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DISCUSS HEALTH COMMUNICATION FROM THEORY TO PRACTICE

Health communication operates within a very complex environmentin which encouraging and supporting people to adopt and sustain healthy behaviors, or policymakers and professionals to introduce new policies and practices, or health care professionals to provide adequate and culturally competent care are never easy tasks. Moreover, most of these potential changes and behavioral and social results depend on var- ious socially determined factors such as our living, working, and aging environments; access to health services and information; adequate trans- portation, nutritious food, parks and recreational facilities; socioeconomic opportunities; and social and peer support, among many others.

Childhood immunization, for example, is one of the greatest medical and scientific successes of recent times. Because of immunization, many diseases that were once a threat to the life and well-being of children have become rare or have been eradicated in many countries in the world. Yet as for most other health-related issues and interventions, changing public and professionalminds and enabling parents to immunize their healthy children have required a worldwide multidisciplinary effort. Health communication has played a fundamental role in this success story since the introduction of the first childhood vaccine. Consider the case of Bonnie, the mother of a newborn child, who is offered a vaccine for her baby at birth or a few days after.

Bonnie, an American, is the twenty-five-year-old mother of a beautiful baby girl. She is thrilled about her child but quite fearful because parenting is new to her. She has read about the benefits of immunization but is too young to remember any of the diseases against which she should immunize her child. She does not know anyone who had polio or whooping cough or Hib (Haemophilus influenzae type B) disease. She has also heard conflicting information about the potential adverse events or risks that may be associated with immunization and is unsure about which of the available information is correct. She is confused and does not know whether she wants to immunize her child.

xxiv INTRODUCTION

Bonnie’s case is a typical example of issues that health communication interventions can successfully address: • Engaging Bonnie, her peers, and her community in discussing their

perceptions and opinions about the pros and cons of immunization as well as any barriers, social norms, or other socially determined factors that may influence their decisions

• Providing Bonnie with research-based and reliable information on immunization

• Encouraging participation of Bonnie, her peers, other community members, andprofessionals across sectors in developing a communica- tion intervention thatwould address existing barriers to immunization, and effectively integrate the opinions, preferences, andneeds of parents and other key groups and stakeholders

• Improving Bonnie’s communication with her pediatrician or health care provider by empowering her with information and questions to ask at clinical encounters

• Raising awareness among health care providers of patients’ needs and most frequent concerns, and equipping them with training and resources on cross-cultural health communication, health literacy, and health disparities

• Developing tools such as brochures, posters, web pages, and other informational vehicles from reputable sources that will reinforce the information Bonnie will hear from her health care provider

• Encouraging peer-to-peer support by establishing venues, events, and social media–based forums where new mothers can discuss immu- nization and be supported on their decisions

• Raising awareness of the impact of vaccine-preventable childhood diseases and benefits of immunization among the general public by targeting consumer media, parenting publications, social media sites, and other vehicles so that Bonnie and other parents can become familiar with the severity of vaccine-preventable diseases and the benefits of immunization

• Advocating for policies, mandates, and other regulations that would increase ease of access to timely immunization, convey the importance of immunization in child and community protection, and also be inclusive of vulnerable and underserved populations as it may relate to their specific needs and concerns

INTRODUCTION xxv

• Addressing socially determined factors (for example, access to or qual- ity of health services and information, education, living and working conditions, and others) that may contribute to low immunization rates in specific segments of the general population

Health communication approaches will work only if they rely on an in-depth understanding of Bonnie’s and other new mothers’ lifestyles, concerns, beliefs, attitudes, social norms, barriers to change, and sources of information about newborns and immunization. It would also be important to research and understand the cultural, social, and political environment in which Bonnie lives. What kind of support does she get from family, friends, and her working environment? Who most influences her decisions on her child’swell-being andupbringing?What does she fear about immunization? Is there any existing program in her community that focuses on childhood immunization? What are the lessons learned? Does she have access to timely immunization? Does she feel satisfied with the way her health care provider communicates on immunization (in otherwords, does she feel that she can understand and relate to the information her provider discusses)? These are just some of the many questions that need to be answered before developing a health communication program intended to promote behavioral and social change among Bonnie and her peers.

Most important, any kind of health communication intervention needs to be grounded in communication theory and lessons learned from past interventions aswell as an in-depth understanding of the full potential of the field of health communication. Communication is considered an important discipline in the attainment of the Millennium Development Goals (“the eight MDGs—which range from halving extreme poverty rates to halting the spread of HIV/AIDS and providing universal primary education, all by the target date of 2015—form a blueprint agreed to by all the world’s countries and all the world’s leading development institutions” in 2000; United Nations, 2013) as well as the post-2015 global agenda. In fact, health communication can help integrate population, health, and environment- related issues to improve public health and social outcomes in different countries. For example, emerging best practices in health communication in Rwanda have led to the creation of a Population, Health, and Environ- ment (PHE) Network. This newly established East Africa PHE Network is designed to “improve communication about PHE issues among policymak- ers, researchers, and practitioners within Rwanda and throughout eastern Africa. The PHENetwork serves as a forum for information exchange about cross-cutting PHE issues, community networking, accessing resources” and also relies on various traditional communication channels (for example,

xxvi INTRODUCTION

community-level meetings, participatory planning) and mass and new media (for example, local radio, newspapers, and Internet).

In the United States, Healthy People 2020, the country’s public health agenda for one decade, has defined several domains for health communica- tion and health information technology, which are listed in the following.

Goal: Use health communication strategies and health information technology (IT) to improve

population health outcomes and health care quality, and to achieve health equity.

The objectives in this topic area describe many ways health communication and health IT

can have a positive impact on health, health care, and health equity:

• Supporting shared decision making between patients and providers • Providing personalized self-management tools and resources • Building social support networks • Delivering accurate, accessible, and actionable health information that is targeted or

tailored

• Facilitating themeaningful use of health IT and exchange of health information among health care and public health professionals

• Enabling quick and informed action to health risks and public health emergencies • Increasing health literacy skills • Providing new opportunities to connect with culturally diverse and hard-to-reach

populations

• Providing sound principles in the design of programs and interventions that result in healthier behaviors

• Increasing Internet and mobile access

Source: US Department of Health and Human Services. Healthy People 2020. “Health Communication and Health

Information Technology.” http://healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=18. Retrieved July 2012b.

As you may realize yourself after reading this book, in many ways three of “these areasmay encapsulate all others” (Schiavo, 2011b, p. 68): “Building social support networks . . . providing new opportunities to connect with culturally diverse and hard-to-reach populations . . . providing sound prin- ciples in the design of programs and interventions that result in healthier behaviors” (Healthy People 2020). These areas speak of innovation; the

INTRODUCTION xxvii

integration of different communication areas, strategies, and media, and health and social issues (after all, there is no magic fix in health communi- cation); the need to include disadvantaged groups and effectively connect with them as part of the communication process; and the importance of making sure that communication is grounded in theoretical models, planning frameworks, and lessons learned from past experiences.

About This Book

Since its first edition in 2007,Health Communication: FromTheory to Prac- tice has provided students and professionals from the public health, health care, global health, community development, nonprofit, and public and pri- vate sectors with a comprehensive introduction to health communication as well as a strategic review of advanced topics and issues that affect the field’s theory andpractice, and a hands-on guide to planning, implementing, and evaluating health communication interventions. This second edition further emphasizes the importance of a people-centered and participatory approach to health communication interventions, which should take into account key social determinants of health and the interconnection among various health and social fields.

Although maintaining a strong focus on the importance of the behavioral, social, and organizational results of health communication interventions, the second edition also includes new or updated informa- tion, theoretical models, resources, and case studies on health equity, urban health, new media, emergency and risk communication, strategic partnerships in health communication, policy communication and public advocacy, cultural competence, health literacy, and the evaluation of health communication interventions as they relate to various health topics.

Who Should Read This Book

There are many people who I hope will read this book and, if willing, share their perspectives and feedback withme in the years to come. The following is only a short list of professionals and health and social change agents for which this book is designed with the intention to help in everyone’s efforts to make a difference in people’s health and lives.

Academics: If you are a faculty member in a school or program in public health, global health, health communication, community health, communication studies, health education, nursing, environmental health, nutrition, journalism, design for social innovation, medicine, health and life sciences, social work, public affairs, international affairs, or psychology, the

xxviii INTRODUCTION

multidisciplinary approach to health communication this book proposes will, I hope, complement other theoretical or practical approaches youmay be using in your work, and provide you with a helpful didactic tool. I also hope that some of the theoretical concepts, lessons learned, and questions highlighted in this book will be further explored as part of your teaching and research efforts together with your colleagues, students, and relevant communities. The book is designed to fitmost course schedules and tomeet the needs of a variety of graduate and advanced undergraduate courses.

Students: Because health communication is an integral part of everyday life as well as various interventions for health and social change, I hope that this book will further motivate your interest in this field, and that some of its key concepts will stay with you throughout your career. The book is designed to provide you with some of the theoretical resources and practical skills to address the many challenges of any path you may decide to pursue. It also reflects my teaching philosophy, which is grounded in my commitment to help students develop essential strategic and critical skills, as well as my belief that all courses should be a forum for vibrant information exchange in which I learn from the students’ perspectives while they learn from my experience. To this end, this second edition also incorporates the perspectives and suggestions of many of my students who used the first edition.

Health and social change agents: Regardless of whether you work in the public, nonprofit, academic, health care, or private sector, or a multilateral agency, Ihopehealthcommunication, asdescribed in thisbook,will comple- ment your efforts to implement interventions that explore the connection between health and social issues, or support the creation of a movement for improved health outcomes and quality of life among different groups and populations, and ultimately promote behavioral, social, and organizational change. I hope that this book will help you achieve your vision.

Program managers: Because this book also includes many practical suggestions and a comprehensive hands-on guide, it is an easy-to-access resource for the development, implementation, and evaluation of health communication interventions, as well as for your training efforts of staff members and relevant partners.

Health care providers:Health communication is an increasingly impor- tant competency in provider-patient communication and professional medical communication settings because it is essential to improving patient outcomes and promoting widespread application of best clinical practices. This book covers both communication areas and also includes other rele- vant topics such as the role of health care providers in public health settings, using IT innovation to address emerging needs and global health workforce

INTRODUCTION xxix

gaps, and prioritizing disparities in clinical education via increased train- ing in cross-cultural health communication. These topics are designed to appeal to educators and health care providers in light of the expanded role of clinicians in patient, public health, and global health outcomes.

