Framing health: how health communication theories and strategies shape NCD prevention content on Facebook Sri Lanka

Abstract

Background

Social media platforms like Facebook are increasingly used for health communication, particularly for the prevention of non-communicable diseases (NCDs). This study evaluates the use of health communication theories and strategies in Facebook campaigns in Sri Lanka organized by the entities of the Ministry of Health.

Methods

A two-phase approach was used. First, a literature review identified suitable theories and strategies to create an evaluation framework. Second, 15 Facebook posts from Sri Lanka’s NCD Unit, Health Promotion Bureau (HPB), and Ministry of Health were analyzed. Data were evaluated based on a scoring system to assess the application of health communication theories and strategies.

Results

The Health Belief Model (HBM), a psychological model that explains and predicts health behaviors by focusing on individual perceptions of health risks and benefits, and the Social Marketing Mix (SMM) and Lasswell’s 5W, were identified as the most popular and comprehensive theories and strategies in health communication. Results showed strong strategic use, including audience targeting and content structure, but the use of health communication theories, such as HBM, is minimal. Posts aligned well with the Social Marketing Mix and Lasswell’s 5W model. Animated videos showed the best theoretical alignment, but engagement was low unless posts were boosted with paid promotions. Content on physical inactivity was underrepresented.

Conclusions

Facebook posts used strategies but lacked strong theoretical foundations. Training content creators to include theory-based approaches and balancing theory with strategy can improve the quality of health communication. This study highlights the need for better policies, training programs, and further research to make social media a more powerful tool in preventing NCDs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-026-27403-3.

Introduction

In the digital age, public health communication requires more than simply broadcasting health advice [1]. While platforms such as Facebook offer broad reach and speed, effective messaging must be guided by both strategic design and theoretical grounding [2, 3]. Social media, with its growing influence in health promotion, offers an unparalleled opportunity to engage with audiences [4]. Yet, many health campaigns prioritize aesthetics and visibility over behavior change, often resulting in low-impact messaging [2–5].

Health communication theories, such as the Health Belief Model (HBM) [6, 7], provide critical insights into how individuals assess risks and make decisions about their health [8]. Strategic frameworks like Lasswell’s 5 W model [9] and the Social Marketing Mix [10] further help tailor messages to specific audiences by focusing on the who, what, where, when, and how of communication [11]. These models ensure that health messages are not only informative but also behaviorally persuasive [12, 13].

In Sri Lanka, Facebook is widely used by public health agencies to communicate health related messages of non-communicable disease (NCD) prevention [14]. Despite the volume of content, there is limited evidence evaluating whether these messages are strategically and theoretically sound [15].

Facebook is one of the most widely used social media platforms in Sri Lanka, with an increasingly diverse user base. The age distribution of Facebook users in Sri Lanka skews towards adults aged 25–54, though younger populations, particularly those aged 18–24, also comprise a significant portion of the user base [16, 17]. Urban and rural differences are apparent, with urban users showing higher engagement rates and more frequent use of Facebook compared to rural areas. In terms of target populations for NCD prevention, Facebook user demographics align well with the primary demographic for NCD prevention, particularly adults aged 18–45, who represent a key audience for health messaging [18, 19]. Facebook was chosen over other platforms such as Instagram, TikTok, or WhatsApp because FB is the most prominently used social media platform in Sri Lanka due to its broader reach across these demographic groups and its established presence as a tool for public health communication in Sri Lanka [17, 20, 21].

While global campaigns such as Australia's "Live Lighter" [22] and Canada's "Make Health Last" [23] have demonstrated the effectiveness of theory-driven social media communication, similar evaluations are scarce in low-and middle-income settings such as Sri Lanka [24].

This study aims to evaluate how Facebook posts used for NCD prevention in Sri Lanka and how they align with health communication theories and strategies. We evaluated selected Facebook posts, on the use of components of the Health Belief Model theory, and strategies such as Lasswell’s 5 W model, and the Social Marketing Mix. As identified by literature, these frameworks comprehensively cover major elements of health communication theories and fundamental strategies of health communication. Findings are expected to identify approaches to improve the effectiveness of social media-based health campaigns.

