Kevin Ruck
Andrew Cooper
Andy Hurley
Kathryn Ashton
Chris Lines
Alan Willson
Publication Date
July 3, 2017

PR Academy (Ruck); Public Health Wales (Cooper, Ashton); Independent Website Developer (Hurley); Office for National Statistics (Lines); Swansea University (Willson)

"...provides empirical evidence that the selection of channels used in a health improvement campaign is an important factor in the success of the desired behavioural outcome."

This study out of the United Kingdom (UK) describes how the use of internal communication messages and channels contributed to engagement and improvements in health of National Health Service (NHS) Wales employees who took part in a 6-month programme to improve their personal health. It reviews the channels and messages used in the Champions for Health campaign, which was implemented by Public Health Wales to encourage NHS Wales employees to select 2 or more healthy lifestyle changes from the following 5 options: smoking, alcohol consumption, body mass index, fruit and vegetable consumption, and exercise. The paper begins with a review of literature on the key concepts for the study. The review sets out the research questions investigated in the research. Next, the research questions and research methods used are outlined, followed by analysis and discussion of the findings. (In short: A mixed-medium, high frequency strategy focused on email, information on a website, and a progress recording facility on a website had the most impact on health improvement actions.) Implications for theory, research, and practice are provided in the conclusion. 

As this paper is based upon a communication campaign with employees, two primary conceptual frameworks are explored:

  1. Internal communication channels - Despite the growing availability of internal and external social media that employees can access, studies suggest that email remains the preferred medium of most employees for internal communication, together with face-to-face communication. According to Towers Watson, one-way electronic media is the most used medium for employee health and welfare in the workplace.
  2. Medium theory - This involves asking questions about message dissemination, about how the medium enables long-term messages to be established, and the ability to respond either individually or with everyone. Information richness is defined as the ability of information to change understanding within a time interval. "Rich media" enable people to interpret and reach agreement about unanalysable, difficult, and complex issues, while "lean media" are more appropriate for communicating about routine activities. "Internet-based modes of mass conversation and 'intercreativity', where participants create content in a collaborative partnership, provide new opportunities for health communication which has traditionally controlled content very tightly." Channel expansion theory focuses on how individuals develop perceptions of a medium's richness or capacity to facilitate shared meaning. It is argued that perceptions are fluid and contingent on one's relevant experiences, such as using the channel, the communication topic, and one's communication partner. A further dimension of medium theory is the psychological affects of a particular medium on employees. This raises questions of appropriateness and acceptability of the message and the medium used. This study therefore seeks to explore the way that different media can be used to have the greatest impact on behaviour.

The campaign in this study incorporated website information focused on news and resources, including tips and health advice for each of the 5 lifestyle challenges. SMS (text) messages were sent such as "Last week 1 champion said 'I've lost 1st 5lbs and my family and friends are all supportive and some have followed suit!' Can you share something similar?" Weekly emails contained "read more" links that took the recipient to further related information on the website. The website also incorporated a password-controlled recording tool used by participants to record their weekly data for lifestyle challenges. The tool provided online forms to record weekly data, a "personal dashboard" providing an at-a-glance measure of how the participant was doing against their challenges, and a graph for each challenge providing a visual representation of their progress.

A mixed methods research approach was taken that incorporated a post-programme evaluation survey and 13 semi-structured interviews conducted 9-12 months after the communication programme. All employees who had registered to improve 2 lifestyle behaviours were invited to participate (n=1,320). In brief, the campaign was found to have had a notable effect on the lifestyle of participating individuals. In total, 35.3% (n=122) reported an improved general health status, 33% (n=110) reported an improved mental health status, and 84.2% (n=294) stated they would continue with changes to their lifestyle after the campaign had ended. In addition, 67.3% (n=235) indicated that they would pass on what they learned from the programme to family and friends, an indicator of advocacy. A summary of the reported usefulness of channels is shown in Table 1. Frequency analysis shows that employees found email briefings (2.84, standard deviation (SD)=1.24), information on the website (2.79, SD=107), and text messages (2.53, SD=1.40) to be the 3 most useful methods of communication. Information on the website (r=0.22, P<0.01) and email briefings (r=0.20, P<0.01) were positively and statistically significantly correlated with a general health outcome. Usefulness of the face-to-face communication element of the campaign was notably rated lower than with other media, but it was not possible to implement face-to-face communication support in every location. Usefulness of two social media elements was also relatively low; Twitter (1.89, SD=1.27) and a forum discussion (1.87, SD=1.04). This emphasises the importance of understanding how media richness perceptions are dependent on experiences with the communication media utilised.

Three themes emerged from interviews:

  • Different communication channels appeal to people at a variety of levels - The appeal of certain channels was often expressed as being dependent upon the stage of the health challenge journey. This suggests that personal and social aspects may impact media choice and the way that the symbolic meaning of technology is jointly produced through interaction with the technology and broader social structures. It also reinforces observations that message frequency moderates intervention effectiveness and the suggested use of variable schedules where participants can set their own schedule and programmes with decreasing frequency over time.
  • Local support activity can enhance computer-mediated communication and social media - Many interviewees expressed a wish for greater local support during the programme, in terms of local groups, local events, and "buddies". The lack of available face-to-face communication highlighted by interviewees suggests that it is the absence of it that may account for the relatively low levels of usefulness for face-to-face communication reported. Indeed, where local face-to-face activities were in place, interviewees highlighted the benefit of them.
  • Examples of real success stories are highly motivational - The study emphasises how real-life stories are useful examples that enable employees to assess their own achievements and struggles. This point illustrates the importance of stories about employees "like me" and how, in a health communication campaign, they can resonate.

Among the reflections in the paper's discussion section is that this study reinforces the argument that a defining attribute that new technologies share is the ability to exchange information between individuals and groups. For example, employees reported the website to be "supportive and motivational when things got tough". However, although some participants stated that completing the regular challenge data provided an incentive to keep going, other interviewee comments indicated a mixture of emotions, combining a sense of irritation and guilt inducement with a recognition that it is something that is required to maintain engagement with the health improvement challenge. Communication practitioners may therefore need to be more aware of the potential negative impact of messages and incorporate mechanisms for dealing with this into campaigns. That is, it is important to look at how technologies can sometimes change the contexts for human interaction.

This study indicates that internal communication programmes that are based primarily on electronic and social media channels can be effective in behavioural change. However, this approach may not be appropriate for all employees as participants reported that they would like more control over the timing and frequency of communication, based on personal preferences and access and/or familiarity with a specific medium. A recommendation for practice is to provide employees with the ability to personalise channels and content.


Journal of Communication in Healthcare DOI: 10.1080/17538068.2017.1343173. Image credit: Betsi Cadwaladr University Health Board