Community leaders: Although community leaders are by definition health and social change agents, I felt the need to include this specific category given the role communities in the United States and in interna- tional settings play or should play in the health communication process. I hope that community leaders from a variety of sectors read this and find it helpful in designing and implementing community-based interventions and forums to raise the influence of community voices on how we com- municate about health and illness and the kinds of behavioral, social, and organizational results we seek to achieve.

Finally, one of the book’s fundamental premises is the role good health (or lack thereof) plays either positively or negatively in influencing com- munity development and people’s ability to connect with socioeconomic opportunities. Because health communication can play a key role in raising awareness of the strong interconnection among these fields, or in advo- cating for policy and social change, and in promoting healthy behaviors, I certainly hope that colleagues from the community and social development fieldswill consider this book to be a useful resource on how to communicate about key social determinants of health as well as the influence health issues can have on their work and community and social outcomes.

Overview of the Contents

Two of the fundamental premises of this book are (1) the multidisciplinary and multifaceted nature of health communication and (2) the interdepen- dence of the individual, social, political, and disease-related factors that influence health communication interventions, and,more in general, health and social outcomes. With these premises in mind, the division of topics in parts and chapters is only instrumental to the text’s readability and clarity. Readers should always consider the connection among various theoretical and practical aspects of health communication as well as all external fac- tors (political, social, cultural, economic, market, environment, and other influences that shape or contribute to a specific situation or health problem as well as affect key groups and stakeholders) that influence this field. This introduction is an essential part of the book and is instrumental to maximize use and understanding of the text.

This book is divided in four parts. Part One focuses on defining health communication—its theoretical basis as well as its contexts and

xxx INTRODUCTION

key action areas. Part One also establishes the importance of considering cultural, geographical, socioeconomic, ethnic, age, and gender influences on people’s concepts of health and illness, as well as their approach to health problems and their solutions. Finally, this part addresses the role of health communication in public health, health care, community development, as well as in the marketing or private sector contexts.

Part Two focuses on the different areas of health communication defined in Part One: interpersonal communication, mass media and new media communication; community mobilization and citizen engagement; professional medical communications; constituency relations and strategic partnership in health communication; policy communication, and public advocacy.

In all chapters in Part Two, key health communication issues are raised in the form of a question or brought to life in a case study. This is followed by a discussion of a specific communication approach or area. All chapters discuss specific communication areas in the context of themultidisciplinary nature of health communication and the need for an integrated approach. Special emphasis is placed on the importance of selecting and adapting health communication strategies, activities, materials, media, and channels to a fast-changing social, political, market, and public health environment. Case studies and testimonials from experts and practitioners in the field are included in many of the chapters in Part Two.

Part Three provides a step-by-step guide to the development, imple- mentation, and evaluation of a health communication intervention. Each chapter covers specific steps of the health communication planning process or implementation and evaluation phases. Case studies, practical tips, and specific examples aim to facilitate readers’ understanding of the planning process, as well as to build technical skills in health communication plan- ning. Recent methodologies and trends in measuring and evaluating results of health communication programs are explored here, and so are specific strategies and tools to evaluate new media–based interventions.

Part Four examines select health communication case studies and related lessons. This last section of the book includes two chapters, respectively featuring case studies from the United States and global health communication. Yet, as discussed in Chapter Sixteen, and in light of the existing comprehensive definition of global health, key themes, emerging trends, and potential lessons that emerged from case studies in both chapters for the most part apply across geographical boundaries and health issues.

Appendix A contains resources and worksheets on health communica- tion planning. Online resources listed in Appendix B point to job listings,

INTRODUCTION xxxi

conferences, journals, organizations, centers, and programs in the health communication field. The Glossary of key health communication planning terms at the end of the text should be used as a reference while reading this book, as well as a way to recap key definitions in health communication planning. Some of the key terms from the Glossary are highlighted in bold type and briefly defined the first time they are mentioned in the text so that readers can become familiar with them before approaching the chapters in Part Three that more specifically cover these topics. Other topic-specific definitions are included in all relevant chapters.

Many chapters start with a practical example or case study. This is often used to establish the need for communication approaches that should be based on an in-depth understanding of intended audiences’ perceptions, beliefs, attitudes, behavior, and barriers to change, as well as the cultural, social, and ethnic context in which they live. Although referring to current theories and models, the book also reinforces the importance of the experi- ence of health communication practitioners in developing theories,models, and approaches that should guide and inform health communication plan- ning and management.

Each chapter ends with discussion questions for readers to reflect on, practice, and implement key concepts. Finally, all chapters are intercon- nected but are also designed to stand alone and provide a comprehensive overview on the topic they cover. An instructor’s training supplement is available at www.josseybass.com/go/schiavo2e. Additional materials such as videos, podcasts, and readings can be found at www.josseybass publichealth.com. Comments about this book are invited and can be sent to publichealth@wiley.com, or via the contact form at www.renataschiavo.com.

Author’s Note

As someone who has been spending a lot of time teaching, practicing, and thinking about health communication, I fully understand the complexity of communicating about health, behavior, and related social issues. Changing human and social behavior to attain better health outcomes and positively affect people’s quality of life is often a lifetime endeavor, which is also intertwined with our own professional changes. We change, and our work and beliefs may change or evolve over time. In a way, I hope that we never stop questioning ourselves, and learning from professional and personal experiences, because this is the only way to stay true to what we should value the most: making a difference in people’s health and lives.

xxxii INTRODUCTION

My heartfelt appreciation and admiration go to all professionals, stu- dents, patients, policymakers, and ordinary people who every day dedicate their time to make a difference to their own health outcomes or those of their families, communities, special groups, or populations. These include all professionals and researchers in the public health, health care, com- munity development, and urban planning fields; the students or young practitioners who have committed themselves to a rewarding but demand- ing career; the patients who strive to keep themselves informed and make the right health decisions; the health care providers who dedicate their lives to alleviate and manage human suffering; the urban planners and environmentalists who work to leave to our communities and children the kind of natural and built environments they need to stay healthy; the mass media, new media gurus, government officers, associations, advocacy groups, global health organizations from the public and private sectors, and everyone else who may have an impact on health and social change.

I believe that being awareof current health communication theories and experiences may ease the process of affecting health and social outcomes andmake the taskmore approachable for all of these groups and individuals. I hope this book will help and will give you a glance into my world.

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PART ONE

INTRODUCTION TO HEALTH COMMUNICATION

As readers approach Part One, I cannot help but wonder what they may already think or know about health communication. I wish this book had eyes and ears to listen to all of your discussions so I could learn about each one of you. I would love to know how health communication may help advance your professional goals and what you find helpful in achieving the kinds of behavioral, social, and organizational results that may support improvedhealth outcomes in your neighborhoods, communities, and coun- tries. After all, one of themainmantras of health communication is to get to know the groups we seek to engage and care about. This is why I hope that as for the first edition,many of youwill write and share your experiencewith this book.

Part One is the backbone of the book. It focuses on defining health communication—its theoretical basis as well as its contexts and key action areas. It also establishes the importance of cultural, geographical, socio- economic, ethnic, age, and gender influences on people’s concepts of health and illness, as well as their approach to health problems and their solutions. Finally, this part addresses the role of health communication in public health, health care, community development, as well as in the marketing or private sector contexts.

This section is divided into three chapters, which are strictly inter- connected in their scope and aim to provide a balanced theoretical and practical introduction to the field. ChapterOne introduces readers to health communication, its key contexts and action areas, as well as its cyclical nature and the planning framework that we will discuss in detail in Part Three. Chapter Two provides an overview of key theoretical influences in health communication as well as contemporary health-related and public issues that influence or may influence its theory and practice. The chapter also includes a brief discussion of select planning frameworks and models used for the development of health communication interventions by a variety of US and international organizations. Chapter Three discusses the importance of cultural, ethnic, geographical, gender, age, and other factors in communicating about health and illness with a variety of groups and

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2 INTRODUCTION TO HEALTH COMMUNICATION

how communication is influenced by and influences all of these factors. It also provides examples of different concepts of health and illness and establishes cultural competence as a core competency for effective health communication.

Once again, welcome to my world!

CHAPTER 1

WHAT IS HEALTH COMMUNICATION?

IN THIS CHAPTER

• Defining Health Communication

• Health Communication in the Twenty-First Century: Key Characteristics and Defining Features

• The Health Communication Environment

• Health Communication in Public Health, Health Care, and Community Development

• The Role of Health Communication in the Marketing Mix

• Overview of Key Communication Areas

• The Health Communication Cycle

• What Health Communication Can and Cannot Do

• Key Concepts

• For Discussion and Practice

• Key Terms

Health communication is an evolving and increasingly prominent field in public health, health care, and the non- profit and private sectors. Therefore, many authors and organizations have been attempting to define or rede- fine it over time. Because of the multidisciplinary nature of health communication, many of the definitions may appear somewhat different from each other. Nevertheless, when they are analyzed, most point to the role that health communication can play in influencing, supporting, and empowering individuals, communities, health care pro- fessionals, policymakers, or special groups to adopt and sustain a behavior or a social, organizational, and policy change that will ultimately improve individual, commu- nity, and public health outcomes.

Understanding the true meaning of health commu- nication and establishing the right context for its imple- mentation may help communication managers and other public health, community development, and health care professionals identify early on the training needs of staff, the communities they serve, and others who are involved in the communication process. It will also help create the right organizational mind-set and capacity that should lead to a successful use of communication approaches to reach group-, stakeholder-, and community-specific goals.

4 CHAPTER 1: WHAT IS HEALTH COMMUNICATION?

CHAPTER OBJECTIVES

This chapter sets the stage to discuss current health communication contexts. It also positions

the importance of health communication in public health, health care, and community

development as well as the nonprofit and private sectors. Finally, it describes key elements,

action areas, and limitations of health communication, and introduces readers to “the role

societal, organizational, and individual factors” play in influencing and being influenced

by public health communication (Association of Schools of Public Health, 2007, p. 5) and

communication interventions in clinical (Hospitals and Health Networks, 2012) and other

health-related settings.

Defining Health Communication

There are several definitions of health communication, which for the most part share commonmeanings and attributes. This section analyzes and aims to consolidate different definitions for health communication. This analysis starts from the literal and historical meaning of the word communication.

