication messages to more iterate members. Motivation: Can a strategy appea to rura women in the same way as urban women? If not, consider segmenting these audiences to ensure that approaches are appropriate for both of these groups. Consider whether most everyone in your audience wi respond to the same appea and approach, even if the message and desired behavior are simiar. Segmenting the Audience The Romania Exampe A women s heath communication strategy was undertaken in Romania. Romania provided an unusua exampe of how formative research was conducted to determine very distinct audience segments, and then many of these segments were coapsed into one primary audience. Some of this segmentation was given as part of the program. For exampe, the origina geographic program area was concentrated in three judets, or counties.the strategy designers knew from initia data that there were differences in ifestye between rura and urban women and differences in ifestye between singe and married women. They aso knew from past experience that they woud probaby have to deveop different messages for each of these segments, so they asked the research firm to gather data based on these segments. Interestingy, the findings showed that a need for more information about modern FP methods was common to a segments, and the desire to use modern methods was equay great. In addition, mass media were highy accessibe by a segments.the strategy designers reaized that they coud conduct one campaign with cear messages and reach a segments except Roma women (a subset of Romanian women). Their cutura differences and iteracy eves were so different from the others that it woud not have been cost-efficient to incude this group during this campaign phase (Liskin & Yonker, 1999). 2 A Fied Guide to Designing a Heath Communication Strategy 57

68 TIPS for Using the Audience Segmentation Worksheets: Once the team has decided to segment the audience, use the foowing worksheets to hep divide the audience into smaer groups. This segmenting wi hep communicate more effectivey by better focusing the messages, communication channes, and approaches. To compete the worksheets, ist the potentia audiences identified in the situation anaysis in the first coumn of the first worksheet. Then answer the remaining questions on each of the worksheets. By the end of this process, you and your team shoud be abe to define the key audiences for the communication efforts. Literacy, anguage, and other considerations may indicate the need to deveop taiored materias for different groups within an audience, even if the basic message and desired behavior change are simiar. Is one set of messages enough to effectivey communicate with them a? If not, consider segmenting your audience according to who wi need different kinds of materias. Focusing on motivation means more than simpy taking the same communication materias and customizing them in a oca anguage, using oca modes. It is a matter of understanding particuar motivations among the segmented audiences and deveoping specific communication strategies to meet their needs. 3. When separate groups are ikey to identify with different spokespersons, segment by effective sources of information. Exampe: Peope trust different sources of information In many paces, young peope may respond to messages given by their peers rather than to messages given by aduts or providers. Peope may trust those who can speak to them in their own anguage; peope reate better to those who ook and sound ike they do. Some peope trust a neighbor s advice more than that of a heath provider. Athough everyone s preferences are individua, common preferences among groups shoud be considered when seecting audience segments. If research from the situation anaysis shows that certain groups of peope wi respond better to different messages or different sources, you may want to segment. 58 A Fied Guide to Designing a Heath Communication Strategy

69 Exampe 2.1: Step-by-Step Audience Seection Worksheet Instructions: Step 1: Identify Audience Segments. Based on your anaysis of the situation, identify potentia audiences for your communication efforts. Name the potentia audiences in the first coumn in the foowing chart. For each audience, identify possibe segments (subgroups with traits that make them significanty different from others in the arger group). A significant difference is one that wi require a different communication message or approach. 2 Exampe: Romania A Fied Guide to Designing a Heath Communication Strategy 59

70 60 A Fied Guide to Designing a Heath Communication Strategy Worksheet 2.1: Step-by-Step Audience Seection Instructions: Step 1: Identify Audience Segments. Based on your anaysis of the situation, identify potentia audiences for your communication efforts. Name the potentia audiences in the first coumn in the foowing chart. For each audience, identify possibe segments (subgroups with traits that make them significanty different from others in the arger group). A significant difference is one that wi require a different communication message or approach.

71 Step 2 Prioritizing Audience Segments Within the Strategy The need to prioritize is based on the answer to this question: Are enough resources avaiabe to reach a the peope identified as being affected by or at risk of the heath probem? If not, the team needs to decide which audience segments shoud receive attention first. A phased approach to audiences heps to buid momentum for a communication effort and to create in one segment of the audience the capacity to hep others who are at different stages of behavior change. The communication strategy may start by addressing the audience that is easiest to reach, most receptive to hearing the message, or at a stage where it is most ikey to move to the next behavior change stage. An audience segment that aready practices a behavior can be encouraged to advocate the behavior to others. These practitioners become credibe motivators of the intenders, who wi foow them through the stages of behavior change. Worksheets 2.2.1, 2.2.2, and tabe wi hep you and your team determine whether to prioritize audience segments. Exampe In Ghana, a nationa strategy was deveoped to increase the use of ong-term FP methods specificay injectabes, Norpant, intrauterine device (IUD), TLs, and vasectomies. One of the partners in the strategy, Engender Heath (formery Association for Vountary Surgica Contraception [AVSC]), has a successfu history of working with satisfied users to hep promote the concept of ong-term FP methods to nonusers. However, there were so few users of ong-term contraceptives that the first priority was to buid a soid base of ong-term users who ater coud hep promote the concept to others. The strategy was to direct the first phase of the campaign to users of shorter term contraceptives who wanted to widey space or imit their famiy size but who were currenty using the pi and condoms, since they were aready predisposed to use modern FP methods. The partners reaized that there woud be ongoing communication to increase the number of pi and condom users at the same time. Therefore, the priority was as foows: Phase 1, buid a base of satisfied users by appeaing to current users of shorter term methods who woud seek to use onger term methods; and phase 2, work with the now arger base of ong-term users to have them advocate to others about the benefit of ong-term methods. 2 A Fied Guide to Designing a Heath Communication Strategy 61

72 Exampe 2.2.1: Prioritize Audience Segments Worksheet Instructions: Review your work in step 1, and identify potentia audience segments. Segments shoud be audiences with common characteristics. Write the names of potentia audiences in coumn 1. Then answer the questions to hep you decide which audience segments to focus on. Exampe: Romania 62 A Fied Guide to Designing a Heath Communication Strategy

73 Worksheet 2.2.1: Prioritize Audience Segments Instructions: Review your work in step 1, and identify potentia audience segments. Segments shoud be audiences with common characteristics. Write the names of potentia audiences in coumn 1. Then answer the questions to hep you decide which audience segments to focus on. 2 A Fied Guide to Designing a Heath Communication Strategy 63

74 Exampe Audience Prioritization Worksheet Instructions: Using your answers from worksheet 2.2.1, rate each of your potentia audiences as described beow. Exampe: Romania 64 A Fied Guide to Designing a Heath Communication Strategy

75 Worksheet 2.2.2: Audience Prioritization Instructions: Using your answers from worksheet 2.2.1, rate each of your potentia audiences as described beow. 2 A Fied Guide to Designing a Heath Communication Strategy 65

76 66 A Fied Guide to Designing a Heath Communication Strategy Exampe 2.2.3: Potentia Audience Phasing Strategies Worksheet Instructions: This chart shows three exampes of potentia audience phasing strategies and the rationae for phasing. Your team needs to determine if resources are avaiabe to achieve individua objectives for each of these audience segments within the timeframe of the strategy. When possibe, state the specific time frame associated with each phase.

77 Tabe 2.2.3: Potentia Audience Phasing Strategies Instructions: This chart shows three exampes of potentia audience phasing strategies and the rationae for phasing. Your team needs to determine if resources are avaiabe to achieve individua objectives for each of these audience segments within the timeframe of the strategy. When possibe, state the specific time frame associated with each phase. 2 A Fied Guide to Designing a Heath Communication Strategy 67

78 Step 3 Identifying Infuencing Audiences Step 3 identifies infuentia peope in the primary audience s socia networks. The goa is to mobiize these groups to infuence the primary audience in favor of the heathy behaviors. Chapter 1 discussed how to ook for and ist potentia infuencing audiences. After reviewing that materia and the text beow, use worksheets and to hep your team work through this step. To hep you determine who infuences the audience s knowedge and attitudes about the heath probem, ask these questions: Who suggests ways that they can prevent or treat the heath probem? Who infuences their decision to seek assistance in preventing or treating the heath probem? Who infuences their decision to try certain products or practice certain heath behaviors? Who infuences their decision to continue or not to continue their new heath behaviors? Describe these outside infuences both in terms of such characteristics as age and gender and in terms of their reationship to the primary audience. For exampe, are they friends or reatives? Are they offering services or products to the audience? 68 A Fied Guide to Designing a Heath Communication Strategy

79 Identify a providers of services and suppies to the primary audience. Identify your own provider network and aternative providers. For exampe, does the primary audience seek treatment from traditiona heaers? If so, these heaers are ikey to have a strong infuence on the audience. Does the audience seek services from government cinics, nongovernmenta outets, or private cinics? When identifying the audience s heath care providers, be as specific as possibe. For exampe, identify whether the peope in the audience visit nurses or doctors. Note if they visit the nearest provider or if they trave some distance to reach a preferred provider. This information wi hep you seect key providers. 2 To identify opinion eaders, ask program managers and community workers who infuences community opinions about heath probems and who directs poicy decisions about heath care matters. Interview these peope about their views on the heath probem, and ask them for the names of other opinion eaders and poicymakers in the area. As you ist the infuencers, estimate their degree of infuence. For exampe, the reationship between a cient and a provider is a powerfu one in infuencing heath behaviors. Certain reatives, spouses and parents, are aso strongy infuentia. When it comes to abstinence, for exampe, reigious eaders or parents may pay an infuentia roe, particuary among youth. Neighbors may have ess infuence. By estimating the degree of infuence that others may have on the primary audience, your team wi be abe to make more informed decisions on how to spend communication resources to encourage advocacy by these groups. Aso, ask the infuencers about their attitude toward the desired behavior. Knowing this wi hep determine how much of an investment the team wi need to make in promoting positive attitudes and advocacy among this group. A Fied Guide to Designing a Heath Communication Strategy 69

