450879 HPPXXX10.
1177/1524839912450879Health
Promotion Practice / Month XxxxEdgar, Volkman / Using Communication Theory
2012
Social Marketing and Health Communication
Using Communication Theory for Health
Promotion: Practical Guidance on
Message Design and Strategy
According to the U.S. Department of Health and Human
Services, health communication is “the study and use
of communication strategies to inform and influence
individual and community decisions that enhance
health.” The purpose of this article is to look at how
health educators can use communication theory to cre-
ate messages that are innovative, relatable, and motivat-
ing to intended audiences. Three specific communication
theories are presented, along with examples of how they
have been successfully used in behavior change initia-
tives. These three theories are offered in an effort to
stimulate further investigation into how theory supports
the creation of targeted, tailored, and effective commu-
nication strategies.
Keywords: communication theory; fear appeals; sen-
sation seeking; narrative
>>
A Look At Three Communication
Theories
The noted psychologist Kurt Lewin frequently said,
“There is nothing so practical as a good theory”
(Sandelands, 1990, p. 235). Too often, theory is unfairly
perceived as an academic exercise that creates an unnec-
essary hurdle for practitioners, but we concur with
Lewin. Robust theory serves as a trustworthy guide and
actually allows us to do our work more efficiently and
effectively. Without it, we have to rely on intuition and
guessing for strategic decision making in health promo-
tion. As two scholars/practitioners experienced in the
health communication field, we turn regularly to models
Health Promotion Practice
September 2012 Vol. 13, No. 5 587­–590
DOI: 10.1177/1524839912450879
© 2012 Society for Public Health Education
587
Timothy Edgar, PhD1
Julie E. Volkman, PhD2
and theories familiar to most health educators, such as
the health belief model, social cognitive theory, the
theory of planned of behavior, and the transtheoretical
model. These frameworks have stood the test of time
and also inform effective approaches to behavior change.
However, we also rely on theoretical foundations devel-
oped within the communication discipline that have
tremendous value for health promotion. The goal of this
article is to identify multiple theories developed by
communication scholars and show how they can be
applied in public health. Our hope is that readers not
already familiar with these approaches will be intrigued
by their potential and will further explore how they
might be added to their theoretical toolbox.
1
Emerson College, Boston, MA, USA
2
ENR Memorial Veterans Hospital, Bedford, MA, USA
Authors' Note: The authors wish to thank Susan Vitulli for her
assistance with preparation of the article.
Associate Editors, Social Marketing and Health
Communication Department
Heidi Keller is a health promotion and social marketing
consultant based in Olympia, Washington.
Claudia Parvanta, PhD, leads the behavioral science research
and health communication programs at the University of the
Sciences (U Sciences) in Philadelphia. Together with Nelson,
Parvanta (S), and Harner, she is the author of Essentials of
Public Health Communication (Jones & Bartlett Learning,
2011) and Communicating Public Health Information
Effectively: A Guide for Practitioners (APHA, 2002) with
Nelson, Brownson, and Remington. Before joining U Sciences
in 2005, Claudia headed the Division of Health Communication
(in the Office of the Director) at the CDC for six years.
Activation Model
The first two models we discuss offer very specific
guidance on message design. The activation model is the
narrowest in scope. It is unusual in that most frameworks
that explain behavior change commonly focus on cogni-
tive thought processes but rarely offer detailed guidance
on the audio and visual components of message design.
This model is atypical in that understanding of a person-
ality characteristic lies at its core. The activation model
examines individual needs for stimulation and the likeli-
hood that messages will attract attention and continue to
engage, depending on the audience’s need for sensation
seeking (Stephenson & Southwell, 2006).
Sensation seeking refers to the desire for “varied,
novel, complex, and intense sensations and experiences,
and the willingness to take physical, social, legal, and
financial risks for the sake of such experiences”
(Zuckerman, 1994, p. 27). Those at the high end of the
sensation-seeking spectrum are more likely to partici-
pate in thrill-seeking activities such as bungee jump-
ing, rock climbing, and watching horror movies. They
also are more likely than their low-sensation-seeking
counterparts to engage in risky health-related behaviors
such as illegal drug use, heavy alcohol consumption,
and unprotected sex with multiple partners (Stephenson
& Southwell, 2006).
As a guide for effectively reaching sensation seekers,
the model posits a media strategy called SENTAR
(SENsation seeking TARgeting) that recommends that
campaign planners create messages with high sensa-
tion value for high sensation seekers (Palmgreen &
Donohew, 2010). Communication activities with high
sensation value typically have the following charac-
teristics: “(a) novel, creative, or unusual; (b) complex;
(c) intense stimuli that are emotionally powerful or
physically arousing; (d) graphic or explicit; (e) some-
what ambiguous; (f) unconventional; (g) fast paced;
and (h) suspenseful” (Noar, Palmgreen, Zimmerman,
Lustria, & Lu, 2010, p. 24). Once health educators
develop high-sensation value messages, the goal is to
place them strategically so that high sensation seekers
encounter them while engaged with forms of entertain-
ment consistent with their need for stimulation, such
as ads placed on MTV or during sporting events.
