Writing for publication in health education.

Abstract: Health educators working in community settings possess a wealth of information that can shape future biomedical research and health policy. Though publishing this information in professional journals is an effective communication channel, time constraints and lack of publication training can serve as barriers. Thus, valuable community-based insights may never be disseminated to the professional audiences who need it. The purpose of this article is to encourage and equip those who possess community-specific information to share it with others through journal publications. The authors overview selected health journals, describe common review processes, and provide detailed guidelines for manuscript development.

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In the world of health communication, health educators often expect to serve as information translators" by converting medical research results into meaningful public messages. But some may not recognize their equally important role in facilitating a reversed flow of information from public settings to health research venues. Public health professionals possess a wealth of information about the communities they serve that can shape biomedical research and health policies. Yet, there are those who have never published this valuable information in a professional journal: the forum commonly used and read by health researchers.

Reasons vary for this missing link in professional communication. Time and energy are precious commodities, and those on the front lines of community health spend large amounts of both to serve populations in need. There are few hours left in a day to devote to manuscript writing, an activity seldom rewarded in community settings. Some have submitted manuscripts only to become discouraged by rejections or revision requirements. Still others have never attempted to publish because its importance to the profession and the skills needed to accomplish it were not promoted in their educational and professional development experiences.

Health education journal editors and university professors recognize the need to encourage and equip public health practitioners to submit publishable works. Guidelines for using technology to conduct literature reviews have been published in health related journals (Schindler & Middleton, 2001). Health textbook authors (Doyle & Ward, 2001) have briefly introduced writing concepts.

Others have attempted to familiarize health practitioners with the journals through which they can obtain and publish pertinent information. Ding and Hu (1999) reported research targets and methods of two health education journals over a 10-year span (1988-1997). Price and Dake (2001) identified articles cited most frequently from four health education journals. Laflin, Horowitz, Nims, and Morrell (2000) reported availability of health education journals in university libraries. Kittleson (n.d.) broadened consideration of more journals as viable communication channels for the profession. Laflin, Horowitz, and Nims (1999) and Ogletree, Golove, and Hu (1997) overviewed the characteristics of a number of health education journals, though the formats and requirements of some have since changed.

Yet, to date, no work has been published in health education paradigms that provides a comprehensive perspective on the complex publication process, which begins with journal selection and doesn't end until the article is in press. The authors of this article address this need in a threefold approach. They, first, overview readership interests and publication requirements for nine selected health education journals. They then provide general information about the journal review process that an author should know before work begins. Thirdly, they guide potential authors through the practical steps of developing a manuscript for journal submission.

HEALTH EDUCATION JOURNALS

Because societies constantly change, current health issues and viable solutions are often also in flux. Health educators who continually read the professional literature can enhance their community efforts and awareness of burning questions in the profession. Potential answers to these questions and the new questions they generate should be the focal topic of manuscripts submitted for publication. The more authors know about existing health education journals and the audiences who

read them, the better equipped they will be to publish viable information.

The first step toward successful publication is to become familiar with a variety of health-related journals and the general interests and needs of their readerships. Readers can be drawn to journals for practical programming guidelines; research evidence and designs; or discussions about theory, policy, and community issues. Though some journals serve a broad readership and incorporate a variety of writing foci and formats, others have more precise requirements.

The list of journals in which health educators publish is long (Price & Dake, 2001). A detailed review of each would impede the focus of this article, which is on the broader perspective of publishing and manuscript development. The National Library of Medicine (http://www.nlm.nih.gov/nlmhome.html) provides an extensive index of health-related journals

The nine journals selected for description in this article (Figures 1 and 2) were chosen because of their connection with or recent official support from one of four major professional organizations: the American Association for Health Education [AAHE], American Public Health Association [APHA], American School Health Association [ASHA], and the Society for Public Health Education [SOPHE] These organizations often lead efforts to further research and enhance practice in the health education profession.

As a whole, the journals described in Figure 1 represent a diverse spectrum of health education-related publishing. Some health-related journals attract readers from a wide array of work settings and publication interests. The American Journal of Health Education (AJHE, 2003) and the American Journal of Health Studies (AJHS, 2003) are among those. However, subscribers to these journals are largely interested in health education and promotion. A disease diagnosis and treatment focus, for instance, would rarely be considered an appropriate topic.

