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CLIC-CPHE RESOURCE FILE
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pHPublic Health

5. PUBLIC HEALTH
"Improvement in health is likely to come, in the future as in the past, from modification of the
conditions which lead to disease, rather than from intervention into the mechanisms of disease
after it has occurred."
- Thomas Mckeown, 1976

5.1

PUBLIC HEALTH AND PRIMARY HEALTH CARE : A CONTINUUM AND SYNERGY

The Task Force on Health and Family Welfare is specifically mandated to improve Public Health and Primary
Health Care in the State. This was because public health, though strong in the state from the 1930s to 1960s,
had subsequently gradually declined and got fragmented. The Task Force found through discussions with a

variety of people over the past year, that most people had very divergent views on what exactly public health
meant. Hence this section is an introduction to the entire chapter on public health, describing briefly public

health concepts, principles and practice as they have developed over time, and linking them with the situation
in Karnataka, India and elsewhere.

Defining Public Health
Public health is an evolving discipline through which major health gains for populations have been made in several

countries around the world, since the early nineteenth century, i.e., before' the development of antibiotics and

vaccines. It has been defined by the Association of Epidemiologists as follows:
"Public health is one of the efforts organized by society to protect, promote and restore people’s health.

It is the combination of services, skills and beliefs that are directed to the maintenance and improvement
of the health of all people through collective or social actions. The programs, services and institutions

involved emphasize the prevention of disease and the health needs of the population as a whole.

Public

health activities change with changing technology and social values, but the goals remain the same: to

reduce the amount of disease, premature death and disease produced discomfort and disability in the

population" (JM Last 1983).
In clinical or curative medicine, efforts are focussed on the individual person who is ill. In public health, a
population based approach is taken, focussing on disease patterns, distributions, trends and risk factors. Public
health interventions are organized usually through government as larger collective action is required. The scope

is wide and includes health protection, promotion, diseases prevention, cure and rehabilitation.

State responsibility for health and health care
One of the key principles of public health, that the State is responsible for the health of its people,

was conceived over 150 years ago, leading to the first Public Health Act of 1848. The importance of this

social principle remains and has been reiterated by several bodies such as the World Health Assembly, of the
WHO (1977), WHO and UNICEF in 1978 and more recently by the Peoples Health Assembly (PHA) in 2000.
The role of the state remains critical, in present times and for the future, to protect and promote the health of

j

all people as a public good or common good, where health is a human right. Public health has in particular an

■

REPORT OF THE TASK FORCE

Public Health

abiding concern for the health and social conditions of the poor and vulnerable sections of society. The state
is also the only constitutionally, legally, mandated sector with the responsibility of improving the health and living

conditions of its citizens.

Public health has consistently struggled with and challenged structural roots underlying poverty. The political
economy dimensions of health and people’s access to care include the strong underlying forces influencing

the development, functioning and programme implementation of the health system. This is evident in strong

medical professional lobbies, and vested interests of various groups of allied health professionals, both of which
result in an unhealthy politicization of the health system and in non-implementation of programmes. It is also
evident in pesticide, pharmaceutical, medical industry and insurance lobbies functioning at global and national

levels and influencing local policies and practices. Class, caste/ethnicity, gender, age all play a role. The unfettered
play of political economy factors results in increased inequalities in health status and in access to care. Public

health emphasises the critical role required to be played by the state in shifting the balance towards better health

and access to care for all, but particularly the poor and socially disadvantaged.

Addressing determinants of health
^Diseases like cholera and typhoid earlier widely prevalent in Europe and the USA, were controlled by public

health systems that ensured a mandated supply of clean, safe or potable water, functioning sewage
systems, garbage and refuse disposal. Karnataka has initiated measures for water supply and sanitation
through different projects namely the Dutch assisted project, DANIDA, UNICEF and the World Bank assisted
Karnataka Integrated Rural Water Supply and Environmental Sanitation Projects. However the need and

demands of the public in this regard are yet to be fully met. Water and sanitation related diseases still take a

heavy toll in terms of sickness (see section on communicable diseases) and person days of work lost. The role

of the Directorate of Health and Family Welfare Services will be in setting standards for water quality, use of
chlorination I other methods of water purification, monitoring through regular water quality testing at local, taluk
and district levels, and initiating quick containment measures following any disease outbreak. Related measures
include intersectoral collaboration at different levels; health promotion of children, women and the community,

and special training of panchayatraj members, as water and sanitation fall specifically under their purview, under
the 73rd and 74111 Constitutional Amendments. The specific responsibility and accountability of the male junior
health assistant needs to be clarified. They also need supervision in this regard. Provision of safe water

supply and sanitation form the very basic, first generation, public health interventions and need to be
owned by the health department. ]
Another early development in preventive medicine, closely linked to public health, started in the IS01 century

relates to nutrition, another basic determinant of health. Use of fresh fruits and vegetables was
recommended in 1753 for the prevention of scurvy among sailors even before the causative agent was known.
There has been tremendous growth and development in the science of nutrition since then. Our own ancient

Indian systems evolved food production patterns, diets and methods of cooking that provided a balanced diet

in different seasons and suited to various physiological conditions. Despite rich traditional and modem knowledge
bases, recent data from the National Family Health Survey II (NFHSII) and NationaFNutrition Monitoring

Board (NNMB), regarding nutritional status reveals widespread under nutrition particularly in young children and

among women in Karnataka. Nutrition has also been found to have been very, neglected by the DHFW.

Malnutrition in Karnataka is a major public health issue and is being accorded the highest priority as an area for
intervention by the Task Force on Health & FW. It is therefore being covered in a separate chapter (Chapter

7). Deeper underlying issues of food and nutrition security are linked to irrigation, agriculture and seed policies;

^^REPORT OF THE TASK FORCE

Public Health

to employment, income and purchasing capacity; and to access by the poor to public distribution systems. These
too need to be addressed.

The Germ Theory and Infectious Diseases Control
The second generation of public health evolved with the discovery of bacteria and the growth of

microbiology. Development of diagnostics, therapeutics, vaccines, and an understanding of disease transmission
patterns made it feasible to initiate control programmes for communicable diseases. The current disease burden

due to communicable or infectious diseases in Karnataka still accounts for a major share of morbidity and

mortality. Cost effective public health interventions exist for most infectious diseases. For newer emerging
diseases such as HIV/AIDS, research is taking place at a fairly rapid pace and diagnostics and anti-retroviral

drugs are already available. However about 30 new infectious diseases have been reported globally over the
past 2-3 decades and the State needs to be alert to them.
An important underlying public health principle is that the method of transmission of communicable

Diseases with similar
modes of transmission are grouped or classified together e.g., water borne diseases, faeco-oral diseases,
diseases determines the choice of the method of disease control to be used.

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soil mediated infections, food borne diseases, respiratory infections that are air borne, insect or vector borne

diseases, diseases transmitted via body fluids, ectoparasite zoonoses, domestic zoonoses etc. Only important
diseases that require priority attention and intervention are covered in this report. The faeco-oral group of
diseases include amoebiasis, giardia, gastro-enteritis, bacillary dysentery, cholera, typhoid, hepatitis A & E,
and poliomyelitis. Breaking the faecal-oral chain is the basis of control, namely by personal hygiene, increase

in water quantity, improvement in water quality, food hygiene and provision of sewage disposal and sanitation

systems.
Another public health principle is that priority is given for control of infectious diseases based on criteria

such as magnitude of problem using epidemiological criteria, severity of diseases, and availability of
effective, safe interventions at reasonable cost. Though appearing commonsensical and obvious, a review

of major public health programmes reveals the lack of priority given to these priority problems and to practicing
public health principles in their control, with resultant heavy preventable burdens of morbidity and mortality. For
example, tuberculosis which was identified in 1947-48 as India’s foremost public health problem, continues to

£

be so in Karnataka in 2000-1, despite having a well researched and designed control programme and despite
the availability of diagnostics and cost effective drugs for treatment, all of which are indigenously manufactured.

The National Tuberculosis Programme (NTP) has not received adequate attention or resources from politicians,
decision makers, administrators and the DHFW. Thus it has been neglected and poorly supervised and

implemented. In the Revised National Tuberculosis Control Programme (RNTCP) also, Karnataka is currently
the second poorest performing State in the country. This apathy has resulted in much avoidable suffering and
even in unnecessary death.

Another example is of malaria. The early successes of the National Malaria Control Programme have not been
sustained. The increased number of cases and outbreaks in different parts of the state are of concern. Malaria
was controlled in Mysore State in the pre-DDT era, through public health interventions including public health

engineering and larvicidal fish. These bioenvironmental methods were unfortunately later abandoned with

complete reliance on chemical pesticides and chemotherapy. Increasing resistance to drugs and pesticides and
the harmful toxic efforts of pesticides have resulted in a rethinking of strategy. Other vector borne diseases also
-'•v have a fairly high incidence and prevalence in certain regions e.g. filari^dengue fever, Japanese encephalitis, etc.

Specific technical dimensions for each disease are given later. Another simple public health principle in

REPORT OF THE TASK FORCE

Public Health

communicable diseases control is that the health system should ensure early detection, complete treatment,
recording and reporting (or notification) through a disease surveillance system (this is covered in
greater detail later).

Public health and non-communicable diseases
The major burden of disease in developing country situations is often thought to be mainly “diseases of poverty”:
which is thought of synonymously, as infectious diseases and malnutrition. This is reflected in health planning and

financing priorities, with little attention paid to chronic, non-communicable diseases. It is now recognized that
social, demographic and epidemiologic transitions have been occurring over the past few decades, and countries

and states like ours have a substantial burden of these diseases as well. A public health approach addresses
the risk factors that predispose to these diseases such as tobacco, alcohol, exercise and food habits,
environment and occupational risk. For instance, lower salt intakes at a population level are found to result

in lower blood pressure levels and less hypertension. More recently, it is found that poor nutrition and other
factors during intra-uterine foetal life increases risk to these diseases later in life. Reduction of risk factors
through health promotion, community and public action, are part of the control strategy along with

early detection and good clinical management.

Health systems and public health
An additional premise is that there are certain health system prerequisites and primary health care

principles that need to be met, in order to achieve good infectious disease control. The strategy of
improving the functioning of general health services especially at PHC and CHC level is important in providing
comprehensive, affordable, good quality, diagnostic and treatment facilities as close to the homes of people as

possible. Diseases control interventions need to be integrated into the functioning of the general health services
as part of a comprehensive primary health care service. This horizontal integration at primary care level
is to be supported by more specialized referral and support services at taluk/district and state level,

through a referral system. The primary health care service needs to be credible so as to win the confidence
of people. Only then will people utilize it to meet their basic health care needs and for what government may
consider priority health programmes, be they communicable diseases control, family welfare, non-communicable
diseases control, etc.

These basic tenets of a good community health care service have been found lacking in our sub-centres, PHCs
and CHCs in the state. The Interim Report of the Task Force recommended 24 hour services at PHCs, with

filling up of gaps in infrastructure including residential quarters, water supply, electricity, vacancy positions for
different grades of personnel, supply lines for drugs and laboratory equipment/consumables, communication
systems etc. These are prerequisites for a good service and for infectious disease control.

Primary Health Care
The Primary Health Care approach, as a strategy to attain the international social goal of Health for All by
2000, was articulated and accepted at a WHO-UNICEF conference in Alma-Ata in 1978. It expanded the

scope and strategies for public health. Recognizing the limitations of medical science alone in improving the health
of people, it emphasized the need to address determinants of health through inter-sectoral collaboration,
especially with departments of agriculture, food supply, water supply, sanitation, housing and education. It

emphasised the need for equity and social justice in health, and health care. It recommended shifting
control over health care systems, with greater decentralization; and involvement of local people and
communities in decision making and planning health care systems to suit their own social, economic and cultural

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REPORT OF THE TASK FORCE

Public Health

conditions. It utilized scientific methods of proven effective, safe, acceptable and affordable treatments and

interventions in the preventive, promotive, curative and rehabilitative areas, but also encouraged indigenous
and traditional systems of medicine. It had a social goal of improved health and quality of life; access to

health care by all; maximum health benefits to the greatest number; increased self-reliance of individual persons
and communities, and the promotion of social means of reaching these goals. Thus public health went through

another paradigm shift. Experience and thinking from India along with those from other countries, helped in
making this shift

The following excerpts from the original documents are given for a clear understanding of concepts. These are

being given in some detail as they form a core element of the task force recommendations.
“Primary Health care is essential health care made universally accessible to individuals and families in

the community by means acceptable to them, through their full participation and at a cost that the
community and country can afford. It forms an integral part of the country’s health system of which it
•

is the nucleus and of the overall social and economic development of the community" (WHO-UNICEF,
1978).
“It means much more than the mere extension of basic health services. It has social and developmental

dimensions, and ifproperly applied will influence the way in which the rest of the health system functions"
(ibid).
"It is the first level of contact of individuals, the family and the community with the national health
system bringing health care as close as possible to where people live and work, and constitute the first

element of a continuing health care process" (ibid).

The four key underlying principles of primary health care are
Equity through equitable distribution of health resources.

Community participation and involvement.
Intersectoral co-ordination between health and development.

Use of appropriate technology for health.
a

The eight components of primary health care comprising the core technical package are :
Education concerning prevailing health problems and about methods of identifying, preventing and controlling
them.

Promotion of food supply and proper nutrition.
Adequate safe water supply and basic sanitation.
Mother and child health services including family planning.

Immunization against major infectious diseases

Prevention and control of locally endemic diseases .

Appropriate treatment of common diseases and injuries

Provision of essential drugs.
India was a significant contributor and signatory to the World Health Assembly (WHA), 1977 and the Alma Ata
Declaration of 1978. Theconceptof comprehensive health carehad already been articulated in India through the

BhoreCommitteeReport, in 1946, a document which formed theearly basis for India’s health planning. Primary health

REPORT OF THE TASK FORCE.Public Heah/i

centres had been initiated since 1952. The National TB programme, 1962, had the seeds ofthe primary health care

approach. The Shrivastava Committee report 1974, made links between education and training ofsocially oriented
doctors, all grades of health personnel and community health needs. A national scheme for Village Health Workers
was launched in 1977. Post Alma Ata, in 1981,theIndianCouncilforSocialScienceResearchandtheIndianCouncil

for Medical Research brought out apublication “Health for All”. The National Health Policy based on principles of
primary health care was tabled in 1982 and passed by Parliament in 1983. It is still the operating policy statement as
of now. State governments, including Karnataka, accepted the Health for All (HFA) goals and Primary Health Care

(PHC) strategies. The Ninth Plan document of the Government of India committed itself to the goal of
“Health for all, particularlyfor the underprivileged".