Methods

This study was conducted in two phases: first, to identify health communication theories and strategies in order to develop framework for assessing the use of theory and strategy in health communication content on social media; and second to critically evaluate and test selected Facebook content using the selected framework.

Phase 1: identification of theoretical frameworks

Phase 1 involved a scoping review to identify health communication theories and strategies relevant to NCD prevention on social media. The full methodology, screening process, PRISMA-ScR checklist, and findings of this scoping review are reported in detail in a companion manuscript currently under peer review at BMC Public Health (Wanasinghe T, et al. 'From Beliefs to Behaviour: A Scoping Review of Health Communication Theories and Strategies for NCD Prevention on Social Media.' BMC Public Health, under review, Submission ID: abe6d069-35ce-415d-8ba0-a0f1437245c4).

Literature published from 2013 to 2023 in the databases Scopus, Web of Science, PubMed, ZLibrary, Science Direct, JSTOR, Google Scholar, EBSCO, and ProQuest were searched. Boolean operators and Mesh terms and appropriate synonyms were used to develop the following search strategy; “‘health communication theor* OR communication theor* AND health communication strateg*,AND (NCD OR non communicable diseases) AND ‘social media’/“(((Health communication theories) AND (strategies)) AND (non-communicable disease prevention))”.

Theories/frameworks were identified from the literature review as best suited to evaluate health communication theories and strategies. They were adapted to create two frameworks to separately evaluate health communication theory and strategy. Thereafter, a scoring system given in Table 1, was developed to evaluate each Facebook content using the two frameworks. The scores per each component ranged from zero to three based on how evident the use of theory or strategy was in each post. Both frameworks had six components each scoring both health communication theory and strategy evaluation out of 18.

Table 1.

Scoring system for theory and strategy evaluation

Index	Marks
Not evident	0
Poorly evident	1
Moderately evident	2
Strongly evident	3

Phase 2: evaluation of facebook content

Using the two frameworks developed in Phase 1, content analysis was performed on 15 selected Facebook Content. This content included posters, videos, and 2D/3D animation videos addressing physical inactivity and unhealthy diets, published on the official Facebook pages of the NCD Unit, Health Promotion Bureau, and the Ministry of Health in Sri Lanka from 2018 to 2022. Some FB content were paid for better reach while others were not. Thus, the conent were categorized was paid or organic. Although the NCD unit and Health Promotion Bureau shared both physical inactivity and unhealthy diet related content the Nutrition Division only addressed unhealthy diets as per their institution mandate.

In this study, we analyzed a total of 137 posts (28 videos and 109 still images) from three official Facebook pages over a period of four years (2018–2022), focusing on non-communicable disease (NCD) risk factors related to physical activity (PA) and healthy diet. Out of these, 15 posts were purposively selected based on their engagement relative to their reach for a qualitative analysis. These posts were categorized into still images, hybrid posts, and animated videos. The posts with the highest Relative Engagement (RE) scores were chosen, calculated using the following formula:

The 15 posts selected represent a sample from the total posts analyzed, rather than the entire population. We used purposive sampling to select posts based on their engagement levels, ensuring that the posts chosen were the most engaging relative to their reach. The selection was appropriate as the objective was to adopt a qualitative analysis approach.

Accordingly this sample size of 15 posts was considered adequate for framework testing as it represents a diverse range of post types (videos and images) across the 4-year period and focuses on those with the highest engagement metrics, providing a solid foundation for qualitatively analyzing the application of health communication theories.

Two authors independently evaluated the content using the predefined marking scheme given in Table 1. Each content was scored out of 18 and then percentages were calculated.

Inter-rater reliability was employed to ensure consistency, compatibility, and agreement of the chosen framework. Cohen's Kappa statistical measurement was used to confirm the agreement between the observers.

Results

In this section results of the two phases are discussed separately.

Phase 1: developing a health communication theory evaluation framework

A scoping review was conducted to identify suitable theories and strategies to develop the theoretical framework. Two authors screened 2549 papers to identify any theoretical basis in the discussion of health communication.

Key health communication theories highlighted in the review were; HBM [25], Elaboration Likelihood Model (ELM) [26], Protection Motivation Theory (PMT), Theory of Planned Behavior (TPB) [27], Social Cognitive Theory (SCT) [28], and Diffusion of Innovation (DOI) Theory [29]. These theories delve into psychological, sociological, and behavioral aspects of change within sociocultural contexts.