80 Exampe 2.3.1: Identify Infuencing Audiences Worksheet Instructions: In coumn 1, write the names of the audiences you seected in step 2. Then answer the questions. Exampe: Romania Worksheet 2.3.1: Identify Infuencing Audiences Instructions: In coumn 1, write the names of the audiences you seected in step 2. Then answer the questions. 70 A Fied Guide to Designing a Heath Communication Strategy

81 Exampe 2.3.2: Infuencer Anaysis Worksheet Instructions: Write the name of the primary audience (the audience that you want to encourage to practice a heathy behavior) above the tabe. Exampe: Romania Worksheet 2.3.2: Infuencer Anaysis Instructions: Write the name of the primary audience (the audience that you want to encourage to practice a heathy behavior) above the tabe. In the first coumn, ist the groups who infuence the audience s heath behavior. In the second coumn, estimate how much infuence they have on the primary audience (strong, moderate, weak). In the third coumn, state what they are currenty infuencing the audience to do (or not to do). In the fourth coumn, describe what woud be ikey to motivate them to encourage the desired behaviors. In the fifth coumn, describe what woud be ikey to motivate them to discourage the desired behaviors. In the sixth coumn, describe their primary sources of information for infuencing the primary audience. 2 A Fied Guide to Designing a Heath Communication Strategy 71

82 Step 4 Painting a Portrait of the Primary Audience To hep you and your team prepare a creative approach for effectivey communicating with the primary, secondary, and infuencing audiences, step 4 shows how to deveop a description of each segmented audience to paint a portrait. In other words, this step provides a way to bring each audience to ife. The purpose of painting the portrait is to fuy understand the desires, wants, and hopes of the intended audience, so that when you and your team deveop messages, you can focus on that one person in the portrait rather than on a mass of peope. Start by ooking at quantitative research as a foundation, and then ayer quaitative information on top of it. As you describe each segment, consider psychographic variabes as we as physica and socioeconomic data. Data coection sometimes incudes the psychoogica traits of audience members and can hep in understanding such issues as sefesteem, risk-taking tendencies, and fataism. Anayze these characteristics together with socioeconomic data. Then, compose a profie of the audience that is reaistic and vivid. This exercise wi hep you get inside the mind of the audience by painting a portrait of one person in that audience. Think of the characteristics of the key audience, and begin to paint a menta picture of a person that best represents that audience. What is his or her name? Get a photo or picture that represents that person. Describe him or her. If a woman, how od is she? What does she ook ike? Where does she ive? If she s married, what is her husband ike? How many chidren does she have? Does she ive with her mother-in-aw? Does she ive in a viage? Does she work? If so, what does she do? What are her media habits? Is she more ikey to watch teevision or isten to the radio? Deveop a story about the character. In the story, describe her behavior and some key attitudes about the heath behavior that the program is going to communicate to her. This portrait won t be soey based on facts, athough the audience research you have gathered wi provide many factua detais. 72 A Fied Guide to Designing a Heath Communication Strategy

83 Worksheet 2.4: Paint a Portrait of the Primary Audience 2 A Fied Guide to Designing a Heath Communication Strategy 73

84 Exampe: A Story from Ghana Meet Kwame. He is a farmer iving in Centra Region and is 42 years of age. He has two wives and five chidren ranging in age from 20 to 8. He ives a traditiona Ghanaian rura ifestye. He spends his eary morning tending his fied and spends the ate afternoon with his friends in the chop bar. Athough he considers himsef to be a famiy man, he occasionay has extramarita affairs. He cares about his chidren s we-being and woud ike them to ive a better ife than he does. He cares about his two wives because they raise his chidren. However, he is not at ease in communicating with them about intimate matters, such as reproductive heath. He assumes that they know what to do. He is aso more comfortabe in having his wives tak to their chidren about these matters. Kwame was a character that was created at a strategy deveopment workshop to represent men 35 years of age and oder. One of the exercises in the workshop was to set priorities among severa heath topics one of them being mae motivation for a nationa popuation communication strategy. The typica audience segment initiay addressed for mae motivation is men more than 35 years od. The exercise was a reveation for workshop participants. When the participants started thinking ike a 42-year-od rura farmer, they reaized that the concept of mae motivation was totay aien to Kwame. And if Kwame was asked to rank the importance of taking to his wives about reproductive heath compared to deaing with his adoescent chidren s sexua behavior or the threat of HIV/AIDS, it was not a priority. On the other hand, materna and chid heath topics were important to him because he cares about the heath of his chidren and reaizes that it is aso important for his wives to stay heathy and take care of them (Yonker, 1998). This exercise heped in two ways: (1) it put a face on the audience and heped to bring the strategy to ife; and (2) it heped the communicators reaize that athough they may spend a day thinking of specific heath topics, the audience doesn t focus on them the way heath professionas do. It heped to put these issues in perspective. 74 A Fied Guide to Designing a Heath Communication Strategy

85 Exampe 2.5: Summary of Audience Segmentation Decisions Worksheet Exampe: Uganda 2 Worksheet 2.5: Summary of Audience Segmentation Decisions Instructions: In the first coumn of the summary worksheet, ist the key audiences that you wi communicate with and the rationae for each. Then describe each audience segment. In the third coumn, note the phasing strategy if this is appicabe. Lasty, describe the key infuencers who wi be reached and rationae for each group. Next Steps Now that you have identified primary and infuencing audiences, you are ready to set the behavior change objectives for each audience segment. A Fied Guide to Designing a Heath Communication Strategy 75

86 References Liskin, L. & Yonker, J. (1999). The Romania Women s Heath Campaign Description. Johns Hopkins Schoo of Pubic Heath, Popuation Communication Services. Yonker, J. (1998). Nationa Popuation Communication Strategy Workshop. Sogakope, Vota Region, Ghana. 76 A Fied Guide to Designing a Heath Communication Strategy

87 Chapter 3 Behavior Change Objectives By the end of this chapter, the reader wi understand how to deveop behavior change objectives that are SMART specific, measurabe, appropriate, reaistic, and time-bound for each audience segment, by competing the foowing steps: 3 Step 1: Step 2: Step 3: Step 4: Step 5: Stating the Behavior Change That Wi Meet the Audience s Heath Needs Stating How Much the Behavior Wi Change Deciding the Timeframe Within Which the Expected Change Wi Occur Linking Behavior Change Objectives to Program Objectives Identifying Indicators To Track Progress A Fied Guide to Designing a Heath Communication Strategy 77

88 Overview Your friend, the architect, reviews the cient s needs and, within any inherent imitations such as the size of the site where the schoo wi be and the estimated budget, estabishes the objectives for designing the schoo. His overa objective is to create spaces and areas that fit the needs of his audiences. Specific objectives incude creating: Cassrooms that are arge enough for the estimated number of students and teachers, that have penty of ight, and that are conducive to earning. Rooms for teachers (a ounge), the principa (an office), and the entire student body (an auditorium). Toiet faciities for boys and girs and for men and women. Pay areas, perhaps indoors as we as outdoors. Aso, for a of these spaces, he wi pan a network for the movement of his audiences, fowing from outside to within the schoo; and within, from cassroom to cassroom, to offices, to pay areas, and to and from the toiet faciities. At this point, the architect aso estabishes a preiminary schedue or timeine, setting miestones or indicators that wi measure progress towards competing the buiding. For you, too, the importance of setting cear objectives is paramount, and this chapter shows you how to set them. 78 A Fied Guide to Designing a Heath Communication Strategy

89 Behavior change objectives are short, cear statements of the intended effect of a communication effort. Cear, concise behavior change objectives keep a communication program focused and on track. Objectives that are on strategy drive the program forward and move it coser to the ong-term vision of improved heath. This chapter provides guidance on deveoping behavior change objectives for each audience segment. It discusses how to deveop objectives that are congruent with the needs and characteristics of the intended audience, as determined by your anaysis of the situation and audience segmentation. You wi ink the objectives to the outcome or evauation measures deveoped for the communication program. To faciitate measuring the impact of the communication interventions, you wi identify indicators that wi hep measure progress toward objectives. The use of cear objectives and indicators that track progress wi benefit the strategic communication effort, whie simutaneousy demonstrating the program s contribution to the overa heath situation in a given community, region, or country. The key to deveoping strategic behavior change objectives is keeping them SMART (Piotrow, Kincaid, Rimon, & Rinehart, 1997). A SMART objective is: Specific: The objective shoud say who or what is the focus of the effort and what type of change is intended. Measurabe: The objective shoud incude a verifiabe amount or proportion of change expected. Appropriate: The objective shoud be sensitive to audience needs and preferences as we as to societa norms and expectations. Reaistic: The objective shoud incude a degree of change that can reasonaby be achieved under the given conditions. Time-bound: The objective shoud ceary state the time period for achieving these behavior changes. Exampe: Specific Improve the knowedge of mothers of chidren up to 5 years of age in three rura provinces of Nicaragua about the benefits of hand washing (2001). Exampe: Measurabe Improve the knowedge of 80 percent of mothers of chidren up to 5 years of age in three rura provinces of Nicaragua so that hand washing increases from 10 percent of the time to 90 percent of the time. Exampe: Appropriate Improve the knowedge of 80 percent of mothers of chidren up to 5 years of age in three rura provinces of Nicaragua so that hand washing increases from 10 percent of the time to 90 percent of the time by expaining the ink between ack of proper hand washing and diarrhea disease (research showed ow eves of understanding among the audience concerning the ink between proper hand washing and prevention of diarrhea disease). 3 A Fied Guide to Designing a Heath Communication Strategy 79