However statements and public commitments are at risk of becoming rhetorical. They need to be followed

by action, resource flows, systems for accountability and measurement of outcomes and impacts. Analysis

reveals declining state expenditures on nutrition and lack ofresponsibility and accountability for nutrition by the

DHFW. Intersectoral work to ensure potability ofwaterand provision ofsanitation facilities is ongoing since theearly
1990s, butcoverageis incomplete. Datareveals the high, continuing preventable burden ofwaterrelateddiseases. A
State heal th expenditure is stagnant and below norms. A large proportion ofprimary health centres continue to function

sub-optimally. Coverage and quality of basic antenatal care and immunization continues to be low in Category C

districts. Diseases likeTB continue to take a heavy toll with government health services providing complete treatment
or cure to only 8-16% ofexpected sputum positive pulmonary TB patients. School health services are ofpoor quality

and have limited coverage. Community mental health care programmes at district level have not been taken up
seriously, though the epidemiological burden has been well documented. The essential drugs concept is not practiced

in spirit. Health education and promotion receive little interest and is too focussed on Family Welfare. The public lack
ofconfidence in public health services. Public health and primary health care have been neglected and distorted and
that planned, systematic efforts are required to revive and institutionalize public health practice into the Directorate

of Health and Family Welfare Services.

Recommendations
•

All the staff of the Department of Health and Family Welfare Services must appreciate the

importance of Public Health and the synergy between primary health care and public
health. This will be reinforced through in-service orientation programme and short training
programmes for all health personnel.

•

The Public Health Institute will be upgraded to be a nodal centre for all laboratory services and
research. It will be headed by the Additional Director of Communicable diseases.

5.2

WATER AND SANITATION

Water is variously considered as life giving, life sustaining, purifying, a vital nutrient and essential for life. However,

it can also spread diseases and kill. Predictions are that drinking water is becoming a scarcer commodity. With
ground water being used faster than it can be recharged, shortage of drinking water is likely to become an
important problem in the future. Fifty percent of infant deaths are attributed to waterborne diseases. An
estimated 1.5 million under- five deaths occur in India every year, due to water related diseases, and

approximately 1800 million person hours are lost annually in the country, due to the same. It is estimated that
poor quality and inadequate quantity of water accounts for about 10% of the total burden of disease in

developing country situations, as in Karnataka State.

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Building consensus on competencies/themes of SOCHARA interest

Using the draftframework ofpublic health competencies prepared by Dr Ravi and Dr Adithya for an
IPHA project, the group was asked to read and reflect on the document, and then to comment on the
competencies that they thought were important for SOCHARA and SOPHE.

Public Health Competency: A unique set of applied knowledge, skills, and other attributes

grounded in theory and evidence, for the broad practice of public health .. ASPH

The group was asked to list out the special features offellowship and training programmes at

SOCHARA in terms of competencies and themes. It was decided that the community health training
programmes should have a certain commonality in terms of core perspectives and themes. These

have been enlisted here as a check list. Broadly the idea is "community health approach to public
health problems":
1.

Social epidemiology (SEPC)

2.

Social determinants/Action

3.

Equity (social inclusiveness)

4.

Communitization (which includes monitoring and planning)

5.

Responsibilities and rights

6.

Participatory research

7.

Ethics/integrity and accountability

8.

Health in all policies/ intersectoral coordination

9.

Plural system (AYUSH, traditional and complementary medicine)

10.

Engagement with the system

11.

Public health biology

12.

Communication

13.

Health system? (CPHC + all systems)

14.

Advocacy (movement)

15.

Resources

Each programme may use these items at different levels (CHFP, CHLP, CAH and the flex! fellows). All

programmes, from 3-day workshops to 2-year fellowships should introduce these concepts to
participants. It is important to reflect on these points for every session/learning programme we
conduct and the attempt should be to cover all these points.
Discussion:

The need to introduce the concepts of global dimension to local problems is debatable and
challenging at community level. It is not easy to convince the community by saying "foreign

15

policy influences our public health". The faculty however needs to be touch with the global

scenario. It is important to understand the history of public health and international health

systems of other countries, and a deeper understanding on the health systems (includes

both state and the non-state).

•

Need to include topics such as Theories of Social Change, Health and Human Rights, Political
Economy, Globalization and Trade.

•

Participatory Research, Plural Systems, Ethics and Public Health Biology are some of the
areas which need to be worked on.

•

Engaging with the system is crucial, which include: private, civil society, governmental and
traditional. When we think of operationalising/implementing, resources including financial

and human, will be needed.

•

Interlinking community health and development and bringing in perspectives of social
change, gender, caste, class and equity, and "health as a human right" becomes vital.

•

Prioritize which competencies to give importance to in both short and longer programmes

The group discussed about their thoughts on the competency list, and decided that "themes" rather

than "competencies" suit the curriculum development process more at the moment. The team was
requested to look at the 15 points mentioned above (Special features ofSOCHARA programmes), and

the list of competencies provided, and to come up with a list of themes that need to be covered in the

training programmes:

Themes which should be covered in any learning programme at SOCHARA:
-

Management and resources

Family community diagnosis
Critical analysis
Environmental health
-

Social behavioural

-

Leadership

Communication
Equity (with social inclusiveness - class, caste and gender perspectives)
Lifelong learning

Human resource development

Governance

Policy advocacy and implementation?
Health systems and evolution

Theories of change

-

Health and human rights

-

Information management

-

Public health perspective

-

Community health and development

-

Global health
Health promotion

-

Environment and occupational health

16

(including Foundation points: history, definitions, perspectives and development and change)

The competency list and the list of "themes" developed can be used as reference, and the "ASK"
sub-framework could be applied to it to decide what our curriculum will be about.

The competencies of the SOCHARA faculty should also be assessed:

Themes
Health and society
Determinants of health
Health systems and
alternatives
Public health problems
and action/epidemiology
Communitization
Right to health
Participatory research
Public health biology
Monitoring and
evaluation/accountability
etc
Policy process and
implementation
(.... continues)

Attitudes

Skills

Knowledge

Some of the points mentioned in the principles listed in the Report of the Learning Facilitation

Workshop were reflected upon, and further discussed. These points are available on pages 112-114
of the report.
Some major reflections on those points:
•

Inclusion of the terms "migration and transgender" into situation analysis of health in the

section 4b
•

Inclusion of the participatory into the Health (section VII)

•

Whether caste, class and gender can be added into the overall perspectives? ( can there be
any other term instead of caste as there are different ethnic clans in north eastern part of

India)

•
•

Good governance can replace governance in the principles (or guiding principles)

Under overall perspectives - critical analysis and systems thinking; gender perspectives (with
caste, class)

•

Public health biology / technical knowledge of public health problems has to be included

•

The complexity of the procedures of the government at different levels needs to be
understood (which includes the policy processes and implementation)

•

In Bangalore we have the materials in English but in M.P there is a need for materials in
Hindi

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1/30/2013

KJA: Building a Knowledge Society

Introducing Mission Group on Public
Health of Karnataka Jnana ayoga

Short Introductory Presentation
during dialogue of MGPH- K JA team
with KSHSRC, KSIHFWand RGUHS on
3rd July 2012

Dr. Ravi Narayan
Community Health Advisor, SOCHARA
Chairperson - Mission Group on Public
Health - KJA

KJA - Perspectives -1

o

A knowledge society is centered on
knowledge for its development. It
can be built when the inherent new
knowledge of a state rhythmically
translates into :
•Human Development
•Productivity
•Social Welfare
•Good Governance
.
•Competitiveness

KJA - Perspectives- II

KNOWLEDGE SOCIETY FRAME WORK
o Empowering its citizens
o Universalizing Access
o Ensuring equity
o Promoting new knowledge generation.
CHARACTERISTICS
o Universal Presence
o Universal Access
o Equity Access
o Knowledge empowerment
o Life long learners.

COMPONENTS:

• Knowledge Creation
• Knowledge Leadership
• Knowledge Services
• Knowledge Application
■ Knowledge Excellence

1

1/30/2013

KJA: Mission Group on Public Health - H

KJA : Mission Group on Public Health

Chairperson : Dr. Ravi Narayan, SOCHARA.
Co-chairperson: Smt. Sita Lakshmi Chinnappa, ICMR

Tasks:
1.
Make necessary recommendations and prepare
detailed report on
a) Status and recommendations on Public
Health.
b) Status and recommendations on AYUSH in
state of Karnataka.

Methods:
1.

2.
3.

Engagement with Health and AYUSH
Departments
Consultation with Stake holders
Minor Research Studies.

KJA Past Recommendations in
Health (2008-2011) -1
1.BUILD EXCELLENCE IN EDUCATION SYSTEM.
2.PROMOTE CREATION OF KNOUTEDGE
• Develop Ayurveda University as a unitary
/contemporary
research university *
• PG department in Govt Homeopathy College *
3.IMPROVE LEADERSHIP AND MANAGEMENTOF
HEALTH INSTITUTIONS
• Introduce Public Health Cadre in Health and Family
Welfare Department. **
• Establish a School of Public Health for HRD Needs. *
* Introduce an HRD Division in the Ministry of Health and
Family Welfare. **

*v

Members:
1.
Secretary - Department of Health and Family
Welfare (GoK)
2.
Sri Darshan Shankar - Vice Chairman - I-AIM
3.
Dr. R. Balasubramaniam - SYVM, Mysore.
4.
Dr. G. Gururaj- NIMHANS, Bangalore.
6.
Dr. Gopal Dabde, Chairperson, JAAK, Dharwad
6. Dr. Ruth Manorama- President, NAWO
7.
Director - Department of AYUSH
8.
Dr. Kishore Kumar.R - RO- NADRI
9.
Smt. Jayashri.M - Research Associate, KJA ( Convenor^
10.
Special Invitees - Health Commissioner and Direc^oi
NRHM.

KJA Past Recommendations in Health
(2008-2011)-II

MAKING GOVERNMENT AN
EFFECTIVE SERVICE PROVIDER:

tn (HMIS)
tj the overall budgetary allocations to the health.

and corporations.
(PPP) schemes launched by Department of Health nnd Family
Welfare, GoK since 2005 **

o

2

1/30/2013

I

Evolving Public Health Charter for
State of Karnataka

KJA Past Recommendations in Health
(2008-2011)-III

( BASED ON MGPH MEMBER SUGGESTIONS)

PROMOTE KNOWLEDGE APPLICATION:
o Develop regional pharmacies **
o Constitute multi-user, multi-lingual,
tradition medicine portal, Electronic
Ayurvedic encyclopedia and medical
dictionary. *
PROMOTE INTERSECTORAL
INTERACTION

o

Evolving Public Health Charter for
State of Karnataka
Emerging Themes-1 (Updated 3.7.2012)

1. Public Health in Karnataka - Overview and key
Challenges including review of state 12,h Plan
chapters
2. Public Health - Capacity Building
3. Public Health - Governance
4. Public Health - Intersectoral Challenges
5. Public Health - System Responses to Challenges
6. Promoting Pluralism and Integration (AYUSH)
7. Public Health Strengthening - HMIS, GIS, and
Knowledge translation.\
8. Plan of Action and overall recommendations

Evolving Public Health Charter for
State of Karnataka
Emerging Themes-II
5. Public Health System Response to Challenges

6. Promoting Pluralism and Integration (AYUSH)

O Public Health orlentellon of AYUSH Personnel

7. Strengthening HMIS, GIS, nnd Knowledge translation.
<• Strengthening HMIS

3

1/30/2013

Multi disciplinary State School of Public
Health -1
( Proposal for State Budget)

STRUCTURE AND FRAME WORK
Policy Imperative
Campus
Departments
University affiliation and accreditation
of courses
5. Financial support
6. Governance
7. Bench Marking
8. Technical resource network
9. Education and IT technology

1.
2.
3.
4.

Multi disciplinary State School of
Public Health - II
COURSES AND TRAINING
PROGRAMMES
Public Health (Short certificate course )
Public Health Management ( PG Diploma)
Public Health Masters Program ( Two Years)
Public Health Special Courses
a) Public Health Engineers - MPH in PHE
b) Health Promoters - MPH in HPA
5.
Public Health - Induction / Orientation
courses for PHC staff
6.
Public Health modules in other disciplines (
Strengthening public health consciousness)
|
1.
2.
3.
4.

MULTI DISCIPLINARY STATE
SCHOOL OF PUBLIC HEALTH - IV
Departments / Units

Multi disciplinary State School of
Public Health - III
RESEARCH
1. Socio - epidemiological research
2.
Health system research
3.
Health policy research
4.
Health Economics
5.
Health Impact assessment
6.
Health Policy advocacy and Knowledge
translation.
•

■Public health planning and management,
"Epidemiology & bio statistics,
■Social and population sciences (Sociology,
Social Work, Anthropology, Demography)
■Health information and communication
systems including IT for health
■Environmental and occupational health,
■Health policy and health systems (
including economics)

4

1/30/2013

Multi disciplinary State School of Public
Health - V
Partners - Public Health Resource
Network

Multi disciplinary State School of
Public Health - VI
Challenges Ahead

1.
SIHFW/SHSRC/DHFVV
2.
I1M-B 1 Health Policy Unit)
3.
NLSU1
4.
1SEC
5.
SWASTHYA - Karnauika Network. (1PH, IHMR, KARUNA etc)
6.
KHPT
7.
NIMHANS
8.
NTI/ NIMR/ NIOH etc.
9.
SOCHARA- SOPHEA
10. EACH

□ Development of evidence based public health

12. RGUHS
13. PHF1 - IIPH- Hyderabad.
1-1. Other Public Health Schools - RLE, KMC, PS etc.
15. Other NGO training and research centres.

□ Community health based public health research
□ Ability to solve complex societal problem to
multidisciplinary

□ Development of institutional capabilities for
closing the gap between knowledge and practice
□ Development of appropriate human resource at
□ Health promotion, healthy lifestyles with
□ Strengthening of public health regulation and

©

Stake holder consultation - mgph-kja
(23BI> AND 24th July 2012)
Key Themes:

1.
2.
3.

Public Health Capacity Building
Affordable essential drugs in Karnataka
Tackling malnutrition, water supply and
sanitation challenges in Karnataka
4. Urban Primary Health Care charter
5. Strengthening pluralism andAYUSH
Integration in Public Health System.
6. Community prevention and management of
Chronically ill and aged using palliative
approach.
(Dialogue of Stakeholders from Government, Academia,
Polley Researchers . NGO &Civil Society and Others)

5

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ith program planning com­
pleted, you are ready to pro­
duce messages and materials
for your program. This chapter ad­
dresses:

W

■ developing message concepts
s testing message concepts and draft
materials
h production tips
b content issues, including message
appeal, spokespersons and consid­
erations for "hard-to-reach" or other
special audiences.

If you have located suitable materials
for your program, you will be able to
skip or simplify this process. If you are
unsure whether the materials you have
located are appropriate—or think that
they may need alterations—you can
move directly to pretesting.

Develop and Test Message
Concepts
Your communication strategy state­
ment and the information you gathered
about the target audiences (stage 1)
form the basis for developing message
concepts. These message concepts
are your messages in "rough draft."
and represent different ways of
presenting the information to the target
audiences. You may want to prepare
two or more message concepts using
different:
■ spokespersons (e.g., a physician, a
peer)
■ appeals (e.g., humor, fear, factual)

~ styles (eg., photographs, graphs)
J formats (eg., audiovisual with music.
instructional poster) for testing with
gatekeepers and the target audi­
ence.