The Health Belief Model (HBM) and the Elaboration Likelihood Model (ELM) provide frameworks for understanding how people are persuaded by health communication. While the HBM focuses on the factors that motivate an individual to take a health-related action, the ELM examines the cognitive processes through which a person evaluates and responds to a message. In addition, Framing Theory highlights how the presentation of a message can influence its reception, and the Health Promotion Model explains the complex factors that affect health-promoting behaviours. Together, these theories offer complementary perspectives that are essential for designing health communication strategies that are both persuasive and tailored to their target audience.

All the above theories elucidate behaviour prediction, attitude formation, and knowledge acquisition processes [12]. Moreover, health communication theories offer philosophical paradigms for understanding human behaviour and communication dynamics [30]. Despite primarily descriptive explanations, these theories address functional, diffusion, persuasion, and cultural factors, often leveraging fear and threat for motivation. Although empirical evidence of their application is limited, they provide invaluable insights for understanding and guiding health communication practices. However, out of the persuasion theories used in prevention and content evaluation, HBM was identified as the most widely used theory in social media studies that discussed disease prevention. It is one of the most extensively used and validated models in health communication research and promotion [31].

Health Belief Model (HBM)

HBM is a theoretical framework for health promotion and disease prevention programs [32]. It explains individual changes in health behaviours by emphasising the influence of beliefs regarding health threats, perceived benefits of action, and barriers to action [33, 34]. Widely employed in health communication, the HBM informs interventions and messages to foster positive health behaviours [35]. HBM demonstrates versatility and comprehensiveness by integrating various theoretical concepts and has been successfully adapted across diverse cultural and topical contexts [31, 36, 37].

Considering the incorporation of Health Belief Model (HBM) into health communication offers a framework for understanding the psychological factors influencing decision-making in health-related contexts. Therefore, the evaluation of health communication theory in this study will focus on examining the adaptation of the HBM and its key components [38]. This was identified as the most suitable framework to evaluate the use of Health Communication Theory (HCT) in social media. Furthermore, the HBM is a strong theory that has been widely used as a foundation of health communication programs and content, compared to other theories that are less popular (Table 2).

Table 2.

The theoretical framework of using Health Belief Model (1984)

Concept	Definition	Application
Perceived susceptibility	One's opinion of chances of getting a condition Perceived	Does the content heighten perceived susceptibility if too low
Perceived severity	One's opinion of how serious a condition and its consequences are	Does the content specify the consequences of the risk and the condition
Perceived benefits	One's belief in the efficacy of the advised action to reduce risk or seriousness of the impact	Does the content clarify the positive effects to be expected
Perceived barriers	One's opinion of the tangible and psychological costs of the advised action	Does the content reduce barriers through reassurance, incentives, and assistance
Cue to action	Strategies to activate "readiness"	Does the content, promote awareness, and reminders for action
Self-efficacy	Confidence in one's ability to take action	Does the content provide training, and guidance on taking action

Source [38]

Developing a model to evaluate health communication strategy

The fundamentals of communication and marketing cannot be undermined when developing health communication strategies. Based on the literature available on health communication theories, the most suitable theory to evaluate strategies were identified as Lasswell’s 5 W model and Social Marketing mix [39–41].

The social marketing approach [10] is widely discussed in communication research and especially in health communication and promotion [42]. It suggests planning, implementing and controlling programs with the intention of increasing acceptability of an idea or beneficial behaviour among a target audience. While social marketing may not be able to induce behavioural change, it fosters acceptance and willingness to engage [10]. The social marketing mix by Philip Kotler suggests leveraging the product, price, place, promotion, partnerships, and policy [43] to deliver desired behaviours or ideas to the target audience.

Lasswell’s 5 W model, developed in 1948, is one of the earliest and most influential core communication models [40]. This model has significantly contributed to academic advancements in strategic communication, particularly within the realm of political psychology, laying the groundwork for contemporary strategic communication practices [44, 45]. There appears to be an overlap between certain elements of the social marketing mix and Lasswell’s 5 W model. Thus, these two theories have been combined to form the basis of the evaluation framework for health communication strategies (Fig. 1).

Fig. 1.