90 Exampe: Reaistic Improve knowedge of 80 percent of mothers of chidren up to 5 years of age in three rura provinces of Nicaragua so that handwashing increases from 10 percent of the time to 90 percent of the time using a phased approach. Athough you may sometimes find it difficut to craft an objective that fufis each of these requirements, this is the idea format to foow. You and your team must decide how to deveop feasibe behavior change objectives, based on your audience s situation and the information avaiabe to you. Step 1 Stating the Behavior Change That Wi Meet the Audience s Heath Needs Exampe: Time-bound Improve knowedge of 80 percent of mothers of chidren up to 5 years of age in rura Nicaragua so that hand washing increases from 10 percent of the time to 90 percent of the time between January 2002 and January Based on the work discussed in chapter 2, you and your team shoud aready have a written description of the intended audience. Use this description to ensure consistency throughout the deveopment of the communication strategy. Each audience segment may require a different behaviora change objective. You and your team shoud be consistent in defining the objectives for each group or audience segment. Name the behavior that wi change as a resut of the audience hearing, seeing, or participating in the strategic communication messages. Is the behavior change utimatey going to impact the audience s heath needs? For exampe, washing hands propery can reduce deaths due to diarrhea disease. Review the summary of the anaysis of the situation (worksheet 1.6), and note any behavior identified as needing attention. At this point, you may need to carify further the intended audience s behavior. If so, consider conducting some quaitative research to make sure that the program is on the right track. By foowing this step, you wi ensure that the behavior change objectives are specific and appropriate. 80 A Fied Guide to Designing a Heath Communication Strategy

91 Step 2 Stating How Much the Behavior Wi Change By competing step 2 you wi ensure that the behavior change objectives are measurabe and reaistic. To make a reasonabe estimate about the amount of behavior change that wi occur, given the overa context of the program and the resources avaiabe, consider: Barriers to change. Experiences of simiar programs in the past. Conditions under which the communication wi occur. How much behavior change is needed for the success of the program. Barriers Keep in mind the barriers to change that affect the intended audience. How difficut wi it be to get the attention of the audience? Are others activey trying to convince the intended audience to adopt behaviors different from those that this communication strategy wi promote? Are there competing demands for the time and actions of the audience? In genera, adopting a new behavior is easier for individuas than changing an existing behavior. For exampe, a woman may decide that it is more urgent for her to spend time at work than go to the cinic for an antenata checkup. In this case, despite the best communication efforts, she may not go to the cinic. Simiary, a famiy may have imited financia resources avaiabe to treat heath probems, and some other heath issue may take precedence over the one that you are promoting. Keeping considerations such as these in mind wi hep ensure that expectations for behavior change are reaistic. Prior Experiences Examine avaiabe research data and reports that describe prior heath communication campaigns reated to the issue at hand. How were the behavior change objectives stated? What changes were achieved? This information wi hep ensure that the objectives are reaistic and feasibe. Exampe In Zambia, the Heping Each Other to Act Responsiby Together (HEART) Campaign (Seremitsos, 2001) used mass media to change norms reated to risk reduction and safer sex among youth ages The main objective was to promote heathy sexua behaviors among young peope by reinforcing those behaviors that are safe whie changing the unsafe ones. Specificay, increases were sought in: The number of youth who beieved that they coud be at risk of HIV infection The number of femaes who had never had sex and who continue to practice abstinence The number of sexuay active maes who formery were occasiona condom users and who now wi aways use a condom 3 A Fied Guide to Designing a Heath Communication Strategy 81

92 Conditions Under Which the Communication Wi Occur Review how conditions under which the communication wi occur might affect resuts. Consider the portion of the anaysis of the situation that examined: The affordabiity of behavior change. The avaiabiity and accessibiity of services and products needed to practice the desired behavior. Socia, economic, and poitica factors. 82 A Fied Guide to Designing a Heath Communication Strategy Amount of Behavior Change Needed Compare the amount of behavior change needed for the strategy to succeed and the amount of behavior change that is manageabe within the strategy s timeframe. Can the objectives be accompished with avaiabe resources? Are there sufficient interpersona, community-based, and mass media channes to reach the intended audience? Wi more demand be created than the program can fufi? Discuss proposed objectives with service deivery managers, and ensure that they wi be abe to provide enough suppies and services to meet the expected increase in requests. In Ghana a FP program generated significanty more demand for FP beyond initia expectations so much so that in the midst of the campaign the MOH s cinics ran out of ora contraceptives. Cients became frustrated when they discovered that they coud not receive what they had been motivated to get. Give a numerica or percentage change expected. State the existing baseine measure as we as an expected measure. Review avaiabe data and consut research experts to determine a reaistic goa for the expected change. For exampe, revise an objective that says increase the proportion of peope practicing the behavior to 20 percent to increase the proportion of peope practicing the behavior from 10 percent to 20 percent. If it is not possibe to measure behavior change in precise terms, try to estabish a means of verifying that the audience s behavior is at east foowing the genera trend that woud support the aim of the communication program. Refer to chapter 8, which discusses the issues invoved in panning for evauation, and then revisit the objectives in this chapter to make sure that they are measurabe.

93 Step 3 Deciding the Timeframe Within Which the Expected Change Wi Occur Identify the timeframe in which change wi be achieved. Use timeframes that give peope enough time to change. Strategic communication objectives may be stated in terms of months or years. Keep this ong-term horizon in mind as you deveop your behavior change objectives. A campaign wi often have a shorter duration than an overa communication program, and the timeframe estabished to achieve the behavior change objectives wi depend on this context. Sustained behavior change over time wi ceary not be achieved during a brief campaign period. Remember to set the timeframe within the framework of the overa program. The timing of the communication objectives may coincide with those of the rest of the program. In some cases, however, it may be important to achieve resuts before the program s end. Ask if it wi be necessary to generate demand earier in the program to ensure that products and services are fuy utiized as soon as they are avaiabe. Take into account such situations, and adjust timeframes accordingy. You may find it hepfu to ink the program s timing to existing data coection schedues, such as the DHS. Such a ink aows the heath program to gather baseine and monitoring information in a scientificay sound and costeffective manner. At this point, you and your team shoud now have deveoped one or more behavior change objectives that are SMART. Exampe In the Zambia HEART Campaign, the behavior change objectives were initiay stated for the first phase of the campaign, which ran from June to October A Fied Guide to Designing a Heath Communication Strategy 83

94 Exampe Program Objective: Within the next 2 years, decrease the Tota Fertiity Rate (TFR) among married women of reproductive age from 5.9 to 5.3. Behavior Change Objective: Within the next 2 years, increase from 1 percent to 10 percent the proportion of the intended audience who use a permanent contraceptive method. Step 4 Linking Behavior Change Objectives to Program Objectives Your behavior change objectives shoud be ikey to contribute directy to achieving program objectives. Behavior change objectives shoud aways advance one or more program objectives even if the program objectives do not incude a specific behavior change or communication component. Linking your change objectives to the arger program objectives and goas strengthens your communication strategy. Step 5 Identifying Indicators To Track Progress Indicators are the interim measures used to track progress toward achieving objectives. Once you have fixed an indicator s beginning point, or baseine vaue, you can monitor it over time to see whether the intended behavior change is being achieved. Looking at the work competed thus far, identify the interim measures or indicators that wi show the impact of the communication effort on the behaviora characteristics eading to the behavior change desired. Good indicators are (Bertrand & Kincaid, 1996): Vaid: They measure the phenomenon that they are intended to measure. Reiabe: They produce simiar resuts when used more than once to measure the same phenomenon. Specific: They measure ony the phenomenon that they are intended to measure. Sensitive: They refect changes in the status of the phenomenon being studied. Operationa: They are measurabe or quantifiabe with deveoped and tested definitions and reference standards. 84 A Fied Guide to Designing a Heath Communication Strategy

95 For exampe, increases in information seeking to understand how FP methods work, increases in the frequency of communication between coupes about FP, increases in participation in community events reated to FP, and increases in the intent to adopt an FP method are a vaid indicators when the behavior change objective is to increase contraceptive use among a specific audience. Indicators can aso be used to assess changes at the community eve (Figueroa, Kincaid, Rani, & Lewis, 2002). For exampe, to track changes that ead to community empowerment, you coud anayze: 3 Leadership Degree and Equity of Participation Information Equity Coective Sef-Efficacy Sense of Ownership Socia Cohesion Socia Norms Use the worksheet on the foowing page to summarize the behavior change objectives that you have crafted. A Fied Guide to Designing a Heath Communication Strategy 85

96 Exampe 3.1: Deveoping Objectives Worksheet Exampe: Boivia Las Manitos I (Vaente et a., 1996) Project background: Boivia s Nationa Reproductive Heath Program was designed to address high rates of infant and materna mortaity and to satisfy an unmet demand for FP. The program aso worked to improve the cimate for FP and to broaden the range of services offered to incude a variety of reproductive heath services. A series of campaigns was designed and impemented over a number of years, the first of which was caed Las Manitos I. 86 A Fied Guide to Designing a Heath Communication Strategy