Audiovisual Materials

If you have decided to produce PSAs
or other audiovisual materials, here are
some presentation options to consider:
demonstration—the audiovisual
format is ideal for demonstrating the
desired health behavior, especially if
skills must be taught.
testimonials—a credible presenter
(eg., the Surgeon General) can lend
credibility to your message. A rec­
ognizable spokesperson may be
attention-getting. The most credible
and relevant presenter may vary for
different audiences—and may be a
target audience representative, an
authority (e.g., a physician) or a
celebrity connected with the health
issue.
slice of life—a dramatization within
an “everyday"—or familiar—setting
may help the audience associate with
your message. A simple story may be
easy to remember; you might choose
to present the health problem and
show the solution. This style may be
both credible and memorable, but it
may also be "corny."

animation—beyond use for young
children, animation can be eye­
catching for adults (older children may
consider some animation "silly" or
“babyish"). You can use animation to
demonstrate desired actions; it may
also be a good choice for addressing
abstract subjects (eg., explaining
"respite care”) or sensitive subjects
(such as AIDS), or several disparate
target audiences (eg., different ethnic
groups) at once.
humor—can be memorable, heart­
warming and effective. However,
humor is difficult to do well. The
lighthearted can also be silly, and a
punchline can become stale quickly.
For some audiences or subjects.
humor can be offensive. (“There is
nothing funny about cancer," agreed
one men’s focus group.) It can also be
expensive.
emotion—can make a message
real, and personal; it can also "turn
off" the viewer. Emotional approaches
range from warm and caring to fear
arousing and disturbing. As with
humor, emotional appeals may be
“high risk" production choices—these
cnoices should be pretested and
produced with care.
use of music—can lend to a mood
you are trying to create; it can also
compete with the message.

31

How the Public Perceives Health Messages
hinking about how the public perceives health messages prior to message development can help assure that the
public will hear and heed the information you want to convey. Factors affecting public acceptance of health
messages include:
“Health risk” is an intangible concept—Many people do not understand the concept of relative risk, and so
personal decisions may be based on faulty reasoning. For example, the public tends to overestimate their risk of car
and airplane accidents, homicides and other events that most frequently make the news, and underestimate their
risk of less newsworthy, but more common health problems such as strokes and diabetes.
The public responds to easy solutions—The ability to act to reduce or eliminate an identified risk not only can
lessen actual risk, but can abate the fear, denial, or mistrust that may result from new health information. The public
is more likely to respond to a call for action if the action is relatively simple (e.g., get a blood test to check for
cholesterol) and less likely to act if the “price" of that action is higher, or the action is complicated (e.g., quitting
jnoking to reduce cancer risk). Therefore, when addressing a complex issue, there may be an intermediate action to
krecommend (calling for information, preparing to quit).

T

People want absolute answers—Some people don't understand probabilities; they want concrete information
upon which they can make certain decisions. In the absence of firm answers from a scientist, the media will
sometimes draw an inappropriate conclusion, providing the public with faulty but conclusive-sounding information
that the public finds easier to accept and deal with. Therefore, you must carefully and clearly present your
information to both the public and the media.

The public may react unfavorably to fear—Frightening information, which sometimes cannot be avoided, may
result in personal denial, disproportionate levels of hysteria, anxiety and feelings of helplessness. Worry and fear may
be accentuated by faulty logic and misinterpretation, and compounded if there are no immediate actions an individucan take to ameliorate the risk.
The public doubts the verity of science—The public knows that scientists can be wrong and recalls incidents
such as the predicted swine flu epidemic. They may hesitate to believe a scientist's prediction.
The public has other priorities—New health information may not be integrated as one of an individual's
priorities. When the National Cancer Institute conducted focus groups with retired shipyard workers, they found that a
future threat of cancer from a long-ago exposure to asbestos paled in importance in comparison with their daily
infirmities. Conversely, teenagers, many of whom may never have experienced poor health, may find it inconceivable
that they will be susceptible to future illness. For many people, intangible health information cannot compete with
more tangible daily problems.
Individuals do not feel personally susceptible—The public has a strong tendency to underestimate personal
jisk. An NCI survey found that 54 percent of respondents believed that a serious illness "couldn't happen to them"
^nd considered their risk as less than that of the general public, regardless of their actual risk.
The public holds contradictory beliefs—Even though an individual may believe that “it can't happen to me," he
or she can still believe that “everything causes cancer” and, therefore, there is no way to avoid cancer “when your
time comes," and no need to alter personal behavior.
The public lacks a future orientation—The majority of Americans say that it is better to live for the present tha
to worry about tomorrow. The public, especially lower SES groups, has trouble relating to the future concept, and
many health risk messages foretell of outcomes far in the future. Focus group participants who were convened to
help plan a cancer prevention program agreed that it would take an actual health scare, or seeing a health problem in
a friend or loved one, to make them alter their own behavior.
The public personalizes new information—New risk information is frequently described in terms of its effect on
society (such as predicted morbidity and mortality rates). The individual needs to translate that information into
personal risk to understand it; translation of information offers an opportunity for misinterpretation and misjudgment.
especially because technical analyses may be incomprehensible to the public.
The public does not understand science—Technical and medical terminology, the variables involved in
calculating risk, and the fact that science is not static, but evolves and changes over time, are all poorly understood
by the public. Therefore, individuals lack the basic tools required to understand and interpret some health information.

Considerations for Message Construction
oth the channel and the purpose of communicating health infor­
mation influence message design. Information may be designed to
convey new facts, alter attitudes, change behavior or encourage partici­
pation in decision making. Some of these purposes overlap; often they are
□regressive. That is, for persuasion to work, the public must first receive
□formation, then understand it, believe it, agree with it and then act upon
it. Regardless of the purpose, messages must be developed with
consideration of the desired outcome. Factors that help determine public
acceptance include:

B

Clarity—Messages must clearly convey information to assure the
public's understanding and to limit the chances for misunderstanding or
inappropriate action. Clear messages contain as few technical/scientific/
bureaucratic terms as possible, and eliminate information that the audience
does not need in order to make necessary decisions (such as
unnecessarily detailed explanations). Readability tests (see appendix B for
instructions) can help determine the reading level required to understand
drafted material and help writers to be conscientious about the careful
selection of words and phrases.
Consistency—In an ideal world there would be scientific consensus on
the meaning of new health findings, and all messages on a particular topic
would be consistent. Unfortunately, consistency is sometimes elusive.
Experts tend to interpret new health data differently, making consensus
among government, industry, health institutions and public interest groups
difficult.

Main points—The main points should be stressed, repeated and never
hidden within less strategically important information.
Tone and appeal—A message should be reassuring, alarming, chal­
lenging or straightforward, depending upon the desired impact and the
target audience. Messages should also be truthful, honest and as complete
as possible.

Credibility—The spokesperson and source of the information should be
believable and trustworthy.

Public need—For a message to break through the "information clutter"
of society, messages should be based on what the target audience
perceives as most important to them, what they want to know, and not
what is most important to or most interesting to the originating agency.
Health messages should be drafted with consideration of these factors.
°rior to final production, messages should be pretested with the target
audiences (and in some cases with channel "gatekeepers") to assure
oublic understanding and other intended responses.

Print Materials

You may decide to produce a single
booklet, or your program and budget
may call for a range of materials, each
for a different purpose (e.g., a poster
for attention, a booklet for explanation
or teaching) or use (in a supermarket
display, a physician's office or a class­
room).
As you decide what print materials
to produce, consider that:
□ all messages in all the media you
choose should reinforce each other
and follow the communications
strategy
□ no matter how creative, compelling
or wonderful a message is, if it does
not fit the strategy statement, objec­
tives and identified audiences, throw
it out. Don't compete for attention
with your own campaign

□ whatever approach or style you have
chosen should be echoed in all
campaign elements. In print ma­
terials, use the same or compatible
colors, types of illustrations and
typefaces throughout the campaign.
If there is a logo or theme, use it in
all print and audiovisual materials

33

□ use illustrations to gain attention, aid
understanding and recall; make sure
they reinforce, and don't compete
with your message. Use captions,
headlines and summary statements
for additional reinforcement.

As you consider a particular tone or
style for either audiovisual or print
materials, make sure that you have
access to the expertise and budget to
suit your choice. Think about whether
the style will enhance or compete with
your message. Simplicity may offer the
greatest chance of success.
?roduction Values

|No matter which approach you
choose, high quality production is
necessary to make the message work.
If you feel you have to skimp on pro­
duction, choose a simpler way of
presenting the message. Producing
poor quality materials wastes funds
and can damage your program’s—and
your own—credibility.
Need for Audience Testing

Even if you think you've chosen the
presentation style most suited to the
message and audience, you should
pretest it to be sure. Check each
concept to make sure that it complies
with your communications strategy
and objectives. Testing alternative
concepts with the target audience
lay:

E> help identify which has the strongest
" appeal and potential for effect

a identify new concepts
□ identify confusing terms or concepts

□ identify language used by the target
audience
□ help eliminate weaker concepts and
save production costs.

In developing a mass media cam­
paign to increase public awareness
of the health risks associated with
workplace exposure to asbestos in
World War II, four message con­
cepts were tested with older, blue
collar males and females typical of
the target audience. These con­
cepts were based on a communica­
tion strategy "to increase public
understanding of the problems of
asbestos exposure and to convey
the importance of taking specific
actions if exposure had occurred."
Each concept used a different mes­
sage presenter: a retired shipyard
worker; a doctor; the family of a
former shipyard worker; and a
celebrity associated with World War
II.
To help the respondents visualize
the concepts, a sketch and several
lines of copy were presented in
poster form. Pretesting indicated
that using a doctor as a presenter
did not fare well with male re­
spondents and was considered the
least interesting visually; this option
was eliminated. In addition, words
used in the message concepts were
found to be misleading and were
changed.

Focus groups are most commonlused for testing at this stage becau
they permit open and extended discus­
sion about concepts and ideas. You
may show rough illustrations or a tele­
vision "storyboard" (frame-by-frame
illustrated description) to the group, or
just discuss the messages and presen­
tation style with them and ask them to
visualize the product. A description
focus groups and alternative test
methods begins on page 39.

Develop Draft Materials
Based on findings from testing mes­
sage concepts, you will want to refine
the most promising approach and
produce materials in draft or “roug‘
form. A graphic designer or audio­
visual producer will frequently provioe
a facsimile version of a poster or
pamphlet, or a storyboard of a
television PSA for your review and
approval. Materials in—or close to—
this format should be tested at this
stage to:

□ assess comprehension
□ identify strong and weak points

□ determine personal relevance
□ gauge confusing, sensitive or
controversial elements.

Testing at the concept stage helps to
choose the strongest from among
more than one potential approach to ,
presenting your message. Now, you
have refined the strongest concept
into the language, style and format you
want to use Additional testing is de­
signed to strengthen the approach you
have chosen—before your production
funds are spent.
Because materials production is
one of the most costly steps in pro­
gram development, it makes sense to
test before you invest in final produc­
tion. Draft materials should resemble
the final product as closely as
possible, but without expensive pro­
duction. For example, radio announceents may be produced in a nonstudio
setting and with nonprofessional
voices for testing. A television anouncement may be tested with a story­
board, or with an animatic (videotaped
sketches with voice over). A booklet
may be prepared using good quality
word processing copy, rough illus­
trations. and a copy machine. Similarly,
posters, print ads and flyers can be
produced in rough form for pretesting.

Using Celebrity Spokespersons
sing the right celebrity to present your message or represent your
campaign can be an exciting proposition. Here are a few considera­
tions to think about as you make your decision:

U

a celebrities can be effective if they are directly associated with your mes­
sage by the audience (eg., an ex-cancer patient, a pregnant woman, an
ex-smoker)

□ celebrities speak for themselves, and their image: have a firm agreement
about their role and what they will—and will not—say
□ celebrities can increase attention to your message from audiences and
gatekeepers
□ the appearance of a celebrity may compete with your message for
attention

□ some audiences may not react favorably to some celebrities
□ a network may not use a top star from a rival network’s show

□ production schedules will be built around the celebrity’s schedule, which
could result in production delays or a need to re-schedule, increasing
production time and costs
□ be sure that the celebrity does not practice health habits or hold healthrelated opinions that could later contradict your own messages (e.g., a
spokesperson for eating well during pregnancy who is recognized as a
bulemic)

□ remember that celebrities live in the public eye. A change in their
popularity or personal lifestyle could affect the acceptability of your
message
□ a local celebrity or well-known person may be more credible for some
audiences than a national figure.

Pretest graphics with the target
audience. People interpret graphics in
different ways, just as they do the
written word. If your graphics style or
illustrations depart from what
"gatekeepers" (e.g., PSA directors.
physicians, teachers) expect, test with
them, or ask them to review, as well.
Use favorable responses from the
target audience as a “selling point”
with gatekeepers.

NCI developed and tested two
logos for their new Prevention
Education Program. One was a
cartoon depiction of a person, the
other an abstract symbol. Partici­
pants in the pretest said that they
preferred the cartoon character
because it was less serious and
"softened” a serious project more
than the abstract symbol. NCI also
tested the phrase “Cancer
Prevention" with an apple (for good
health) substituted for the “o” in
prevention. The apple symbol was
deleted when respondents failed to
linkapples to “good-health" or
preyention.

35

Pretesting—What It Can and
Cannot Do
Pretesting draft materials is a type of
formative evaluation used to help
ensure that communications materials
will work. Pretesting is used to answer
questions about whether materials are:

s understandable
0 relevant
b attention-getting and memorable

□ attractive
□ credible

acceptable to the target audience.
^Piese are factors that can make the

difference in whether materials work or
don’t work with a particular group: they
also involve value judgments on the
part of the respondents and your
interpretation of what they mean. Most
pretesting involves a few persons
chosen as representative of intended
target audiences, and not a statistical­
ly valid sample (in number or selection
method). That is, pretesting is general­
ly considered "qualitative research”—
research which can be interpreted
somewhat loosely to provide clues
about audience acceptance and
direction regarding materials pro­
duction and use.
The Public Health Service develped a series of booklets on nutri^b'on, smoking and other health
^subjects for low-income women.

The draft booklets were tested to
reveal any confusing or incompre­
hensible information; the tests
showed that the information was
easy to understand, but the format
was considered long and dull. The
booklet format was discarded, and
the information was redesigned as
a less expensive, more colorful
series of fact sheets.

Tips for Developing TV PSAs
0 Keep messages short and simple—just one or two key points
s Be sure every word works
s Repeat the main message as many times as possible

0 Identify the main issue in the first 10 seconds in an attention-getting way
0 Summarize or repeat main point/message at the close
□ Superimpose the main point on the screen to reinforce the oral message

a Recommend a specific action

a Demonstrate the health problem, behavior or skills (if relevant)
s Provide new, accurate, straightforward information

0 Present the facts in a straightforward manner
s Use a memorable slogan, theme, music or sound effects to aid recall
□ Be sure that the message presenter is seen as a credible source of infor
mation, whether an authority, celebrity or target audience representative
□ Use only a few characters
s Select an appropriate approach (e.g., testimonial, demonstration or sliceof-life format)

E) Make the message understandable from the visual portrayal alone
□ Use positive rather than negative appeals

□ Emphasize the solution as well as the problem
a Use a light humorous approach, if appropriate, but pretest to be sure it
works—and doesn't offend the audience

s Avoid high degrees of fear-arousal, unless the fear is easily resolved and
the message carefully tested

0 Be sure the message, language and style are considered relevant by the
intended audience
□ Use 30- or 60-second spots to present and repeat complete message,
use 10-second spots only for reminders

a If the action is to call or write, show the phone number or address on the
screen for at least 5 seconds, and reinforce orally (phone calls require
less effort than writing for most people)
□ Check for consistency with campaign messages in other media formats

0 Use language and style appropriate for the target audience

Pretest prior to final production
... and remember, the most careful message planning won't replace the
need for creativity!