Framework for evaluating health communication strategy (based on Laswell’s 5 W model and social marketing mix)

While this study focused on Facebook, the frameworks used such as the Health Belief Model and Social Marketing Mix are adaptable to other popular social media platforms like Instagram, Twitter, and TikTok. Each platform has unique features that could influence how health communication theories are applied. For example, Instagram’s emphasis on visual content may require a stronger focus on the perceived benefits of health behaviours, leveraging images and videos to make health messages more compelling. In contrast, Twitter’s character limit may demand more concise calls to action, with a focus on direct and clear messaging to prompt immediate engagement. By adapting these frameworks to different social media formats, health communicators can effectively tailor messages to suit the strengths of each platform while maintaining theoretical integrity.

Phase 2: testing the health communication theory and strategy frameworks

The 15 Facebook contents selected for analysis using the frameworks included five still posts(n = 5), eight hybrid videos (n = 8) and two animated videos (n = 2). Only three contents addressed the topic of physical inactivity while all others addressed unhealthy diets. Some posts had an organic reach while others were paid for boost.

Table 3 provides details of the content including the health communication theory and strategy mean scores given by two independent reviewers (TW and LA). The attached supplementary materials provide a detailed example of how the scoring was done (Supplemenatry material 01). of Health communication theory evaluation scores ranged from 5.5% – 94.4%, and the strategy evaluation scores ranged from 61.1% – 94.4%. Six contents (Table 3) scored > 70% in health communication theory evaluation and the majority (n = 11, 73.3%) scored high (> 70%) on the health communication strategy evaluation.

Table 3.

Data of critical evaluation on 15 selected Facebook contents

Content ID	Content Category	Risk factor addressed	Reach	Engagement	Paid (P)or Organic (O)	Theory evaluation score as %	Strategy evaluation score as %
Content 01	Still Post	Physical inactivity	1024	10	O	50	77.7
Content 02	Still Post	Unhealthy diet	11,046	822	O	5.5	61.1
Content 03	Hybrid Video	Unhealthy diet	323,247	718	O	38.8	72.2
Content 04	Hybrid Video	Unhealthy diet	88,255	125	O	55.5	88.8
Content 05	Hybrid Video	Unhealthy diet	1408	33	O	72.2	88.8
Content 06	Hybrid Video	Unhealthy diet	1339	23	O	66.6	83.3
Content 07	Still Post	Physical inactivity	162	143	O	22.2	77.7
Content 08	Still Post	Unhealthy diet	51,776	8441	P	5.5	72.7
Content 09	Hybrid Video	Unhealthy diet	1,116,000	42,072	P	72.7	66.6
Content 10	Hybrid Video	Unhealthy diet	1182	242	O	88.8	83.3
Content 11	Animated Video	Physical Inactivity	9099	157	P	88.8	94.4
Content 12	Animated Video	Unhealthy diet	132,000	93	P	94.4	77.7
Content 13	Still Post	Unhealthy diet	0	0	O	5.5	66.6
Content 14	Hybrid Video	Unhealthy diet	0	3	O	88.8	94.4
Content 15	Hybrid Video	Unhealthy diet	0	3	O	55.5	66.6

ID numbers 01–06 represent NCD unit Sri Lanka Facebook page, 07–12; HPB Facebook page,13–15; ND Sri Lanka Facebook page

The evaluation revealed a clear distinction in performance based on theoretical and strategic application. The content with the highest mean theory evaluation score (94.4%) was a paid animation video on an unhealthy diet (Content 12). While it had a high reach (n = 132,000), its engagement (n = 93) was very poor.

Two FB content (Content 11 and 14) reported the highest health communication strategy score of 94.4%. One was an animated video (Content 11) posted by the HPB with a high user reach (n = 9,099) but low engagement (n = 157). The second video was aslo an animated video (Content 14) that was an organic one, which had a theory evaluation score of 88.8%. It has very poor engagement (n = 3) and reach (n = 0) (Table 3).

There is a link between the type of content created and how well it follows health communication theories. Animated videos performed best, consistently earning high scores in health communication theory, ranging from 88.8% to 94.4%. Still posts showed the lowest scores for health communication theory (5.5%—50%) (Table 4).

Table 4.