What Is Communication? An understanding of health communication theory and practice requires reflection on the literal meaning of the word communication. Communica- tion is defined in this way: “1. Exchange of information, between individuals, for example, by means of speaking, writing, or using a common system of signs and behaviors; 2. Message—a spoken or written message; 3. Act of communicating; 4. Rapport—a sense of mutual understanding and sym- pathy; 5. Access—a means of access or communication, for example, a connecting door” (Encarta Dictionary, January 2007).

In fact, all of these meanings can help define the modalities of well- designed health communication interventions. As with other forms of communication, health communication should be based on a two-way exchange of information that uses a “common system of signs and behav- iors.” It should be accessible and create “mutual feelings of understanding and sympathy” amongmembers of the communication team and intended audiences or key groups (all groups the health communication program is

intended audiences or key groups All groups the health communication intervention is seeking to engage in the communication process

seeking to engage in the communication process.) In this book, the terms intended audience and key group are used interchangeably. Yet, the term key group may be better suited to acknowledge the participatory nature of well-designed health communication interventions in which communities

DEFINING HEALTH COMMUNICATION 5

and other key groups are the lead architects of the change process com- munication can bring about. For those who always have worked within a participatorymodel of health communication interventions, this distinction is concerned primarily with terminology-related preferences in different models and organizational cultures. Yet, as audience may have a more passive connotation, using the term key groupmay indicate the importance of creating key groups’ ownership of the communication process, and of truly understanding priorities, needs, and preferences as a key premise to all communication interventions.

Finally, going back to the literal meaning of the word communication as defined at the beginning of this section, channels or communication channels (the means or path, such as mass media or new media, used

communication channels The path selected by program planners to reach the intended audience with health communication messages and materials

to reach out to and connect with key groups via health communication messages andmaterials) andmessages are the “connecting doors” that allow health communication interventions to reach and engage intended groups.

Communication has its roots in people’s need to share meanings and ideas. A review of the origin and interpretation of early forms of communication, such as writing, shows that many of the reasons for which peoplemay have started developing graphic notations and other early forms of writing are similar to those we can list for health communication.

One of the most important questions about the origins of writing is, “Why did writing begin and for what specific reasons?” (Houston, 2004, p. 234). Although the answer is still being debated, many established theories suggest that writing developed because of state and ceremonial needs (Houston, 2004). More specifically, in ancient Mesoamerica, early forms of writing may have been introduced to help local rulers “control the underlings and impress rivals by means of propaganda” (Houston, 2004, p. 234; Marcus, 1992) or “capture the dominant and dominating message within self-interested declarations” (Houston, 2004, p. 234) with the intention of “advertising” (p. 235) such views. In other words, it is possible to speculate that the desire and need to influence and connect with others are among the most important reasons for the emergence of early forms of writing. This need is also evident in many other forms of communication that seek to create feelings of approval, recognition, empowerment, or friendliness, among others.

Health Communication Defined One of the key objectives of health communication is to engage, empower,

health communication Amultifaceted and multidisciplinary field of research, theory, and practice concerned with reaching different populations and groups to exchange health-related information, ideas, and methods in order to influence, engage, empower, and support individuals, communities, health care professionals, patients, policymakers, organizations, special groups, and the public so that they will champion, introduce, adopt, or sustain a health or social behavior, practice, or policy that will ultimately improve individual, community, and public health outcomes

and influence individuals and communities. The goal is admirable because health communication aims to improve health outcomes by sharing

6 CHAPTER 1: WHAT IS HEALTH COMMUNICATION?

health-related information. In fact, the Centers for Disease Control and Prevention (CDC) define health communication as “the study and use of communication strategies to inform and influence individual and com- munity decisions that enhance health” (CDC, 2001; US Department of Health and Human Services, 2012a). The word influence is also included in the Healthy People 2010 definition of health communication as “the art and technique of informing, influencing, and motivating individual, institutional, and public audiences about important health issues” (US Department of Health and Human Services, 2005, pp. 11–12).

Yet, the broader mandate of health communication is intrinsically related to its potential impact on vulnerable and underserved populations. Vulnerable populations include groups who have a higher risk for poor

vulnerable populations Includes groups who have a higher risk for poor physical, psychological, or social health in the absence of adequate conditions that are supportive of positive outcomes physical, psychological, or social health in the absence of adequate con-

ditions that are supportive of positive outcomes (for example, children, the elderly, people living with disability, migrant populations, and spe- cial groups affected by stigma and social discrimination). Underserved populations include geographical, ethnic, social, or community-specific

underserved populations Includes geographical, ethnic, social, or community-specific groups who do not have adequate access to health or community services and infrastructure or adequate information

groups who do not have adequate access to health or community services and infrastructure or information. “Use health communication strategies . . . to improve population health outcomes and health care quality, and to achieve health equity,” reads Healthy People 2020 (US Department of Health and Human Services, 2012b). Health equity is providing every

health equity Providing every person with the same opportunity to stay healthy or to effectively cope with disease and crisis, regardless of race, gender, age, economic conditions, social status, environment, and other socially determined factors

person with the same opportunity to stay healthy or to effectively cope with disease and crisis, regardless of race, gender, age, economic conditions, social status, environment, and other socially determined factors. This can be achieved only by creating a receptive and favorable environment in which information can be adequately shared, understood, absorbed, and discussed by different communities and sectors in a way that is inclusive and representative of vulnerable and underserved groups. This requires an in-depth understanding of the needs, beliefs, taboos, attitudes, lifestyle, socioeconomics, environment, and social norms of all key groups and sectors that are involved—or should be involved—in the communication process. It also demands that communication is based on messages that are easily understood. This is well characterized in the definition of com- munication by Pearson and Nelson (1991), who view it as “the process of understanding and sharing meanings” (p. 6).

A practical example that illustrates this definition is the difference between making an innocent joke about a friend’s personality trait and doing the same about a colleague or recent acquaintance. The friend would likely laugh at the joke, whereas the colleague or recent acquain- tance might be offended. In communication, understanding the context

DEFINING HEALTH COMMUNICATION 7

of the communication effort is interdependent with becoming familiar with intended audiences. This increases the likelihood that all meanings are shared and understood in the way communicators intended them. Therefore, communication, especially about life-and-death matters such as in public health and health care, is a long-term strategic process. It requires a true understanding of the key groups and communities we seek to engage as well as our willingness and ability to adapt and redefine the goals, strategies, and activities of communication interventions on the basis of audience participation and feedback.

Health communication interventions have been successfully used for many years by public health and nonprofit organizations, the commercial sector, and others to advance public, corporate, clinical, or product-related goals in relation to health. As many authors have noted, health commu- nication draws from numerous disciplines and theoretical fields, including health education, social and behavioral sciences, community development, mass and speech communication, marketing, social marketing, psychol- ogy, anthropology, and sociology (Bernhardt, 2004; Kreps, Query, and Bonaguro, 2007; Institute of Medicine, 2003b; World Health Organiza- tion [WHO], 2003). It relies on different communication activities or action areas, including interpersonal communication, mass media and new media communication, strategic policy communication and public advocacy, community mobilization and citizen engagement, professional medical communications, and constituency relations and strategic partner- ships (Bernhardt, 2004; Schiavo, 2008, 2011b; WHO, 2003).

Table 1.1 provides some of the most recent definitions of health communication and is organized by key words most commonly used to characterize health communication and its role. It is evident that “shar- ing meanings or information,” “influencing individuals or communities,” “informing,” “motivating individuals and key groups,” “exchanging infor- mation,” “changing behaviors,” “engaging,” “empowering,” and “achieving behavioral and social results” are among the most common attributes of health communication.

Another important attribute of health communication should be “to support and sustain change.” In fact, key elements of successful health com- munication interventions always include long-term program sustainability as well as the development of communication tools and steps that make it easy for individuals, communities, and other key groups to adopt or sustain a recommended behavior, practice, or policy change. If we integrate this practice-based perspective with many of the definitions in Table 1.1, the new definition on page 9 emerges.

8 CHAPTER 1: WHAT IS HEALTH COMMUNICATION?

Table 1.1 Health Communication Definitions

KeyWords Definitions

To inform and influence (individ- ual and community) decisions

“Health communication is a key strategy to inform [emphasis added throughout table] the public about health concerns and to maintain important health issues on the public agenda” (New South Wales Department of Health, Australia, 2006).

“The study or use of communication strategies to inform and influence individual and community decisions that enhance health” (CDC, 2001; US Department of Health and Human Services, 2005).

Health communication is a “means to disease prevention through behavior modification” (Freimuth, Linnan, and Potter, 2000, p. 337). It has been defined as “the study and use of methods to inform and influence individual and community decisions that enhance health” (Freimuth, Linnan, and Potter, 2000, p. 338; Freimuth, Cole, and Kirby, 2000, p. 475).

“Health communication is a process for the development and diffusion of messages to specific audiences in order to influence their knowledge, attitudes and beliefs in favor of healthy behavioral choices” (Exchange, 2006; Smith and Hornik, 1999).

“Health communication is the use of communication techniques and technologies to (positively) influence individuals,populations,andorganizationsforthepurposeofpromotingconditionsconduciveto human and environmental health” (Maibach and Holtgrave, 1995, pp. 219–220; Health Communication Unit, 2006). “It may include diverse activities such as clinician-patient interactions, classes, self-help groups, mailings, hot lines, mass media campaigns, and events” (Health Communication Unit, 2006)…………………………………………………………………………………………………………………………………………………………………………….

Motivating individuals and key groups

“The art and technique of informing, influencing and motivating individual, institutional, and public audiences about important health issues. Its scope includes disease prevention, health promotion, health care policy, and business, as well as enhancement of the quality of life and health of individuals within the community” (Ratzan and others, 1994, p. 361).

“Effective health communication is the art and technique of informing, influencing, and motivating individuals, institutions, and large public audiences about important health issues based on sound scientific and ethical considerations” (Tufts University Student Services, 2006)…………………………………………………………………………………………………………………………………………………………………………….

Change behavior, achieve social and behavioral results

“Health communication, likehealth education, is an approachwhich attempts to changea setofbehaviors in a large-scale target audience regarding a specific problem in a predefined period of time” (Clift and Freimuth, 1995, p. 68).

“There is good evidence that public health communication has affected health behavior . . . In addition, . . . many public agencies assume that public health communication is a powerful tool for behavior change” (Hornik, 2008a, pp. xi–xv).