Make Print Materials Easier to Read
riting about health often requires the use of some technical lan­
guage. However, the way your message is presented—the writing
style, vocabulary, typography, layout, graphics and color can favorably
affect whether it is read and understood.

W

Text should be:
□ introduced, stating the purpose to orient the reader
□ summarized at the end to review major points
□ presented in short sentences, short paragraphs
□ "broken up" with visuals placed to emphasize key points, text as
“bullets,” and titles or subtitles to reinforce important points
□ written in the active, not passive, voice
□ underlined, boldfaced, or “boxed" for reinforcement

□ clarified with the use of examples
□ tested for readability
□ tested with the audience

o explained, if necessary, in a glossary (with key words defined within the
sentence)

Try to avoid:

□ jargon and technical terms or phrases
□ abbreviations and acronyms.

Just as necessary as clear writing is text that is easy to read and graph­
ics that help the reader understand and remember the text.

Graphics should be:
□ immediately identifiable
□ relevant to the subject matter and reader
□ simple, uncluttered
□ used to reinforce, not compete with the text.

Try to avoid:
□ small type (less than 10-point)

□ lines of type that are too long or too short
□ large blocks of print
□ "justified" right margins

ci photographs that won’t reproduce well

A variety of procedures may be
used to test messages and materials.
The best methods for a particular
program depend upon the nature of
the materials, the target audience and
the amount of time and resources
available for pretesting. There is no
formula for selecting a pretest
methodology, nor is there a "perfect"
method for pretesting. Methods should
be selected and shaped to fit each
pretesting requirement, considering
the objectives of and resources
available for each project.
Included here are descriptions of
some frequently used methods of
pretesting health concepts, messages
and materials. In addition, sample
questionnaires or other forms that
have been developed for some of
these methods are included in
appendix C, for you to adapt. Each
method carries with it benefits and
limitations. Sometimes using several
methods in combination will help
overcome the limitations of individual
procedures. For example, focus group
interviews may be used to identify
issues and concerns relative to a
particular audience, followed by
individual interviews to discuss
identified concerns in greater depth.
Readability testing should be used as
a first step in pretesting draft manu­
scripts. followed by individual question­
naires or interviews regarding materi­
als with target audience respondents.
Central location interviews or theater
testing of messages for television or
radio permit contact with larger
numbers of target audience respond­
ents—especially useful prior to final
production of materials. Following the
descriptions of pretesting methods is a
discussion of how to choose the most
suitable method for a particular
situation.

Q less than professional-quality drawings (they may make your text appear
less credible)
b technical diagrams.

37

'5'

Given the qualitative nature of most
pretesting research, it is important to
recognize its limitations:
’ □ Pretesting cannot absolutely predict
or guarantee learning, persuasion,
behavior change or other measures
of communication effectiveness.
Pretesting in health communication
is seldom designed to quantitatively
measure small differences among
large samples: it is not statistically
precise. It will not reveal that booklet
A is 2.5 percent better than booklet
8. (Presumably, pretests of such
ecision could be applied, but the
g^pst of obtaining such data would be
WRgh, and the findings may be no

more useful than the diagnostic
information from more affordable
approaches.)

Pretesting is not a substitute for
experienced judgment. Rather, it can
provide additional information from
which you can make sound
decisions.
It is important to avoid misuse of
pretest results. Perhaps the most
common error is to overgeneralize.
Qualitative, diagnostic pretest methods
should not be used to estimate broad­
scale results. If 5 of the 10 respond­
ents in a focus group interview do not
understand portions of a pamphlet, it
do°s not necessarily mean that 50
p.. ent of the total target population
vApe confused. The lack of undersWtding among those pretest re­
spondents suggests, however, that the
pamphlet may need to be revised to
improve comprehension. In sum.
pretesting is indicative, not predictive.
Another problem that arises in
health communication pretesting
concerns interpretation of respondent
reactions to a sensitive or emotional
subject such as breast cancer or
AIDS. Respondents may become
unusually rational when reacting to
such pretest materials, and cover up
their true concerns, feelings and
behavior. As a result, the pretester
must examine and interpret responses
carefully.
38

Producing Materials for Special Audiences
lthough every target audience needs separate consideration to some
extent, two kinds of audiences may require special message planning
and materials development: ethnic minorities and patients.

A

Ethnic Minorities
Interaction with the target audience and ‘‘intermediaries” familiar with
them is especially important when you are targeting ethnic minorities.
Remember:
use of a language may vary for different cultural groups (e.g„ a word may
have different meanings to different groups)

differences in target groups extend beyond language to include diverse
values and customs
different kinds of channels may be credible and most capable of
reaching minority audiences

don't assume that "conventional wisdom,” published research studies or
“common knowledge” will hold true for minority audiences. The degree
of assimilation and "mainstreaming” is everchanging, so current
information will be needed to choose the best channels and message
strategies

message appeals should be developed separately for each minority
group, since their perceived needs, values and beliefs may differ from
others
□ print materials should be simply written, reinforced with graphics and
pretested. People perceive graphics and illustrations in different ways,
just as their language skills differ
using bilingual materials will assure that intermediaries and family mem­
bers who are most comfortable with English can help the reader under­
stand the content

print materials should never be simply translated from the English; con­
cepts and appeals may differ by culture just as the words do
audiovisual materials or interpersonal communication may be more suc­
cessful for some messages and audiences.

Patients
Patients and their families facing a disorder or disease may require dif­
ferent information in different formats at various points in the disease
continuum. Remember:
□ all patients are not alike, and may have nothing in common except their
illness. Therefore, their interests in information and ability to understand it
may vary
□ few patients and family members can handle everything they need to
know at once, and may find it particularly difficult to absorb information
at the time of diagnosis

□ patients’ information needs may change as they emotionally adjust to
their illness.

Examples of What Pretesting Can Do
Assessing Comprehension
Understanding of health messages and materials is essential as a prior
condition to acceptance.

By pretesting a slide-tape presentation on breast cancer, OCC learned
that the presentation was considered clear and informative, but the
narration needed to be slowed down so that all of the information could
be better understood.
Assessing Attention and Recall
Television and radio PSAs and posters must first attract audience attention
to work. These messages are rarely seen or heard in an isolated environ­
ment, and they must compete (e.g., with advertisements, news and
entertainment) for attention.

After pretesting two different versions of television PSAs to promote
exercise, program planners learned that the message showing runners
talking about their own exercise experiences was remembered more
often. A second message, which used special visual techniques and a
voice-over announcer, was not effective in attracting the attention of
pretest respondents.
Identifying Strong and Weak Points
This means making sure that all elements of the materials (e.g., message,
format, style) are likely to work with the target audience.

A booklet on health risk appraisal contained a self-test for readers to
complete. The pretest indicated that the booklet was considered inter­
esting and informative. However, the instructions for scoring the test were
confusing. Respondents needed clearer directions to calculate their
scores.
Determining Personal Relevance
For the message to take effect, the audience must understand the
problem, accept its importance in their lives and agree with the value of
the solution for them.
Pretest results of a booklet on high blood pressure among hypertensives
and a general audience revealed several important differences in the
responses of these two groups. Hypertensives recalled and understood
more specific points related to high blood pressure control than did the
general audience group. Further, when asked whom the booklet was for.
a higher proportion of hypertensives felt the booklet was "talking to
someone like me."

Gauging Sensitive or Controversial Elements
Questions about audience sensitivity to subject matter often arise in devel­
oping health messages. Pretesting can help predict whether messages
may alienate or offend target audiences.

Would a televised demonstration of breast self-examination on a live
model be an affront to viewers? Pretest results of such a PSA indicated
that respondents held a range of views about the propriety of this
demonstration.

Pretesting offers both the opportu­
nity and the temptation to structure the
test and interpret the results to support
or justify a preconceived point of view.
It is natural to want your favorite con­
cepts or messages to test well, but
there is no need to test unless you are
willing to consider the results ob­
jectively.
One final point: pretesting does not
guarantee success. Good planning
and sound pretesting can be negated
by mistakes in final production. The
message in a television PSA on cancer
treatment, for instance, may pretest
well, but then be flawed by an execu­
tion that uses an actress who seems
too happy to be awaiting the results of
a biopsy report. Similarly, leaflet copy
that pretests well may be rendered
ineffective by a poor layout, hard-toread type, and inappropriate
illustrations.

Pretesting Methods
The most frequently used pretesting
methods are described below. These
include:
□ self-administered questionnaires

□ central location intercept interviews
□ theater testing
□ focus group interviews

~ readability testing
1 gatekeeper review.

Following these descriptions there is
a summary chart on page 47 to help
you compare the advantages and dis­
advantages of each method.
1. Self-administered Questionnaires

Self-administered questionnaires:
~ enable program planners to elicit
detailed information from respond­
ents who may not be accessible for
personal interviews (e.g., doctors,
teachers or residents of rural areas)
□ allow respondents to maintain their
anonymity and reconsider their
responses

□ do not require interviewer time and
can be done relatively inexpensively
39

□ can be answered by many respond­
ents at once

To pretest a long booklet on
coping with cancpr,.OCC sought th
cooperation of severaloaricer
patient groups and;co.mprdhehsive
cancer centers. The tkrokletand the
pretest questionri^fds^iere "mailed
to cancer.patients frpm^theicancer
center. Completed, questionnaires
were returned directly to program
planners. Because reSppndents he
been asked to mark'the booklets
with editorial commentS^'jfwvas
essential that these be returned as
well. Self-addressed; stamped'
envelopes were provided for this
purpose. To boost the response
rate, follow-up telephone calls were
made.

□ require time to locate respondents
and secure their cooperation
□ require follow up to increase re­
sponse rates if mailed.

Self-administered questionnaires
also can be:
□ mailed to respondents along with the
pretest materials

□ distributed to respondents gathered
at a central location

t? -ed where personal interviews are
^.ot feasible
• inexpensive pretesting technique
for agencies with minimal resources.

A self-administered questionnaire
should be designed (see sample in
appendix C). then pilot tested with 5 to
10 respondents. Usually, question­
naires and pretest materials are dis­
tributed to respondents whose partici­
pation is sought in advance, but they
also may be mailed to potential
respondents without advance noti­
fication. Respondents are asked to
review the materials on their own, to
complete the questionnaire and then
to return it within a specified time.
The questionnaire should be rela­
tively short and clear or respondents
may not complete it. Clear, concise
ir actions to the respondent are
iafiortant because there is no
iBRviewer to offer clarification. Openended questions may be used to
assess comprehension and overall
reactions to materials and close-ended
questions to assess such factors as
personal relevance and believability of
the material. Measures of attention or
recall may not be reliable when used
with this technique since respondents
may refer back to the material.
Resources are invested primarily in
questionnaire development and anal­
ysis of results. The latter expense can
be kept to a minimum by using many
close-ended questions.

Self-administered questionnaires
have certain disadvantages:
□ The primary problem with this
technique is the possibility of a low
response rate.
□ It is important to over-recruit re­
spondents and recontact respond­
ents to encourage them to return
their questionnaires to ensure a
sufficient number of returns.
□ The data collection may take longer
than with other methods (e.g.,
central location intercept interviews)
because of delays in responses.
especially if the questionnaires are
mailed.
□ The type of respondents who return
the questionnaires may be different
from those who do not respond, and
this approach cannot be used with
respondents who have reading and
writing limitations. Hence, a certain
degree of bias may be introduced
and results should be interpreted
with this in mind. (Contacting those
who did not respond by telephone
will permit a comparison of
respondent/nonrespondent
answers.)

2.

Central Location Intercept Interviews

Central location intercept interviews in­
volve stationing interviewers at a point
frequented by individuals from the
target audience and asking them to
participate in the pretest. There are
two advantages to this:

□ a high traffic area (e.g., a shoppim
mall, hospital waiting area or school
yard) can yield a number of inter­
views in a reasonably short time

□ a central location for hard-to-reach
target audiences can be a costeffective means of gathering dat'

A typical central location intervi-.begms with the intercept. Potential
respondents are stopped and asked
whether they will participate. Then,
specific screening questions are asked
to see whether they fit the criteria of
the target audience. If so. they are
taken to the interviewing station­
quiet spot at a shopping mall or oi
7b test alternative skin cancer
communication concepts, NCI went
to construction sites and beach
areas to interview respondents who
were exposed excessivpl^todfte
SUn'

site- -are shown the pretest materials,
and asked questions. The questions
may help assess:
□ comprehension
□ individual reaction

□ personal relevance
□ credibility

o recall (if test situation includes
exposure to the materials prior to the
interview).
Although the respondents inter­
cepted through central location
interviews may not be statistically
representative of the target population,
the sample is usually larger than those
used in focus groups or individual indepth interviews.
Unlike focus groups or in-depth
interviews, the questionnaire used in
central location intercept pretesting is
highly structured and contains pri­
marily multiple choice or close-ended
questions to permit quick response.
Open-ended questions, which allow
"free flowing" answers, should be kept
to a minimum because they take too
much time for the respondent to
answer and for the interviewer to
record responses. The questionnaire.
as in any type of research, should be
pilot tested before it is used in the
field. A sample questionnaire is
included in appendix C.
A number of market research
companies throughout the country
conduct central location intercept
interviews in shopping malls. Clinic
waiting rooms, churches, Social
Security offices, schools, worksites or
other locations frequented by individu­
als representative of the target audi­
ence also can be used for this
purpose. It is advisable to obtain
clearances or permission to set up
interviewing stations in these locations
well in advance.
Posters can be tested in the kind
of setting (&g., a clinic waiting room or
schoolroom) where they will be used.
Posters should be mounted on a wall
along with other materials—just as
they are expected to be used—where

To pretest a bilingual (Spanish/
English) booklet on. breastfeeding, a
market researctijcompany with
bilingual interyi&wprs conducted.
pretest interviews at several clinics
in a large metropolitan area. These
clinics served members of the
target audience (Hispanic women
who had recently given birth). Inter­
viewers were stationed in the clinic
waiting room"to intercept respond­
ents, who were led to a quiet
location for the 'actual interview.
Respondents were given the breast­
feeding booklet to read. When they
were through, the interviewers re­

the target audience passes, gathers or
waits. Selecting respondents from
among those who have been "ex­
posed" to the poster in its "natural
setting" prior to the interview, and then
moving to a nearby but separate
location to ask questions will permit an
assessment of factors such as com­
prehension and personal relevance.
and also whether:
n the material attracts attention
□ the respondent can recall the
material when exposed to it in a
"natural” setting

The major advantage of the central
location intercept approach is its cost­
effectiveness for interviewing large
numbers of respondents in a short
amount of time. Because these
interviews are intended to provide
guidance ("qualitative" information).
the size of the sample should only be
large enough to give you answers to
your pretest questions. If you have
interviewed 50 respondents and most
of them feel similarly about your
materials, you are probably ready to
stop. If. however, there are substantial
disagreements or differences oetween
respondents, or their responses have
raised new questions, additional

turned to ask them questions. The
total amount of time required, from
intercept to completion of the inter­
view, averaged about 35 minutes.

interviews should be conducted until
you are satisfied that you have clear
direction from the respondents. You
may decide to revise (and perhaps test
again) after fewer interviews if it is
clear that changes are needed.
Designing a central location inter­
cept pretest can be relatively easy. A
few simple questions ("Do you
smoke?” “How old are you?" "Do you
have teenaged children?") can identify
respondents typical of the target audi­
ence quickly at the point of intercept.
Questions to assess comprehension
and target audience perceptions of the
pretest materials form the core of the
questionnaire (see appendix C). A few
additional questions, tailored to the
.
specific item or items being tested
’
("Do you prefer this picture—or this
one?"), also may be constructed to
meet program planners’ particular
needs. The interview should be no
longer than 15-20 minutes. If it must
be longer, you may need to design
special incentives to convince the
respondent to continue the interview
(e.g„ a small fee or gift, or a plea
regarding the importance of the
subject and their opinions).