Summary of content analysis by category

Content Category	Content ID	Reach (Min–Max)	Engagement (Min–Max)	Theory Score (%) (Min–Max)	Strategy Score (%) (Min–Max)
Still Post	01, 02, 07, 08, 13	1024—51,776	0—8,441	5.5—50.0	61.1—77.7
Hybrid Video	03, 04, 05, 06, 09, 10, 14, 15	0—1,116,000	3—42,072	38.8—88.8	66.6—94.4
Animated Video	11, 12	9,099—132,000	93—157	88.8—94.4	77.7—94.4

Assessing Inter-Rater Reliability (IRR)

Inter-rater reliability of the evaluation was assessed using Cohen’s Kappa formula (Table 4). Two members (TW & LA) of the research team individually scored each content. In the theoretical evaluation framework, the overall IRR was 0.6 indicating moderate agreement (0.41—0.60). The data indicated the perfect agreement in nine out of 15 ratings and Six disagreements. The IRR of health communication strategy evaluation framework indicated the same interpretation (0.41—0.60) with eight moderate agreements (IRR = 0.53) and seven disagreements.

The two independent reviewers blindly scored using the tool. The final scores were determined through averaging. Prior to review, the first author trained the other reviewer and discussed what is expected. Common disagreements were seen in areas such as the intensity of theoretical constructs and the specific impact of health communication strategies, particularly where subjective judgment was required for nuanced content. These disagreements could be on account of the different backgrounds of the reviewers; one trained in communication and the other in public health space. This led to an overall Inter-Rater Reliability (IRR) of 0.60 for the theory evaluation and 0.53 for the strategy evaluation, both indicating a moderate level of agreement (Table 5).

Table 5.

Agreement of rater’s rates for theory and strategy evaluation

Strategy evaluation				Theory evaluation
Cases	Rater 01	Rater 02	Agreement of rater's rates	Rater 01	Rater 02	Agreement of rater's rates
Content 01	14	14	1	9	9	1
Content 02	11	9	0	1	1	1
Content 03	13	13	1	7	7	1
Content 04	16	14	0	10	11	0
Content 05	16	14	0	13	13	1
Content 06	15	15	1	12	9	0
Content 07	14	14	1	4	4	1
Content 08	3	12	0	1	1	1
Content 09	12	15	0	13	16	0
Content 10	14	14	1	17	13	0
Content 11	15	11	0	14	14	1
Content 12	12	12	1	16	16	1
Content 13	12	12	1	1	3	0
Content 14	17	15	0	16	16	1
Content 15	12	12	1	10	11	0
IRR- Theory				0.60
IRR- Strategy				0.53

Discussion

This study was conducted to develop frameworks to evaluate health communication theory and strategy used on Facebook content. A literature review helped identify and adapt health communication theory and strategy which were then tested for reliability. Findings highlighted the varying level of integration of health communication theory and strategy on Facebook posts about NCD prevention in Sri Lanka. While the posts were generally strong in their strategic use, they were weaker in their application of health communication theories. Specifically, all the posts that scored higher above 70% appear strong in strategy-related factors, such as message timing, content structure, and audience targeting. However, the contents that scored lower (below 60%) in terms of theoretical alignment, particularly in aligning with the HBM elements, showed poor integration of theoretical constructs. Animated videos showed better alignment with theoretical constructs but had low audience engagement unless boosted through paid advertisements. Additionally, content related to physical inactivity was sparse, highlighting a significant gap in NCD prevention efforts.

Reach and engagement are important indicators in social media matrices that suggest audiences' have interacted with the content. However, neither reach nor engagement can be considered as outcomes or proxies for the effectiveness of health communication content. Additionally, reach or engagement do not indicate message comprehension or changes in attitudes or behaviours, but merely the fact that FB users have seen and reacted to it either positively or negatively.

One of the strengths of this study is its use of dual frameworks—one based on the health belief model [34] and the other combining Lasswell’s 5 W model [46] with the social marketing mix [10]. This allowed for a comprehensive evaluation of Facebook posts, considering both strategic and theoretical dimensions. Furthermore, Kappa demonstrated moderate inter-rater agreement, suggesting acceptable consistency in evaluation.