Journals also vary in the degree to which data-based research, theoretical discussion, and/or programmatic interventions are emphasized. For example, the editorial board of Health Education and Behavior (HEB, 2003), priotitizes research and/or theory-based works, but also requires that implications for practitioners be discussed. In contrast, the Journal for Health Promotion Practice (JHPP, 2003) is largely dedicated to field application ideas for practitioners. These two journals, both published by SOPHE, represent a critical distinction in readership needs that can significantly impact manuscript compatibility.

Some journal editorial boards target a specific audience, topic, or work area. For instance, authors are encouraged to submit to the International Electronic Journal of Health Education (2003) manuscripts that address technology or topics related to international or immigrant populations. The American Journal of Public Health (AJPH, 2003) emphasizes efforts in public health arenas and the Journal of School Health (JSH, 2003) focuses on school populations. Health promotion and behavior change strategies are stressed in the American Journal of Health Promotion (AJHP, 2003) and the American Journal of Health Behavior (AJHB, 2003) encourages descriptions of multidisciplinary programs and factors that influence health behavior. The responsibilities of a Certified Health Education Specialist are strongly supported in a number of health education journals, but are particularly highlighted within the submission guidelines of the American Journal of Health Studies (AJHS, 2003).

Some journals meet the interests of a diverse readership through specific article categories such as classroom teaching strategies (e.g., AJHE, JSH) and/or community-based strategies (e.g., AJHS, AJHE, HEB). In some journals, special sections are set aside for specific types of research (AJHP, AJHS) or health policy issues (AJPH).

Matching the manuscript to an appropriate journal readership and focus is paramount. Yet, other journal characteristics should also be considered, such as the allowed number and format of tables and figures, whether a fee is charged for those visuals (e.g., AJHB), page limits, and style preferences. For a more complete perspective on journal foci and publication trends, potential authors should study articles published within those journals over the past three to five years and seek journal editor input.

Journals differ in the number of volumes or issues published per year as well as the number and size of articles published in each volume (see "Format" in Figure 1). They also differ in the volume of manuscript submissions that must be routinely processed, the size and availability of the journal's editorial staff and volunteer reviewer pool, and the degree to which electronic versus hardcopy processing is used. All of these factors can affect a journal's acceptance rate (as low as 19% for some journals) and the wait period between the dates of acceptance and actual publication. For this reason, it helps to become familiar with varying journal characteristics, as well as common approaches to the manuscript review process.

THE MANUSCRIPT REVIEW PROCESS

Most professional journals are peer reviewed in that a panel of approximately three manuscript reviewers critiques the manuscript and contributes to the decision-making process regarding its publication. Upon manuscript receipt, a journal editor first determines the "fit" of the manuscript topic in light of readership interest and journal goals and either immediately rejects the manuscript or distributes it for blind review (with author identification removed). The reviewers individually critique the manuscript and submit suggestions to the editor about acceptance/rejection and/or needed manuscript revisions.

POTENTIAL EDITOR DECISIONS

The editor synthesizes the reviewer's critiques and usually makes one of four choices. One choice, though rare, is to publish the article with no revisions required. The second and more likely choice is to inform the author that the manuscript has been "accepted with revisions," meaning that stipulations for some relatively small changes must be made by the author before full acceptance is awarded. The editor may provide copies of each reviewer's comments or a synthesized list of required changes.

A third possible decision is that the manuscript holds potential for becoming a publishable work, but substantial revisions are needed. Thus, the editor may suggest that the author make those major revisions and re-submit the article for a second review. With this suggestion comes no definite promise, however, that the resubmitted manuscript will be accepted for publication even if revisions are made. And, the author is under no obligation to resubmit.

The fourth editor option, manuscript rejection, can evoke much frustration for an author who has worked long hours to prepare a manuscript. But, experienced authors know that good work can be rejected for a variety of reasons and, later, accepted by another quality journal. Prior to submitting to a second journal, it pays to consider reviewer comments from the first journal.