Central location intercept interviews
should not be used if respondents
must be interviewed in depth or on
emotional or very sensitive subjects.
The intercept approach also may not
be suitable if respondents are likely to
be skeptical or resistant to being
interviewed on the spot (e.g.,
commuters anxious to return home).
Although it is time-consuming to set up
prearranged appointments, they may
actually save time if respondents may
not be willing to cooperate in a central
location.
3.

Theater Testing

"Theater” tests are so-called because
they gather a large group of respond­
ents to react, usually to audio or
audiovisual materials, into a room (or
“theater"-style setting) at once.
Commercial services conduct theater­
style tests for advertising agencies;
this technique can be adopted for
health messages. In commercial
theater testing, approximately 300
respondents are recruited by tele­
phone to a central location, such as a
hotel. Respondents are asked to watch
a "pilot" television program to judge
whether it should be aired. Commer­
cials are included in the program;
some are control (constant) spots,
others are being tested. At the conclu­
sion of the program, respondents are
asked whether they recalled any
commercials (or PSAs), and then
asked questions regarding content and
personal relevance. A similar se­
quence can be used to test radio
commercials.
Theater testing quickly gathers a
large number of responses. Unlike
some other pretest methods, the
materials being tested are imbedded
within a program, with commercials, to
simulate a natural viewing situation.
This permits the assessment of how
likely the audience is to pay attention
to and remember the message.
Because commercial testing
services are costly, a guide to con­
ducting your own theater-style tests is
included in appendix D. You can
42

choose a setting where the target
audience gathers and where they can
assemble in a large group (e.g., a
senior citizen center, a school
auditorium) to conduct your own
theater-style test.
4.

thinking of communication profession­
als. The group discussion stimulates
respondents to talk freely, providing
valuable clues for developing materials
in the consumers' own language, an-:
suggestions for changes or new
directions.

Focus Group Interviews

Focus group interviews are a form of
qualitative research adapted by market
researchers from group therapy. Also
called exploratory group sessions, they
are used to obtain insights into target
audience perceptions, beliefs and
language. Focus group interviews are
conducted with a group of about 8 to
10 people. Using a discussion outline,
a moderator keeps the session on
track while allowing respondents to
talk freely and spontaneously. As new
topics related to the outline emerge,
the moderator probes further to gain
useful insights.
Focus group interviews are es­
pecially useful in the concept develop­
ment stage of the communication
process. They provide insights into
target audience beliefs on a health
issue, allow program planners to
explore perceptions of message
concepts, and help trigger the creative

For example, in a pretest of po­
tential names and logos for a
county-wide heart disease preven­
tion program, program planners
conducted focus group interviews
with respondents representative of
the county's population. Respond­
ents' perceptions of 10 possible
logos and program names, repre­
senting a range of ideas related to
heart disease prevention, were
gathered. Preferences were ex­
pressed for program names which
specified the name of the county.
Names that contained abbreviatin'
were rejected as confusing. In logo
designs, respondents preferred
visual symbols of the program such
as a heart or the shape of the coun­
ty. These findings gave program
planners direction for selecting a
program name and creating a new
logo design that incorporated both
of these symbols.

In the planning stages of program
development focus groups can be
used to develop the hypotheses (or
broad study issues) for larger quantitaive studies. Focus groups also can
>elp determine public perceptions,
misconceptions and attitudes before a
questionnaire is developed and the
field research is conducted.
For example, in planning a major
national survey on public knowl­
edge, attitudes and practices re­
lated to breast cancer, researchers
conducted separate focus groups
with white, black and Hispanic men
and women to formulate the key
issues to be addressed in the sur­
vey. This qualitative research with
minorities was particularly impor­
tant because little information was
available on their beliefs about
breast cancer. The focus groups
helped researchers generate hy­
potheses and develop the wording
for specific questions.

Focus groups also can be used to
supplement quantitative research.
Market researchers originally devel­
oped this technique to explore in
greater depth the data from large scale
consumer surveys. Obtaining in-depth
information from individuals typical of
the target audience can provide
insights into what the statistical data
mean, or why individuals respond in
certain ways.
As with all respondents, those
elected for focus groups should be
typical of the intended target audience.
Various subgroups within the target
audience may be represented in sep­
arate group discussions, especially
when discussing sensitive or emotion­
al subjects, to segregate respondents
by age, sex, race or whatever other
variable is likely to hinder freedom of
expression. Teenage girls are less
likely to be inhibited in discussing
sexual activity, for instance, if their
parents, or teenage boys, are not in
the group. Respondents are recruited

1 to 3 weeks in advance of the inter­
view sessions, usually by telephone.
They may be recruited using the
telephone directory, and interviewed by
phone to determine if they qualify for
the group. Or, they may be recruited
from among members of a relevant
organization, place of employment or
other source. Recruiting respondents
“at random” is not required because
the results from focus group research
are not intended to be statistically
representative.
There are several important criteria
for conducting effective group inter­
views. Ideally, respondents should not
know the specific subject of the
sessions in advance, and they should
not know each other. Knowing the
subject may result in respondents
formulating ideas in advance and not
talking spontaneously about the topic
during the session. Knowing other
respondents may inhibit individuals
from talking freely. Finally, all respond­
ents should be relative “newcomers"
to focus group interviews. This permits
more spontaneity in reactions and
eliminates the problem of "profession­
al" respondents who may lead or
monopolize the discussion. For the
same reasons you may want to
exclude health professionals and
market researchers from focus groups.
There is no firm rule about the
number of focus groups that should be
conducted. The number of groups
depends upon program needs and
resources. If target audience percep­
tions appear to be comparable after a
few focus groups (you'll need at least
two groups to make this decision), you
may not find out any more by con­
vening additional sessions. If per­
ceptions vary, and the direction for
message development is unclear,
additional groups may be beneficial. In
this case, revisions in the discussion
outline after several groups can help
clarify unresolved issues in the
additional groups.

An experienced, capable moderator,
who can skillfully handle the group
process, should be used. The moder­
ator does not need to be an expert in
the subject matter being discussed:
rather, a good moderator builds rap­
port and trust and should probe
respondents without reacting to, or
influencing, their opinions. The
moderator must be able to lead the
discussion, and not be led by the
group. The moderator must emphasize
that there are no right or wrong
answers to questions posed. A good
moderator understands the process of^
eliciting comments, keeps the dis"

cussion on track, and makes it clear
that he or she is not an expert on the
subject. You will need to rehearse with
the moderator to point out any topics
or concerns you want emphasized, or
discussed in more depth.
As noted earlier, the results of focus
group interviews should be interpreted
carefully. It is useful for an unseen
observer (e.g., behind a one-way
mirror) to take notes as well as to tape
record or videotape the session for
later review. In interpreting the findings
from group interviews, you should look
for trends and patterns in target audi­
ence perceptions rather than just a "he
said... she said” kind of analysis.

43

Group discussion should not be
used when individual responses or
quantitative information are needed.
For example, when assessing the final
copy for a booklet, it is more important
to gather individual rather than group
reactions to indicate the individual’s
actual comprehension, perceptions
and potential use. However, self­
administered questionnaires can be
completed by each participant prior to
beginning a group discussion to
combine individual and group
reactions.
5.

•

Readability Testing

“Readability testing" simply predicts
the approximate educational level a
person must have in order to under­
stand written materials. Health infor­
mation materials such as pamphlets,
flyers, posters and magazine articles
are designed for distinct target groups;
a readability test will indicate if a
printed piece is written at a level most
of the audience can understand. As­
sessing the readability of a pamphlet
or another printed message will not
guarantee its effectiveness, and is by
no means an absolute indicator of
success.
Readability formulae use counts of
language variables such as word and
sentence length. The formulae have
been devised statistically to predict
readability scores. Generally speaking,
the reading level required to understand a given pamphlet will be higher
when its sentences are long and/or
when a large number of polysyllabic
words is found within the text.
It is important to note that readabil­
ity formulae measure only the structur­
al difficulty (i.e., vocabulary, sentence
structure and word density) of written
text. They do not measure other
factors related to how "readable" a
certain text is, such as sentence
"flow," conceptual difficulty, organiza­
tion of material, the influence of format
or design of materials on comprehen­
sion, accuracy or credibility. Readabili­
ty tests are conducted by program

staff and do not include participation
by the audience for whom the materi­
als are being produced. Consequently,
readability testing supplements but
does not supplant the need to pretest
with the target audience.
Despite its limitations, readability
testing is useful because it:

□ is quick
□ is virtually without cost
□ provides a tangible measure
□ reminds the writer to choose words
and terms carefully.

Based on a review of the advan­
tages, disadvantages and predictive
validity of 12 selected readability
formulae, the NCI Office of Cancer

Communications chose the SMOG
grading formula for testing the
readability levels of its public and
patient education materials. SMOG
was chosen because it is both simple
to use and accurate. Complete
instructions for using the SMOG
readability test to print materials are
included in appendix B.
Health and medical subjects ofte~
include many polysyllabic words arcomplex terms; readability formulae
have not been designed to take into
account the special terminology used
in describing health subjects. In some
cases, extensive use of multisyllabic
words known to be understandable to
a particular audience (e.g„ “cigarette")
may lead to an unwarrantedly high

Readability Scores of Selected Magazine
Articles
ou may want to compare the scores of your materials to those of these
health-related consumer magazine articles:

Y

Publication/
Article

SMOG
Grade

SMOG ±1.5 Grades

Ebony
"A Simple Test for Breast Cancer"

11

9.5-12.5 grade level

“Project Hi Blood"

11

9.5-12.5 grade level

“Is There a Male Change of Life?”

12

10.5-13.5 grade level

Reader’s Digest
"Say No to Your Children"

9

7.5-10.5 grade level

"What Smoking Does to Women”

12

10.5-13.5 grade level

"Cigarettes and Sudden Death"

13

11.5-14.5 grade level

Ladies’ Home Journal
“(en-do-me-tri-o'sis)"

14

12.5-15.5 grade level

“What You Need to Know About the New
Breast Cancer Therapy Everybody's
Discussing”

14

12.5-15.5 grade level

Time
"The Joseph Illness”
"Kidney in a Suitcase"

12
13

10.5-13.5 grade level
11.5-14.5 grade level

!*^ i. l

i

44

-eadability score. Therefore, as with all
etesting, readability test results
_,nould be used as indicative and not
predictive of problems or success.
6.

Gatekeeper Review

Often, public and patient education
materials are routed to their intended
target audiences through health prorssionals or other intermediaries such
s organizations that can communi­
cate for you to their members. These
intermediaries act as "gatekeepers."
controlling the distribution channels for
reaching your target audiences. Their
approval or disapproval of materials
may be a critical factor in a program's
success. If they do not like a poster or
: booklet, or do not believe it to be
credible or scientifically accurate, it
may never reach the intended audi­
ence. Also, because they may be in
closer touch with the target audience
than you are, they may provide good
advice about whether the audience
will accept the materials.
Although not a pretesting technique
n the strictest sense of the term,
gatekeeper review of rough materials
is important and should be considered
part of the formative evaluation pro­
cess. It is not a substitute for pretest­
ing materials with target audience
representatives. Neither is it a
substitute for obtaining clearances or
expert review for technical accuracy;
these should be completed before

While cancer patients and family
. members reviewed a coping-withcancer manuscript, copies also
were sent to staff at the Cancer
Information Service (CIS), a toll-free
telephone network that provides
information about cancer to the
public and to health professionals.
Because the CIS offices wouldJxm.
trey distribution channel for the.w

pretesting is undertaken. Sometimes
telling the gatekeeper that technical
experts have reviewed the material for
accuracy may provide reassurance
and hasten gatekeeper approval.
Gatekeeper reviews may be
conducted simultaneously with target
audience pretesting so that data from
both groups can be gathered, analyzed
and synthesized to provide direction
for revising materials. A short, self­
administered questionnaire may be
directed to individuals representative
of the gatekeeper population. A
sample is included in appendix C.
Questions may include overall reac­
tions to the materials and assess­
ments of whether the information is
appropriate and useful.
In other cases, there may be no
formal questionnaire, but rather a
telephone or personal conversation or
meeting held to review and comment
on (or approve) materials. If there is no
questionnaire, you should consider in
advance what kind of questions you
want to ask in the meeting or interview
and whether or not you need formal
approval of the materials. A discussion
with gatekeepers (e.g., a television PSA
director, the executive director of a
medical society) at this point can also
be used to introduce your program and
solicit their involvement in a variety of
ways beyond materials development.
(See Stage 4: Implementing Your
Program.)

Determine What and How
Much to Test
Qualitative research should be
conducted in the early stages of
program development before full funds
have been committed to materials
production and messages can be
changed if necessary. As noted earlier,
testing can be useful at the concept
development stage, once audiences
and communication strategies have
been determined, and prior to mes­
sage development. Exploration with
the target audience at this stage, most
frequently through focus group
discussions, can help determine
appropriate message appeals (e.g.,
fear arousing vs. factual), spokes­
person (e.g., a scientist, public official
or member of the target audience) and
appropriate language (determined by
listening to the group discussion).
Testing of drafted materials prior to
final production permits identification
of flaws prior to the expenditure of
funds for final production, and
especially prior to the use of materials
with target audiences.
Completed information materials are
sometimes tested prior to beginning a
new phase of a pre-existing program.
A combination of methods can be
used to assess an audience's compre­
hension, the message’s believability,
personal relevance, acceptability and
other strong and weak points. Methods
should be selected to suit the purpose
of the testing, the sensitivity of the
subject and the resources available for
testing. Adequate investigation is
especially important when developing
sensitive or potentially frightening
messages, presenting complex, new
information or designing a new
program. In these cases, pretesting
can reveal potential problems, but
must be carefully structured, con­
ducted and analyzed.