The findings from this study are consistent with research conducted in other countries regarding social media-based health communication. For example, global campaigns like Australia’s “LiveLighter” and Canada’s “Make Health Last” have been recognized for their successful use of health communication theories, particularly HBM, in motivating behaviour change [22, 23]. These studies have demonstrated that combining theory with strategy can lead to more effective health messaging.

In contrast, many campaigns in low-and middle-income countries (LMICs), including Sri Lanka, continue to struggle with applying theoretical frameworks. The gap between strategy and theory in Sri Lanka’s public health campaigns is a concern, as it reflects a broader trend in LMICs where campaigns tend to prioritize aesthetics and visibility over evidence-based health communication [47]. Studies in countries like India and Nigeria have also reported that while social media campaigns are visually appealing and widely shared, they often lack theoretical grounding [2, 12, 13]. Thus, this study contributes to this body of research by providing a detailed evaluation of the theoretical and strategic underpinnings of Facebook posts in Sri Lanka on NCD prevention.

The integration of health communication theories in Sri Lanka’s digital campaigns differs significantly from high-income countries like Australia and Canada, where campaigns such as LiveLighter and Make Health Last benefit from widespread internet access and digital literacy [48, 49]. In Sri Lanka, digital health communication must contend with challenges like lower internet penetration and varying levels of health literacy, which can limit the effectiveness of theory-driven messages. For instance, while the Health Belief Model (HBM) is widely used in high-income countries, its application in Sri Lanka requires adaptation to address local cultural contexts and digital engagement patterns [50]. This highlights the need for more localized strategies, as seen in similar LMICs like India, where campaigns integrate both traditional and digital media to reach diverse audiences [51]. A more nuanced comparison of these socio-digital contexts could provide valuable insights into how theory-based health communication can be adapted for greater impact in Sri Lanka.

One key finding of this study is that posts with stronger theoretical alignment showed low engagement unless supported by paid boosts. This challenges the assumption that theory-based content will always perform better in terms of engagement. Similar studies in high-income countries have found that creative content, even when theory-driven, requires effective distribution strategies to reach a wider audience and generate engagement [42]. We find that while content theory is important, the strategic use of social media tools, such as paid promotions, also plays a significant role in engagement.

The study was not without its limitations. The sample size of the study was relatively small, with only 15 Facebook posts. While the findings provide valuable insights, the sample size may not fully represent the range of content produced by Sri Lankan Health Ministry or the diversity of social media health campaigns. The study only focused on Facebook contents and not on other popular social media platforms such as TikTok, Instagram etc. Further, even the frameworks were developed based on an extensive literature review, expert validation was not conducted. The strengths of the study include the comprehensiveness of the frameworks which are based on empirical evidence. This is a descriptive study conducted at a single point in time and is unable to assess the temporal trends of the three Facebook pages or the quality for their content posted over time which could also impact the clients' engagement or reactions. Although IRR testing of the frameworks would ensure its reliability, its findings indicate only moderate reliability. This indicates some discrepancies in how the posts were scored by different raters. Thus, further refinement of the evaluation tools may be needed.

Implications for policymakers and practitioners

This study has important implications for health communicators, policymakers, and clinicians involved in digital health campaigns. While Facebook can be an effective social media platform for health communication [2, 52], the study demonstrates the importance of ensuring that messages are both strategically designed and theoretically grounded [30]. The integration of health communication theories, such as the Health Belief Model [7], with strategic approaches such as the Social Marketing Mix [10] and Lasswell’s 5 W model [46], can help create more persuasive and impactful messages.

The Thai Health Promotion Foundation, which has played a crucial role in addressing NCDs in Thailand over the past two decades, has implemented programs that focus on improving health communication strategies, promoting healthier behaviours, and training health professionals to enhance their effectiveness in combating NCDs [53, 54]. These initiatives emphasize the importance of integrating communication strategies into public health campaigns as found in this study where the combination of theory and strategy in health communication was found to contribute to reach and engagement of Facebook content. For Sri Lanka, such initiatives serve as a valuable model, emphasizing the need for strong theoretical underpinnings, a strategic approach and the application of research to improve health communication and prevention efforts.