“. . . behavior change is credibly associated with public health communication . . . ” (Hornik, 2008b, p. 1).

“. . . health communication strategies that are collaboratively and strategically designed, imple- mented, and evaluated can help to improve health in a significant and lasting way. Positive results are achieved by empowering people to change their behavior and by facilitating social change” (Krenn and Limaye, 2009).

Health communication and other disciplines “may have some differences, but they share a common goal: creating social change by changing people’s attitudes, external structures, and/or modify or eliminate certain behaviors” (CDC, 2011a)…………………………………………………………………………………………………………………………………………………………………………….

Increase knowledge and under- standing of health-related issues

“The goal of health communication is to increase knowledge and understanding of health-related issues and to improve the health status of the intended audience” (Muturi, 2005, p. 78).

“Communication means a process of creating understanding as the basis for development. It places emphasis on people interaction” (Agunga, 1997, p. 225).

HEALTH COMMUNICATION IN THE TWENTY-FIRST CENTURY 9

Table 1.1 Health Communication Definitions (continued)

KeyWords Definitions

Empowers people “Communication empowers people by providing themwith knowledge and understanding about specific health problems and interventions” (Muturi, 2005, p. 81). “. . . transformative communication . . . seek[s] not only to educate people about health risks, but

also to facilitate the types of social relationships most likely to empower them to resist the impacts of unhealthy social influences” (Campbell and Scott, 2012, pp. 179–180). “Communication processes are central to broader empowerment practices through which people are

able to arrive at their own understanding of issues, to consider and discuss ideas, to negotiate, and to engage in public debates at community and national levels” (Food and Agriculture Organization of the United Nations and others, 2011, p. 1)…………………………………………………………………………………………………………………………………………………………………………….

Exchange, interchangeof informa- tion, two-way dialogue

“A process for partnership and participation that is based on two-way dialogue, where there is an interactive interchange of information, ideas, techniques and knowledge between senders and receivers of information on an equal footing, leading to improved understanding, shared knowledge, greater consensus, and identification of possible effective action” (Exchange, 2005). “Health communication is the scientific development, strategic dissemination, and critical evaluation

of relevant, accurate, accessible, and understandable health information communicated to and from intended audiences to advance the health of the public” (Bernhardt, 2004, p. 2051)…………………………………………………………………………………………………………………………………………………………………………….

Engaging “One of the most important, and largely unrecognized, dimensions of effective health communication relates to how engaging the communication is” (Kreps, 2012a, p. 253). “To compete successfully for audience attention, health-related communications have to be polished

and engaging” (Cassell, Jackson, and Cheuvront, 1998, p. 76).

Health communication is a multifaceted and multidisciplinary field of research, theory, and practice. It is concerned with reaching differ- ent populations and groups to exchange health-related information, ideas, and methods in order to influence, engage, empower, and support individuals, communities, health care professionals, patients, policymakers, organizations, special groups and the public, so that they will champion, introduce, adopt, or sustain a health or social behavior, practice, or policy that will ultimately improve individual, community, and public health outcomes.

Health Communication in the Twenty-First Century: Key Characteristics and Defining Features

Health communication is about improving health outcomes by encouraging behavior modification and social change. It is increasingly considered an integral part of most public health interventions (US Department of Health and Human Services, 2012a; Bernhardt, 2004). It is a comprehensive approach that relies on the full understanding and participation of its intended audiences.

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Health communication theory draws on a number of additional dis- ciplines and models. In fact, both the health communication field and its theoretical basis have evolved and changed in the past fifty years (Piotrow, Kincaid, Rimon, and Rinehart, 1997; Piotrow, Rimon, Payne Merritt, and Saffitz, 2003; Bernhardt, 2004). With increasing frequency, it is considered “the avant-garde in suggesting and integrating new theoretical approaches and practices” (Drum Beat, 2005).

Most important, communicators are no longer viewed as those who write press releases and other media-related communications, but as fundamental members of the public health, health care, nonprofit, or health industry teams. Communication is no longer considered a skill (Bernhardt, 2004) but a science-based discipline that requires training and passion, and relies on the use of different communication vehicles (materials, activities,

communication vehicles A category that includes materials, events, activities, or other tools for delivering a message using communication channels

events, and other tools used to deliver a message through communication channels; Health Communication Unit, 2003b) and channels. According to Saba (2006):

In the past, and this is probably the most prevalent trend even today, health communication practitioners were trained “on-the-job.” People from different fields (sociology, demography, public health, psychology, communication with all its different specialties, such as filmmaking, journalism and advertising) entered or were brought into health communication programs to meet the need for professional human resources in this field. By performing their job and working in teams, they learned how to adapt their skills to the new field and were taught by other practitioners about the common practices and basic “lingo” of health communication. In the mid-90s, and in response to the increasing demand for health communication professionals, several schools in the United States started their own curricular programs and/or “concentrations” in Health Communication. This helped bringmore attention from the academicworld to this emerging field. The number of peer-reviewed articles and several other types of health communication publications increased. The field moved from in-service training to pre-service education.

As a result, there is an increasing understanding that “the level of tech- nical competence of communication practitioners can affect outcomes.” A structured approach to health communications planning, a spotless program execution, and a rigorous evaluation process are the result of ade- quate competencies and relevant training, which are supported by leading organizations and agendas in different fields (Association of Schools of

HEALTH COMMUNICATION IN THE TWENTY-FIRST CENTURY 11

Public Health, 2007; USDepartment of Health andHuman Services, 2012b; AmericanMedical Association, 2006; Hospitals and Health Network, 2012; National Board of Public Health Examiners, 2011). “In health communica- tion, the learning process is a lifetime endeavor and should be facilitated by the continuous development of new training initiatives and tools” (Schiavo, 2006). Training may start in the academic setting but should always be influenced and complemented by practical experience and observations, and other learning opportunities, including in-service training, continuing professional education, and ongoing mentoring.

Health communication can reach its highest potential when it is discussed and applied within a team-oriented context that includes public health, health care, community development, and other professionals from different sectors and disciplines. Teamwork and mutual agreement, on both the intervention’s ultimate objectives and expected results, are key to the successful design, implementation, and impact of any program.

Finally, it is important to remember that there is no magic fix that can address health issues. Health communication is an evolving discipline and should always incorporate lessons learned as well as use a multidisciplinary approach to all interventions. This is in line with one of the fundamental premises of this book that recognizes the experience of practitioners as a key factor in developing theories, models, and approaches that should guide and inform health communication planning, implementation, and assessment.

Table 1.2 lists the key elements of health communication, which are further analyzed in the following sections.

Table 1.2 Key Characteristics of Health Communication

• People-centered • Evidence-based • Multidisciplinary • Strategic • Process-oriented • Cost-effective • Creative in support of strategy • Audience- and media-specific • Relationship building • Aimed at behavioral and social results • Inclusive of vulnerable and underserved groups

12 CHAPTER 1: WHAT IS HEALTH COMMUNICATION?

People-Centered Health communication is a long-term process that begins and ends with people’s needs and preferences. In health communication, intended audi- ences should not be merely a target (even if this terminology is used by many practitioners from around the world primarily to indicate that a communication intervention will focus on, benefit, and engage a specific group of people that shares similar characteristics—such as age, socio- economics, and ethnicity. It does not necessarily imply lack of audience participation) but an active participant in the process of analyzing and pri- oritizing the health issue, finding culturally appropriate and cost-effective solutions, and becoming effectively engaged as the lead change designer in the planning, implementation, and assessment of all interventions. This is why the term key group may better represent the role communities, teachers, parents, health care professionals, religious and community lead- ers, women, and many other key groups and stakeholders from a variety of segments of society and professional sectors should assume in the communication process. Yet, different organizations may have different cultural preferences for specific terminology even within the context of their participatory models and planning frameworks.

In implementing a people-centered approach to communication, researching communities and other key groups is a necessary but often not sufficient step because the effectiveness and sustainability of most inter- ventions is often linked to the level of engagement of their key beneficiaries and those who influence them. Engaging communities and different sec- tors is often accomplished in health communication practice by working together with organizations and leaders who represent them or by directly involvingmembers of a specific community at the outset of programdesign. For example, if a health communication intervention aims to reach and benefit breast cancer survivors, all strategies and key program elements should be designed, discussed, prioritized, tested, implemented, and eval- uated together with membership organizations, patient groups, leaders, and patients who can speak for survivors and represent their needs and preferences. Most important, these groups need to feel invested and well represented. They should be the key protagonists of the action-oriented process that will lead to behavioral or social change.

Evidence-Based Health communication is grounded in research. Successful health com- munication interventions are based on a true understanding not only of key groups but also of situations and sociopolitical environments. This

HEALTH COMMUNICATION IN THE TWENTY-FIRST CENTURY 13

includes existing programs and lessons learned, policies, social norms, key issues, work and living environments, and obstacles in addressing the specific health problem. The overall premise of health communication is that behavioral and social change is conditioned by the environment in which people live and work, as well as by those who influence them. Several socially determined factors (also referred to as social determi- nants of health)—including socioeconomic conditions, race, ethnicity,

social determinants of health Different socially determined factors that affect health outcomes as well as influence and are influenced by health communication

culture, as well as having access to health care services, a built environ- ment that supports physical activity, neighborhoods with accessible and affordable nutritious food, health information that’s culturally appropri- ate and accurately reflects literacy levels, and caring and friendly clinical settings—influence and are influenced by health communication (Associ- ation of Schools of Public Health, 2007). This requires a comprehensive research approach that relies on traditional, online, and new media-based research techniques for the formal development of a situation analysis

situation analysis A planning term that describes the analysis of individual, social, political, environmental, community-specific, and behavior-related factors that can affect attitudes, behaviors, social norms, and policies about a health issue and its potential solutions

(a planning term that describes the analysis of individual, social, politi- cal, environmental, community-specific, and behavior-related factors that can affect attitudes, behaviors, social norms, and policies about a health issue and its potential solutions) and audience analysis (a comprehen-

audience analysis A comprehensive, research-based, participatory, and strategic analysis of all key groups’ characteristics, demographics, needs, preferences, values, social norms, attitudes, and behavior

sive, research-based, participatory, and strategic analysis of all key groups’ characteristics, demographics, needs, preferences, values, social norms, attitudes, and behavior). The audience profile, a report on all findings, is

audience profile An analytical report on key findings from audience-related research (also called audience analysis) and one of the key sections of the situation analysis

the culminating step of a process of effective engagement and participation that involve all key groups and stakeholders in the overall analysis). Situa- tion and audience analyses are fundamental and interrelated steps of health communication planning (the audience analysis is described in this book as a component of the situation analysis), which should be participatory and empowering in their nature, and are described in detail in Chapter Eleven.

