PUBLIC HEALTH COMMUNICATIONS: A MANAGEMENT PERSPECTIVE FOR ORGANIZED COMMUNICATION
Leon Hudson, Jr. and Tom Cook
Regardless of the public health organization's size or scope, the manager must be involved in external communications. The organization's mission statement must not only be pinned on the manager's office wall but broadcast and reinforced through an organized communication effort including marketing, public relations, and effective use of the media. The manager must be prepared to be both a spokesperson and defender of the organization's goals and actions. Even when resources for publicity are scarce, understanding the media in terms of its power and limitations are key to a public health organization's success. Whether it's organizing a health campaign or responding to a crisis, the manager must help develop and monitor the public relations and marketing plans.
The focus of this chapter is on external communications, that is, public relations public communication. The principle of marketing can be applied to the principle presented in this chapter. Every instance of external communication can be viewed as the marketing of a public health issue. The theory and practice of internal communications in public health organizations overlaps closely with that of other organizations, the details of its management is covered extensively in business management texts and therefore willnot be covered in this chapter. The goal of this chapter is to provide an introduction to public relations, communications, and media relations as it relates specifically to public health with some attention to a few broader principles of communications. While there is a large literature devoted to public relations management, this chapter is for the non-specialist who may need to take on both formal and informal public relations duties.
The public health professional must understand the needs of the community and be able to facilitate dialogue concerning the technical issues of public health risk and the psychological, political, social and economic needs of the community. Because health information is often based on scientific evidence presented in a technical language in medical journals, it must be communicated in a way that is understandable to the general public or even to specific target audiences with lower than 6th grade reading levels. In the effort to make a public health message clear, what is often lost is that scientific evidence may be inconclusive, contradictory and ever-changing. While often not justified, certain scientific results may arouse fear and panic, something health communicators must be cautious not to incite. As the manager of public health information, it must be understood that at some point this information will be out of your control and will often be distorted by the time it reaches its intended audience. Thus every opportunity to inform the public must also be considered a challenge not to misdirect the public. Careful planning and understanding the channels of public health communication are important to effectively convey a public health message without unintended consequences.
Cancer information, for example, has the potential for creating fear and false hope. The Office of Cancer Communications of the National Cancer Institute has developed some general guidelines in developing health communication programs1. In its manual it identifies six stages of effective health communications: 1) Planning and strategy selection, 2) Selecting channels and materials, 3) Developing materials and pre-testing, 4) Implementation, 5) Assessing effectiveness and 6) Feedback to refine program.
It should be noted that not all of these stages will be relevant, necessary or possible for all public health communication efforts, but it is important to emphasize that these stages form a circular process that involves constant planning, strategizing, and feedback.
The Role of the Public Health Manager in Public Relations
Public relations must function as an integral part of public health management and its practitioners must be involved in management decision-making2. While large organizations generally have designated public relations specialists, in public health organizations this function may be one of many roles managers perform. This is despite the fact that promoting healthy behavior, changing public policy, or creating a new public health program all requires an orchestrated public relations and marketing effort.
Because public relations involves "boundary-spanning", collecting information from and interacting with the organization's environment to help guide central decision making, requires understanding the organization from both inside and outside, a valuable skill for any manager. This is also an important public relations function that comes naturally to some and for others it must be learned.
Public health communication efforts should be well integrated into the overall organizational structure but when diagramed will often flow along channels different from patterns of responsibility and power within the organization or may only occur along a single path. For example, whereas there may be an overall vertical organizational structure, channels of information to and from the outside environment may move horizontally involving only department managers. Whatever the case, management of public relations requires that the flow of information to the public is through well delineated paths with clear responsibilities and roles. One strategy might be to create an organizational flow chart strictly in terms of public relations, which may include two or three individuals or the entire organization.
Public relations strategies must remain tied to long-term organizational goals and may even form the core the organization's goals as in health communication campaigns. In other instances public relations is a key to reaching the organization's objectives. The mission statement must be consistently checked against the public image and the messages received by the public must change along with or in advance of the organization's changes. In fact, public relations may often have to precede larger organizational changes to make them more palatable to the public. Further, as most public health organizations have many collaborators which may share certain public relations functions, goals, and missions, the relationships among organizations must be managed to assure an overall vision and consistent message.