97 Exampe: Boivia Las Manitos I (continued) 3 A Fied Guide to Designing a Heath Communication Strategy 87

98 Exampe 3.1: Summary of Behavior Change Objectives Worksheet Exampe: Uganda 88 A Fied Guide to Designing a Heath Communication Strategy

99 Exampe: Uganda (continued) 3 A Fied Guide to Designing a Heath Communication Strategy 89

100 90 A Fied Guide to Designing a Heath Communication Strategy Worksheet 3.1: Summary of Behavior Change Objectives

101 Next Steps This chapter has expained how to deveop SMART objectives and has offered country exampes. You shoud now be abe to deveop behavior change objectives for your program and move to the next step deciding how to achieve these objectives. Chapter 4 discusses this process, which invoves deveoping a strategic approach. 3 A Fied Guide to Designing a Heath Communication Strategy 91

102 References Bertrand, J. T. & Kincaid, D. L. (1996). Evauating Information-Education-Communication (IEC) Programs for Famiy Panning and Reproductive heath. Fina Report of the IEC Working Group, the EVALUATION Project. Chape Hi: Caroina Popuation Center, University of North Caroina at Chape Hi. Communication Strategy to Conserve/Improve Pubic Heath, October September 2001 (2001). Johns Hopkins University/Center for Communication Programs. Figueroa, M. E., Kincaid, D. L., Rani, M., & Lewis, G. (2002). Communication for socia change: A framework for measuring the process and its outcomes. The Rockefeer Foundation and Johns Hopkins Center for Communication Programs. 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. Seremitsos, E. (2001). Zambia Heart Program. Lusaka: Johns Hopkins Schoo of Pubic Heath, Center for Communication Programs. Vaente, T. W., Saba, W. P., Merritt, A. P., Fryer, M. L., Forbes, T., Pérez, A., & et a. (1996). La Saud Reproductiva Está en Tus Manos: Impacto de a Camapaña de Programa Naciona de Saud Reproductiva de Boivia. Batimore: Johns Hopkins Schoo of Pubic Heath, Center for Communication Programs. 92 A Fied Guide to Designing a Heath Communication Strategy

103 Chapter 4 Strategic Approach By the end of this chapter, the reader wi know how to deveop an overa strategic approach for a heath communication program by competing the foowing steps: 4 Step 1: Step 2: Step 3: Step 4: Reviewing the Key Issue or Probem, Audience Segments, and Objectives Determining Long-Term Identity and Positioning Strategy Of The Behavior Exporing Strategic Aternatives Determining Strategic Approach and Rationae A Fied Guide to Designing a Heath Communication Strategy 93

104 Overview Using the knowedge gained in anayzing the situation, thinking about the cient s needs, and setting objectives, your friend the architect deveops his strategic approach for buiding the schoo. He decides how he wants the students, teachers, administrators, and parents to fee about their schoo: a serious encosure for earning but aso a friendy space and, in some areas, a pay space. He may sketch out how the various cassrooms, offices, ounges, and meeting areas wi ook, where the visitor areas, payrooms, and bathrooms wi be, and how these wi reate to the entire buiding, inside and out. He aso decides on the overa ook or impression that the schoo wi give. For a schoo in a city, his approach wi be to design the spaces and use buiding materias that fit into a cityscape. As part of deveoping his strategy, he reviews the different approaches avaiabe to him for meeting his objectives and determines which options he wi choose. He may reaffirm earier decisions or refine them to ensure that when competed the schoo wi fufi its purpose of providing a functiona and attractive earning center for a ong time. So too, you need to deveop a specific strategy that inks a the eements of your proposed communication efforts. 94 A Fied Guide to Designing a Heath Communication Strategy

105 In addition to being famiiar with the heath areas to be addressed and the needs and wants of the audience, you and your team, having determined the behavior change objectives, have to describe how the communication efforts are going to meet these objectives. In other words, together, you deveop the overarching direction that dictates and guides the choice of the tactica toos that the team wi use to achieve the objectives. The strategic approach is one of the most important eements in a communication strategy. It drives the rest of the program. It ensures synergy, consistency, and coordination among stakehoders and partners. It enabes the team to picture how a the eements wi fa into pace. Think of it this way: What is the communication strategy going to ook ike? How is it going to work? What shape wi it take? Your heath communication team s efforts to deveop a strategy wi ead to a strategic approach statement, which is different from the objectives. Objectives are specific and measurabe and te you what needs to be achieved. The strategic approach is descriptive and tes you how the objectives wi be achieved. Step 1 Reviewing the Key Issue or Probem, Audience Segments, and Objectives Review the summary sheets deveoped for chapters 1 through 3 to understand the key issue or probem, the defined primary and secondary audience segments, and the behaviora objectives. At this point, the team is faced with an array of possibe approaches to achieve objectives, but some may be better ways than others. You and your team shoud ensure that you deveop the most appropriate strategic approach by ooking at a the options. Before proceeding to expore strategic aternatives and to determine your strategic approach and its rationae, you wi need to understand the communication concepts of ong-term identity and positioning, so that you can determine these components for your program. Exampe To meet the objective of increasing the use of primary heath care faciities, a strategy can take many directions: 1. Focus on the faciities themseves, and deveop a communication strategy that emphasizes quaity services (provided that these faciities can deiver quaity services). 2. Concentrate on the audience, and deveop messages reated to each of the heath services being offered at these faciities. 3. Package these heath services together under a heathy ifestye approach, and focus on weness as a way for audiences to utiize these faciities. A three approaches may be reasonabe ways to achieve the objective. Each option describes a particuar direction and wi affect the choice of messages to be deivered, the channes to be used, and, in many ways, the management of the overa program. Obviousy it wi not be feasibe to impement a three approaches. You probaby do not have the resources or the manpower to foow through with a approaches. The best strategy is to focus on one approach that appears to be the most appropriate based on the knowedge and behavior stage of the audience, the eve of services being offered, and the access of the audiences to different communication channes. Focus demands sacrifice. 4 A Fied Guide to Designing a Heath Communication Strategy 95

106 Step 2 Determining the Long-Term Identity and Positioning Strategy of the Behavior In the evoving word of strategic heath communication, panners are focusing more energy on two cosey interreated and sometimes overapping components: (1) the behavior s ong-term identity (sometimes referred to as the brand ) and (2) positioning the behavior. Long-Term Identity As the members of the intended audience perceive and respond to the heath communication effort to change behavior, they create in their minds a perception that becomes a behavior s ong-term identity. In the course of such perception, the audience buids an image or an idea of the behavior. This image exists ony in the minds of the intended audience and is, for them, an identity for the behavior. At best, it is cear, distinct, and easiy recognized, and it shows the behavior s benefits as desirabe. Exampe: Physica fitness is a good exampe of a behavior that has a ong-term identity. For some, the identity is a positive one. When peope who are predisposed to exercising reguary think of the term physica fitness, they may make the foowing positive associations: it is good for you; it heps keep you sim; it heps prevent heart disease; it gives you energy. On the other hand, some peope may have negative associations: it is too time-consuming; it is not enjoyabe; it is too much work; it takes too much discipine. Positive or negative, the behavior itsef has a set of associations that may immediatey come to mind when the term physica fitness is mentioned, and any of those associations reinforce a ong-term identity to an audience member. A ong-term identity or brand: Provides a visua signature or brand mark (symbo, name, design, coors, or combination of these) that is attached to products, services, or behaviors. Fosters a reationship of trust, reiabiity, and excusivity between the behavior and the audience. 96 A Fied Guide to Designing a Heath Communication Strategy

107 Adds vaue to the basic product, service, or behavior. Provides some kind of psychoogica payoff to the audience. Simpifies the probem of differentiation between other ike products, services, or competing behaviors. Possesses personaity traits, which wi aow the audience to form a reationship with the brand (Smith, Berry, & Puford, 1997). A ong-term identity is a unique set of associations that represent what the product, service, or behavior stands for in the minds of the cient. Think of a box abeed with the name of the product, service, or behavior. Then store a the features, benefits, and thoughts in that box. Peope keep these boxes in their minds. Everything that comes to mind about that product becomes part of its ong-term identity. One of the very important components of this identity is the emotiona connection that is estabished between the audience and the product, service, or behavior. 4 Exampe: Coca-Coa is a good exampe. It is more than a beverage among many other beverages. Coke enjoys a specia reationship with peope a over the word based on the ong-term identity that it has buit over many years. Some of Coke s attributes can be shared with other beverages. For exampe, peope know that Coke offers a refreshing taste; it aways tastes the same, and is aways within an arm s reach accessibe. However, other beverages can make that same caim in many paces. In addition, bind taste tests have shown that many peope actuay prefer the taste of Pepsi (Aen, 1994). It doesn t matter. Coke is sti the number one brand in the word (2000). The reason is the emotiona connection between the audience and the brand, a connection buit over many years through a ong-term identity system that the company deveoped and nurtured with its customers on a consistent and ongoing basis. The company accompished this connection through ongoing advertising, exceent packaging, distribution, merchandising, and PR, among other things, over a ong period of time. Coke, the brand, has become a trustworthy friend. Coke purchasers depend on this brand to provide satisfaction. A Fied Guide to Designing a Heath Communication Strategy 97