Multidisciplinary Health communication is “transdisciplinary in nature” (Bernhardt, 2004, p. 2051; Institute of Medicine, 2003b) and draws on multiple disciplines (Bernhardt, 2004; WHO, 2003). Health communication recognizes the complexity of attaining behavioral and social change and uses a multi- faceted approach that is grounded in the application of several theoretical frameworks and disciplines, including health education, social marketing, behavioral and social change theories, and medical and clinical models (see Chapter Two for a comprehensive discussion of key theories and models). It draws on principles successfully used in the nonprofit and corporate sec- tors and also on the people-centered approach of other disciplines, such as

14 CHAPTER 1: WHAT IS HEALTH COMMUNICATION?

psychology, sociology, and anthropology (WHO, 2003). It is not anchored to a single specific theory or model. With people always at the core of each intervention, it uses a case-by-case approach in selecting those models, theories, and strategies that are best suited to reach their hearts; secure their involvement in the health issue and, most important, its solutions; and support and facilitate their journey on a path to better health.

Piotrow, Rimon, PayneMerritt, and Saffitz (2003) identify four different “eras” of health communication:

(1) The clinic era, based on a medical care model and the notion that if people knew where services were located they would find their way to the clinics; (2) the field era, a more proactive approach emphasizing outreach workers, community-based distribution, and a variety of information, education, and communication (IEC) products; (3) the social marketing era, developed from the commercial concepts that consumers will buy the products they want at subsidized prices; and, (4) . . . the era of strategic behavior communications, founded on behavioral science models that emphasize the need to influence social norms and policy environments to facilitate and empower the iterative and dynamic process of both individual and social change. (pp. 1–2)

More recently, health communication has evolved toward a fifth “era” of strategic communication for behavioral and social change that rightly emphasizes and combines behavioral and social science models and dis- ciplines along with marketing, medical, and social norms–based models, and aims at achieving long-lasting behavioral and social results. However, even in the context of each different health communication era, many of the theoretical approaches of other periods still find use in program planning or execution. For example, the situation analysis of a health com- munication program still uses commercial and social marketing tools and models—even if combined with community dialogue and other participa- tory or newmedia–basedmethods (seeChaptersTwoandTen for a detailed description)—to analyze the environment in which change should occur. Instead, in the early stages of approaching key opinion leaders and other key stakeholders (all individuals and groups who have an interest or share

stakeholders All individuals and groups who have an interest or share responsibilities in a given issue, such as policymakers, community leaders, and community members

responsibilities in a given issue, such as policymakers, community leaders, and communitymembers), keeping inmindMcGuire’s steps about commu- nication for persuasion (1984; see Chapter Two), may help communicators gain stakeholder support for the importance or the urgency of adequately addressing a health issue. This theoretical flexibility should keep commu- nicators focused on key groups and stakeholders and always on the lookout for the best approach and planning framework to achieve behavioral and

HEALTH COMMUNICATION IN THE TWENTY-FIRST CENTURY 15

social results by engaging and empowering people. In concert with the other features previously discussed, it also enables the overall communication process to be truly fluid and suited to respond to people’s needs.

The importance of a somewhat flexible theoretical basis, which should be selected on a case-by-case basis (National Cancer Institute, 2005a), is already supported by reputable organizations and authors. For example, publications by the US Department of Health and Human Services (2002), and theNational Cancer Institute at theNational Institutes ofHealth (2002) points to the importance of selecting planning frameworks that “can help [communicators] identify the social science theories most appropriate for understanding the problem and the situation” (National Cancer Institute at the National Institutes of Health, 2002, p. 218). These theories, mod- els, and constructs include several theoretical concepts and frameworks (see Chapter Two) that are also used in motivating change at individual and interpersonal levels or organizational, community, and societal levels (National Cancer Institute at the National Institutes of Health, 2002) by related or complementary disciplines.

The goal here is not to advocate for a lack of theoretical structure in communication planning and execution. On the contrary, planning frame- works, models, and theories should be consistent at least until preliminary steps of the evaluation phase of a program are completed. This allows communicators to take advantage of lessons learned and redefine theoreti- cal constructs and communication objectives (the intermediate steps that

communication objectives The intermediate steps that need to be achieved in order to meet the overall program goals as complemented by specific behavioral, social, and organizational objectives

need to be achieved in order tomeet program goals and outcome objectives; National Cancer Institute, 2002) by comparing program outcomes, which

program outcomes Changes in knowledge, attitudes, skills, behavior, social norms, policies, and other parameters measured against those anticipated in the planning phase

measure changes in knowledge, attitudes, skills, behavior, and other param- eters, with those that were anticipated in the planning phase. However, the ability to draw onmultiple disciplines and theoretical constructs is a defini- tive advantage of the health communication field and one of the keys to the success of well-planned and well-executed communication programs.

Strategic Health communication programs need to display a sound strategy and plan of action. All activities need to be well planned and respond to a specific audience-related need. Consider the example of Bonnie, a twenty- five-year-old mother who is not sure about whether to immunize her newborn child. Activities in support of a strategy that focuses on facilitating communication between Bonnie and her health care provider make sense only if evidence shows all or anyof the followingpoints: (1) Bonnie is likely to be influenced primarily, or at least significantly, by her health care provider

16 CHAPTER 1: WHAT IS HEALTH COMMUNICATION?

and not by family or other new mothers; (2) there are several gaps in the understanding of patients’ needs that prevent health care providers from communicating effectively; (3) providers lack adequate tools to talk about this topic with patients in a time-effective and efficientmanner; (4) research data have been validated by community dialogue and other participatory methods that are inclusive of Bonnie and her peers; and (5) Bonnie and her peers and organizations that represent them have participated in designing all interventions.

Communication strategies (the overall approach used to accomplish communication strategies A statement describing the overall approach used to accomplish communication objectives

the communication objectives) need to be research-based, and all activities should serve such strategies. Therefore, we should not rely on any work- shop, press release, brochure, video, or anything else to provide effective communication without making sure that its content and format reflect the selected approach (the strategy), and that this is a priority to reach people’s hearts. For this purpose, health communication strategies need to respond to an actual need that has been identified by preliminary research and confirmed by the intended audience.

Process-Oriented Communication is a long-termprocess. Influencing people and their behav- iors requires an ongoing commitment to the health issue and its solutions. This is rooted in adeepunderstandingof key groups, communities, and their environments, and aims at building consensus among affected groups, com- munity members, and key stakeholders about the potential plan of action.

Most, if not all, health communication programs change or evolve from what communication experts may have originally envisioned due to the input and participation of communities, key opinion leaders, patient groups, professional associations, policymakers, community members, and other key stakeholders.

Inhealth communication, engaging key groupson relevant health issues as well as exploring suitable ways to address them is only the first step of a long-term, people-centered process. This process often requires theoretical flexibility to accommodate people’s needs, preferences, and priorities.

While in themidst ofmany process-oriented projects, many practition- ers may have noticed that health communication is often misunderstood. Health communication uses multiple channels and approaches, which, despite what some people may think, include but are not limited to the use of the mass media or new media. Moreover, health communication aims at improving health outcomes and in the process help advance public health and community development goals or create market share (depend- ing on whether health communication strategies are used for nonprofit

HEALTH COMMUNICATION IN THE TWENTY-FIRST CENTURY 17

or for-profit goals) or encourages compliance to clinical recommendations and healthy lifestyles. Finally, health communication cannot focus only on channels, messages, andmedia. It also should attempt to involve and create consensus and feelings of ownership among intended audiences.

Exchange, a networking and learning program on health communi- cation for development that is based in the United Kingdom and has multiple partners, views health communication as “a process for partner- ship and participation that is based on two-way dialogue, where there is an interactive interchange of information, ideas, techniques, and knowl- edge between senders and receivers of information on an equal footing, leading to improved understanding, shared knowledge, greater consensus, and identification of possible effective action” (2005). This definitionmakes sense in all settings and situations, but it assumes a greater relevance for health communication programs that aim to improve health outcomes in developing countries. Communication for development often needs to rely on creative solutions that compensate for the lack of local capabilities and infrastructure. These solutions usually emerge after months of discussion with local community leaders and organizations, government officials, and representatives of public and community groups. Word of mouth and the ability of community leaders to engage members of their own communities is often all that communicators have at hand.

Consider the case of Maria, a mother of four children who lives in a small village in sub-Saharan Africa together with her seventy-five-year-old father. Her village is almost completely isolated from major metropolitan areas, and very few people in town have a radio or know how to read. Maria is unaware that malaria, which is endemic in that region, poses a higher risk to children than to the elderly. Because elderly people benefit from a high hierarchical status in that region, if Maria is able to find money to purchase mosquito nets to protect someone in her family from mosquito bites and the consequent threat of malaria, she would probably choose that her father sleep under them, leaving her children unprotected. This is despite the high mortality rate from malaria among children in her village. If her village’s community leaders told her to do otherwise, she would likely change her practice and protect her children. This may be the first building block toward the development and adoption of new social norms not only by Maria but also her peers and other community members.

Involving Maria’s community leaders and peers in the communication process that would lead to a potential change in her habits requires long-term commitment. Such effort demands the involvement of local organizations and authorities who are respected and trusted by community leaders, as well as an open mind in listening to suggestions and seeking

18 CHAPTER 1: WHAT IS HEALTH COMMUNICATION?

solutions with the help of all key stakeholders. Because of the lack of local capabilities and limited access to adequate communication channels, this process is likely to take longer than any similar initiative in the developed world. Therefore, communicators should view this as an ongoing process and applaud every small step forward.

Cost-Effective Cost-effectiveness is a concept that health communication borrows from commercial and social marketing. It is particularly important in the com- petitive working environment of public health and nonprofit organizations, where the lack of sufficient funds or adequate economic planning can often undermine important initiatives. It implies the need to seek solutions that allow communicators to advance their goals with minimal use of human and economic resources. Yet, communicators should use their funds as long as they are well spent and advance their evidence-based strategy. They should also seek creative solutions that minimize the use of internal funds and human resources by seeking partnerships, using existing mate- rials or programs as a starting point, and maximizing synergies with the work of other departments in their organization or external groups and stakeholders in the same field.