A national high blood pressure
education program produces new
PSAs each year. Prior to beginning
new production, spots from the
previous.year are tested to
determine whether the target
audience recalls, likes and identifies
with them. Based on test results,
themes may be used for several
years to help reinforce message
recall or new themes may be
developed.

□ How much do you know about the
target audience?
□ How much do you know about them
in relation to your health problem or
issue?
□ Is your issue or program new,
controversial, sensitive or complex?

□ Have you conducted related
research that can be applied to this
topic?
□ Can you afford to make a mistake
with a particular message or
audience?

Plan and Conduct Pretests

9 Qualitative research responses
cannot be considered representative of
the public, or projectable to the popu­
lation as a whole. If projectable data
are required, more formal methodolo­
gies should be used. However, for
most pretesting purposes, qualitative
methods may be more valuable
because they provide insights into
thinking and reasons for attitudes or
misunderstandings that are vital to
help refine messages and materials.
When deciding when, whether and
how much you should use pretest
methods in developing your program.
consider:

The level of effort and staff resources
required will vary considerably from
one pretest to the next. Most pretest­
ing is conducted with small samples
consisting of respondents who are
typical of the target audience and who
are easily accessible. These results,
combined with your professional
judgment, provide important direction
for improving messages and materials.
This section provides practical
suggestions for how to plan and
implement pretests. These sug­
gestions should help you reduce the
time and costs involved, whether or
not commercial research firms are
hired to supply field work and tabula­
tion. The cost estimates in the chart
on page 50 are for direct costs only;
not included are staff time to provide
direction or other support you would
provide to the firm conducting the test.
In some cases, you may reduce these
costs by conducting pretests on your
own, with the help of an expert. Some
market researchers will tell you that
bad research is worse than no re­
search, and you must use profession­
als; others say that with proper in­
struction, you can do some testing on
your own. Both points of view are
valid; venture on your own with care.
Designing the Questionnaire

As in the planning stage of program
development, a first step in planning a
pretest is to formulate the research
objectives. These objectives should be

46

...........

stated specifically to provide a clear
understanding of what you want to
learn. Measures of attention, compre­
hension, believability and personal
relevance are key. Other specific
questions to identify strengths and
weaknesses in rough messages and
materials also should be developed
based on the pretest objectives.
Questions should not be asked just to
satisfy someone’s curiosity.
There are several ways to keep
pretesting costs down:
□ keep the questionnaire short and to
the point

o try to use as many close-ended c
multiple choice questions as
possible for easy tabulation and
analysis
□ try to develop codes for quantifying
responses in advance when openended questions are necessary
□ whenever possible, borrow quest
from other pretesting research.

Sample questionnaires are included in
appendix C as one resource.
Recruiting Respondents

If your budget does not allow you to
hire a market research firm to recruit
you can recruit respondents yourse
A small donation may encourage
members of local church, school, civic
social organizations to participate in a
pretest.
An incentive is often used to help
ensure that respondents participate in
a pretest. Small amounts of money
($5-$30), gifts, movie passes or a fr<
dinner may be offered as an incenti.
to participants. Another way to ensure
sufficient participation is to recruit
more people than are actually needed.
Often respondents who agree to parti­
cipate do not show up. If all partici­
pants do show up, they should be
included in the pretest, or the "extra"
respondents should be informed that
too many respondents are present,
given the agreed-upon incentive,
thanked, and asked to leave.

Pretest Methods: Summary
I. Individual
a. Self-administered Questionnaires (mailed or personally delivered)
Purpose—To obtain individual reactions to draft materials
Application—print or audiovisual materials
Number of Respondents—Enough to see a pattern of response (Minimum 20; 100-200 ideal)
Resources Required— IList of respondents; Draft materials; Questionnaire; Postage (if mailed); Tape recorder or
VCR (for audiovisual materials)
Pros—Inexpensive; Does not require staff time to interact with respondents (if mailed); Can be anonymous for
respondents; Can reach homebound, rural, other difficult to reach groups; Easy and (usually) quick for
respondents
Cons—Response rate may be low (if mailed); May require follow-up; May take long time to receive sufficient
responses; Respondents self-select (potential bias); Exposure to materials isn't controlled; May not be
appropriate if audience has limited writing skills
b. Individual Interviews (phone or in person)
Purpose—Probe for individual's responses, beliefs, discuss range of issues
Application—Develop hypotheses, messages, potentially motivating strategies; Discuss sensitive issues or
complex draft materials
Number or Respondents—Minimum of 10 per type of respondent
Resources Required—List of respondents; Discussion guide/questionnaire; Trained interviewer; Telephone or quiet
room; Tape recorder
Pros—In-depth responses may differ from first response; Can test sensitive or emotional materials; Can test more
complex/longer materials; Can learn more about “hard-to-reach" audiences; Can be used with individuals
who have limited reading and writing skills
Cons—Time consuming to conduct/analyze; Expensive, and may yield no firmer conclusion or consensus

a Central Location Intercept Interviews
Purpose—To obtain more quantitative information about materials/messages
Application—Broad range, including concepts, print, audiovisual materials
Number of Respondents—60-100 per type (enough to establish pattern of response)
Resources Required—Structured questionnaire; Trained interviewers; Access to mall, school, other location;
Room or other place to interview; Tape recorder or VCR (for audiovisual materials)
Pros—Can quickly conduct large number of interviews; Can provide "reliable" information for decision-making;
Can test many kinds of materials; Quick to analyze close-ended questions
Cons—Short (10 min.) interviews; Incentive/persuasion needed for more time; Cannot probe; Cannot deal with
sensitive issues; Sample is restricted to individuals at the location; Respondents choose to cooperate and
may not be representative

47

2oi

Pretest Methods: Summary continued
II. Group
a. Focus Group Interviews
Purpose—To obtain in-depth information about beliefs, perceptions, language, interests, concerns
Application—Broad; concepts, issues, audiovisual or print materials, logos/other artwork
Number of Respondents—8-12 per group; Minimum 2 groups per type of respondent
Resources Required—Discussion outline; Trained moderator; List of respondents; Meeting room; Tape recorder;
VCR (for audiovisual materials)
Pros—Group interaction and length of discussion can stimulate more in-depth responses; Can discuss concepts
prior to materials development; Can gather more opinions at once; Can complete groups and analyses
quickly; Can cover multiple topics
Cons—loo few respondents for consensus or decision-making; No individual responses (group influence) unless
combined with other methods; Can be expensive; Respondents choose to attend, and may not be typical of the
target population

b. Theater Testing
Purpose—To test audiovisual materials with many respondents at once
Application—Pretest audio or audiovisual materials
Number of Respondents—60-100 per type (enough to establish a pattern of response)
Resources Required—List of respondents; Questionnaire; Large meeting room; AV equipment
Pros—Can test with many respondents at once; Large sample may be more productive; Can be inexpensive; Can
analyze quickly
Cons—Few open-ended questions possible; Can require more elaborate preparation; Can be expensive if
incentives required

III.
Nonparticipatory
a. Readability tests
Purpose—To assess reading comprehension skills required to understand print materials
Application—Print materials
Number of Respondents—None
Resources Required—Readability formula; 15 minutes
Pros—Inexpensive; Quick
Cons—“Rule of thumb" only/not predictive; Does not account for health terminology; No target audience reactio:.

isAppIic^bilrtjhpf Pretesti ng.Meth&ds^

Nonparticipatory

Readability
Tests
1. Concept Development
2. Roster
3. Flyer
4. Booklet
5. Notification Letter
6. Storyboard
7. Radio PSA
8. TV PSA
9. Videotape

X
X
X
X

... v
.................. «.;■

Qualitative

Focus
Groups
X
X
X
X
X
X
X
X
X

Self
Tests

Qualitative or Quantitative
Individual Central Location
The?
Mail
Interviews
Questionnaires Tests
Interviews
X

X
X
X

X
X
X

X
X
X
X
X
X
X
X

X
X
X
X
X
X

For conducting central location
interviews, university and college
departments of marketing, communi­
cations or health education might be
able to provide interviewer training and
student interviewers. Pretesting a
poster or an advertisement is an
excellent "real world" project for a
faculty member to adopt as a class
project. Students in these departments
are being trained in research methods,
and pretesting can give them a
chance to develop their skills.
Facilities

Pretesting facilities should be quiet
and comfortable. Meeting rooms at
churches, office buildings or other
institutions can be used for conducting
focus group or individual in-depth
interviews. If an observation room with
a one-way mirror is not available, you
may allow staff to listen by hooking up
speakers in a room nearby, or by
audiotaping or videotaping the session
Getting Help

Other ways to increase participation
elude:
- scheduling the pretest at a time that
is most convenient for respondents
(e.g., at lunch or after work)
□ choosing a safe and convenient site

o providing transportation

arranging for child care during the
time of the pretest, if necessary.

Recruiting patients or their families
must be given special consideration.
Clinics, hospitals or local HMOs can
be contacted for help, and adequate
plans should be made to ensure that
the respondents are not inconveni­
enced. Human subjects' clearance
lay be needed before proceeding.
Cooperation with the medical staff and
a concern for the physical and
emotional status of the patient and

family (especially if the patient needs a
family member's assistance to attend)
must be considered in planning the
pretest.
Identifying Interviewers

Trained interviewers should be used
whenever possible. For focus group
and in depth interviews, this is essen­
tial. If your agency has no experience
in focus group studies, you might
consider hiring a good, experiences
moderator, observing and taping tne
sessions and using them as training to
develop in-house skills. Local adver­
tising agencies may be of assistance
in identifying a good moderator.
Continuing education courses in
interpersonal communication or group
interaction also may be useful for staff
training or identifying potential
interviewers.

Many resources exist for obtaining
professional assistance in pretesting
As mentioned in the previous section,
the faculty at university departments of
marketing, communications, health
education, psychology or sociology
can be helpful in designing and con­
ducting pretests. Marketing research
firms that specialize in respondent
recruitment, interviewing, tabulation
and other services may have facilities
for conducting group sessions and
other techniques. The American
Marketing Association's Marketing
Services Guide lists suppliers and
services geographically throughout the
United States. Also, advertising clubs
(many affiliated with the American
Advertising Federation), and chapters
of the Public Relations Society of
America may undertake public service
projects at no charge to nonprofit
organizations. Other sources include
the Marketing Research Association,
and the Association of Public Opinion
Researchers.

49

Estimated Costs of Pretesting, 1988
hese estimated costs are included to suggest how you should budget
for pretesting using commercial research firms. Actual costs will vary
depending upon geographic location, audience to be recruited, amount of
effort contributed by staff, companies and respondents. The potential for
such contributions may be significant for some health issues. However, be
careful not to jeopardize the quality of results with a too-skimpy budget.

T

Qualitative Studies
(Estimated costs for 10 general population respondents for 1.5 hours)

a. Questionnaire development
b. Recruitment
c. Respondent Fees
d. Facilities, Travel
e. Moderator/lnterviewer
f. Analysis and Report
Total

Focus Group
(One)
$ 100- 300
350- 600
0- 400
250- 500
300- 500
300-1800
$1300-4000

Individual In-depth
Interviews (Ten)
$ 200- 500
400- 600
0- 300
150- 500
400- 600
450-2500

$1600-5000

Quantitative Surveys
(Estimated costs for 100 general population respondents for 15-20 minutes)
Door-to-Door

Central
Location
(Intercept/
Single Site)

a. Questionnaire
Development
b. Questionnaire
Production +
Travel/Facility
Phones/Mail
c. Screen/
Conduct
Interviews
d. Code/
Keypunch/
Tabulation
e. Analysis &
Report
Total

$ 400- 3000

$ 200-3000

Telephone
(Local)

Mail

$ 400-3000

$ 500-3000

One caution: individuals trained ir
commercial testing may not be
completely aware of all the nuances
and subtleties involved in health
communication. They will be able to
draw on their commercial experience
for selecting the appropriate pretest
methodology. However, there are other
factors such as the wording and
interpretation of questions and rest
that are influenced by the complexity;,
of health information. The old adage
that managers should know enough
about each facet of their business to
manage their experts holds true for
pretesting. You should be prepared to
supervise and guide your consultan’-■
Summary

To yield useful results, a pretest should
be planned carefully. Ample time
should be allowed for:
□ contracting with research firms (if
necessary)
□ arranging for the required facilitie(1-2 weeks)

□ developing and testing the question­
naire (2-3 weeks)
□ recruiting interviewers and respond­
ents (2-4 weeks)
□ gathering the data (1-2 weeks)

□ analyzing the results (1 week)

400- 1000

200- 500

300- 500

2500- 4000

1500-2000

1000-1500

100- 300

□ making the appropriate alteration;.
messages or materials
□ pretesting again, if needed.

0

And adequate pretesting should
include:

500- 1000

500-1000

500-1000

500-1000

□ carefully defining the target
audience

1000- 3000
$4800-12,000

1000-3000
$3000-9500

1000-3000
$3000-9000

1000-3000
$2100-7500

□ recruiting from that audience

Note: Although many costs increase consistently with increases in sample size. "Question­
naire Development" and "Analysis/Report" increase more slowly, reducing the cost-pen
interview with larger samples.

considering tests with "gate­
keepers'' or intermediaries

□, defining the purpose of materials
prior to designing questionnaire

□ locating a trained interviewer and
interpreter for some tests

Excuses for Avoiding Pretesting

□ carefully assessing results
□ considering using a “mix" of
methods to tailor your pretesting to
your needs.

Without adequate planning, pre­
testing may not serve its intended
purpose—to improve your messages
and materials. Instead, it could
become expensive research that is of
little or no use.

Selected Readings
Allman, William F„ "Staying Alive in the
20th Century," Science 85. pp. 31-41,
October 1985.

American Marketing Association.
Marketing Services Guide. Chicago:
published yearly.
Basch, Charles E.. "Focus Group
Interview: An Underutilized Research
Technique for Improving Theory and
Practice in Health Education." Health
Education Quarterly. Winter 1987. vol.
14(4), pp. 411-448.

Bertrand. Jane E„ Communications
Pretesting. Community and Family Study
Center. Media Monograph 6. University of
Chicago. 1978.
Sudman, Seymour and Bradburn, Norman
M.. Asking Questions: A Practical Guide to
Questionnaire Design. San Francisco. CA:
Jossey-Bass Publishers. 1986.

"I don't have the time or money."
Pretesting needs to be included as one step in your program development
process from the beginning. Time and resources for the pretest and for any
changes you might need to make as a result of the pretest should be
included in your project plans. Otherwise, you may not have the funds, and
your boss may see the time for pretesting and alterations in materials as a
delay in production rather than evidence of careful program development.