108 Long-term identities or brand images can work we with products, services, and behaviors. Here are some exampes: Products Many car brands have buit up ong-term identities to ensure a oya customer base. Mercedes-Benz is an exampe of a uxury car that conjures up many positive images not ony among uxury car customers, but aso among the genera pubic. The reason for this is simpe. Athough peope may not currenty be abe to afford a Mercedes, they sti ink the brand name with positive associations. Perhaps someday they may be abe to afford the car, or at east they aspire to owning the car. Whie there are many other car brands in the uxury car category and whie a of them provide the same functions and amenities, the Mercedes brand image is strong enough to be at the top of peope s ist when naming uxury cars. Inte, the microprocessor chip manufacturer, has spent a great dea of money over many years, to support its brand name. It insists that computer manufacturers use the Inte ogo on any persona computer they make that uses one of its products and then pays part of the manufacturers ad campaign when the Inte ogo is featured. The Inte brand image ends credibiity to the computer manufacturer, whie reinforcing its own brand image with each ad exposure. Pus an active ad campaign demonstrating product benefits supports a of these efforts and further embeds the vaue of the Inte name to the consumer. Inte s brand image is strong enough to demand higher prices for computers that offer Inte Inside than computers that offer competing chip manufacturers (Aaker, 1996). Services American Express (Amex) offers credit for purchases, as does Visa and MasterCard. Whie Visa and MasterCard offer credit through banks and other organizations, Amex offers credit directy through its organization and for a fee that is often higher than the other credit card companies. Pus Amex cardhoders cannot pay over time. They have to pay in fu every month for the previous month s charges if they hod the typica green Amex card. Considering the ease of getting a bank credit card, the (sometimes) ower fees or (on occasion) no fees, and the fexibiity in paying off charges, why are there 42.7 miion Amex cardhoders (2002)? The answer is that Amex has promoted its Members Ony brand image consistenty 98 A Fied Guide to Designing a Heath Communication Strategy

109 over time to its two distinct audiences the cardhoder customers and the retaiers, hotes, airines, and restaurants that accept Amex at their estabishments. Both audiences trust, rey on, and have a reationship with Amex and the easiy identifiabe green credit card. The Egypt God Star campaign was the first nationwide FP communication strategy in a deveoping country focused on promoting quaity of care and positioning government cinics as a source of high-quaity care (Piotrow, Kincaid, Rimon, & Rinehart, 1997). Over severa phases, the God Star program branded cinics that passed a 101-item checkist of quaity improvement indicators in two consecutive quarters, with a God Star to certify to both potentia cients and providers that these cinics met the requirements of better service. The God Star ogo was used throughout the cinic and in a campaign materias and was promoted heaviy in the media. This ogo came to represent the cinics ong-term identity of quaity service. 4 Behaviors Long-term identities for behaviors are not as we documented and are not usuay thought of in this way. However, in the United States the use of seat bets in cars has become so ubiquitous that it is hard to reaize that it has ony become a common behavior within the ast 12 years (Nationa Highway Traffic Safety Administration, 1999). It took a combination of pubic service advertising, poicy advocacy, and roe modeing to insti this behavior. Now most States have seat bet aws requiring the use of seat bets by anyone sitting in the front seat of an automobie. And a car manufacturers are required to incude seat bets in both front and back seats. Does the use of seat bets have a ong-term identity? The answer is to read any newspaper artice or watch any teevision news program that announces a fata car accident. One of the key pieces of information wi be whether the passenger or driver was wearing a seat bet. The same can be true for behavior change in heath communication. Communication efforts can buid ong-term identities with cients by promoting products, services, and behaviors that are trusted to consistenty deiver exceence, and perceived by customers to be both reevant and distinctive (Shore, 2001). A ong-term identity or brand consists of tangibe and intangibe components. A Fied Guide to Designing a Heath Communication Strategy 99

110 The tangibe components consist of the functiona benefits of the product, such as what the product does, and any specia identification markings (ogo or name). The intangibe components consist of the emotiona benefits of the product, such as trust, reiabiity, added vaue, and quaity of differentiation. What can ong-term identity do for a heath program? Long-term identity: The same concept can be used in behavior change communication. For exampe, a cient can continue to use and think positivey about modern FP methods because modern methods offer the functiona benefit of reiabiity and the emotiona benefit of giving cients a feeing of security and confidence. Integrates the heath program and a its efforts. It is the gue that hods together the program s broad range of activities and functions, a designed to buid reationships with the intended audience. Provides for consistent, effective communication over the ong term. Encourages the audience to maintain the behavior by predisposing the audience to accept messages favoraby and to remain oya to the program s activities. Differentiates the program s product or services from those of other programs.. Attracts peope invoved in heath care, such as medica personne and poicymakers, to participate in and support the program. Peope have certain attitudes and beiefs about products, services, and behaviors, and store bits of information about them in their heads. These attitudes and beiefs may be positive, negative, or a combination of both. For exampe, whie some peope think positivey about the term famiy panning and may practice FP, others may associate the term with side effects or find that FP runs counter to their cutura beiefs. Deveoping a ong-term identity program can hep frame the way that peope think about behaviors by fufiing a need, fostering positive attitudes, and at the same time diminishing negative attitudes and beiefs. The ong-term identity, if managed propery and continuay, wi hep to buid an ongoing positive and trusting reationship between intended audiences and the behavior. Your chaenge is to hep shape every aspect of a communication strategy to foster the deveopment and maintenance of the behavior s ong-term identity in the minds of the intended audience. Your job is to hep give the behavior its identity and meaning, thus providing a framework for those who work with the strategy to buid in the minds of the audience a perception of the behavior s worth. The chaenge is to deveop a strong identity, a successfu communication strategy, awareness in the community, and oyaty in the intended audience. Athough ong-term identity (or brand) is usuay associated with products and services, the term is not yet a common term associated with behaviors. However, the ong-term identity process can hep organize and frame an entire heath program. A key concept is to name the behavior. In Ghana, to increase demand for 100 A Fied Guide to Designing a Heath Communication Strategy

111 FP, the ong-term identity was named Life Choices. FP was not just a heath program to reduce unwanted pregnancies but was seen as a too enabing audiences to achieve their persona ife goas. See the exampe on this page of naming an antismoking effort directed to U.S. teenagers as truth. Positioning Behavior change communicators use positioning to determine the best approach to motivate audiences to change or adopt a specific behavior. Once communicators have determined the objectives for an audience and have deveoped a ongterm identity, they need to think about how they are going to position the behavior to achieve the objectives and maintain the ong-term identity. Cosey intertwined with the ong-term identity, positioning estabishes in the minds of the audience an image of the desired behavior that heps the audience remember it, earn about it, act upon it, and advocate for it. If the ong-term identity is everything an audience knows and fees about the product, service, or behavior, then positioning is the promotiona image that is intentionay communicated to an audience. An effective position: Resonates with the audience. Differentiates from the competition. Stands out as better than the known aternatives. Provides a benefit that is worth the cost or effort. To succeed in our overcommunicated society, a company must create a position in the prospect s mind, a position that takes into consideration not ony a company s own strengths and weaknesses, but those of its competitors as we... IBM didn t invent the computer. Sperry Rand did. But IBM was the first company to buid a computer position in the mind of the prospect. (Ries & Trout, 1981). Exampe: The Truth Program In the United States, the tobacco contro program is an ongoing effort that has resuted in a marked decrease in the use of tobacco. However, smoking among young peope has increased. Once peope start to smoke in their teenage years, they become addicted to tobacco, and it becomes more difficut for them to stop smoking as they reach aduthood. The American Legacy Foundation funded a program to deveop a cuture of not smoking among young peope. To accompish this goa, the foundation and its communication partners deveoped a ong-term identity program (or branding program) to treat not smoking as a brand, by managing the program in the same way that a manufacturer manages a branded product. They first conducted considerabe research to gain insight about their audiences and then segmented their audiences by specific attitudes. They studied 3,000 teens in midde schoo and high schoo and earned about their heath behaviors, worries, dreams, vaues, sef-descriptions, and socia connectedness. They earned that teens are open to smoking and that initiation begins when they are in the 5th, 6th, and 7th grades. Teens who were open to smoking are more ikey to use drugs and acoho and are ess future-oriented. Their dreams are of becoming rich, being a hero, having a great car, and getting even with peope who may cross them. A key insight about them was their desire to assert contro and their wiingness to engage in a variety of risky behaviors to assert contro (taking contro away from parents, teachers, and other authority figures). Contro was expressed by need states, such as rebeion, taking risks, fitting in, being independent, sef-expression, and feeing respected. Tobacco satisfies a of the need states in the minds of these teenagers. In other words, the use of tobacco was seen as a too of contro. (continued on next page) 4 A Fied Guide to Designing a Heath Communication Strategy 101