The activation model has been used most frequently
to guide the production and placement of advertise-
ments for initiatives aimed at young sensation seekers
around issues such as marijuana use, delay of first
sexual experience, and condom use. For example, the
design team for a project conducted in Kentucky and
Tennessee created a 30-second ad with approximately
15 cuts, beginning with college-aged people dancing to
588 HEALTH PROMOTION PRACTICE / September 2012
loud, pulsating music at a club with lights flashing.
The text “Believe everything you hear?” appears super-
imposed over the blurred image of the dancers. The
scene then cuts rapidly to a close-up of a young man in
a tight T-shirt flirtatiously informing a potential female
partner “I can give you everything you’ve ever dreamed
of.” Before she can respond, their image fades into the
background as the following text is stamped on screen
in bolded capital letters in rhythm with a distinctive
pounding sound: DIRTY DIAPERS, SCREAMING
BABIES. Another dancing woman then twirls to a man
and seductively utters the line “I can give you some-
thing you’ll never forget.” To the same pulsating noise,
the words GONORRHEA, CHLAMYDIA, AIDS appear.
The final cut is to a young man who lasciviously says
to yet another woman “I can put a smile on your face
for weeks!” Again, bold-lettered wording appears, but
instead of a warning of negative outcomes, the text says
“HE’S RIGHT . . . HE USES CONDOMS.” The final image
is the campaign’s tagline: “Use a condom. Every partner.
Every time.” (Noar et al., 2010). Data from numerous
initiatives based on the activation model have demon-
strated positive results (Palmgreen & Donohew, 2010).
Extended Parallel Process Model
The second theory that provides details on message
content is the extended parallel process model (EPPM).
The EPPM is a useful tool for understanding how to
construct effective risk messages that are grounded in
fear appeals and scare tactics. It is always tempting to
want to frighten people into behavior change, because it
seems so intuitive that people will behave differently if
they just understand the risk of not changing course.
However, studies are mixed about the efficacy of appeal-
ing to fear. Empirical evidence exists both for and
against the use of communicating high-risk messages
(Witte, Meyer, & Martell, 2001). Drawing from both the
parallel process model (Leventhal, 1971) and the pro-
tection motivation theory (Rogers, 1975), the EPPM
explains the conditions under which fear appeals are
likely to succeed.
According to the model, people respond to health
risk messages through two forms of cognitive apprais-
als that occur sequentially. With initial exposure to a
fear appeal, recipients engage in a threat appraisal.
Individuals base their first appraisal on assessment of
both severity and susceptibility, which are familiar con-
cepts from other frameworks. That is, message recipi-
ents determine if the unpleasant outcome associated
with not changing behavior is serious enough to be
concerned about (i.e., severity) and if there is a reason-
able probability that the negative outcome will actually

happen (i.e., susceptibility). If the result of the appraisal
is that the threat is not sufficiently severe and/or one is
not realistically susceptible to the threat, then people
simply ignore the message (Witte et al., 2001).
If, however, both severity and susceptibility are
high enough for someone to feel threatened, one
moves to efficacy appraisal. Here attention turns to
the recommended behavior for responding to the
threat by evaluating two forms of efficacy. The first
form is self-efficacy, which is a concept familiar to
health educators that focuses on an individual’s con-
fidence in his or her own ability to perform the behav-
ior. The second type of efficacy appraisal is response
efficacy. With this form, message recipients look
beyond the ability to perform the behavior and ask
whether the behavior will really make any difference.
The EPPM teaches us that a fear appeal will only have
a likelihood of success if the two forms of efficacy
appraisal are high in tandem. Too often health educa-
tors overlook the essential response efficacy ingredi-
ent. Campaign planners frequently ask message
recipients (at least implicitly) to accept on faith that
engaging in the prescribed behavior will in reality lead
to the desired outcome. Imbedding evidence for
response efficacy within messages fortifies any call for
change (Witte et al., 2001).
One example of the successful application of the
EPPM comes from a gun safety campaign conducted
in Michigan (Roberto, Meyer, Johnson, Atkin, & Smith,
2002). The goal of the initiative was to persuade gun
owners to acquire a gun trigger lock. The primary pro-
motional tool for the campaign was a radio public
service announcement in which campaign planners
first steered the target audience toward a threat
appraisal by focusing on the vulnerability of children
in a household with a gun by communicating a sense
of severity and susceptibility. As the listener hears the
voices of two children discovering a gun, an announcer
says “You should know that last year over 1,300 peo-
ple, including children, died from accidental gunshot
wounds” and “. . . gun accidents are one of the leading
causes of death for 5- to 14-year-olds in the US.” The
script then moves to eliciting an efficacy appraisal
when the children begin to play with the weapon and
one exclaims “Something’s over the trigger . . . I can’t
pull it” (response efficacy in demonstrating the rec-
ommended action truly makes a difference), and the
announcer tells the audience how easy it is to engage
in the desired behavior by emphasizing that anyone
can acquire a trigger lock at no cost by calling a toll-
free number (self-efficacy). Outcome evaluation
results showed that when the two forms of efficacy
teamed together, a substantial number of gun owners
Social Marketing and Health Communication
exposed to the message obtained locks and not only
perceived the device as easy to use but also viewed
the action as a reliable behavioral response to prevent
injuries.
