Creating effective messages about environmental health.

Introduction

Environmental health practitioners have never been more in the news than they are today. Rarely a day goes by without a story about West Nile virus, a foodborne outbreak, a closed swimming pool, school days lost because of asthma, or some other environmental health issue. The public are concerned about how the environment affects their health. Policy makers are concerned about making wise decisions that will enhance their popularity with their constituents and address health priorities. With all of this concern, why is it that environmental health practitioners still have to explain their jobs to most people?

[ILLUSTRATION OMITTED]

The answer to this question lies in the failure to develop concise messages about the field. More than at any other time in recent history, environmental health issues are on the radar screens of policy makers and the public because of issues such as West Nile virus and bioterrorism. Environmental health professionals all know that the work that they do affects everyone every day; now is an opportune time to move the message from the choir to the congregation.

The research presented here offers some valuable information for environmental health practitioners to consider as messages about the field are developed. The Centers for Disease Control and Prevention (CDC) provided funding to the Association of Environmental Health Academic Programs (AEHAP) for a study that would contribute to understanding how people perceive environmental health.

The Impetus for Developing Messages

Environmental health practitioners have always played a critical role in ensuring safety with respect to the critical components of quality of life. In a time of emerging infectious diseases and concerns about bioterrorism, qualified environmental health practitioners are on the front lines of preserving national health and safety. Yet at this time when they are most needed, it is painfully obvious that they are too few in number. A Pew Environmental Health Commission report compared four media-specific areas--air/radiation, water programs, solid waste, and pesticides/toxic substances--and showed that federal public health agencies lacked the personnel to track health issues related to environmental exposure (Pew Environmental Health Commission, 2000). An additional Pew Environmental Health Commission Report written for the new administration in 2001 urged the President to enhance the capacity of environmental health practice because of a "serious lack of trained personnel" (Pew Environmental Health Commission, 2001).

The Seventh Report to the President and Congress on the Status of Health Personnel in the United States (U.S. Department of Health and Human Services [HHS], 1990) presented perhaps the most urgent plea about the shortage. This report calculated a need for 137,000 additional environmental health professionals. Accredited undergraduate programs currently graduate approximately 600 students each year, far too few graduates to fill this need. Low undergraduate enrollment in environmental health is further aggravating the shortage.

One of the greatest barriers to recruiting students into the field of environmental health is that there is little lay knowledge of and thus little respect for the field. Even though recent events have drawn attention to the critical role of environmental public health, most people remain unaware of its importance. Some of the greatest advances in public health in the 20th century, such as increased life expectancy, were a function of transforming environmental health conditions through improved sanitation, water purification, hazardous material control, and waste management. Environmental conditions are a crucial determinant of health. Communicating effectively about these conditions and the ways in which their improvement is pivotal to human life is a central element in protecting the public's health and attracting a qualified workforce.

Methods

The overall goal of this project was to gather data that can be used to create messages about environmental health practice. To this end, the project combined several methods: 1) a Web-based survey of environmental health practitioners, 2) development of marketing materials and message concepts, 3) focus group testing of the marketing materials, and 4) dissemination of the results.

Web-Based Survey

Before creating messages to test with various groups of stakeholders, it was important to get a sense of the perceptions of practicing environmental health professionals. To accomplish this task, a survey was developed by Earth Communications Office (ECO), a not-for-profit message creation organization based in Los Angeles. The purpose of the survey was to gather information from environmental health professionals about messages and techniques for message delivery. This information would then be used to create messages to test with several audiences. The survey involved three major sections:

1. statements assessing how environmental health professionals perceive public awareness of the environmental health field,

2. a rating of potential concepts for use in communicating environmental health messages to the public, and

3. statements about the effectiveness of communications methods and techniques.

The survey was Web-based, and potential respondents were sent an e-mail asking for their participation. The National Association of City and County Health Officials (NACCHO) and the National Environmental Health Association (NEHA) distributed the survey to their members. In addition, ECO solicited the participation of environmental leaders and public health advocates. Respondents were encouraged to forward the e-mail with the Web link to their colleagues, creating a "snowball" effect to gather additional participants. This approach to gathering respondents for survey research may not have led to a representative sample because respondents were self-selected; the results presented below should be interpreted with this limitation in mind.

One section of the survey asked professionals if they would be willing to participate in a focus group to further discuss environmental health messages. The response from survey respondents interested in additional participation was overwhelming, further exemplifying the interest in creating messages.