Creative in Support of Strategy Creativity is a significant attribute of communicators because it allows them to consider multiple options, formats, and media channels to reach and engage different groups. It also helps them devise solutions that preserve the sustainability and cost-effectiveness of specific health communication interventions. However, even the greatest ideas or the best-designed and best-executed communication tools may fail to achieve behavioral or social results if they do not respond to a strategic need identified by research data and validated by key stakeholders from intended groups. Too often communication programs and resources fail to make an impact because of this common mistake.

For example, developing and distributing a brochure on how to use insecticide-treated nets (ITNs)makes sense only if the intended community is already aware of the cycle of malaria transmission as well as the need for protection frommosquito bites. If this is not the case and most community members still believe that malaria is contracted by bathing in the river or is a complication of some other fevers (Pinto, 1998; Schiavo, 1998, 2000), the first strategic imperative is disease awareness, with a specific

HEALTH COMMUNICATION IN THE TWENTY-FIRST CENTURY 19

focus on the cycle of transmission and subsequent protective measures. All communication materials and activities need to address this basic information need before talking about the use of ITNs and reasons to use them as an alternative to other potential protection methods. Creativity should come into play in devising culturally friendly tools to start sharing information aboutmalaria and to engage communitymembers in designing a community-specific communication intervention that would encourage protective behaviors andwould benefit the overall community. In a nutshell, we should refrain from using creativity to develop and implement great, sensational, or innovative ideaswhen these donot respond to people’s needs and key strategic priorities of the health communication intervention.

Audience- and Media-Specific The importance of audience-specificmessages and channels became one of the most important lessons learned after the anthrax-by-mail bioterrorist attacks that rocked the United States in October 2001. At the time, several letters containing the lethal agentBacillus anthracisweremailed to senators and representatives of the media (Jernigan and others, 2002; Blanchard and others, 2005). The attack also exposed government staff workers, including US postal workers in the US Postal Service facility in Washington, DC, and other parts of the country, to anthrax. Two workers in the Washington facility died as a result of anthrax inhalation (Blanchard and others, 2005).

Communication during this emergency was perceived by several mem- bers of the medical, patient, and worker communities as well as public figures and the media to be often inconsistent and disorganized (Blanchard and others, 2005; Vanderford, 2003). Equally important, postal workers and US Senate staff have reported erosion of their trust in public health agencies (Blanchard and others, 2005). Several analyses point to the pos- sibility that the one message–one behavior approach to communication (UCLA Department of Epidemiology, 2002)—in other words, using the same message and strategic approach for all audiences, which is likely to result in the same unspecific behavior that may not be relevant to specific communities or groups—led to feelings of being left out among postal workers, who in the Brentwood facility in Washington, DC, were primarily African Americans or individuals with a severe hearing impairment (Blan- chard and others, 2005). They also point to the need for public health officials to develop the relationships that are needed to communicate with groups of different racial and socioeconomic backgrounds as well as “those with physical limitations that could hinder communication, such as those with hearing impairments” (Blanchard and others, 2005, p. 494; McEwen and Anton-Culver, 1988).

20 CHAPTER 1: WHAT IS HEALTH COMMUNICATION?

The lessons learned from the anthrax scare support some of the funda- mental principles of good health communication practices. Messages need tobe key group–specific and tailored to channels allowing themost effective reach, including among vulnerable and underserved groups. Because it is very likely that communication efforts may aim at producing multiple key group–appropriate behaviors, the one message–one behavior approach should be avoided (UCLA Department of Epidemiology, 2002) even when time and resources are lacking. As highlighted by the anthrax case study, in developing audience-specific messages and activities, the contribution of local advocates and community representatives is fundamental to increase the likelihood that messages will be heard, understood, and trusted by intended audiences.

Relationship Building Communication is a relationship business. Establishing and preserving good relationships is critical to the success of health communication inter- ventions, and, among other things, can help build long-term and successful partnerships and coalitions, secure credible stakeholder endorsement of the health issue, and expand the pool of ambassadors on behalf of the health cause.

Most important, good relationships help create the environment of “sharedmeanings and understanding” (Pearson andNelson, 1991, p. 6) that is central to achieving social or behavioral results at the individual, com- munity, and population levels. Good relationships should be established with key stakeholders and representatives of key groups, health organi- zations, community-based organizations, governments, and many other critical members of the extended health communication team. A detailed discussion of the dos and don’ts as well as the development of successful partnerships and relationship-building efforts is found in Chapters Eight and Thirteen.

Aimed at Behavioral and Social Results Nowadays, we are transitioning from the “era of strategic behavior com- munications” (Piotrow, Rimon, PayneMerritt, and Saffitz, 2003, p. 2) to the era of behavioral and social impact communication. Several US and inter- national models and agenda (for example, Healthy People 2020, COMBI, Communication for Development; see Chapter Two) support the impor- tance of a behavioral and social change–driven mind-set in developing health communication interventions. Although the ultimate goal of health communication has always been influencing behaviors, social norms, and

HEALTH COMMUNICATION IN THE TWENTY-FIRST CENTURY 21

policies (with the latter often being instrumental in institutionalizing social change and norms), there is a renewed emphasis on the importance of establishing behavioral and social objectives early on in the design of health communication interventions.

“What do you want people to do?” is the first question that should be asked in communication planning meetings. Do you want them to immunize their children before age two? Become aware of their risk for heart disease and behave accordingly to prevent it? Ask their dentists about oral cancer screening? Do you want local legislators to support a stricter law on the use of infant car seats? Or communities and special groups to create an environment of peer-to-peer support designed to discourage adolescents from initiating smoking? Or encourage people from different sectors (for example, employers, clinicians, etc.) to provide social support and tools to members of underserved communities so they are more likely to adopt and sustain a healthy lifestyle? Answering these kinds of questions is the first step in identifying suitable and research-based objectives of a communication program.

Although different theories (see Chapter Two)may specifically support the importance of either behavioral or social results as key outcome indicators, these two parameters are actually interconnected. In fact, social change typically takes place as the result of a series of behavioral results at the individual, group, community, social, and political levels.

Inclusive of Vulnerable and Underserved Groups With a precise mandate fromHealthy People 2020 and the fact that several international organizations, such as UNICEF, have been investing overtime in rolling out an equity-based approach to programming, health commu- nication is increasingly considered a key field that can contribute to a reductionof healthdisparities (“diseases or health conditions that discrim-

health disparities Diseases or health conditions that discriminate and tend to be more common and more severe among vulnerable and underserved populations; or overall differences in health outcomes

inate and tend to be more common andmore severe among vulnerable and underservedpopulations” [HealthEquity Initiative, 2012b]; or overall differ- ences in health outcomes) and an advancement of health equity. Therefore, health communication programs need to be mindful and inclusive of vul- nerable and underserved populations. Such inclusiveness is not only limited to making sure that programs intended for the general population or spe- cific communities also have a measurable impact on disadvantaged groups but it also entails that such groups are involved in the planning, implemen- tation, and evaluation of all interventions so that their voices are heard and considered as part of the overall communication process. This is also impor- tant to build leadership capacity among vulnerable and underserved groups

22 CHAPTER 1: WHAT IS HEALTH COMMUNICATION?

so they can adequately address current and future health and community development topics and find their own solutions to pressing issues.

The Health Communication Environment

When looking at the health communication environment where change should occur and be sustained (Figure 1.1), it becomes clear that effective communication can be a powerful tool in seeking to influence all of the factors that are highlighted in the figure. It is also clear that regardless of whether these factors are related to the audience, health behavior, product, service, social, or political environment, all of them are interconnected and can mutually affect each other. At the same time, health communication interventions can tip the existing balance among these factors, and change the weight theymay have in defining a specific health issue and its solutions as well as within the living, working, and aging environment of the people we seek to reach and engage in the health communication process.

Figure 1.1 also reflects some of the key principles of marketing mod- els as well as the socioecological model (Morris, 1975), behavioral and social sciences constructs, and other theoretical models (VanLeeuwen,

HEALTH COMMUNICATION

Recommended Health or Social Behavior, Service, or Product Benefits Risks Disadvantages Price or lifestyle trade-off Availability and access Cultural and social acceptance

Social Environment Stakeholders’ beliefs, attitudes, and practices Social norms and practices Social structure Social support Existing initiatives and programs

Political Environment Policies, laws

Political willingness and commitment

Level of priority in political agenda

Communities and Other Key Groups Health beliefs, attitudes, and behavior

Gender-related factors Literacy levels

Risk factors Lifestyle issues

Socioeconomic factors Living and working environments Access to services and information

Figure 1.1 The Health Communication Environment

HEALTH COMMUNICATION IN PUBLIC HEALTH, HEALTH CARE, AND COMMUNITY DEVELOPMENT 23

Waltner-Toews, Abernathy, and Smit, 1999) that are used in public health, health care, global health, and other fields to show the connection and influence of different factors (individual, interpersonal, community, sociopolitical, organizational, and public policy) on individual, group, and community behavior as well as to understand the process that may lead to behavioral and social results. Health communication theoretical basis is discussed in detail in Chapter Two.

Health Communication in Public Health, Health Care, and Community Development

Prior to the recent call to action by many federal and multilateral organizations, which encouraged a strategic and more frequent use of communication, health communication was used only marginally in a vari- ety of sectors. It was perceivedmore as a skill than a discipline and confined to the mere dissemination of scientific and medical findings by public health and other professionals (Bernhardt, 2004). This section reviews cur- rent thinking on the role of health communication in public health, health care settings, and community development, and also serves as a reminder of the need for increased collaboration among these important sectors.

Health Communication in Public Health Health communication is a well-recognized discipline in public health. Many public health organizations and leaders (Bernhardt, 2004; Freimuth, Cole, and Kirby, 2000; Institute of Medicine, 2002, 2003b; National Cancer Institute at theNational Institutes ofHealth, 2002; Piotrow,Kincaid, Rimon, andRinehart, 1997; Rimal andLapinski, 2009;USDepartment ofHealth and HumanServices, 2005, 2012b)understandand recognize the role that health communication can play in advancing health outcomes and the general health status of interested populations and special groups. Most important, there is a new awareness of the reach of health communication as well as its many strategic action areas (for example, interpersonal communication, professionalmedical communications, communitymobilization and citizen engagement, and mass media and new media communication).