"My boss won't support pretesting."
Use the information in this guide and in the Suggested Readings to con­
vince him or her that you need to pretest. Beautiful materials and an ele­
gant program design can't guarantee that the target audience will pay
attention, understand and relate to your messages. It's cheaper to find out
whether the materials have a chance to work before they are produced
than to have to start over later, or worse—have an unsuccessful program.
Once you have pretested, be sure to explain to your superiors (in person or
in a report) how it worked and what resulted. Build a case for their accept­
ance of future pretesting. Using quotes from the target audience or anec­
dotes to illustrate your findings can make your report more interesting and
memorable.
"I can tell the difference between good and bad materials—I don't need to
pretest."
Many people have said this over the years, only to find out they can be
wrong. Your training and experience are essential credentials, but are you
sure you can react objectively to materials you have created or are
responsible for? Can you really assume the role of someone who is
different from you (if you are not representative of the target audience) and
see your materials through their eyes? Can you defend your decision with
those who may disagree without objective evidence?
"Our artist/producer says that pretesting can't be used to judge creativity."
Graphics staff, artists and creative writers may be sensitive to criticism
from "nonprofessionals." including the target audience. Explaining the
purpose of pretesting or involving them in the pretest process may help
them understand and appreciate the process. You should explain that you
are testing all elements of the communication—your original communica­
tion strategies, the message, the presentation—and not just their work. All
elements will be judged regarding their contribution towards the piece. By
testing alternative creative concepts you can provide the creative staff with
direction without telling them their work “failed.”

Chapter 1.

The Traditional View of
the Health Field

The traditional or generally-accepted view of the health field is that the art
or science of medicine has been the fount from which all improvements in health
have flowed, and popular belief equates the level of health with the quality of
medicine. Public health and individual care, provided by the public health physi­
cian, the medical practitioner, the nurse and the acute treatment hospital, have
been widely-regarded as responsible for improvements in health status. Individual
health care, in particular, has had a dominant position, and expenditures have
generally been directed at improving its quality and accessibility.

’ L i-H d

The success of the Canadian personal health care system, particularly in the
treatment of disease, is unquestioned, and the demand by the Canadian people
for more and better personal health care continues unabated. Preventive med­
icine, as exemplified by immunization, has practically eliminated such scourges
as smallpox, diphtheria and poliomyelitis, and advanced surgical procedures save
thousands more lives annually than they did thirty years ago. Graduates of Cana­
dian medical colleges and of post-graduate specialty training are the equal of any
in the world and Canadian hospitals have a general high level of service and
equipment that matches that of any other country. In both numbers and skills the
members of the Canadian nursing profession generally provide the finest of
nursing care. Taken as a whole, then, the amount, quality and method of financing
health care in Canada, while still improvable, is one'to be envied.
In most minds the health field and the personal medical care system are
synonymous. This has been due in large part to the powerful image projected by
medicine of its role in the control of infective and parasitic diseases, the advances
in surgery, the lowered infant mortality rate and the development of new drugs.
This image is reinforced by drug advertising, by television series with the physician
as hero, and by the faith bordering on awe by which many Canadians relate to
their physicians.

The consequence of the traditional view is that most direct expenditures on
health are physician-centered, including medical care, hospital care, laboratory

tests and prescription drugs. When one adds dental care and the services of such
other professions as optometrists and chiropractors, one finds that close to seven
billion dollars a yeacare-spenton a_personal health care system which is mainlyoriented to treating existing illness.

Chapter 2.

The Limitations of the
Traditional View

There are two approaches which can be taken to assess the" influence of
various factors on the general level of illness. One is by analysing the past and
determining the extent to which various influences have contributed, over the
years, to changes in the nature and incidence of sickness and death. A second
approach is to take present statistics on illness and death and to ascertain their
underlying causes.

The historical approach is most clearly expressed by Dr. Thomas McKeown,
Professor of Social Medicine at the University of Birmingham Medical School.2
Dr. McKeown traces the level of health in England and Wales back to the eigh­
teenth century, and evaluates the effect of the several influences on the health
level. His conclusions are:

,

“that, in order of importance the major contributions to improvement in
health in England and Wales were from limitation of family size (a
behavioural change), increase in food supplies_and a healthier physical
environment (environmental influences), and specific preventive and
therapeutic measures”3
and

“Past improvement has been due mainly to modification of behaviour
and changes in the environment and it is to these same influences that
we must look particularly for further advance”.4

These conclusions, drawn from an analysis of the history of the level of
health of the population, are not surprising when one recalls the progress in
income security, in education and in protection from public health hazards during
the past century.

The second approach is to examine the nature and underlying causes of
present mortality and hospital morbidity in Canada.

Chapter 4.

The Health Field Concept

A basic problem in analysing the health field has been the absence of an
agreed conceptual framework for sub-dividing it into its principal elements.
Without such a framework, it has been difficult to communicate properly or to
break up the field into manageable segments which are amenable to analysis
and evaluation. It was felt keenly that there was a need to organize the thousands
of pieces into an orderly pattern that was both intellectually acceptable and suffi­
ciently simple to permit a quick location, in the pattern, of almost any idea,
problem or activity related to health: a sort of map of the health territory.

Such a Health Field Concept6 was developed during the preparation of
this paper and it envisages that the health field can be broken up into four broad
elements: HUMAN BIOLOGY, ENVIRONMENT, LIFESTYLE and HEALTH
CARE ORGANIZATION. These four elements were identified through an exam­
ination of the causes and underlying factors of sickness and death in Canada,
and from an assessment of the parts the elements play in affecting the level of
health in Canada.

Human Biology
The HUMAN BIOLOGY element includes all those aspects of health, both
physical and mental, which are developed within the human body as a conse­
quence of the basic biology of man and the organic make-up of the individual.
This element includes the genetic inheritance of the individual, the processes of
maturation and aging, and the many complex internal systems in the body, such
as skeletal, nervous, muscular, cardio-vascular, endocrine, digestive and so on.
The human body being such a complicated organism, the health implications of
human biology are numerous, varied and serious, and the things that can go
wrong with it are legion. This element contributes to all kinds of ill health and
mortality, including many chronic diseases (such as arthritis, diabetes, atherosclerosis, cancer) and others (genetic disorders, congenital malformation, mental
retardation). Health problems originating from human biology are causing untold
miseries and costing billions of dollars in treatment services.

Environment

One of the evident consequences ofthe Health Field Concept has been to raise
HUMAN BIOLOGY, ENVIRONMENT and LIFESTYLE to a level of categorical
importance equal to that of HEALTH CARE ORGANIZATION. This, in itself, is a
radical step in view of the clear pre-eminence that HEALTH CARE ORGANIZA­
TION has had in past concepts of the health field.

The ENVIRONMENT category includes all those matters related to health
which are external to the human body and over which the individual has little or
no control. Individuals cannot, by themselves, ensure that foods, drugs, cosmetics,
devices, water supply, etc. are safe and uncontaminated; that the health hazards
of air, water and noise pollution are controlled; that the spread of communicable
diseases is prevented; that effective garbage and sewage disposal is carried out;
and that the social environment, including the rapid changes in it, do not have
harmful effects on health.

-/

-

A second attribute of the Concept is that it is comprehensive. Any health
problem can be traced to one, or a combination of the four elements. This com­
prehensiveness is important because it ensures that all aspects of health will be
given due consideration and that all who contribute to health, individually and
-/
collectively, patient, physician, scientist and government, are aware of their roles^'5

Lifestyle

and their influence on the level of health.

The LIFESTYLE category, in the Health Field Concept, consists of the
aggregation of decisions by individuals which affect their health and over which
they more or less have control. The importance of the LIFESTYLE category has
already been elaborated on in the section on The Limitations of the Traditional
View. Personal decisions and habits that are bad, from a health point of view,
create self-imposed risks. When those risks result in illness or death, the victim’s
lifestyle can be said to have contributed to, or caused, his own illness or death.

A third feature is that the Concept permits a system of analysis by which any
question can be examined under the four elements in order to assess their relative
significance and interaction. For example, the underlying causes of death from
traffic accidents can be found to be due mainly to risks taken by individuals, with
lesser importance given to the design of cars and roads, and to the availability of
emergency treatment; human biology has little or no significance in this area. In
order of importance, therefore, LIFESTYLE, ENVIRONMENT and HEALTH
CARE ORGANIZATION contribute to traffic deaths in the proportions of some­
thing like 75%, 20% and 5% respectively. This analysis permits program planners
to focus their attention on the most important contributing factors. Similar assess­
ments of the relative importance of contributing factors can be made for many

Health Care Organization
The fourth category in the Concept is HEALTH CARE ORGANIZATION,
which consists of the quantity, quality, arrangement, nature and relationships of
people and resources in the provision of health care. It includes medical practice,
nursing, hospitals, nursing homes, medical drugs, public and community health
care services, ambulances, dental treatment and other health services such as
optometry, chiropractics and podiatry. This fourth element is what is generally
defined as the health care system.

other health problems.

A fourth feature of the Concept is that it permits a further sub division of
factors. Again for traffic deaths in the Lifestyle category, the risks taken by in­
dividuals can be classed under impaired driving, carelessness, failure to wear
seat belts and speeding. In many ways the Concept thus provides a road map
which shows the most direct links between health problems, and their underlying
causes, and the relative importance of various contributing factors.

Until now most of society’s efforts to improve health, and the bulk of direct
health expenditures, have been focused on the HEALTH CARE ORGANIZA­
TION. Yet, when we identify the present main causes of sickness and death in
Canada, we find that they are rooted in the other three elements of the Concept:
HUMAN BIOLOGY, ENVIRONMENT and LIFESTYLE. It is apparent, there­
fore, that vast sums are being spent treating diseases that could have been pre­
vented in the first place. Greater attention to the first three conceptual elements
is needed if we are to continue to reduce disability and early death.

Finally, the Health Field Concept provides a new perspective on health, a
perspective which frees creative minds for the recognition and exploration of
hitherto neglected fields. The importance on their own health of the behaviour
and habits of individual Canadians is an example of the kind of conclusion that
is obtainable by using the Health Field Concept as an analytical tool.

Characteristics of the Health Field Concept
The HEALTH FIELD CONCEPT has many characteristics which make it a
powerful tool for analysing health problems, determining the health needs of

9
*

jjears responsibility for his patient, encourages the pracBe of physicians and
dentists carrying out tasks which could be'done by others, as well or better, and
often at a lower cost. In the Canadian North the role of the nurse has been ex­
panded along these lines with great success. Similarly, the Government of Saskat­
chewan has successfully implemented a dental care system for school children
in which a major part of the work is done by dental health professionals other
than dentists, according to protocols established by dentists and under their

Chapter 4.

The Health Field Concept

overall supervision.

Finally, there is the paradox of everyone agreeing to the importance of re­
search and prevention yet continuing to increase disproportionately the amount
of money spent on treating existing illness. Public demand for treatment services
assures these services of financial resources. No such public demand exists for
research and preventive measures. As a consequence, resources allocated for
research, teaching and prevention are generally insufficient.

It would appear that steps need to be taken to reconcile the foregoing, and
other conflicting goals and principles, while retaining all that is necessary to pro­
perly reward health manpower, control costs and ensure accessibility to quality
service.

A basic problem in analysing the health field has been the absence of an
agreed conceptual framework for sub-dividing it into its principal elements.
Without such a framework, it has been difficult to communicate properly or to
break up the field into manageable segments which are amenable to analysis
and evaluation. It was felt keenly that there was a need to organize the thousands
of pieces into an orderly pattern that was both intellectually acceptable and suffi­
ciently simple to permit a quick location, in the pattern, of almost any idea.
problem or activity related to health: a sort of map of the health territory.
Such a Health Field Concept6 was developed during the preparation of
this paper and it envisages that the health field can be broken up into four broad
elements: HUMAN BIOLOGY, ENVIRONMENT. LIFESTYLE and HEALTH
CARE ORGANIZATION. These four elements were identified through an exam­
ination of the causes and underlying factors of sickness and death in Canada,
and from an assessment of the parts the elements play in affecting the level of
health in Canada.

Human Biology

30

31

p H - \T

The HUMAN BIOLOGY element includes all those aspects of health, both
physical and mental, which are developed within the human body as a conse­
quence of the basic biology of man and the organic make-up of the individual.
This element includes the genetic inheritance of the individual, the processes of
maturation and aging, and the many complex internal systems in the body, such
as skeletal, nervous, muscular, cardio-vascular, endocrine, digestive and so on.
The human body being such a complicated organism, the health implications of
human biology are numerous, varied and serious, and the things that can go
wrong with it are legion. This element contributes to all kinds of ill health and
mortality, including many chronic diseases (such as arthritis, diabetes, athero­
sclerosis, cancer) and others (genetic disorders, congenital malformation, mental
retardation). Health problems originating from human biology are causing untold
miseries and costing billions of dollars in treatment services.

Environment
The ENVIRONMENT category includes all those matters related to health
which are external tothe human body and over which the individual has little or
no control. Individuals cannoETylhemselves, ensure that foods, drugs, cosmetics,
devices, water supply, etc. are safe and uncontaminated; that the health hazards
of air, water and noise pollution are controlled; that the spread of communicable
diseases is prevented; that effective garbage and sewage disposal is carried out;
and that the social environment, including the rapid changes in it, do not have
harmful effects on health.

Lifestyle
The LIFESTYLE category, in the Health Field Concept, consists of the
aggregation of decisions by individuals which affect their health and over which
they more or less have control. The importance of the LIFESTYLE category has
already been elaborated on in the section on The Limitations of the Traditional
View. Personal decisions and habits that are bad, from a health point of view,
create self-imposed risks. When those risks result in illness or death, the victim’s
lifestyle can be said to have contributed to, or caused, his own illness or death.

Health Care Organization
The fourth category in the Concept is HEALTH CARE ORGANIZATION,
which consists of the quantity, quality, arrangement, nature and relationships of
people and resources in the provision of health care. It includes medical practice,
nursing, hospitals, nursing homes, medical drugs, public and community health
care services, ambulances, dental treatment and other health services such as
optometry, chiropractics and podiatry. This fourth element is what is generally
defined as the health care system.

Until now mo.stQLsocietv’s efforts to improve health, and the bulk of direct
health expenditures, have been focused on the HEALTH CARE ORGANIZA­
TION. Yet, when we identify the present main causes of sickness and death in

One of the'^dent consequences of the Health Field Concept has been to raise

HUMAN BIOLOGY, ENVIRONMENT and LIFESTYLE to a level of categorical
importance equal to that of HEALTH CARE ORGANIZATION. This, in itself, is a
radical step in view of the clear pre-eminence that HEALTH CARE ORGANIZA­
TION has had in past concepts of the health field.
A second attribute of the Concept is that it is comprehensive. Any health
problem can be traced to one, or a combination of the four elements. This com­
prehensiveness is important because it ensures that.all,aspects_of,health.will.be...
given due consideration and that all who contribute to_health, individually and
collectively, patient, physician, scientist and government, are aware of their roles
and their influence on the level, of health.
A third feature is that the Concept permits a system of analysis by which any
question can be examined under the four elements in order to assess their relative

significance and interaction. For example, the underlying causes of death from
traffic accidents can be found to be due mainly to risks taken by individuals, with
lesser importance given to the design of cars and roads, and to the availability of
emergency treatment; human biology has little or no significance in this area. In
order of importance, therefore, LIFESTYLE, ENVIRONMENT and HEALTH
CARE ORGANIZATION contribute to traffic deaths in the proportions of some­
thing like 75%, 20% and 5% respectively. This analysis permits program planners
to focus their attention on-themost important contributirigTactors. Similar assess­
ments of the relative importance of contributing factors can be made for many
other health problems.