Public health external communication strategies, like epidemiological studies, often prove to be lessons in themselves with unique challenges and unanticipated problems. There is not extensive research on effective organization of public health communication strategies with case studies or personal or organizational experience providing the core of public health communication theory3-4. One underlying theme is the importance of strategic planning and organization. These are two skills that public health managers must develop regardless of their involvement in public relations, marketing and external communications. At a minimum, organizational roles and responsibilities need to be in writing and a plan should be in place for public relations crises.
Marketing and Public Health
While the idea of "selling" public health is a relatively recent phenomenon, one need only turn on the television during a major sporting event to find 30-second ads promoting healthy behaviors competing with $2 million dollar ads selling beer or fast-food. Public health advertising, especially in terms of electronic media, has molded itself along commercial marketing principles. More recently, public health commercials have attempted to both parody and emulate commercials selling caffeinated beverages and other products, often at a comparable high cost. Coincidentally, just as public health has learned to adopt the marketing strategies of the consumer market, marketers of traditional products have capitalized on the selling of "healthy lifestyles." Selling health has grown more complicated with the explosion of the alternative medicine market whose peddlers often makes promises of medical miracles for a low monetary cost.
Financial resources for public relations and marketing are often scarce in public health and often comprise a small portion of the overall budget. This is despite the fact that public health organizations must often aggressively use public relations to attain their goals and assure their future survival. Long-lived, stable public health organizations which are not funded by the government must practice sound public relations to get contributions, political support, or even recruit free labor through volunteers. Creative use of existing resources requires input from all employees.
Marketing public health has emerged as a sub-discipline requiring a different set of skills which are often absent in traditional epidemiological public health training. According to Siegel, the principles of marketing provide a disciplined, audience-focused, research-based process to plan, develop, implement and assess interventions designed to influence the behavior change of target audiences in order to improve their personal welfare and/or that of their society.5 While the four basic marketing principles of product, price, place and promotion provide some guidance for public health, selling public health has a different set of challenges.
The Public Health "Product"
Traditional marketing textbooks are often focused on the marketing of consumables or the identity that surrounds them. A broader view, taken by Kotler, defines a product as "anything capable of rendering a service, that is, satisfying a need...this include persons, organizations, and ideas."6 This view forms the basis of social marketing which borrows its language and theories from commercial marketing7. It emphasizes that the consumer or target audience should be the focus when planning and implementing a program. While occasionally there will be a tangible product or consuming behavior endorsed by public health marketing (e.g., condom-use, dietary supplementation), in general public health is concerned with intangible products such as modifying risk behavior, a new public health program or changing public policy.
In terms of behavior, the product can be defined as the benefit the person will receive by stopping or changing an existing behavior. One important rule for public health marketing is that people will be more responsive to products that directly affect them and not simply the greater good or public health. Thus while public health intervention marketing is a population-level effort, it must be packaged as an individual consumable product. More importantly, it must be at a low cost to the consumer.
Some public health advertising is intended as "counter-messaging;” competing with other advertisements or unhealthy lifestyle choices portrayed in the media as being positive. The health benefit or "product" will be weighed against the difficulty or desirability of changing behavior. A further challenge to marketing public health is that the product must be repeatedly "sold" to the consumer in order to sustain the positive behavior or until the advertisement is digested internally (the goal of the famous but ineffective "Just say no" campaign). When marketing a public health program or policy, the competition will be largely for economic resources and will often confront political ideology and special interests (e.g., the tobacco lobby).
The "Price" of Public Health
Just as the products are often intangible in public health marketing, behavior change rarely has a monetary cost with a few exceptions such as buying more healthy foods. The price is often in terms of psychological costs and the time and effort required changing a behavior. For example, consider the psychological costs of a female asking a long-term sex partner to use a condom because of information received from a program based on recent evidence of heterosexual HIV among steady partners.
When promoting a policy change or program, the cost may be thought of in terms of the cost to taxpayers or the cost of ignoring other more pressing concerns. The cost will be political costs for politicians and policy makers. Or the costs of giving up of personal freedoms for the common person. For example, anti-smoking campaigns often attempt to limit the freedom of smokers, something that attracts the attention of both smokers and non-smokers concerned with how the use of public space is regulated. This introduces the idea of "social cost" as well.