As defined by Healthy People 2010 (US Department of Health and Human Services, 2005), in the US public health agenda, the scope of health communication in public health “includes disease prevention, health pro- motion, health care policy, and the business of health care as well as enhancement of the quality of life and health of individuals within the

24 CHAPTER 1: WHAT IS HEALTH COMMUNICATION?

community” (p. 11–20; Ratzan and others, 1994). Health communica- tion “links the domains of communication and health” (p. 11–13) and is regarded as a science (Freimuth and Quinn, 2004; Bernhardt, 2004) of great importance in public health, especially in the era of epidemics and emerging diseases, the increasing toll of chronic diseases, the aging of large segments and percentages of the population of many countries, urban- ization, increased disparities and socioeconomic divides, global threats, bioterrorism, and a new emphasis on a preventive and patient-centered approach to health. Finally, Healthy People 2020 establishes health com- munication as a key discipline in contributing to advance health equity (US Department of Health and Human Resources, 2012b).

Health Communication in Health Care Settings Health communication has an invaluable role within health care settings. Although provider-patient communications—which is perhaps the best known and most important use of communication within health care settings—is discussed in detail within Chapter Four, it is worth mentioning here that communication is also used to coordinate the activities of interdependent health care providers, encourage the widespread use of best clinical practices, promote the application of scientific advancements, and overall to administer complexandmultisectoral health caredelivery systems (see Chapter Seven and other relevant sections throughout this book).

As Healthy People 2020 suggests, by combining effective health com- munication processes and integrating themwith new technology and tools, there is the potential to

• Improve health care quality and safety. • Increase the efficiency of health care and public health service delivery. • Improve the public health information infrastructure. • Support care in the community and at home. • Facilitate clinical and consumer decision-making. • Build health skills and knowledge (US Department of Health and

Human Services, 2012b).

Among other things, Healthy People 2020’s recommendations reflect the support many reputable voices and organizations—in the United States and globally—have lent to the need for effective integration of the work and strategies from our public health and health care systems.

THE ROLE OF HEALTH COMMUNICATION IN THEMARKETINGMIX 25

Health Communication in Community Development As previously mentioned, health is influenced by many different factors and is not only the mere absence of illness. Health is a state of well-being that includes the physical, psychological, and social aspects of life, which in turn are influenced by the environment in which we live, work, grow, and age.

Community development refers to a field of research and practice community development A field of research and practice that involves community members, average citizens, professionals, grant-makers, and others in improving various aspects of local communities

that involves community members, average citizens, professionals, grant- makers, andothers in improving various aspects of local communities.More traditionally, community development interventions have been dealing with providing and increasing access to adequate transportation, jobs, and other socioeconomic opportunities, education, and different kinds of infrastructure (for example, parks, community centers, etc.) within a given community or population. Yet, because all of these interventions or factors are greatly connected to people’s ability to stay healthy or effectively cope with disease and emergency, many organizations have been calling for increased collaboration among the community development, health care, and public health fields (Braunstein and Lavizzo-Mourey, 2011).

Health communication can play a key role in moving forward such a collaborative agenda. It can help bridge organizational cultures and show- case relevant synergies among the works of public health, health care, and community development organizations and professionals; increase awareness on how key social determinants of health influence health out- comes; establish “good health,” and more in general health equity, as key determinants of socioeconomic development; and engage and mobilize professionals from different sectors to take action. Health communication can be instrumental in empowering community members and profession- als from different sectors to implement such cross-sectoral collaborative agenda, which would benefit different communities and populations in the United States and globally. We will continue to explore this important theme throughout the book.

The Role of Health Communication in theMarketingMix

As mentioned, health communication strategies are integral to a variety of interventions in different contexts. In the private sector, health communi- cation strategies are primarily used in a marketing context. Still, many of the other behavioral and social constructs of health communication—and

26 CHAPTER 1: WHAT IS HEALTH COMMUNICATION?

definitely the models that position people at the center of any commu- nication intervention—are considered and used at least at an empirical level. As in other settings (for example, public health), health communica- tion functions tend to be similar to those described in the “What Health Communication Can and Cannot Do” section of this chapter.

Many in the private sector regard health communication as a critical component of the marketing mix, which is traditionally defined by the key four Ps of social marketing (see Chapter Two for a more detailed descrip- tion): product, price, place, and promotion—in other words, “developing, delivering, and promoting a superior offer” (Maibach, 2003). Chapter Two includes a more detailed discussion of marketing models as one of the key theoretical and practical influences of health communication.

Overview of Key Communication Areas

Global health communication is a term increasingly used to include dif- ferent communication approaches and action areas, such as interpersonal communication, social and communitymobilization, and advocacy (Haider, 2005; Waisbord and Larson, 2005). Well-planned health communication programs rely on an integrated blend of different action areas that should be selected in consideration of expected behavioral and social outcomes (WHO, 2003;O’Sullivan, Yonkler,Morgan, andMerritt, 2003; HealthCom- munication Partnership, 2005a). Long-term results can be achieved only through an engagement process that involves key groups and stakehold- ers, implements participatory approaches to research, and uses culturally appropriate action areas and communication channels. Remember that there is no magic fix in health communication.

Message repetitiveness and frequency are also important factors in health communication. Often the resonance effect, which can be defined as the ability to create a snowball effect for message delivery by using multiple vehicles, sources, and messengers, can help motivate people to change by reminding them of the desired behavior (for example, complying with childhood immunization requirements, using mosquito nets for protection against malaria, attempting to quit smoking) and its benefits. To this end, several action areas are usually used in health communication and are described in detail in the topic-specific chapters in Part Two:

• Interpersonal communication, which uses interpersonal channels (for example, one-on-one or group meetings), and is based on active listening, social and behavioral theories, aswell as the ability to relate to, and identify with, the audience’s needs and cultural preferences and efficiently

OVERVIEW OF KEY COMMUNICATION AREAS 27

address them. This includes “personal selling and counseling” (WHO, 2003, p. 2), which takes place during one-on-one encounters with members of key groups and other key stakeholders, as well as during group events and in locations where materials and services are available. It also includes provider-patient communications—which has been identified as one of the most important areas of health communication (US Department of Health and Human Services, 2005) and should aim at improving health outcomes by optimizing the relationships between providers and their patients, and community dialogue, which is an example of interpersonal communication at scale and is used in research and practice to solicit community input and engage and empower participants throughout the communication process.

• Mass media and new media communication, which relies on the skillful use of culturally competent and audience-appropriate mass media, new media, and social media, as well as other communication channels to place a health issue on the public agenda, raise awareness of its root causes and risk factors, advocate for its solutions, or highlight its importance so that key stakeholders, groups, communities, or the public at large take action.

• Community mobilization and citizen engagement, a bottom-up and participatory process that at times more formally includes methods for public consultations and citizen engagement. By using multiple commu- nication channels, community mobilization seeks to involve community leaders and the community at large in addressing a health issue, participat- ing in determining key steps to behavioral or social change, or practicing a desired behavior.

• Professional medical communications, a peer-to-peer approach intended to reach and engage health care professionals that aims to (1) promote the adoption of best medical and health practices; (2) establish new concepts and standards of care; (3) publicize recent medical discover- ies, beliefs, parameters, and policies; (4) change or establish new medical priorities; and (5) advance health policy changes, among other goals.

• Constituency relations and strategic partnerships in health commu- nication, a critical component of all other areas of health communication as well as a communication area of its own. Constituency relations refers to the process of (1) creating consensus among key stakeholders about health issues and their potential solutions, (2) expanding program reach by involving key constituencies, (3) developing alliances, (4) managing and anticipating criticisms and opponents, and (5) maintaining key relation- shipswithotherhealthorganizationsor stakeholders. Effective constituency relations often lead to strategic and multisectoral partnerships.

28 CHAPTER 1: WHAT IS HEALTH COMMUNICATION?

• Policy communication and public advocacy, which include government relations, policy briefing and communication, public advocacy, and media advocacy, and use multiple communication channels, venues, and media to influence the beliefs, attitudes, and behavior of policymakers, and consequently the adoption, implementation, and sustainability of different policies and funding streams for specific issues.

The Health Communication Cycle

The importance of a rigorous, theory-driven, and systematic approach to the design, implementation, and evaluation of health communication interventions has been established by several reputable organizations in the United States and globally (Association of Schools of Public Health, 2007; US Department of Health and Human Services, 2012b; WHO, 2003). Chapter Two includes examples of theory-driven planning frameworks used by different types of organizations in a variety of professional settings.

As previously mentioned in the book’s introduction, Part Three pro- vides detailed step-by-step guidance on health communication planning, implementation, and evaluation and at the same time also highlights the cyclical and interdependent nature of different phases of health communication interventions. Although a comprehensive overview of the health communication cycle and strategic planning process can be found in Chapter Ten, Figure 1.2 briefly describes key phases of health communication planning and introduces the basic planning framework

Planning

Implementation and monitoring

Evaluation, feedback, and refinement

• Hard work to ensure spotless execution • Monitor progress, results, and audience feedback

• Starts during planning • A continuing part of the communication process

• Research- and audience-based • Structured approach • Strategic process

Figure 1.2 The Health Communication Cycle

WHATHEALTH COMMUNICATION CAN AND CANNOT DO 29

that is discussed in detail in Part Three. Figure 1.2 also shows how strategic planning is directly connected to the other two stages of the health commu- nication cycle (program implementation and monitoring, and evaluation, feedback, and refinement).

What Health Communication Can and Cannot Do

Health communication cannot work in a vacuum and is usually a critical component of larger public health or community development interven- tions or corporate efforts. Because of the complexity of health issues, it may “not be equally effective in addressing all issues or relaying all messages” (National Cancer Institute at the National Institutes of Health, 2002, p. 3), at least in a given time frame.

Health communication cannot replace the lack of local infrastruc- ture (such as the absence of appropriate health services or hospitals or other essential services that would provide communities with enhanced opportunities to stay healthy, as, for example, parks, adequate transporta- tion systems, recreational facilities, bike-sharing programs, and stores that sell nutritious food) or capability (such as an inadequate number of health care providers in relation to the size of the population being attended). It cannot compensate for inadequate medical solutions to treat, diagnose, or prevent any disease. But it can help advocate for change and create a receptive environment to support the development of new health services or the allocation of additional funds for medical and scientific discovery, or access to existing treatments or community ser- vices, or the recruitment of health care professionals in new medical fields or underserved geographical areas. In doing so, it helps secure politi- cal commitment, stakeholder endorsement, and community involvement to encourage change, devise community-specific solutions, and improve health outcomes.