RESPONDING TO REVIEWERS

A skill often learned early in one's professional development is the art of responding appropriately to criticism. Reviewers' remarks about manuscript weaknesses should not be viewed as a personal attack, particularly when blind reviews protect author identity. Though reviewer comments can provoke a strong emotional response, most suggested changes can serve to strengthen the manuscript. The key is to open-mindedly weigh the legitimacy of each stated manuscript weakness. Prior to resubmission, the author is expected to react to each suggested change by either following the suggestion (and indicating in writing where/how the change was made) or providing an objective, logical rational for how the change could compromise message accuracy or interpretation. An editor can choose to reject a revised manuscript that does not meet a reasonable level of suggested changes. Thus, it is best to ask a trusted, experienced colleague to critique the reviewer response and revised manuscript prior to submitting it to the editor.

Another important tip is to maintain a broad, long-range perspective on the publication process. Valuable information will eventually be published if the author keeps more than one target journal in mind and is patient and persistent in finding the right journal fit. Of course, it is expected that a manuscript will only be submitted to one journal at a time.

MANUSCRIPT DEVELOPMENT

There is no one model that all successful writers follow to develop their manuscripts. Some prefer to first create an outline or concept map as they critically consider manuscript components and, after much careful planning, write the first draft. Others simply begin writing without structure to enhance creativity. The first draft is then analyzed and restructured as needed. But, for the professional who is developing a first-time manuscript, the task can seem daunting and some basic step-by-step guidelines can help. Figure 3 represents a three-step approach that can be adapted to personal preferences.

[FIGURE 3 OMITTED]

STEP 1: IDENTIFY FOCUS

The fact that many community health educators possess a wealth of community-based information would seemingly simplify the process of developing a manuscript theme. However, some practitioners struggle to narrow their broad scope of knowledge and expertise into a focused, publishable topic. A topic is generally considered publishable if it moves the profession to a new or more accurate understanding of a health issue and how to address it. The manuscript should validate or expand on what is already known; provide guidelines or suggestions for how readers can apply the information presented; and identify needed questions or steps for future research or programming. Articles containing suggestions for future research or programming can be a viable source for a cutting-edge manuscript topic.

Schindler and Middleton (2001) described a 10-phase approach to conducting public health-specific literature searches on the World Wide Web that can assist the author with this process. In addition to published works and web sources, professional conferences and workshops and, sometimes, newspaper and television stories, can provide insight about health issues of professional and public concern. The seasoned practitioner will also have first-hand knowledge of the critical needs and concerns of other practitioners who work in similar settings. All of these sources can generate manuscript topics that address current concerns and interests.

Once an author chooses a general topic and narrows it to a more specific focus, a useful next step is to create a one- or two-sentence purpose statement. A purpose statement is a succinctly worded declaration of the primary intention or goal of the manuscript. For example, a specific purpose statement can be derived from the broad topic of childhood obesity that has recently warranted public attention. Some potential publications could, for instance, focus on a specific prevention program through a purpose statement such as "This article contains a description and analysis of the XYZ obesity prevention program designed for elementary school children in an urban school district." The manuscript could include a description and analysis of the strategies and methods used and a report of specific program impact and outcome measurements. Another manuscript might, instead, focus on the development of policies and community capacities needed to support childhood obesity prevention programs. A third manuscript might focus on a particular health-related problem that is commonly associated with childhood obesity (e.g., diabetes, low self-esteem and stress, hypertension risk, eating disorders) and the steps needed to minimize the incidence and symptoms of these problems.

The purpose statement is often used in the culminating paragraph of the introduction, the section in which the author presents a logical case for addressing the topic. The case may begin with a description of the prevalence and consequences of a health problem followed by a brief overview of what has been implemented to address the problem. The next case-building step is to explain what has not yet been addressed in relation to the topic and to include in that explanation missing components the author will address. This sets the stage for the culminating statement about the manuscript purpose and provides a logical explanation for publishing the manuscript.

Even if the purpose statement is not included in the final manuscript draft, it can serve as a guideline for expanding main points and a yardstick or way of determining whether created subtopics truly fit the primary manuscript focus. If one discovers a paragraph or passage that does not match the purpose statement, either the passage should be removed or the purpose statement should be re-written to include the passage's intended message.