Theories of behavioral decision making go well beyond a simple cost-benefit analysis but are beyond the scope of this chapter8.However, it must be emphasized that in practice the costs of even simple decision making models are often calculated by an imprecise method by both the consumer and promoter. Further, these costs will be calculated differently depending on such factors as race, age, income and gender. Public health marketing must be guided by research in order to understand how these costs or barriers can be managed and overcome to achieve the desired result despite growing competition.
The "Place" for Public Health
Accessibility to health, an ongoing universal concern of the public health practitioner, is often a communication problem as much as it is an issue of physical barriers or proximity. Place can also be important both in terms of where the behavior occurs and where the message is heard. For example, while it is often convenient to provide interventions to adolescents while they are a captive audience during the school day, it is debatable whether or not this is the best place to promote healthy sexual behaviors. After all, sexual activity does not generally occur at school, and children are likely to distinguish between behaviors appropriate inside and outside of school. Ideally the message will come from multiple sources in different environments. For example, messages learned in a weeklong teen pregnancy/std prevention program could be reinforced with messages on a local radio station and billboards near popular hangouts or on the major streets surrounding the school. One might also include a peer-led intervention soon after the initial intervention in addition to other continued messaging outside of school.
The "Promotion" of Public Health
Promotion is at the core of public health marketing and broadly defined it encompasses everything from advertising and public relations to special events, fundraising and lobbying. While using the mass media is an important tool, promotion can often best be achieved through more localized resources including grass-roots campaigns and community-driven initiatives. Physicians and other health-care practitioners may even be convinced and trained to learn the art of “hand-selling" public health, a strategy developed in retail environments.
One of the many obstacles facing public health promotion is the need to create a demand or overcome a negative demand for a particular behavior. In fact, most public health programs are created in an environment of negative demand to address a particular problem. Further, while businesses devote a bewildering but ultimately justifiable amount of money on marketing, there are often inadequate funds to develop a public health product and even less to promote it. Test-marketing is largely unheard of in public health, though it is a crucial part of behavioral interventions, akin to a Phase I clinical trial.
The ubiquitous public service announcements (PSA) on college radio are a testament to how little money is often budgeted for public health advertising. A 20-second message read by an untrained and uninspired college "D.J." at 3:00 a.m. between 40 minute segments of acid-rock is hardly an effective promotion strategy but is often all that is feasible. Public health promoters are often at the mercy of the media outlet in terms of timing and placement. Promotion must focus on both creative strategies with limited resources and the creation of an overall media plan that will allow for plenty of "free" advertising. Further, whereas marketers of traditional products can easily assess impact through sales, it is very difficult to measure the impact of public health marketing unless it involves direct participation, use of services or consumption. Thus it is especially difficult to determine the effective elements of an overall promotion strategy.
Developing a Media Plan
The public learns about public health news from any different routes, including newspapers, magazines, books, radio, television, the internet, electronic news services, and films. Each of these media have different needs, different strengths and different weakness’.9 They often have different audiences as well. A crucial part of the overall public relations plan is the creation of an effective media plan. Achieving effective communication with the public depends on selecting methods of communication that will reach them. Consider your message and your target audience in selecting the most appropriate communication media. While an overall media plan should be developed, the plan must be updated annually to help the organization prepare for media attention while maintaining proactive media outreach. The plan should be flexible to accommodate crises and must address several questions, the answers of which may change over time. Some of these perennial questions include: Who is our audience? Are we trying to increase awareness of our program? Are we trying to build financial or political support for our program? How much time can we spend on our plan? How much money is involved? Are there specific projects that will need good media timing and placement? Are there any local or national events this year which we can join to increase our visibility? What collaborations can we utilize to help us with our goals? Once these and other questions are answered one should put the strategy in writing and create a timeline. While the details of dealing with the media are often learned through experience, there are several media "cookbooks" available for the novice, some of which are summarized here.10-12
Types of Outlets
While many of the rules for approaching and handling the media are true for all outlets, there are both advantages and disadvantages of using various media to convey your message. Knowing which type of media and which outlet can be crucial to an effective media strategy. Some questions to consider are: Which outlets are most appropriate for the particular public health message? Which outlet will be considered most credible by the audience? Which outlets will likely support further information to reinforce the message? Which outlets can be afforded? These outlets include: print media, electronic media and the internet.