A fourth feature of the Concept is that it permits a further sub-division of
factors. Again for traffic deaths in the Lifestyle category, the risks taken by in­
dividuals can be classed under impaired driving, carelessness, failure to wear
seat-belts and speeding. In many ways the Concept thus provides a road map
which shows_thg mqst direct: links, bgtyyegn health. problems, and their underlying
causes, and the relatiyejrnportance of various contributing factors.

Canada, we find that they are rooted in the other three elements of the Concept:
HUMAN BIOLOGY, ENVIRONMENT and LIFESTYLE. It is apparent, there­
fore, that vast sums are being spent treating diseases that could have been pre­
vented in the first place. Greater attention to the first three conceptual elements
is needed if we are to continue to reduce disability and early death.

Finally, the Health Field Concept provides a new perspective on health, a
perspective which Trees creative minds.’.for the recognition and exploration of
hitherto neglected- fields.«The importance on their own health of the behaviour
and habits of individual Canadians is an example of the kind of conclusion that
is obtainable by using the Health Field Concept as an analytical tool.

Characteristics of the Health Field Concept

One of the main problems in improving the health of Canadians is that the
essential.piower-to-do so is widely dispersed among individual citizens, govern­

The HEALTH FIELD CONCEPT has many characteristics which make it a
powerful tool for analysing health problems, determining the health needs of
Canadians and choosing the means by which those needs can be met.

32

ments, health professions and institutions This fragmentation of responsibility
has sometimes led to imbalanced approaches, with each participant in the health
field pursuing solutions only within his area of interest. Under the Health Field

Concept, the fragments are brought together into a unifiec^^iole which permits

, everyone to see the importance of all factors, including those which are the
responsibility of others.
This unified view of the health field may well turn out to be one of the Con­
cept’s main contributions to progress in improving the level of health.

Chapter 5.

Issues Arising From
the Use of the
Health Field Concept

The Concept was designed with two aims in view: to provide a greater un­
derstanding of what contributes to sickness and death, and to facilitate the iden­
tification of courses of action that might be taken to improve health.
The Concept is not an organizational framework for structuring programs
emdactiyities, and for establishingjines of command. The'rigid'allocation of prob
lems and activities to one or another of the four elements of the Concept would
be contrary to reality and would perpetuate the present fragmentary approach
to solving health problems. For example, the problem of drug abuse needs atten
tion by researchers in human biology, by behavioural scientists, by those who
administer drug laws and by those who provide personal health care. Contribu­
tions are needed from all of these and it would be a misuse of the Health Field
Concept to exploit it as a basis for capturing all aspects of a problem for one
particular unit of organization or interest group.

A second practical problem is the perennial one pfjederal provincial jurisdictiorial.boundaries.in the health.field. Since the Concept was intended to cover
the whole health field without regard to jurisdiction, and since there are very real
limits on federal powers, the argument could be made that we were looking at
matters which had no history of federal concern or authority.’The only answer
here, of course, is that the right questions must be posed about the health field
before a determination can be made of legitimate federal responses.
A third issue, more theoretical, was whether or not it was possible to divide
external influences on health between the environment, about which the individ­
ual can do little, and JifestylejJn which, he can make choices. Particularly cogent
were arguments that personal choices were dictated by environmental factors,
such as the peer-group pressures to start smoking cigarettes during the teens.
Further, it was argued that some bad personal habits were so ingrained as to
constitute addictions which, by definition, no longer permitted a choice by a

35
34

simple act of will. Smoking, alcohol abuse and drug aEuse were some of the
lifestyle problems referred to in this vein.
The fact that there is some truth in both hypotheses, i.e. that, environment
affectsTilestyle and that some personal habits are addictive, requires a philosophicaTand moral response rather than a purely intellectual one. This response is,
that if we simply give up on individuals whose lifestyles create excessive risks
to their health, we will be abandoning a number who could have changed, and
will be perpetuating the very environment which influenced them adversely in
the first place. In short the deterministic view must be put aside in favour of faith
in the power of free will, hobbled as this power may be at times by environment
and addiction.

One point on which no quarter can be given is that difficulties in categorizing
the contributing factors to a given health problem are no excuse for putting the
problem aside; the problem does not disappear because of difficulties in fitting
ft nicely into a conceptual framework.

Another issue is whether or not the Concept will be used to carry too much
of an analytical workload by demanding that it serve both to identify requirements
for health and to detem2nej.he.mecha.ni5.rns Jor_meefirig_tfem.~AIfh'bugh the
Concept vHlThelp bring out the problems and their causes, and even point to
the avenues by which they can be solved, it cannot determine the.precise steps
that are needed to implement programs. Decisions as to programs are affected
by so many other considerations that they will require the analysis of many prac­
tical factors outside the Concept proper.

The ultimate philosophical issue raised by the Concept is whether, and to
what extent government can get into the.business of modifying human behaviour,
even if it does so to improve Health. The marketing of socialchange is a new
field which applies the marketing.techniques_o£_the business_world.to getting
people to changejheir.behaviour, i.e. eating habits, exercise habits, smoking
habits? driving habits, etc. It is argued by some that proficiency in social market­
ing would inevitably lead government into all kinds of undesirable thought control
and propaganda. The dangers of governmental proficiency in social marketing
are recognized but so are the evident abuses resulting from all other kinds of
marketing. If the siren song of coloured television, for example, is creating an
indolent and passive use of leisure time, has the government not the duty to coun­
teract its effects by marketing programs aimed at promoting physical recreation?
As previously mentioned, in Canada some 76% of the population over age 13
devotes less than one hour a week to participation in sports while 84% of the
same population spends four or more hours weekly watching television. This
kind of imbalance extends to the amount of money being spent by the private
sector on marketing products and services, some of which if abused, contribute

36

to sickness and death. One must inevitably conclude that society, through govern­
ment, owes it to itself to develop protective marketing techniques to counteract
those abuses.
Finally, some have questioned whether an increased emphasis on human
biology, environment and lifestyle will not lead to a diminution of attention to the
system of personal health care. This issue is raised particularly by those whose
activities are centred on the health care organization. On this issue it can be said,
first of all, that Canadians would not tolerate a reduction in personal health care •
and are in fact pushing very hard to make service more accessible and more
comprehensive. In response to this demand, several Canadian Provinces have
extended insured health care services beyond those whose cost is shared by the
Federal Government. These extensions will no doubt continue.

More important, if the incidence of sickness can be reduced by prevention
then the cost of present services will go down, or at least the rate of increase will
diminish. This will make money available to extend health insurance to more
and more services and to provide needed facilities, such as ambulatory care
centres and extended care institutions. To a considerable extent, therefore, the
increased availability of health care services to Canadians depends upon the
success that can be achieved in preventing illness through measures taken in
human biology, environment and lifestyle.

In this section some practical, theoretical and philosophical issues arising out
of the Health Field Concept have been sketched out. No doubt other problems.
including those of analytical methodology, will be encountered but as long as the
ultimate goal is kept in mind, which is to increase the average number of disabilityfree days, in the lives of Canaclians, these difficulties can be overcome.

Role of the Private Sector in Health Systems

Challenges
and
Opportunities

pH-n.
Ta Role of the Private Sector in Health Systems

Challenges

and

Opportunities

The Challenge: Harnessing the
Private Sector for the
Public Good

hroughout the developing world, the
private sector plays a key role in many aspects of
health care. Nevertheless, the impact of private sector
activities on health systems has not been sufficiently
analyzed. A closer look reveals several major problems
common to health systems in the developing world.

T

Lack of affordability: In most developing countries,
health care is individually funded primarily out-ofpocket. Poor people in these low-income countries often
spend money to see private health care providers and
purchase drugs from private markets, even when there
are public sector alternatives. (See chart below.) In
addition, many low-paid public sector doctors also
maintain private practices, or charge "under the table"
fees for services in public facilities. The strain of out-ofpocket payments frequently leads to situations where
the poor either do not get the care they need or become
even more impoverished if they do.

Limited availability: In most developing countries,
poor people have limited access to hospitals, clinics and
other health services. Availability of care is especially
problematic in rural areas where there are typically
fewer resources. Poor people frequently must travel
considerable distances to access health services.
Additionally, the number of available public and private
medical staff continues to decrease in the poorest
^countries because it is difficult to make practicing in
rural areas attractive enough to health care providers.
Widely uneven quality: In the developing world,
services provided by health care practitioners in both
the public and private sectors are often of inadequate
quality. In the public sector, ministries of health are
hampered by limited and inefficiently allocated funding,
as well as misaligned incentive structures that fail to
promote high performance. Both sectors also lack
enforced quality standards for products and services.
While governments maintain some oversight of public
providers, private provision is largely unmonitored,
leading to wide variations in quality.

^>ut-of-pocket spend as percent of total health spend

WE WILL EXPLORE OPPORTUNITIES for improving
health systems through a comprehensive analysis of

how public and private sectors can work together
to improve health outcomes for poor and vulnerable

people. Our efforts will focus on several approaches:
Risk-pooling: Programs that allow individuals to
prepay for medical services and share risk through
_
public or private health insurance, to provide protection Q

against excessive out-of-pocket costs, and increase
access to care. Programs and policies that utilize risk­
pooling and prepayment protect individuals from
catastrophic expenses, encourage increased use of
preventive and curative services, and can provide
mechanisms for subsidizing the poorest families.
Provider purchasing and contracting: The
interface between public or private health insurance
programs and health care providers to align incentives
and payment mechanisms with desired outcomes, while
establishing and monitoring quality and efficiency
targets. Strategic purchasing could significantly improve
availability and quality of care through a greater emphasis

on measurable results.

Government and self-regulation: Monitoring and
enforcement of physician, hospital and medication
standards to promote affordable, high-quality care.
Better regulatory measures, whether established by
governments or self-imposed by professional provider
groups, would improve quality by discouraging
substandard facilities, unqualified practitioners and
questionable medical suppliers.

Innovative service models: Service delivery models
vouEnd I001'SUCh u5 franChi5ing'social marketing,
standi, t
Inin9, Which utilize economies
scale
a e un' h0" °r market incentives to enab'e rapidqUali7‘ 'nn0VatiVe ^“models
P°tentially improve quality and access.

Xmachel tor0DdUCt S“PP'y Chain m°dels: New

PmduS that Pd°CUrement and diStribution of medical
in tran?port tiLepdUCedC°St?nd increase effictencies
reduce costs and in^ reach:Such imProvements could
^^d mease reliability of product inventories.

What We Are Doing and
What We
Hope to Achieve

THERE ARE GENUINE OPPORTUNITIES to improve the
lives of poor people by leveraging and managing the
private sector to improve health systems in developing
countries. During 2008, the Rockefeller Foundation, in
partnership with the Results for Development Institute
and the International Health Policy Program of the
Thai Ministry of Public Health, and other partners will
attempt to:
Identify opportunities to strengthen existing
successful programs, while expanding the
currently limited evidence base. We will identify
promising models incorporating the private sector
(whether implemented by governments or private
organizations) that can be enhanced, adapted to other
countries or more rigorously evaluated.

Advance thinking on health systems stewardship.
We will explore how governments can address private
sector players, as well as the appropriate roles of private
sector entities within broader health systems. We will
also consider how approaches—such as risk-pooling,
regulation, purchasing and innovative service models—
can be adopted and integrated with each other to

improve health systems.

Determine whether there is a need for a shift
in thinking regarding the role of the private
sector in health systems. We will identify the major
barriers to changing policy, practice and funding
priorities and explore appropriate options for inviting

more attention to private sector issues.

Frequently
i Asked
1 Questions

Why is this effort being undertaken now?
The current global commitment to health is high and
there is renewed interest among donors, politicians and
technical experts in building and strengthening health
systems. In fact, the historical pendulum between vertical
and horizontal approaches is moving back toward a
horizontal perspective.

In addition, health spending in developing countries is
growing and will continue to grow at a rate slightly
higher than GDP growth. Much of this growth is likely to
be in the private sector initially. Thus, there is a substantial
opportunity to influence the design of future health

systems now.

The private sector growth phenomenon is clearly evident
in a number of developing countries where overall health
expenditure has significantly outpaced GDP growth,
and the private sector portion (including out-of-pocket
payments) has increased as well.
Haven't others already explored similar
approaches? What makes this effort different?
This initiative will incorporate a broad health systems
perspective in addressing private sector engagement
and government stewardship. Many of the current
and previous initiatives addressing the private health
sector in developing countries have focused on specific
diseases or types of interventions, such as contracting or
franchising. In addition, most existing programs as well
as research on the private sector tend to focus either on
provision of services or on financing. This initiative will
consider the possible roles for the government and the
private sector in financing and provision.

Is this an attempt to promote privatization of
health services in developing countries?
No. While we start with the premise that in many
countries the private health sector is a reality that must
be addressed, the goal of this initiative is not to promote
the privatization of health systems, nor is it to develop
new public-private partnerships designed to accomplish
relatively narrow goals. Rather, this initiative aims to
develop means through which the public and private
sectors can work together to address the challenges of
affordability, quality and availability of health care.

*

Who will be involved in this effort?
The effort will be led by the Rockefeller Foundation,
the International Health Policy Program within the'
Thai Ministry of Public Health, and the Results for
Development Institute, based in Washington, D.C.
A working group comprised of respected public health
professionals, donors, NGOs, health ministry staff and
private sector representatives will provide guidance to
fcthe core group. In addition, the Foundation will seek
additional technical partners.
What happens after 2008?
Our work in 2008 is exploratory in nature. A determination
of possible next steps will depend on a comprehensive
and critical evaluation of this first-year effort. We aim
to broaden knowledge and identify and assess potential
options for a larger-scale, longer-term initiative. Future
efforts might include further knowledge development,
specific country-level investments in promising models,
and/or mobilization of key partners to build global
momentum toward stronger health systems that address
the private sector.

Contacts
■ Gina Lagomarsino, Visiting Fellow, The Brookings Institution,
and Managing Director, Results for Development Institute,
+1.202.741.6580, glagomarsino@brookings.edu

O' Stefan Nachuk, Associate Director, The Rockefeller

Foundation, +1.212.852.8417, snachuk@rockfound.org
■ Supon Limwattananon, Senior Researcher, International
Health Policy Program (IHPP), Thai Ministry of Public Health,

+66.2.590.2370, supon@ihpp.thaigov.net

Initial Working Group Members
■ David de Ferranti (Chair), The Brookings Institution and
Results for Development Institute
. Suwit Wibulpolprasert (Co-Chair), Thai Ministry of Public Health

■ Eduardo Aninat, Isapres, Chile
■ E. A. Elebute, Hygeia Nigeria Limited
■ Anne Mills, London School of Hygiene & Tropica
■ Sania Nishtar, Heartfile, Pakistan
■ Ariel Pablos-Mendez, The Rockefeller Foundation
■ Sangita Reddy, Apollo Group of Hospitals, India
■ Julian Schweitzer, The World Bank
■ Marie-Odile Waty, French Development Agency
■ Miriam Were, African Medical & Research Foun

e i

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FOUNDATION

Q

Results for Development

© 2008 The Rockefeller Foundation, Results For Development and
the International Health Policy Program, Thailand. All rights reserved.
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