112 Exampe: The Truth Program (continued from previous page) Another key insight was that if the program wants to take tobacco away from this audience, it must repace the behavior with something ese that fufis the need states and provides contro. Therefore, the program had to give teens knowedge (about not smoking), a motivation (give them a way to rebe and take risks), and power (put contro in their hands). At the same time, the program had to deconstruct myths, ies, and deceptions about tobacco. The strategy was to package not smoking as a brand to give teens something that they woud want to affiiate with, a badge standing for rebeing, taking risks, being independent, sef-expression, and respect. The resut was the truth program. This program positioned tobacco companies as viains by providing evidence from ongoing itigation that tobacco companies knew that smoking was addictive and harmfu whie continuing to promote their products to young peope. By providing the truth about the companies, the campaign gave young peope something to rebe against the big, authoritative tobacco companies who were trying to harm them. Messages were designed that put teens in contro and aowed them to hep expose big tobacco companies for what they are. Teen advocacy groups were organized to hep expose these truths. These groups enabed teens to rebe and fit into a group at the same time. They were abe to gain respect and be sociay connected. Designing messages, organizing groups, conducting the research, and monitoring and evauating the program were a made part of the ongterm identity system or branding system. This program has been successfuy buiding a reationship between the audience (teenagers) and the brand ( truth ). The State of Forida reports that the truth campaign resuted in high rates of reca, significant changes in attitudes/beiefs, and reduced rates of smoking behavior among youth. Positioning: In the context of strategic design, positioning means presenting an issue, service, or product in such a way that it stands out from other comparabe or competing issues, services, or products, and it is appeaing and persuasive. Positioning creates a distinctive and attractive image, a perpetua foothod in the minds of the intended audience (Piotrow, Kincaid, Rimon & Rinehart, 1997). The commercia marketing sector uses the term positioning in a competitive environment to set or position one product against another. If one car is the uxury car, such as Cadiac, then another car is the economy car, such as Hyundai. If Cairo shampoo offers manageabe hair that is easy to contro, then L Orea shampoo gives you ustrous, shiny hair. Positioning heps to communicate to the audience a unique appeaing difference designed to give the product an edge over the competition. Positioning heps determine the overa strategic approach. Positioning suggests how these changes (desired behavior changes) can be presented to the intended audience in the most persuasive fashion.... From a communication standpoint, positioning may be the key eement because positioning determines the way that peope wi perceive the product/service/behavior, how they wi remember the communication activities, and to what extent those wi prompt action (Piotrow, Kincaid, Rimon & Rinehart, 1997). Think of positioning as a way to deiver PUNCH to the strategy. Positioning: Is aways Positive. Is aways Unique. Deveops a Niche in the minds of the audience. Is aways Competitive. Aways Heps the audience by deivering a benefit. (Sy, Head, & Ray, 2001) 102 A Fied Guide to Designing a Heath Communication Strategy

113 Positioning creates the memorabe cue for the audience to know why they shoud adopt a behavior. It forms the basis for communication tactics: advertising, promotion, packaging, pubicity, specia events, IPC, community-based communication, and advocacy programs. It shapes the deveopment of messages and the seection of channes. It ensures that messages wi be consistent and that each communication effort or activity wi reinforce other activities for a cumuative effect. Many corporations use symbos to further identify their brand to the pubic. Beow are two exampes of very famiiar corporate ogos. 4 Many heath programs have successfuy used positioning. In Zambia the Zambia for exampe, HEART one Program, of the for aspects exampe, of the one HEART of the campaign addressed efforts focused the benefits on deaying of abstaining initiation from of sexua sexua activity. A positioning for adoescent statement girs. Girs was fee deveoped, a ot of peer Virginity pressure is something to engage in to sex be proud as a way of, to and prove the their campaign ove to sogan a boy. used They was, aso Virgin beieve Power-Virgin that a boy shoud Pride. be asking for sex if he reay oves the gir. Girs say they want to maintain their abstinent Figure 4.1 status, shows so a variety they need of positioning support to strategies fee that this used is a in behavior different to countries, be proud of. The together positioning with the statement ogos that of served the campaign as communication was, Virginity toos is to something symboize to the be proud position of (Piotrow, and the Kincaid, campaign Rimon sogan & Rinehart, was, Virgin 1997). Power-Virgin Pride. Figure 4.1 shows a variety of positioning strategies used in different countries, together with the ogos that served as communication toos to symboize the position (Piotrow, Kincaid, Rimon & Rinehart, 1997). A Fied Guide to Designing a Heath Communication Strategy 103

114 Figure 4.1: Various Positioning Strategies By focusing on a unique characteristic, strategic positioning gives a FP/reproductive heath program a memorabe identity, occupying a niche in the minds of the pubic and providers. A we-designed symbo can hep position a service, product, idea, or program. Keep in mind that positioning is about perception, and even if the audience thinks about a behavior or a competing behavior in an incompete or even somewhat incorrect way, audience perception is the reaity that heath communicators must face. Knowing and istening to the audience heps the heath communicator position the program to meet the needs of the intended audience segments. Strategic communicators understand that reaity is based on what the audience beieves and not ony on what the heath communicators think is appropriate. Reaity is aso based on what the audience is wiing to hear or see and not ony on what the heath communicators want them to know. Understanding this audience insight heps communicators to position (or reposition) in the minds of the audience a behavior that, if communicated consistenty, wi be sustained. Steps to Deveoping a Position The first key step in deveoping a position is for you to know where the audience is currenty going for its heath products and services and how the audience is currenty behaving. 104 A Fied Guide to Designing a Heath Communication Strategy

115 For exampe, is the audience going to pubic faciities, to private providers, and to traditiona heaers, or is it not going anywhere? Instead of breastfeeding, is the audience using botted mik or giving its babies soid food earier than recommended? For HIV/AIDS prevention, are sexuay active young men not protecting themseves? Do they have mutipe partners? It is important to know what the audience is doing; it is just as important to know why the audience is doing it. Most peope behave a certain way because they derive a benefit from that behavior. So you have to understand why they are doing it and what they get out of it before you can position a behavior against it. Another way of ooking at this approach is to identify the competition. So the first questions to ask are, What is the audience doing now? And why? 4 The second key step is to determine what the positive behavior can reaisticay deiver that the audience wi perceive as a benefit. This step may require additiona audience research. Start by reviewing and foowing these basic steps: Anayze the program s capabiities, and identify differences from other programs (from Anaysis of the Situation ). Anayze the audience s perceptions of the product, service, or behavior (from Anaysis of the Situation and Audience Segmentation ). List the audiences and their characteristics (from Audience Segmentation ). Match product, service, or behavior characteristics to audience needs and wants. Expore positioning aternatives. Deveop a positioning statement. A Fied Guide to Designing a Heath Communication Strategy 105

116 Refer to the foowing exampes and worksheet 4.1 in competing these steps. Exampes of Positioning 1. By product difference: Is there a unique product feature? Injectabes offer women 1 to 3 months of protection from unwanted pregnancy with just one injection. 2. By key attribute/benefit: What benefit can we offer that the audience wi consider meaningfu? God Star high-quaity reproductive heath services in Egypt. 3. By cients/users: Create an image for an audience that the service or product is ony for them. Youth-friendy cinics geared to provide repro ductive heath services for adoescents. 4. By use: When and where is a service or product being used? Nationa Immunization Days specific dates when immunizations are given. 5. Against a category: Position a product or service against the entire spectrum of products or services in that category. Warm and caring providers compared to a providers. 6. Against a specific competitor: Competitive brands. Brand A condom compared to Brand B. 7. By association: Associate the product or service with a ifestye. Lux Soap: the soap of the stars. If I use Lux Soap, I wi be ike a movie star. 8. By probem: How a product, service, or behavior wi sove a probem. ORS to hep reduce dehydration caused by diarrhea. 106 A Fied Guide to Designing a Heath Communication Strategy

117 When reviewing severa positioning possibiities, use this checkist to hep determine the one that is most appropriate. Checkist: Questions To Ask About the Position: 1. Does it resonate with the audience? 2. Wi it endure? 3. Does it differentiate from the competition? Does it represent something better or different that is vaued? 4. Does it represent a feasibe strategy? Can the program deiver the promise or benefit? 5. Does it support the program view? 6. Does it represent a cear vision? 7. Can peope in the invoved organizations ceary articuate the position? 8. Does it stimuate innovative communication activities? 4 Deveoping a Positioning Statement A positioning statement describes how the behavior wi be paced in the minds of the audience. It is not a catchy sogan. Positioning statements hep writers deveop catchy sogans, but they are not the sogans themseves. A positioning statement is not to be incuded in communication materias that go to audiences. It wi, however, provide direction for the strategic approach and subsequent messages. Commercia Positioning Statements* Appe Computer Easy to use BMW Exceptiona performance Federa Express Guaranteed next-day deivery Visa Accepted everywhere Vovo Safety The next step is to expore strategic aternatives to find one that makes the most sense based on the position that you and your team have seected. * A Fied Guide to Designing a Heath Communication Strategy 107

118 Worksheet 4.1: Positioning Statement Worksheet Instructions: Deveop one or two sentences describing as succincty as possibe the position for the product, service, or behavior. Make sure to incude the name of the product, service, or behavior, the unique difference that sets it apart from the competition, and the benefit to the audience. Keep in mind that this is not a sogan. The positioning statement is the forerunner to a sogan to be used to inform the creative team as they deveop a sogan. Exampe: God Star: Egypt q 108 A Fied Guide to Designing a Heath Communication Strategy

119 Worksheet 4.1: Positioning Statement Instructions: Deveop one or two sentences describing as succincty as possibe the position for the product, service, or behavior. Make sure to incude the name of the product, service, or behavior, the unique difference that sets it apart from the competition, and the benefit to the audience. Keep in mind that this is not a sogan. The positioning statement is the forerunner to a sogan to be used to inform the creative team as they deveop a sogan. 4 A Fied Guide to Designing a Heath Communication Strategy 109

120 Step 3 Exporing Strategic Aternatives Again, the comparison with the work of an architect is hepfu. In buiding a house, the architect has many options. He knows the number of bedrooms and toiets his cient needs; he knows that the house must contain a iving room, a kitchen, cosets, and perhaps other rooms that have aready been determined. Yet, he sti has many choices. Shoud he design a three-story house or one that has rooms a on one eve? Shoud the house have bedrooms facing east, west, south, or north? Where on the property shoud the house be situated at a distance from the road or coser to the road but with a arge backyard? An experienced architect expores aternatives using his mathematica and ogica skis as we as his creative taent to come up with the best design possibe. The same is true of the communication strategy team. Since many ways to sove a communication probem exist, the best way to move forward is to make a ist of possibe soutions and then start eiminating options. Tabe 4.1 on the foowing pages ists exampes of strategic aternatives, with advantages and disadvantages for each one. Review this tabe to become famiiar with the many different approaches avaiabe. Tabe 4.1: Some Strategic Approach Aternatives This ist is by no means a-incusive. The key for you and your team is to find the aternatives that best represent the needs aready identified by thought and discussion. Review tabe 4.1 (page 111) to hep you ist strategic aternatives, and use checkist 4.1 (page 113) to review strategic approach considerations. Then use worksheet 4.2 (page 116) to write down your ideas. 110 A Fied Guide to Designing a Heath Communication Strategy