STEP 2: SOLIDIFY FRAMEWORK

Synthesizing the multifaceted components of a health-related manuscript can become tedious and confusing. Using a concept map as the manuscript develops can enhance consistency and flow. Concept mapping is "a structured process, focused on a topic or construct of interest, involving input from one or more participants, that produces an interpretable pictorial view (concept map) of their ideas and concepts and how these are interrelated" (Trochim, n.d.a, paragraph #3)." Concept mapping has been used in a variety of ways, including health education program planning and evaluation (Trochim, n.d.b), curriculum design (Adsit, 2002), and research problem formation (Trochim, n.d.b). It is also a recommended tool as a pre-writing exercise (College of Agricultural, Consumer, and Environmental Science [ACES], 2002; Margerum-Leys, 1999) and is particularly useful when developing literature reviews as a full manuscript or as part of the introduction or synthesis of a complex data-based research manuscript (Schindler & Middleton, 2001). The sources cited within this section and in Figure 2 are recommended for an in-depth study of concept mapping methods and uses.

Concept mapping can help the author establish a central focus or purpose statement, identify concepts and arguments of primary and secondary importance, explore cause-effect relationships between constructs, and use the resulting visual as a guide for organizing and writing the manuscript. The author can use the concept map throughout the writing stage to gage whether the primary arguments and flow of ideas presented within the manuscript remain true to the map structure. For example, using the manuscript purpose statement introduced earlier that focuses on an elementary education obesity prevention program, one can develop a spider map, a type of concept map, to organize thoughts and concepts. As illustrated in Figure 4, the central node of the spider map would contain the purpose statement. Connected to it would be primary manuscript components such as the incidence/prevalence of childhood obesity and factors contributing to the problem. Solid lines and circles would represent points backed by evidence from published articles and/ or the author's research data. Dotted lines and circles would represent author-generated concepts or suggestions that, though not directly supported by existing evidence, are defended by a strong rationale. Using a visual such as this, or some other organizational process, can streamline the manuscript writing process.

[FIGURE 4 OMITTED]

The author can also simplify the process by becoming familiar with the targeted journal requirements and adjusting the cognitive map or outline in accordance with interest foci and length limitations. The information provided in Figure I about the nine journals mentioned there, and the author guidelines provided in other journals, can provide useful information. A preliminary contact with the editor of some journals can also be useful. For example, in the author guidelines provided by the American Journal of Health Promotion (2003), authors are encouraged to first submit an abstract to check for manuscript compatibility. Some editors also use abstracts to direct authors to specialized categories within the journal. Of course, the editor cannot determine from an abstract whether the full manuscript will be accepted for publication and some journal editors, such as for the American Journal of Public Health (2003), discourage preliminary abstract submissions. If no mention of the practice is found in a journal's author guidelines, a brief inquiry to the editor via email or telephone can clarify related journal policy.

STEP 3: DEVELOP MANUSCRIPT

Authors who use the preliminary steps described in previous sections may find the first draft of the manuscript relatively easy to write because much fore-thought about concepts and interrelationships will have already been invested. A couple of principles will help when writing the first draft of the manuscript. One useful principle to follow is to first critique one's outline or concept map (or ask a professional colleague to do so) to determine the strength of evidence one has to offer in defense of each argument or point. Confidence in that evidence (which comes from literature references and, in some cases, one's own analyzed data) can empower an author to write the manuscript in tones that convey that confidence to the reader.

A second useful principle is to solely concentrate on creating concepts in the first draft. Early attention to structural mechanics (e.g., sentence structure, spelling, syntax) can stifle creative thinking. In the first draft, the goal is to construct a logical flow of arguments that:

[] introduce the reader to the problem and describe the need (manuscript introduction),

[] convey what will be presented in the manuscript (purpose statement),

[] describe the processes used by the author to gather information and evidence (methods),

[] carefully describe and analyze the evidence found (results and discussion), and

[] provide applicable conclusions or guidelines the reader can use (suggestions/conclusions).

Ideally, the first draft should be critiqued by a colleague who can view it from a fresh perspective or by the author after a period of time. Two useful critique questions are "Does the manuscript present a solid rationale backed by sound evidence and logical assumptions?" and "Does the flow of arguments build a case that supports the manuscript conclusions?"

With manuscript concepts and arguments in place, the focus in writing the second draft should be on writing fundamentals. For example, for an energetic tone and good flow, the author can insert transitional statements as topic segues, use active rather than passive voice, create simple sentence structures, and eliminate professional jargon. For some authors, this is also where journal page limitations should be noted.