Message Development

Data from the survey were analyzed to create a series of promotional messages, including slogans, tag lines, and overall concepts, for testing with different audiences. These concepts were prepared in electronic and paper copy and were reviewed by members of CDCs National Center for Environmental Health before the testing.

Message Testing

Focus groups have been employed in social science research since the early 1940s and have proven to provide rich qualitative data (Kleiber, 2004). A major advantage of using focus groups is that researchers are able to gather a more complete picture of the opinions of participants than can be gathered in a survey or questionnaire. On the other hand, focus group research requires considerably more time and analysis by researchers than do other survey techniques. Since the purpose of this research was to obtain in-depth opinions about environmental health, focus groups were employed. Specifically, the messages were tested in three focus groups: 1) environmental health professionals, 2) policy makers, and 3) the public. The professional and public focus groups were held over the telephone, and the policy maker group was held face to face. The proceedings of groups were recorded and transcribed, but individual participants were assured of anonymity. Discussion guides were prepared to facilitate data gathering in the three groups.

The group of environmental health professionals was generated from a list of respondents to the Web survey, and efforts were made to include a cross-section of professionals from various levels and different geographic regions. Participants in all of the focus groups can be found in Table 1. To keep the confidentiality of participants, this table presents job titles, affiliations, and locations. The environmental health professionals received marketing materials in a PDF file that was e-mailed to them just before the telephone focus group was held. They were instructed not to open the file because a major purpose of the focus groups was to get first reactions to the messages.

The policy maker focus group was conducted face to face in Washington, D.C. This group proved to be a challenging one to pull together. It is difficult to gather top-level health and environment aides and legislative directors for a one-hour-long focus group. Nevertheless, AEHAP staff were able to obtain a broad, bipartisan sample of senior policy makers from different geographic areas in the country (see Table 1). Participants in this group were shown the concepts in hard copy, and discussion revolved around their reactions to the messages.

A goal of the public focus group was to gather feedback from a cross-section of American citizens. This was a difficult task since the optimal size for a focus group is eight to 10 people. Nevertheless, a survey research company, Strategic Research Group (SRG), developed a screening mechanism to use when contacting people to participate in the focus group. SRG used a computer-generated list of telephone numbers, and staff members explained that the purpose of the call was to gather participants for a telephone focus group to discuss environmental health issues. The staff member also explained that participants would be paid $50 for their time. When a person who had been called agreed to participate, the screener posed a list of demographic questions such as age, education, gender, and income. More than 300 people were called to develop a list of eight to 12 potential participants.

The purpose of the screening was to assemble a diverse group of people from all over the country. As Table 1 shows, the ages of the participants in the public group ranged from 19 to 73. There were men and women, minorities, participants representing all areas of the country, and participants from rural, suburban, and urban areas. The public participants were mailed hard copies of the concepts with instructions not to open their packets until they were on the conference call. A toll-free number was established, and participants called in to the number at the specified time.

Results and Discussion

The results of the research are divided into three sections: 1) Web-based survey results. 2) development of marketing materials, and 3) focus group results.

Web-Based Survey

The Web-based survey included responses from 254 environmental health professionals. Seventy-five percent of the respondents were from government, 9 percent worked in academia, 9 percent were from nonprofit organizations, and the remainder preferred not to note their affiliation.

One of the most important ways to define the field of environmental health is to be sure that the name of the field accurately represents the work that its practitioners do. With this in mind, survey respondents were asked to identify which of the following they preferred when discussing their chosen profession: 1) "Environmental Health," 2) "Environmental Public Health," or 3) "Environmental Human Health." Not one respondent preferred the latter; 150 respondents preferred "Environmental Health," and 104 respondents preferred "Environmental Public Health."

Table 2 presents the results of the first section of the survey, which was designed to gather information about how professionals believe different audiences perceive the field of environmental health. Respondents were asked about their level of agreement or disagreement with the statements given in Table 2. Overwhelmingly, the responses show that environmental health professionals believe the field is not well understood by members of the public, the media, or policy makers. This result is alarming since these same professionals believe that serious environmental health threats are facing Americans. Respondents were somewhat divided on whether they are able to effectively communicate the message about environmental health to various audiences.

The respondents were asked to identify the effectiveness of using a series of issues to communicate environmental health messages to the public. The results of this section of the survey, as depicted in Figure 1, suggest that the environmental health professionals who responded to the survey believe that using children's health specifically, and human health issues generally, is the most effective way to deliver a message about the field. On the other hand, these respondents believed that the least effective way would involve a message focusing on issues that specifically affect urban or suburban populations.