121 Tabe 4.1: Some Strategic Approach Aternatives 4 A Fied Guide to Designing a Heath Communication Strategy 111

122 112 A Fied Guide to Designing a Heath Communication Strategy Tabe 4.1: Some Strategic Approach Aternatives (continued)

123 Checkist 4.1: Strategic Approach Considerations 4 A Fied Guide to Designing a Heath Communication Strategy 113

124 Exampe Worksheet 4.2: Deveoping Strategic Aternatives Objective: Women ages wi use short-term FP methods to space their chidren. 114 A Fied Guide to Designing a Heath Communication Strategy

125 Exampe Worksheet 4.2: Deveoping Strategic Aternatives (continued) 4 A Fied Guide to Designing a Heath Communication Strategy 115

126 116 A Fied Guide to Designing a Heath Communication Strategy Worksheet 4.2: Deveoping Strategic Aternatives

127 Step 4 Determining the Strategic Approach and Rationae Every strategic approach requires an accompanying rationae. Writing a rationae enabes you to recognize the suitabiity of the approach and to identify any faws that it may have. In addition, you and your team may have to present and defend this approach on many occasions, and a we-thought-out rationae wi serve as a sound basis for justifying your approach. Worksheet 4.3: Summary of Strategic Approach and Rationae Exampe: Uganda Exampe: Approach and Rationae In Bangadesh, the Smiing Sun smies over heath cinics a over the country. One can trave around and see a Smiing Sun sign in urban areas as we as rura areas. The Smiing Sun is a symbo for warm and caring services provided by cinics that are a part of the Nationa Integrated Popuation and Heath Program (NIPHP); the NIPHP is a coaborative effort of rura heath cinic NGOs managed by Pathfinder, urban heath cinic NGOs managed by John Snow, Inc. (JSI), and the Bangadesh Center for Communication Programs (BCCP), with funding from USAID. The major objective was to offer integrated heath services with improved quaity for a sma fee through wetrained and we-stocked NGO cinics throughout Bangadesh. The strategic approach was to use the heath cinic as the major source of information and services and set out to position these cinics as offering attentive, warm, and caring providers something that a cinics within the NGO network coud deiver and something that research showed audiences demanding. This heped to differentiate them from private cinics and government heath faciities. The strategy incuded a ong-term identity program that heped to position the cinics as offering warm and caring providers (worth the sma service fee) through a branding campaign that referred to the Smiing Sun (Paribark Shastho) Cinic. Promotiona toos incuded radio and teevision spots, badges worn by providers, signboards, biboards, and other support materias. In addition, the Smiing Sun ogo was integrated into a brochures, pamphets, and provider materias. 4 A Fied Guide to Designing a Heath Communication Strategy 117

128 Worksheet 4.3: Summary of Strategic Approach and Rationae Next Steps Chapters 5 and 6 wi expain how to use the strategic approach to design specific message points and to choose appropriate channes and toos. The messages and channes seected shoud support and reinforce the positioning and strategic approach deveoped in this chapter. 118 A Fied Guide to Designing a Heath Communication Strategy

129 References Aaker, D. A. (1996). Buiding Strong Brands. New York: The Free Press. American Express Company Quartery Earnings Report, First Quarter (2002). Additiona Financia Information (PDF) [On-ine]. Aen, F. (1994). Georgia Trend. (12 ed.) (Vos. 9) (pp. 55). ISSN: Word s Most Vauabe Brands (2000). Interbrand [On-ine]. Avaiabe: 4 Nationa Highway Traffic Safety Administration (1999). Fourth report to Congress. Effectiveness of occupant protection systems and their use. Washington, DC: U.S. Department of Transportation. Piotrow, P. T., Kincaid, D. L., Rimon, J. G. I., & Rinehart, W. (1997). Heath Communication: Lessons from Famiy Panning and Reproductive Heath. Westport, CT: Praeger Pubishers. Ries, A. & Trout, J. (1981). Positioning. The Batte for Your Mind. New York: McGraw- Hi. Shore, D. A. (2001). Creating brands peope know and trust. Cambridge, MA: Harvard University. Sy, D. F., Head, G. R., & Ray, S. The Forida truth anti-tobacco media evauation: Design, first year resuts, and impications for panning future state media evauations. Tobacco Contro 10, Smith, P., Berry, C., & Puford, A. (1997). Strategic Marketing Communications. London: Kogan Page. A Fied Guide to Designing a Heath Communication Strategy 119

130 120 A Fied Guide to Designing a Heath Communication Strategy

131 Chapter 5 The Message Brief By the end of this chapter, the reader wi understand the purpose of a message brief and how to summarize the strategic rationae for why the messages are being deveoped. In addition, the reader wi earn how to compete the message brief worksheet by: Step 1: Identifying the Key Fact That, if Addressed, Wi Lead to the Desired Behavior Change 5 Step 2: Step 3: Step 4: Step 5: Step 6: Step 7: Identifying the Promise to the Audience That Wi Motivate It To Adopt the Behavior Defining the Support for the Promise That Summarizes Why the Audience Shoud Beieve the Promise Describing the Competition for the Message Deveoping the Statement of the Utimate and Lasting Impression That the Audience Ideay Wi Have After Hearing or Seeing the Message Describing the Desired User Profie: How Does the Intended Audience Perceive Someone Who Uses The Product or Service Being Promoted Identifying the Key Message Points That Wi Be Incuded in A Communication Deivered by the Partners Who Wi Impement the Strategy A Fied Guide to Designing a Heath Communication Strategy 121

132 Overview To ensure that the strategic approach is cear to the buider and then to the workforce, your friend the architect deveops detaied sketches, pans, and utimatey his bueprints. By foowing these bueprints, the subcontractors impement the architect s strategic approach: the eectricians insta the wiring, the pumbers insta the pipes and ventiation system, the carpenters buid the frame, and a of the team members work together to execute the strategy. The message brief that you wi earn about in this chapter performs much the same function as the architect s bueprints: it puts on paper exacty what you want your creative coaborators to accompish. 122 A Fied Guide to Designing a Heath Communication Strategy

133 You and your team have competed much of the groundwork for deveoping a heath communication strategy. Using soid communication theory, research findings, and anaytica thinking, you and your coeagues, such as heath workers and other stakehoders, have isoated the probem and have anayzed the situation and a the factors that impact communication. You have aso identified the primary and secondary audience segments, defined the behavior change objectives, and designed a we-orchestrated strategic approach. The positioning statement, aong with the strategic approach, provides direction and guidance for identifying a centra theme for the overa communication strategy. From this, you wi move to the step of deveoping a message brief for each component of the strategy. A message brief is a document that the communication team deveops and shares with experts at an advertising agency, PR agency, creative writers and designers, or any other organization or person invoved in message deveopment. The creative experts use the message brief as a springboard for deveoping creative concepts. Remember, it is the job of these experts to deveop creative materias. The strategic heath communication team outines what the messages need to say. The creative experts determine the execution how the messages wi be designed. The more precise the message brief is, the more ikey it is that the communication wi be effective. A tight message brief eaves nothing to interpretation and is incapabe of being misunderstood. A we-crafted message brief aows the creative experts to expore a variety of approaches, as opposed to a oosey worded brief that confuses the creative experts and eaves them wondering what the cient reay wants and needs. 5 To communicate effectivey with the intended audiences, the communication team needs to design messages that are (1) on strategy, (2) reevant, (3) attentiongetting, (4) memorabe, and (5) motivationa. The message brief in this chapter presents a way to summarize for the creative experts what we know about the heath issue and the communication needs of the audience. The message brief aso outines the key fact that wi ead to the desired behavior change and the promise or benefit for the intended audience that ideay wi motivate it to adopt the change. Communication team members then define the support for the promise and deveop a statement of the utimate and asting impression that the audience wi take away from the message. A Fied Guide to Designing a Heath Communication Strategy 123

134 Finay, the communication team describes the perception that the intended audience associates with the user of the product, service, or behavior. The desired output from this chapter is a simpe, brief document that competey describes what the message needs to accompish. Message Design Message design cuts across a communication channes, such as IPC, communitybased activities, and mass media. The more the messages reinforce each other across channes, the higher is the probabiity of effective impact. Strategic heath communicators craft key message points that are consistent and reevant for a channes and toos. This consistency and reevance contribute to the overa effectiveness of the communication strategy by ensuring that, for exampe, the service provider, the community mobiizer, and the actor featured in a radio announcement a reinforce the same key message points. This approach does not mean that panners create ony one message for a these venues. It does mean that they identify the key points that are to be made in every message that is communicated to the audience, no matter which channe or too is used. Message Brief Outine There are many variations of the message brief too. They are a designed to generate creative concepts and messages. In the fied of commercia advertising, the creative brief is used for this purpose. In the context of this book, the message brief is suggested as a usefu means of gaining insight into the audience, which is one of the keys to designing messages that wi resonate with audiences. Competing the message brief outine wi provide you and your team with a simpe document that describes what the message shoud say and do. The message brief has two principa parts: a strategy component and a message deveopment component. For the sake of competeness, the entire outine is presented here, even though worksheet 5.1, Strategic Component, was competed by foowing the steps in chapters 1 through 4. To focus on the message deveopment component, compete the steps in worksheet A Fied Guide to Designing a Heath Communication Strategy

135 Worksheet 5.1: The Message Brief Outine Strategic Component Instructions: Summarize from the work aready competed. Exampe: FriendyCare A Network of FP Cinics in the Phiippines (FriendyCare Communication Pan ) 5 A Fied Guide to Designing a Heath Communication Strategy 125

136 126 A Fied Guide to Designing a Heath Communication Strategy Worksheet 5.1: The Message Brief Outine Strategic Component Instructions: Summarize from the work aready competed.