For the third or final draft, the author should pay careful attention to detailed requirements presented in the journal's author guidelines. Failure to adhere to details such as the abstract content, tide and authorship information, length limitations, and figure/table formats can result in an automatic manuscript rejection. Of course, additional spell checking and editing for proper syntax and sentence structure should also be applied to the final drab.

Once submitted, it is acceptable to contact the journal editor within two weeks of a mailed submission and within one week of an electronic submission to confirm that the submission was received. Though the length of the review process varies, an author can expect to wait at least six weeks from the submission date before receiving review results.

CONCLUSION

As is evidenced through the quality of articles published in this and other journals, many community and public health educators are skilled in adapting real-world information about what they've learned in their communities to the linear, research-oriented format often valued by professional journal reviewers. Difficulties in having written information accepted for publication can arise, however, if an author is unaccustomed to the rigors of manuscript development and the review processes commonly followed by journal editors. Patience, persistence, and consistency are needed to keep abreast of the writing process. The benefits to the profession, however, can be worth the price when experienced practitioners invest the time and effort to share what they know with other colleagues in the profession. Publishing that information in professional journals so that community practitioners and health researchers can learn from each other can increase the impact of the health education profession.

Figure 2. Web-Based Resources.

Journals with Web-based Author Guidelines

[] American Journal of Health Behavior: http://131.230.221.136/ajhb/

[] American Journal of Health Education: http://www.aahperd.org/aahperd/ template.cfm?template=ajhe-contributorguide.html

[] American Journal of Health Promotion: http://www.healthpromotionjournal.com/

[] American Journal of Health Studies: http://ajhs.tamu.edu

[] American Journal of Public Health: http://www.ajph.org/misc/ifora.shtml

[] Health Education and Behavior: www.sph.umich.edu/hbhe/heb

[] International Electronic Journal of Health Education: http:// www.aahperd.org/iejhe/template.cfm?template=guidelines.html.

[] Journal for Health Promotion Practice: www.sophe.org (Click on "publications and journals.")

Concept Mapping

An Introduction to Concept Mapping for Planning and Evaluation William M.K. Trochim, Cornell University; http://trochim.human.cornell.edu/research/epp1/epp1.htm

Concept Mapping

William M.K. Trochim, Cornell University; http:/hrochim.human.cornell.edu/kb/conmap.htm

Concept Mapping

Counseling Services Program University of Victoria in British Columbia, Canada http://www.coun.uvic.ca/learn/program/hndouts/map_ho.html

Concept Mapping and Curriculum Design

Teaching Resource Center University of Tennessee at Chatanooga; http://www.utc.edu/Teaching-Resource-Center/concepts.html#what-is:

Introduction to Concept Maps/in The Mind Module]

College of Agricultural, Consumer, and Environmental Science University of Illinois at Urbana-Champaign; http://classes.aces.uiuc.edu/ACES100/

HEALTH EDUCATION RESPONSIBILITY AND COMPETENCY ADDRESSED

Responsibility X: Advancing the Profession of Health Education

Competency A: Provide a critical analysis of current and future needs in health education.

Figure 1. An Overview of Selected Health Education Journals

Journal                 Readership              Stated Focus

American Journal of     Health educators &      Impact of behavior,
Health Behavior         promoters of multi-     social structure, etc.,
[AJHB] (6) (b)          disciplinary efforts    on health;
                                                multidisciplinary
                                                programs; health
                                                behavior analysis

American Journal of     Health educators in a   Community development/
Health Education        variety of settings     awareness, policy,
[AJHE] (6)                                      professional/
                                                instructional programs;
                                                individual health

American Journal of     Health promotion        Health promotion
Health Promotion        researchers/            interventions,
[AHJP] (6)              academicians &          strategies,
                        practitioners           applications, research
                                                (see guidelines for
                                                specifics)

American Journal of     Health education/       Emphasize
Health Studies          promotion researchers   responsibilities of
[AJHS] (4)              & practitioners         Certified Health
                                                Education Specialists
                                                (CHES)

American Journal of     Public health           Public health research,
Public Health           professionals           policy, practice, &
[AJPH] (12)                                     education

Health Education &      Health behavior &       Research, case studies,
Behavior [HEB] (6)      education researchers   program evaluation,
                        & practitioners         literature reviews, &
                                                theories (see web site
                                                for specifics)