The third section of the Web-based survey focused on communication methods and activities. First, respondents were asked about the frequency of their communication with various audiences. More than one-third of the respondents indicated that they communicate with members of the public either daily or weekly. In addition, about one-third of the respondents noted that they communicate with other environmental professionals either daily or weekly. About 20 percent stated that they communicate with policy makers at least once a week. The results of this survey suggest that communication is an integral part of the job of the environmental health professional (Figure 2).

With respect to the most effective way to communicate with various audiences, most professionals generally prefer face-to-face communication regardless of whether they are addressing the public, policy makers, or other environmental health professionals. By contrast, as Figure 3 shows, the respondents do not believe that the Internet is a very effective means of communicating with the public; less than 50 percent agree with the use of this tool for public communication. The Internet is perceived to be even less effective when they are communicating with policy makers as well; only 43 percent of the respondents agreed that the Internet was an effective tool for this audience. Generally, the respondents believe that radio and TV, as well as face-to-face communication, are most effective when the goal is to communicate with the public, and face-to-face meetings are considered the best way to communicate with policy makers. The means of communication affect the choice of message.

The Web-based survey of environmental health professionals had several results:

1. most of the respondents represented government agencies and organizations;

2. generally, the respondents agreed that using children's health specifically and human health issues in general will create the most effective messages about environmental health;

3. communication is an integral part of the job of an environmental health professional, and this communication is targeted toward a range of audiences; and

4. although face-to-face communication is generally perceived to be the most effective means of communication overall, the use of radio and television is also perceived to be an effective means of communicating with the public.

Creative Message Development

The results from the Web-based survey served as the foundation from which to develop creative concepts for messages promoting the field of environmental health. The creative concepts included numerous tag lines and five thematic messages. The thematic elements encompassed messages about security, health, special populations, economics, and pollution. The text of each of the themes is given in Table 3. Each theme had associated with it a descriptive paragraph, photographs, and headlines providing a snapshot of the theme. The following tag lines were developed to explain the environmental health messages:

[FIGURE 1 OMITTED]

* "It's what you eat, drink, and breathe."

* "Our life-support system."

* "Protecting the lives of people."

* "Protecting our world for our well-being."

* "Our world is our well-being."

* "The environment. It's in your blood."

* "The environment. It's in your body."

* "Affecting everyone, every day."

Focus Groups

The purpose of the focus group component of the messaging project was to use research-based focus group methodology to test the creative concepts with the public, environmental health practitioners, and policy makers. Using the methods summarized above, the study conducted three focus groups in November 2003, and the results of these groups provide some interesting guidance on creating effective messages. The following discussion summarizes the results from the focus groups.

Professional Identity

It is clear from the transcribed discussions of all three focus groups that the term "environmental health" is the most preferred and understandable way to describe the profession. "Environmental public health" and "environmental human health" led to much confusion and misunderstanding on the part of the public, and especially on the part of policy makers.

[FIGURE 3 OMITTED]

Tag Lines

One of the more interesting issues that emerged is that there are some striking differences in opinion between the professional group and the other two groups with respect to appropriate tag lines or slogans for promotion of the field. Although there was no general consensus, the tag lines most preferred by all three groups were, in descending order:

* "Affecting everyone, every day."

* "The environment. It's in your body."

* "Protecting our well-being."

Thematic Messages

Each focus group preferred different themes to assist in their understanding of environmental health. The concept that clearly was most interesting to the policy maker group was the theme of tying environmental health to the economy. The concepts that tested best with the public group included the themes of prevention and personalizing the message to include issues that are most salient in their personal lives.

Most of the professional focus group preferred the concept that included specific environmental health issues. Environmental health professionals prefer more specificity and detail about the field and would like to see the messages cover all of the work they are responsible for, including specific issues such as food safety and vector control.

There was not, however, unanimous support for the theme that presented specific issues, and disagreement revolved around using the theme of homeland security. This result contrasted with results from the public and policy maker focus groups, whose members felt that the breadth of the field made environmental health confusing. They preferred messages that focused on selected aspects of the field as a single message. Many of the public and policy maker focus groups reflected a lack of knowledge about environmental health risk.

Specific Comments

Among the more interesting comments made in the course of the focus groups were the following:

* Policy maker: "When you say environmental health, people think forests and deer."

* Public: "When I think of environmental public health,... I think of ... welfare, things like that."

* Environmental health practitioner: "Public health does not have a particularly good image with the public.... I would like to keep some distance between environmental health and public health."

* Policy maker: "I don't see the connection between West Nile virus and environmental health.... I mean, you can't even plan for it or prevent it."