The lack of focus on physical inactivity in the contents of Sri Lanka’s Facebook posts is a major finding in this study. Physical inactivity is a key risk factor for NCDs, yet it was underrepresented in the analyzed content. Similar to Sri Lanka, a health promotion campaign in UK focused predominantly on diet-related content, while physical activity was often overlooked, despite its critical role in NCD prevention [55]. Similarly, India’s “Mission Indradhanush” campaign, while successful in targeting immunization and health education, has faced challenges in addressing NCDs, particularly physical inactivity [56]. This underscores the need for a more balanced approach to NCD prevention – an approach that equally addresses multiple risk factors, including diet and physical inactivity. For practitioners, this study emphasizes the need to ensure that health communication is based on solid theoretical frameworks that account for how individuals perceive health risks and make decisions about health behaviour. Training programs for public health professionals and content creators should integrate health behaviour theories with practical social media strategies to enhance the effectiveness of digital health communication campaigns.

To ensure practical implementation of the recommendations, we propose the development of targeted training programs for content creators, digital marketers, and health communicators. These training sessions, such as workshops or online courses, would focus on how to integrate health communication theories into digital campaigns, emphasizing practical steps for content creation. Additionally, collaboration with policymakers is essential to encourage the inclusion of theory-driven approaches in national health policies and campaigns.

Unanswered questions and future research

Despite the insights provided in this study, several questions remain unanswered. First, while this study focused on Facebook, it would be beneficial to explore how other popular social media platforms, such as Instagram, TikTok, and YouTube, affect audience engagement and behavioural change, as each platform has a unique content style and user interaction [57–59]. Expanding the scope to include these platforms could offer a more comprehensive understanding of digital health communication.

Additionally, future research could explore the role of audience feedback in shaping the effectiveness of social media health campaigns. Understanding how different demographic groups respond to these campaigns would provide useful insights for tailoring content more effectively.

Finally, long-term studies that track behaviour change over time and assess the sustainability of health communication campaigns would provide valuable information on how social media influences lasting health behaviours. Future research should also investigate the effectiveness of paid versus organic social media posts in health campaigns, as this study found that paid ads significantly boosted engagement, particularly for posts with animated videos.

Conclusion

This study sheds light on the current state of Facebook-based health communication in Sri Lanka, specifically in relation to NCD prevention. While health communicators are effective in using strategic elements like timing, targeting, and visuals, there is a need to strengthen the theoretical foundations of health communication. Incorporating established health communication theories, such as the Health Belief Model, Social Marketing mix with Lasswell’s basic communication model, can improve the impact of social media campaigns. This study highlights the need for better policies, training programs, and further research to make social media a more powerful tool in preventing NCDs. Further, future efforts should focus on connecting communication design with evidence-based behavioural strategies. This means that health messages should not only look attractive or use creative visuals but also be developed with a clear understanding of how people think, feel, and make health decisions. By combining appealing design with insights from behavioural science, health communicators can create campaigns that genuinely influence habits and support long-term positive health behaviour change.

Abbreviations

NCD

Non-Communicable Disease

HBM

Health Belief Model

ELM

Elaboration Likelihood Model

TPB

Theory of Planned Behaviour

SCT

Social Cognitive Theory

DoI

Diffusion of Innovations

PMT

Protection Motivation Theory

NIHR

National Institute for Health Research

Authors’ contributions

All authors were involved in the conceptualization of the paper. TW collected the data and wrote the manuscript. TW collected the data. TW and LA conducted the analysis. MC provided feedback on the arrangement results and interpretation of the manuscript. All authors read and commented on the final version of the manuscript.

Funding

This study was conducted as part of the PhD research of TW and was funded by the Global Health Research Unit for Diabetes and Cardiovascular Disease in South Asia, funded by the NIHR (132960) with aid from the UK Government for Global Health Research. The views expressed in this publication are those of the authors and not necessarily those of the NIHR or the UK Government.

Data availability

The data are not publicly available as they form part of the PhD research project of TW. The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Contact: Thilak Wanasinghe, thilakwanasinghe10@gmail.com.

Declarations

Ethics approval and consent to participate

Ethical approval for this study was obtained from the Ethics Review Committee, Faculty of Medicine, University of Kelaniya (Reference no: P/138/11/2022).

Consent for publication

All authors consent to publication. Ethics approval has been obtained to use the names of the Ministry of Health organizations from which Facebook content was extracted.

Competing interests

The authors declare no competing interests.