Health Promotion        Health promotion &      Research/practice
Practice [HPP] (4)      disease prevention      links, community/
                        practitioners.          clinical strategies,
                                                evaluations, policy,
                                                professional
                                                development

Journal of              Health & service        Health promotion in
School Health           professionals,          school settings.
[JSH] (10)              teachers &
                        administrators

Internat'l Electronic   Health educators &      International &
Journal of Health       other health            immigrant groups &/or
Education [IEJHE] (d)   professionals           technology focus

                        Unique Guideline
Journal                 Specifics                   Formats (a)

American Journal of     * Title: 75 character       A: 100 w
Health Behavior           limit.                    M: 4500 w
[AJHB] (6) (b)          * $15 typesetting fee       RS: IM
                          for each table &
                          figure.

American Journal of     * Electronic submissions    A: 200 w
Health Education          only                      M: 15 p
[AJHE] (6)              * Abstracts, key words, &   RS: APA
                          appropriate referening
                          critical

American Journal of     * Encourage preliminary     A: 220 w
Health Promotion          abstract submission       M: 12-18 p
[AHJP] (6)              * Electronic submission.    RS: AMA

American Journal of     * Indicate CHES area(s)     A: 100 w
Health Studies            addressed                 M: 20 p
[AJHS] (4)              * Electronic submissions    RS: APA
                          only

American Journal of     * Good abstracts are        A: 120 w
Public Health             critical.                 M: 3500 w
[AJPH] (12)             * Use subheadings           RS: AMA
                        * Use acronyms sparingly.

Health Education &      * Emphasize implications    A: 100-150
Behavior [HEB] (6)        for practitioners         M: ~20 (c) p
                        * Avoid term: "subjects"    RS: IM

Health Promotion        * Practical application     A: 150 w
Practice [HPP] (4)        urged                     M: 15-20 p
                        * Avoid terms: "subjects"   RS: APA
                          & "target populations"

Journal of              * Avoid: "i.e.", "e.g.,"    A: 250 w
School Health             "etc."                    M: 3500 w
[JSH] (10)              * Use brief, specific       RS: AMA
                          titles.
                        * Address study
                          limitations.

Internat'l Electronic   * Must submit               A: 200 w
Journal of Health         electronically.           M: 15 p
Education [IEJHE] (d)   * Abstracts & correct       RS: APA
                          reference format
                          critical

(a) Abstract, Manuscript (word/page maximum), Reference Style: Index
Medicus format, American Psychological Association, American Medical
Association.; (b) Number of volumes/issues published per year (c) No
pagelimit is published for this journal. According to the editor, Dr.
Mark Zimmerman (personal communication, 09/10/02), ~20-25 pages are
usual.; (d) Published in "open volume" format (within a week of
acceptance.)

REFERENCES

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American Journal of Health Education (2003). Guidelines for authors. Retrieved January 14, 2003, from http://www.aahperd.org/aahperd/ template.cfm?template=ajhe-contributorguide.html

American Journal of Health Promotion (2003). Instructions to authors. Retrieved January 14, 2003, from http://www.healthpromotionjournal.com/resource/instruct.htm

American Journal of Health Studies (2003). Invitation to submit manuscripts. Retrieved January 14, 2003, from http://ajhs.tamu.edu

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Trochim, W. M. K. (n.d.a). Concept mapping. Retrieved January 10, 2003, from http://trochim.human.cornell.edu/kb/conmap.htm

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Eva I. Doyle, Ph.D., MSEd, CHES is the Director, Health Division in the Department of Health, Human Performance, and Recreation at Baylor University. Claudia Coggin, Ph.D., CHES is an Instructor and Public Health Practice Coordinator, School of Public Health at the University of North Texas Health Science Center. Beth Lanning, Ph.D., MSEd, CHES is an Assistant Professor, Health Division in the Department of Health, Human Performance, and Recreation at Baylor University. Address all correspondence to Eva L Doyle, Ph.D., MSEd, CHES, Director, Health Division, Department of Health, Human Performance, and Recreation, Baylor University, One Bear Place #97313, Waco, TX 76798-7313, PHONE: [phone], FAX: [phone], E-MAIL: [e-mail]