* Policy maker: "I think there is great disagreement on our food safety; if our food was polluted, you wouldn't be feeding us lunch."

* Public: "You can't say asthma is caused by the [pollution in the] environment."

Conclusion/Next Steps

The research presented here indicates that environmental health professionals have a substantial amount of work to do to communicate about the profession. Although some messages resonated with members of the public focus group, these same messages did not resonate with the policy makers. There is even more discrepancy with the messages that environmental professionals believe are the most effective.

This project unearthed several other notable issues:

1. Some members of the public never use the Internet to obtain information about health issues. This finding suggests that there needs to be a multimedia approach to getting the messages to the public.

2. The environmental health professionals desire the message to be positive rather than negative. In addition, the members of this group want the message to be comprehensive and to cover all of the work that they do.

3. The group that needs the most basic message is the policy maker group; this group was not aware that environmental health professionals are involved with preventing the spread of West Nile virus or that environmental health professionals are involved with general environmental health risk.

4. It is not a good idea to focus the messages on pollution only, and including the word "pollution" in the message appeared to bias perceptions of the concepts. Specifically, "pollution" messages link the profession with environmental advocacy, and this linkage can have a strong influence on how messages are received.

5. Public and policy maker focus groups were more concerned about environmental health issues that affected the entire public than those that affected children or seniors. Children's environmental health is often thought to be an excellent way to communicate the importance of environmental health issues; these results may indicate that such messages may require more research.

Since this project was completed, AEHAP has discussed these results with many stakeholders, including the National Association of Local Boards of Health and the Association of State and Territorial Health Officials. The American Public Health Association is using this research as a basis for some of its own communication work and as a basis for gauging best next steps. There also has been significant interest from individuals across the environmental health field in this process, demonstrating a clear need and desire to create fieldwide messages.

The research presented here should be considered just the beginning of what needs to be a more comprehensive analysis of perceptions about environmental health. Additional research should include a nationwide public survey and additional focus groups to enhance understanding of how best to present environmental health messages.

There is a need for environmental health leaders, especially professors and agency leaders, who often work with the media, to use effective messages in their communications with the media and policy makers. This research also supports the need for a comprehensive messaging campaign that includes public service announcements on television and in print, as well as tools and assistance in implementing those messages to bolster the importance of environmental health practice.

These findings suggest that, as a profession, we have to stop thinking about how we perceive our field and pay more attention to how the public and the policy makers perceive it. If we can build on external perceptions in developing our messages, we may be more successful in promoting the profession.

TABLE 1 Focus Group Participants

Group                  Description of Participants

Environmental health
professionals (N = 7)
                       NEHA representative
                       City environmental health manager, Texas
                       Sanitarian, state department of public health,
                       Alaska
                       County environmental health director, Iowa
                       Large-urban-area director of environmental
                       health, Illinois
                       County health department, North Carolina
                       RN, director/health officer, county public
                       health, Wisconsin

Policy makers (N = 6)
                       Legislative aides, legislative directors, and
                       fellows from the U.S. Congress representing Iowa,
                       Ohio, New Jersey, California, Illinois
                       Representative from the U.S. Department of
                       Education

Public (N = 8)
                       F, 48, Caucasian, college or higher, $50K to less
                       than $75K, Northeast/Pennsylvania, rural
                       F, 73, Caucasian, high school or higher, less
                       than $25K, South/Tennessee, rural
                       M, 36, Caucasian, college or higher, $75K or
                       higher, West/California, rural
                       F, 19, African-American, high school or higher,
                       $25K to less than $50K, South/Virginia, suburban
                       M, 38, Caucasian, high school or higher, less
                       than $25K, South/Kentucky, suburban
                       F, 31, Hispanic, college or higher, $50K to less
                       than $75K, West/Colorado, suburban
                       M, 26, Hispanic, high school or higher, less than
                       $25K, Midwest/Ohio, urban
                       M, 31, Caucasian, college or higher, $25K to less
                       than $50K, South/Texas, urban

TABLE 2 Survey Results: Status of Environmental Health (n = 254)

                             Percentage           Percentage
                             "Agreeing" or        "Disagreeing" or
Statement                    "Strongly Agreeing"  "Strongly Disagreeing"

Environment-related          74                    5
conditions are currently
threatening the health of
millions of Americans.
Most Americans are aware of  11                   63
these threats.
Environmental health is       4                   87
well understood by the
public.
Environmental health is       3                   79
well understood by the
media.
Environmental health is       5                   90
well understood by decision
and policy makers.
There needs to be a better   87                    4
way to articulate
environmental health.
I am able to quickly and     47                   13
effectively communicate
what environmental health
is to lay audiences.