Though a large percentage of what is printed in newspapers originated as press releases written by organizations, the competition for space in dailies can be very high as editor sort out hundreds of releases per day. Newspapers generally have section editors which may be more or less inclined than others to print your releases and you must consider whether you are willing to chance not getting a story printed at all by trying to get it on the front page or in a particular section. Because you should only send releases to one contact at each paper, this decision must be made carefully. Newspapers and magazines have tight deadlines which need to be respected and thus a press release should be sent in as soon as possible. Because the print media often use photographs, your organization should consider training someone to take photographs in case a staff photographer is not available as photos will increase interest in running your story.
Letters to the editor are an important resource which can more strongly state a particular viewpoint and to correct mistakes or clarify issues. This format should be used sparingly, however, as some papers have rules about the number of letters by the same author. Op-ed articles are also an important resource for public health agencies, especially in terms of building the belief that the organization is a local authority on a particular topic. Whereas press releases can be sent to multiple outlets, op-ed pieces should be sent to only one paper. Op-ed essays often form a good "seed" for generating other media attention and ideas for special features. While not limited to print journalism, use of wire services promises wider coverage but often demands better writing and widespread appeal. Use of wire services can result in worldwide coverage, both negative and positive.
Magazines can better target specific audiences and can often provide more space for detailed treatment of a public health issue. This may be especially important if the message is complicated or controversial and needs to present multiple points of view. As with newspapers, articles can be clipped, reread and stored for latter consumption.
More so than with newspapers, which attempt to be comprehensive, knowing which radio and television stations air particular types of stories is crucial to organizing a media campaign. Whereas a newspaper tends to be consumed as a whole by a wide range of readers, television and radio are broken into much smaller packages with very different audiences. Your organization will need to study the different local stations carefully to know which outlets to contact. The broadcast style is much different than print media and releases should be written to be heard and not read and must include pronouncers.
As television news is often focused on crises, there is little prominent time available for positive publicity or health messaging. Whereas the print media often solicits stories regarding public health, such messages are often not considered exciting enough for a visual medium. Television coverage offers the widest publicity to the largest audience but can be inefficient when there are specific target audiences. Radio listening tends to be more segregated and thus targeting of audiences can be much less expensive and precise. Television, more than radio, tends to edit news down to little more than headlines, so if details are important to the message other media should be considered. Releases to television should include who, what, when, where, and why even if only a few of the W's will make it to the broadcast. Often news releases are often rewritten to be heard and transmitted over wire services to radio and television.
The internet is an increasingly important part of overall public relations and should be used in conjunction with traditional media relations. While traditional media are still the most important source of exposure, information provided on a web-site will often be used by the media so it must be comprehensive, thorough, and accurate. Consider including a section devoted to the media that can include press releases, project summaries, biographical sketches, collaborator links and anything else that would be included in a traditional press kit.
The Designated Spokesperson
Regardless of who manages public relations, it must be decided who will be the primary media spokesperson and designated media contact. This person must be able to articulate the goals and policies of the organization and have a good understanding of what is confidential. The details of projects and organizations should be made readily available to the spokesperson and both memorized and in writing. This person must also be able to think on his feet quickly without panicking and can speak articulately on any topic under pressure. This person ideally will be involved in the management team and under all circumstances must have the backing and full confidence of the managers.
Because it is not always possible to hire a public relations specialist for this role, training of the spokesperson must be led by management. While the emphasis of the training should be on preparedness, other skills must also be taught such as knowing how to stick to key points determined in advance and avoiding getting side-tracked to questions the spokesperson is not able to answer. It must also be emphasized that this spokesperson must always be honest and admit when they are not prepared and do not have an answer rather than making up something.
Some general guidelines which apply to most outlets is that the information should have local interest or a local angle, widespread appeal, involve well known people, or have a special "hook" such as a unique or unusual property. Further, news should be timely, of consequence to people's lives, have human interest, and have elements of conflict or opposing viewpoints. Public health news needs to be especially concerned with inoffensiveness, such as when describing sexual or drug-related behaviors. Presenting scientific or medical information needs to be accurate and understandable. Medical information tends to be distorted towards either having too much promise or creating panic and an unwarranted fear of disease.
While your organization should provide a steady stream of more routine press releases, consider appealing to the media's goals whenever something really needs attention to be successful such as an event or fundraising campaign. What is considered newsworthy will often depend on timing, such as the season or whether it is an election year or not. Take advantage of slow news periods to release important information. Consider other stories recently aired or printed and whether or not your news would be considered old news or can complement an existing trend of stories. If your important story does not get the attention you thought it would or none at all despite the promises of the reporter, consider a different outlet or a reminder to the person you contacted.