137 Steps to Competing Worksheet 5.2 Step 1 Identifying the Key Fact You and your team wi ikey identify a centra theme for the communication strategy. In keeping with this broad theme, you wi compete a message brief for each component of the strategy and wi ensure that a of the messages reinforce one another. The foowing step, Identifying the Key Fact, is critica to deveoping a we-crafted message brief for a particuar strategy component. Strategic communicators ook for the key factor or the singe most important fact in a heath probem or situation that, if addressed in the communication effort, wi most ikey ead to the desired behavior change. The key fact may be an obstace or an opportunity. Seection of the singe most important fact is key because a message is ony effective if it addresses a singe probem. The process of seecting the key fact forces the strategist to ook for the reevance and importance that wi make the message stand out. From the information gathered in the anaysis of the situation, you and your team need to identify the key fact. It crystaizes what you know about the probem and the opportunities for soving the probem. As panning progresses, you can expect to observe a number of facts that might shape the creative work. The key fact can suggest the need to: Eiminate a probem that the audience has with the product or idea. Correct an erroneous or incompete perception that the audience may have. Reinforce or extend a benefit that the program deivers. Strengthen the reason for greater use of the product or an unexpected way to use the product or service. Fi a void. Exampes of Key Facts Peope of ower socioeconomic status in the Phiippines beieve in FP but perceive that they have nowhere to go for advice. Men in Tanzania do not know the advantages of using condoms. In addition, condoms are known to diminish sexua peasure. Therefore, condom use in Tanzania is ow. Athough there is high interest in earning more about HIV/AIDS in Lagos, Nigeria, young men and women do not fee at risk and do not fuy understand the impications of their high-risk behavior. A Fied Guide to Designing a Heath Communication Strategy 127 5

138 Exampes of Promise Statements A successfu campaign for Nike athetic shoes used the tag ine Just do it (Advertising theme ines ). The tag ine appeared on teevision and in print but was never used with a voice-over. Nike s strategy was to et viewers interpret the message themseves, whie showing diverse women and men eading active ifestyes. A ifestye in which the audience coud reaize their goas was the promise; the Nike shoes served as a support for the promise. In the FriendyCare project, the promise tes the consumer that at FriendyCare, he or she is going to find a friend and a partner who is an expert in panning and caring for his or her famiy. A cancer prevention program wanted to increase the number of consumers (Lefebvre et a., 1995) who eat at east five servings of fruits and vegetabes per day. Promise statements that were reevant and motivationa to the intended audience were identified, incuding Eating five servings of fruits and vegetabes a day wi keep me young, Serving more fruits and vegetabes wi make me a better parent, and Eating more fruits and vegetabes wi hep me ose weight. A traditiona pubic heath approach might have promised consumers that by adopting the 5-A-Day behavior they woud reduce their risk of cancer, but pretesting showed these other promise statements to be more persuasive and reevant. Step 2 Identifying the Promise Step 2 is to identify the promise or benefit to the members of the intended audience that wi motivate them to change their behavior. (See behavior change objectives defined in chapter 3.) The purpose of this step is to seect a promise that is most persuasive to the primary audience. The promise is a cear benefit that the audience wi understand after receiving the message. The promise shoud serve to differentiate the message from communication about other products, services, or behavior. It shoud convey a benefit ike happy, strong adoescents or your babies wi ive onger and heathier and wi be stronger and not a product attribute ike a modern, hormona method of contraception. An attribute shoud be used ony when it communicates and supports the consumer benefit. Put another way, the promise is the specific audience benefit that the heath communicator wants the audience to associate most readiy with the objective or proposed behavior change. For exampe, the promise of feeing secure and protected from contracting HIV or other STDs by using a condom is a cear benefit to the audience of adopting a particuar behavior. The promise is a consumer-end benefit whose appea is usuay based on emotion and is consistent with the attributes of the product, service, and/or behavior. Athough a product, service, or behavior may deiver more than one benefit, it is important to highight a singe benefit. Expecting the audience to associate the promise with more than one benefit may confuse the audience and may reduce the impact of the message. A promise need not be tied directy to a product, service, or behavior. In many cases, enduring promises have the feeing that the product, service, or behavior is for a certain kind of person or a certain kind of experience. This approach is particuary reevant when competing products, services, or behaviors are perceived to be simiar in nature. Finding the promise that wi resonate with the audience is one of the most chaenging tasks in deveoping a communication strategy because it reies on having a cear understanding of the intended audience. Identifying the promise may 128 A Fied Guide to Designing a Heath Communication Strategy

139 require additiona formative research beyond what was undertaken in the anaysis of the situation. Many different methods to uncover this information exist. For different ways of gaining insightfu information on determining benefits, it is best to work with a research firm with experience in communication. Step 3 Defining the Support Step 3 is to define the supporting statements that summarize why the audience shoud beieve the promise. The support statements are based on research findings that have been anayzed to understand what wi make the message credibe to the audience. The reasons for the audience to beieve the message may be factua or emotiona. In the message brief, the support statements summarize why the promise is beneficia to the audience and why the promise outweighs any obstaces to using the product or service or any barriers to adopting the behavior. Step 4 Describing the Competition for the Message Even if the audience understands, reates to, and is motivated by the message, there may be other factors that imit the audience s abiity to adopt the proposed behavior. For exampe, socia norms that imit a woman s abiity to use FP methods may inhibit her desire to go to a cinic and determine which method woud be best for her. In many countries, HIV/AIDS is sti considered a socia taboo, and many at-risk individuas are intimidated from seeking testing, counseing, or treatment because they are afraid of the consequences in their communities. Most peope behave the way that they do because they derive a benefit from that behavior. In the case of the woman in the FP exampe above, the benefit to her of not going to the cinic may be good reations with her husband and extended famiy members. For those who do not seek HIV/AIDS testing, counseing, or Exampes of Support Statements: Factua: Condoms prevent the transmission of disease 99.9 percent of the time. A doctors recommend their use. Emotiona: By using condoms, you be ess fearfu of contracting a disease that wi make you sterie, reduce your quaity of ife, or even ki you. Both: In Egypt, the Cinica Services Project (CSI) Project promoted its FP services as, Distinguished Service at an Affordabe Price. The factua support points were that the cinics had modern equipment and were affordabe, accessibe, cean, and comfortabe. The emotiona support point was that the cinics were recommended by cients who had experienced their services. 5 A Fied Guide to Designing a Heath Communication Strategy 129

140 treatment, the benefit may be the protection of the individua s status and reputation within the community. It is critica to understand the reasons behind the competition when crafting new messages. Competition for the message aso exists in the more traditiona sense, where a consumer has a choice of where to go to obtain heath services or where to purchase heath products. For organizations that are promoting their own cinics or brands of products, for exampe, the audience wi evauate the communication message in reation to other aternatives avaiabe to them. Often the chaenge in anayzing the competition is to transate a reative advantage into an absoute advantage. This notion of competition inks back to the positioning statement deveoped in chapter 4, Strategic Approach. Remember that an effective position must differentiate itsef from the competition. A positioning statement heps to communicate to the audience a unique appeaing difference designed to give the product or service an edge over the competition. Chapter 4 aso notes that positioning creates the memorabe cue for the audience to know why it shoud adopt a specific behavior. This idea is aso contained in step 3 of chapter 5, Define the Support. Remember that the support statement shoud state why the message promise wi benefit the audience and why it wi outweigh obstaces to using the product or service or to adopting the behavior. You wi encounter a number of paces in the strategic design process where the concept of competition comes into pay. You and your team need to be consistent in how you articuate what the competition is and why the audience shoud act on your message as compared to other messages. 130 A Fied Guide to Designing a Heath Communication Strategy

141 Step 5 Deveoping the Statement of the Utimate and Lasting Impression That the Audience Wi Have After Hearing or Seeing the Message The utimate and asting impression of the message is what peope retain after seeing it or hearing it, that is, the fu range of thoughts, feeings, and attitudes about the product, service, or behavior proposed in the message. In other words, it is the take-away of the message, incuding its ca to action. The overa impression is not a sogan but the beief and feeing that the audience shoud get from the communication. The take-away message may be expicit or impicit and may be communicated verbay or nonverbay. You shoud strive for a mutifaceted but singe-minded impression that wi contribute to creating a powerfu message brief. Such a message wi communicate the identity of the strategy, paint a picture in the audience s mind, and hep to buid a ong-term identity for the product, service, or behavior. Exampe Promise statement: FriendyCare is my partner and friend in panning and caring for my famiy. Overa impression statement: FriendyCare cinics can provide me and my famiy with high-quaity, affordabe, caring services ike those that I woud expect to get at much more expensive faciities. 5 A Fied Guide to Designing a Heath Communication Strategy 131