FIGURE 2 Percentage of Environmental Health Professionals Who
Communicate with Various Audiences at Least Once a Week--Survey Results

Public                              34%
Environmental Health Professionals  33%
Policy Makers                       20%
Media                               13%

Note: Table made from pie chart.

TABLE 3 Thematic Concepts Tested in Focus Groups

Theme          Concept                        Headlines

Effects of     Environmental health--related  Pollution is just as
pollution      diseases are on the rise.      deadly as a bullet.
               Problems such as asthma,       An ounce of prevention is
               declining fertility rates and  worth a ton of cure.
               cancer are increasingly a      You are what you eat ...
               result of pollution in our     And breathe ... And drink.
               air, water, and food. We are   The environment. It's in
               poisoning ourselves, and       your blood.
               changes must be made if we
               are to live in a healthy
               environment instead of a
               toxic one.
Susceptible    Victims of environmental       Bet you didn't know you
populations    pollution are most commonly    were part of a test group.
               children and seniors.          Did you know you were a
               Childhood diseases are on the  guinea pig?
               rise, including leukemia and   Are we being used as
               other cancers, ADHD (ADD),     guinea pigs?
               lead poisoning, and autism.
               Seniors similarly suffer
               elevated cancer rates and
               extreme reactions to
               contaminated food, air and
               water. While children and the
               elderly are more susceptible
               to environmental health
               hazards, everybody is
               vulnerable.
Economics and  Hundreds of billions of        An ounce of prevention is
prevention     dollars a year go toward       worth a ton of cure.
               treating diseases caused by    A healthy environment
               preventable environmental      makes a healthy economy.
               health hazards. If we were to
               significantly reduce the
               pollution we're creating,
               improve and enforce
               government regulations, and
               increase public awareness of
               the issues, we would be a
               healthier nation, and would
               free up billions now being
               spend on treating preventable
               illnesses.
Homeland       Since our country's founding,  National security begins
security       our national network of        at home.
               environmental health           A healthy nation is a
               professionals have been        secure nation.
               America's first responders     Heroes aren't always who
               for biological and chemical    you would expect.
               threats to national security.
               Environmental health
               professionals cleaned up the
               anthrax on Capitol Hill and
               provided equipment and
               training to the emergency
               workers at the World Trade
               Center. They are also our
               first line of defense against
               chemical spills, toxic
               releases, and other
               contamination to our air,
               water, and soil that
               prematurely kill thousands of
               Americans every year.
               However, at a time of
               increasing need, the United
               States is experiencing a huge
               shortage of environmental
               health professionals.
Specific       Our environment is making us   You are what you eat ...
environmental  sick through the air we        And breathe ... And drink.
health issues  breathe, the water we drink,   The environment. It's in
               and the food we eat. 76        your blood.
               million people get foodborne   You are not separate from
               illnesses in the U.S. every    your environment.
               year. More than 4,000 people   You are part of your
               contracted West Nile virus, a  environment.
               disease spread by mosquitoes,
               and 284 died this year. Four
               million children had an
               asthma attack in the last
               year, making it the leading
               cause of school absenteeism.
               The solution to these and
               countless other environmental
               health threats is really
               pretty simple; protect our
               air, water, and food and we
               protect our own health.

REFERENCES

Kleiber, P. (2004) Focus groups: More than a method of qualitative inquiry. In K.B. DeMarrais & S.D. Lapan (Eds.), Foundations for research: Methods of inquiry in education and the social sciences (pp. 87-102). Mahwah, NJ: Lawrence Erlbaum Associates, Inc.

Pew Environmental Health Commission. (2001). Transition report to the new administration: Strengthening our public health defense against environmental threats. http://healthyamericans.org/reports/files/transition.pdf (15 Nov. 2004).

Pew Environmental Health Commission. (2000). America's environmental health gap: Why the country needs a nationwide health tracking network. http://healthyamericans.org/reports/files/healthgap.pdf (15 Nov. 2004).

U.S. Department of Health and Human Services. (1990). Seventh report to the President and Congress on the status of health personnel in the United States (DHHS Publication No. HRS-P-OD-90-1). Washington, DC: Health Resources and Services Administration, Bureau of Health Professions.

Michele Morrone, Ph.D., R.S.

Alejandra Tres, M.P.A.

Ruben Aronin

Corresponding Author: Michele Morrone. Associate Professor, Ohio University, E 342 Grover Center, Environmental Health Sciences, Athens, OH 45701. E-mail: [e-mail].