While the media pays close attention to health issues, public health programs are often not considered as newsworthy or as exciting as medical breakthroughs or research findings. Public health organizations and the media are often at odds as to what constitutes newsworthiness. For example, where a public health organization may wish to present a sustained message promoting healthy behavior, the media may consider such messages as repetitive and uninteresting to their audience. Thus it may be necessary to think of a new angle whenever attempting to repeat an important public health message.
Whether it’s a rolodex, database, or published media guide your organization must maintain a comprehensive up-to-date media list. It would be good to have this list computerized and linked to a mailing list. This is especially good for mass mailing. While many national and local organizations publish local media guides, these should be updated and built upon as new outlets emerge. At a minimum this listing should include wire services, local and national newspapers, magazines, radio, cable and television stations. While media outlets' general addresses, phone and fax numbers should be regularly checked, it is also important to keep track of individual local reporters and editors which may change quickly due to turnover or the definition of their "beat." Whenever possible multiple contacts will be listed including assignment editors, reporters, bureau chiefs, producers, depending on the type of media.
Press Releases and Advisories
A press release or advisory is a brief (generally no more than one page) news article highlighting an important event, program or piece of information released by your organization. Both should at a minimum succinctly describe who, what, where, when, why and how of the story. Press releases should follow editorial guidelines, with the most important information or "lead" in the first paragraph, followed by the "bridge" paragraph to the more detailed but decreasingly important information that follows. The remainder should elaborate the information mentioned in the first paragraph. Other guidelines include single spacing, avoidance of jargon and technical terms and the inclusion of a short headline. Contact information should also be included.
The National Association of Science Writers suggests the following new release formats for print media, radio and television.
For a paper release:
For a radio release:
Releases for television should be one of two kinds:
Because only a fraction of press releases make it into print or are broadcast, it is essential to provide a steady stream of releases to media outlets, increasing the probability that one will make it to the public. Unless the organization is responding to a crisis, the media should be notified through a press advisory three to five days before the event followed by phone contact to key media.
Public Service Announcements (PSAs)
A PSA, according to the FCC, is "an announcement for which no charge is made and which promotes programs, activities, or services of Federal, State or Local Governments or the programs, activities or services of non-profit organizations and other announcements regarded as serving community interests. What sounds like a dream-come-true for the public health communicator, is actually a severely limited source of exposure. While outlets will designate up to one fourth of their commercial time to public service, these messages are aired during "public service time" which will rarely if ever coincide with when your intended audience may be listening or watching. Stations will also decide which organizations receive free air time, something which might severely limit your audience depending on which stations support your organization.
Pitch Letters and Press Calls
Either by writing or telephone one can pitch a story directly to editors or producers in an attempt to convince them why others would want to know about it. Because these media contacts may be swamped with great story ideas or may have nothing to report, it is often best to send these to multiple outlets. Whether by phone or letter your message should be clear, short, and convincing. Initial contacts should be followed up with additional information and to emphasize the importance of your story.
A press kit is an important element in always being prepared as well as a way to present a consistent image to multiple media outlets. These can be sent along with pitch letters or calls, especially if the organization is not well known by the media or community. The kit should always be available at press conferences and special events. It should contain brochures, newsletters and other information used in other public relations efforts as well as contact information, press releases and biographical sketches of key personnel. The press kit should reflect your organization's point of view and highlight the positive image you wish to present to the public. It should not contain an archive of publicity, both bad and good that may be selectively read by the person receiving it. The format and content of the press kit will likely be determined by budget considerations, ranging from glossy custom designed folders to envelopes stuffed with information. Consideration of the organization's funding might dictate whether or not an expensive looking press kit would be considered a good use of the organization's money.
Press Conferences and Special Events
As an organization creates new programs or enters new partnerships it may want to make a formal invitation to both the media and community leaders to a planned event or press conference. These can coincide with other events in the community which may heighten interest in the event or take advantage of attention generated by other events.
While special events with media invitations can occur regularly, press conferences should only be scheduled when there is major news to be announced such as a new project, new collaboration, or release of project results or year-end progress. The decision to call a press conference rather than writing a press release depends both on the importance of the information and whether the organization is willing to spend the effort and time to conduct an effective conference. If the information can be conveyed equally well in writing, a press release will be a better option.