Fisher’s Narrative Theory
The third theory we highlight—Fisher’s (1987) nar-
rative theory—is one that offers a broader overall stra-
tegic approach. In contrast to the other two theories
discussed, this theory can guide larger decisions in a
health promotion effort. Because sharing of a story can
add credibility and authenticity to the health message
(Kreuter et al., 2007), inclusion of narratives has grown
widely in health communication, and Fisher’s (1987)
paradigm offers practical strategic guidance. Based on
intuition, health educators might already have added
stories to their message mix, but Fisher’s theory
provides insight on how to identify the ideal narrative
and supplies a firmly established framework for those
seeking a theoretical component.
Based in rhetorical theory, Fisher (1987) asserted
that people are essentially storytellers and that we live
in a world full of stories. When people hear another’s
story, it helps provide an understanding about the
world (e.g., an illness experience helps us understand
more about the illness itself), and we place value on
these experiences shared (Fisher, 1987). Thus, we tend
to evaluate stories that we hear because stories in gen-
eral are important to us. Fisher argued that people
make decisions about stories based on a set of reasons
involving our history and culture, or what we think
“sounds right.” In Fisher’s narrative paradigm, it is
called coherence and fidelity. In other words, he
argues people judge a story on whether it has consist-
ency or “hangs together” and there is a level of truth-
fulness to the story. He argued that individuals can tell
when a story does not seem coherent and lacks fidel-
ity; these stories seem “fake.” When coherency and
fidelity are present, people are more likely to be open
to change beliefs and behaviors, because they believe
that the story rings “true.” If the story feels manufac-
tured and lacks coherence or fidelity, people are less
likely to change ideas and behaviors. Although each
story is unique and situation specific, the concepts of
coherence and fidelity in narrative theory paradigm do
provide insights for why some stories may be accepted
and others ignored.
An example of using narratives as part of the over-
all strategy is the Drug Resistance Strategies (DRS)
project (Hecht & Miller-Day, 2007). In this project,
personal narratives from youth were turned into pre-
vention strategies that are applied in middle school
Edgar, Volkman / USING COMMUNICATION THEORY 589
settings as part of a school curriculum on drug pre-
vention called keepin’ it REAL. Planners first solicited
narratives from youth about their experiences in being
offered drugs and resisting drug offers without alien-
ating friends. Specific questions were asked to assess
the who, what, where, when, why, and how of resist-
ing drug offers. Following narrative theory (and other
theoretical concepts), a compilation of strategies about
resistance, avoidance, and refusal was developed and
shared through storytelling by youth in performance
videos. In fact, the acronym for keepin’ it REAL was
derived from these narratives (Refuse, Explain, Avoid,
Leave). The videos shown in the curriculum followed
a sequence of real-life events when being offered
drugs (e.g., coherence), and the experiences showed
through the resistance strategies are representative of
how youth can resist drugs in an authentic way (e.g.,
fidelity). For instance, the language, peer norms, and
settings for videos all follow real-life circumstances
based on shared narratives. The project also was cul-
turally grounded, largely because of the importance of
culture in judging narratives (Hecht & Miller-Day,
2007). DRS founders acknowledged that by speaking
with youth and having their personal experiences
shared, the drug resistance strategies were perceived
as “real” and genuine; consequently, throughout the
project, youth were involved in constructing the narra-
tives in the drug resistance strategies, helping ensure
that the plots, characters, and environments were true
to actual experience. Or, in their words, the DRS pro-
ject is “kid-centric.”
Of note, each story and experience is unique, and
the reasons for evaluating a story are based on people’s
different histories and cultures (Fisher, 1987). Thus,
coherence and fidelity should be evaluated for each
audience and health context in practice. In the DRS
project, it meant speaking with youth at the develop-
ment of the project and letting their thoughts and opin-
ions guide the subsequent decisions. Although this
may mean an extra step in the process, the power of
having just the “right” story for an audience can make
a difference in health behavior change occurring. A
believable story of success can also provide the evi-
dence necessary for response efficacy, as described in
the previous section on the EPPM.
>>
Conclusion
Theory-based health communication programs have
proven valuable in promoting health and preventing
disease (U.S. Department of Health and Human
590 HEALTH PROMOTION PRACTICE / September 2012
Services, 2002). The three theories described in this
article are intended to prompt readers to further explore
how these and additional communication frameworks
can be integrated into health promotion initiatives. We
hope in applying them that readers will agree with
Lewin that “there is nothing so practical as a good
theory” (Sandelands, 1990, p. 235).
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