The logistics of events or press conferences should receive careful attention to detail and advanced planning and rehearsed whenever possible. For example, news conferences in the morning give television stations time to prepare their segments for the evening news. Morning conferences also give reporters for morning newspapers enough time to prepare their stories for the next day.13
Handling Media Calls
While a proactive approach to the media can prepare your organization for handling media calls, the public health organization must be prepared to defend itself and its goals. While many people in the organization can be involved in media relations, it is here that the designated spokesperson is most crucial. Because reporters have deadlines, media calls should receive high priority. All personnel should know the importance of these calls and know how to direct calls if they receive them. Of course there must be a back-up person, preferably a manager, who can respond when the spokesperson is not available. It is important to determine precisely what the reporter is interested in before speaking on behalf of the organization or providing any information. It is also important to find out who else they plan on contacting and when their story is likely to air and in what format. Records should be kept of what was said and when and to whom.
While an organization may never be asked to respond to a typical public health crisis such as a disease outbreak or major public health policy change, the organization must be prepared to provide information in times of crisis and to defend itself during periods of disruption or controversy. Whereas a well developed media plan can generally insure a generally positive view of the organization to the public, times of crisis often produce negative or difficult questions that the organization must be prepared to answer under pressure. Crisis management must be part of the overall media plan. Not only must the designated spokesperson be prepared to respond and not to panic, everyone in the organization must know how to respond and how to direct the media to the right person.
If public relations personnel are aware of the crisis before the general public, it is generally best to approach the media with a prepared statement rather than reacting and waiting to be contacted. This increases the chances that the news will be reported accurately and quickly. While it is always important to convey an image of openness and honesty, there may be times when both the organization and reporters will not have time to research every detail. The organization may even need to seek legal advice before commenting on an issue. Always detail the steps the organization has taken or plan on taking to respond to the crisis. If the crisis not only involves your organization but your collaborators, constant communication and checking of facts with their public relations team and management is essential. If the crisis does not directly involve your organization but you believe your organization may be called upon to comment, designate someone to follow stories as they develop so that your organization is prepared.
Evaluating Public Health Communication
Process evaluation is a key component to an overall public health program and should include monitoring of marketing and public relations strategies and audience impact. An update of progress can generate timely refinements and to isolate different components which may be a key to a program's success. Such evaluation can also guide future communication efforts. For example, evaluation can consider both the quantity and quality of media coverage, a comparison of the audiences targeted and the audiences actually reached or measures of behavior change.
Just as public relations must be well integrated into management decision-making, the evaluation of communication strategies should be a part of overall evaluation strategy. For each component, determine what went well, what could have gone better, and why.14 While data tends to be gathered retrospectively, to inform current efforts it should be an ongoing part of the organization's activities. The evaluation plan should have a clear set of objectives and measures and answer specific questions geared towards making decisions regarding refinement of the program's "product", "place", or "price." It can also address the need to justify expenditures and use of resources and making a case for continued funding. Deciding what information will be most useful to current and future decision-making necessitates oversight by management.
One common mistake is to measure only output (ads placed, brochures mailed, press releases faxed) without monitoring impact or collecting data relevant to the organization's goals. This is because where the former is generally easy to measure; the latter requires careful planning and complex measurement. Useful and meaningful evaluation requires not only the skills of epidemiology, but those of marketing and public relations. It requires a methodology, study design (sample size, sampling frame), measurement tools, and plan for analysis.
While the tools and skills of research are necessary, the public health manager must also consider issues such as the timeline, budgeting, staffing and other resources. Questionnaires and interviews, widely used in epidemiology, can be expensive to develop and require a large amount of effort for coding and entering data. Thus process evaluation should be included with other data collection to avoid duplication of cost and effort whenever possible. Whereas analysis of overall program data might be done on annual basis, collection and analysis of monitoring data must be done as often as weekly depending on the project's duration.
The actual form of evaluation will depend on the program and no single method is suitable for all. Some types of evaluation include bounce-back cards, inventory tracking (to assess cost and pattern of distribution), service delivery (quantity and quality), satisfaction surveys, content analysis of media coverage, tracking advertising placement and monitoring behavior or policy changes. When using these methods and instruments the pitfalls of observational research must be considered. The issues of reliability, validity, temporality, confounding, and interaction are no less important in assessing public relations impact than in epidemiological research.
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