Because of the evolving role of health communication, other authors and organizations have been defining the potential contribution of health communication to the health care and public health fields. For example, the USNational Cancer Institute at the National Institutes of Health (2002) has a homonymous section, which partly inspired the need for this section, in one of its publications on the topic.

Understanding the role and the potential impact of health communi- cation is important to take full advantage of the contribution of this field to health and related social outcomes as well as to set realistic expectations on what can be accomplished among team members, program partners, key groups, and stakeholders. Table 1.3 provides examples of what health communication can and cannot do.

30 CHAPTER 1: WHAT IS HEALTH COMMUNICATION?

Table 1.3 What Health Communication Can and Cannot Do

Health Communication Can Help . . . Health Communication Cannot . . .

Raise awareness of health issues and their root causes to drive policy or practice changes

Engage and empower communities and key groups

Influence research agendas and priorities and support the need for additional funds for medical and scientific discovery

Increase understanding of the many socially determined factors that influence health and illness so they can be adequately addressed at the population and community levels

Encourage collaboration among different sec- tors, such as public health, community develop- ment, and health care

Secure stakeholder endorsement of health and related social issues

“Influence perceptions, beliefs and attitudes that may change social norms” (National Cancer Institute at theNational Institutes of Health, 2002, p. 3)

Promote data and emerging issues to establish new standards of care

“Increasedemandforhealthservices”(National Cancer Institute at the National Institutes of Health, 2002, p. 3) and products

Show benefits of and encourage behavior change

“Demonstrate healthy skills” (National Cancer Institute at theNational Institutes of Health, 2002, p. 3)

Provoke public discussion to drive disease diagnosis, treatment, or prevention

Suggest and “prompt action” (National Cancer Institute at theNational Institutes of Health, 2002, p. 3)

Build constituencies to support health and social change across different sectors and commu- nities

Advocate for equal access to existing health products and services

Strengthen third-party relationships Improve patient compliance and outcomes

Work in a vacuum, independent from other public health, health care, marketing, and community development interventions Replacethe lackof local infrastructure, services,

or capability Compensate for the absence of adequate treat-

ment or diagnostic or preventive options and services “Be equally effective in addressing all issues or

relaying all messages,” at least in the same time frame (National Cancer Institute at the National Institutes of Health, 2002, p. 3)

KEY CONCEPTS 31

Key Concepts

• Health communication is a multifaceted and multidisciplinary field of research, theory, and practice. It is concerned with reaching different populations and groups to exchange health-related information, ideas, and methods in order to influence, engage, empower, and support different groups so that theywill champion, introduce, adopt, or sustain a health or social behavior, practice, or policy that will ultimately improve individual, community, and public health outcomes.

• Health communication should be inclusive and representative also of vulnerable and underserved groups.

• Health communication is an increasingly prominent field in public health, health care, community development, and the private sector (both nonprofit and corporate).

• Health communication can play a key role in advancing health equity. • Several socially determined factors (also referred to as social determi-

nants of health) influence and are influenced by health communication. • One of the key characteristics of health communication is its multidis-

ciplinary nature, which allows the theoretical flexibility that is needed to consider and approach each situation and key group for their unique characteristics and needs.

• We are now in the era of behavioral and social impact communication. In fact, several US and international models and agendas support the importance of a behavioral and social change–driven mind-set in developing health communication interventions.

• Health communication is an evolving discipline that should always incorporate lessons learned and practical experiences. Practitioners should take an important role in defining theories and models to inform new directions in health communication.

• It is important to be aware of key features and limitations of health communication (and more specifically what communication can and cannot do).

• Health communication relies on several action areas. • Well-designed programs are the result of an integrated blend of

different areas that should be selected in light of expected behavioral and social outcomes.

32 CHAPTER 1: WHAT IS HEALTH COMMUNICATION?

FOR DISCUSSION AND PRACTICE

1. Did you have any preliminary idea about the definition and role of health communication

prior to reading this chapter? If yes, how does it compare to what you have learned in this

chapter?

2. Inyouropinion,whatare thetwomost importantdefining featuresofhealthcommunication

andwhy? How do they relate to the other key characteristics of health communication that

are discussed in this chapter?

3. Can you recall a personal experience in which a health communication program, message,

or health-related encounter (for example, a physician visit) has influenced your decisions

or perceptions about a specific health issue? Describe the experience and emphasize key

factors that affected your decision and health behavior.

4. Did you ever participate in the development or implementation of a health communication

intervention? If yes, what were some of the key learnings and how do they relate to the

attributes of health communication as described in this chapter?

5. Can you think of examples of health communication interventions that seek to benefit

and address the needs of vulnerable and underserved groups in your neighborhood,

community, city, and country? If yes, did you observe any results or impact among these

groups?

KEY TERMS

audience analysis

audience profile

channels

communication channels

communication objectives

communication strategies

communication vehicles

community development

health communication

health disparities

health equity

intended audiences

key groups

program outcomes

situation analysis

social determinants of health

stakeholders

underserved populations

vulnerable populations

CHAPTER 2

CURRENT HEALTH COMMUNICATION THEORIES AND ISSUES

IN THIS CHAPTER

• Use of Communication Models and Theories: A Premise

• Key Theoretical Influences in Health Communication

• Select Models for Strategic Behavior and Social Change Communication

• Other Theoretical Influences and Planning Frameworks

• Current Issues and Topics in Public Health and Health Care: Implications for Health Communication

• Key Concepts

• For Discussion and Practice

• Key Terms

Over several decades, the field of health communication has experienced a dramatic growth and evolution, which is still continuing. The multidisciplinary nature of health communication, one of its most important characteristics, has been recognized by several organizations and leaders (Institute of Medicine, 2003b; Bernhardt, 2004; World Health Organization [WHO], 2003; Kreps, 2012b; Rimal and Lapinski, 2009).

Although several authors and organizations have been defining the theoretical basis of health communication, the intersection among many different disciplines (for example, behavioral and social sciences, social market- ing, development theories, and health education) as well as between social sciences and the humanities is still a growing field of research and practical application (Health Communication Partnership, 2005b). Some authors have been referring to a “family tree” (Waisbord, 2001, p. 1) of communication theories and models; others do not emphasize the chronological sequence and interdepen- dence of communication theories, but focus primarily on the impact theories may have on program design and outcomes (Institute of Medicine, 2002). At the same time, current health-related issues and topics influence the theory and practice of health communication so that communication interventions can effectively address the health and social challenges of the twenty-first century.

34 CHAPTER 2: CURRENT HEALTH COMMUNICATION THEORIES AND ISSUES

CHAPTER OBJECTIVES

This chapter provides readers with (1) a brief overview of major theories and planning

frameworks and their implications in health communication; (2) a basic foundation to apply

theory and strategy-based communication principles across different settings and key groups

(Association of Schools of Public Health, 2007); and (3) a review of key current issues that

influence the theory and practice of health communication.

Use of CommunicationModels and Theories: A Premise

Theories and planning models are particularly important for students and young practitioners in this field. Theories help clarify how to approach a health issue and plan to address it through a health communication inter- vention. They also have a significant weight at all levels in communication research, donor-sponsored programs, retrospective analyses, outcome and impact evaluation, and all other circumstances that demand a rigorous pro- gram design. Theories can also provide a powerful tool to organize one’s thoughts and to design interventions that clearly have in mind specific behavioral and social outcomes. Communication theories and frameworks are used in a less rigorous way in the commercial, nonprofit, and private sectors in the interest of time. The downside to this approach is that it may be more difficult to link any specific behavioral or social outcome to the actual health communication program, which is already a notably complex task in health communication (see Chapter Fourteen).

Overall, communication models and theoretical constructs are often used to

• Provide a basis for communication planning, monitoring, and evaluation.

• Inspire specific communication approaches. • Help implement a specific phase of a health communication program. • Support a true understanding of key groups as well as the health

communication environment as part of the planning, implementation, and evaluation processes.

When reviewing these theories and models, junior health commu- nication practitioners and students should remember that these are

KEY THEORETICAL INFLUENCES IN HEALTH COMMUNICATION 35

just selected references, which ideally should prompt further inquiries and readings on the theory of health communication. They should also keep in mind that theories, models, and planning frameworks should (1) be considered part of a tool kit and selected on a case-by-case basis, (2) respond to an audience’s needs, (3) address the specific health situation and all factors that play a role in determining it, (4) inform and guide message development as well as the identification of appropriate communication channels, and (5) be revisited in light of emerging factors and needs. This selection process should take into account expected program outcomes and the behavioral or social impact the communication program seeks to achieve. For all other readers (including current health communication practitioners, researchers, health care providers, and other professionals), the following overview should provide an updated summary of selected theories and models that currently inspire our field, as well as key issues and topics that influence its theory and practice.

Key Theoretical Influences in Health Communication

Health communication is influenced by different disciplines and theoretical approaches (see Figure 2.1). Some of the most important theories can be divided into the following categories: behavioral and social science theories, mass communications theories, new media influence theories,

Marketing and social marketing theories

Behavioral and social science theories

Anthropology

Sociology Medical models

Mass media and new media theories

Health communication

Figure 2.1 Health Communication Theory Is Influenced by Different Fields and Families of Theories

36 CHAPTER 2: CURRENT HEALTH COMMUNICATION THEORIES AND ISSUES

marketing and social marketing, and other theoretical influences, including medical models, sociology, and anthropology. In addition, several planning frameworks and models have been developed to reflect or incorporate key principles from some or all of these categories. The overview that follows focuses on select theories and models as well as their potential or actual impact on health communication practice.

Selected Behavioral and Social Sciences Theories Behavioral and social sciences theories seek to analyze and explain how change occurs at the individual, community, and social levels. Some of these theories focus primarily on the key steps thatmay lead tobehavioral or social change and others look at communication processes and group dynamics. Most of them also emphasize the interconnection and mutual dependence of individual and external factors. As previouslymentioned, this connection is of great importance in health communication.

Diffusion of Innovation Theory Initially developed by Everett Rogers (1962, 1983, 1995), the diffusion of innovation theory addresses how new ideas, concepts, or practices can spread within a community or “society, or from one society to another” (National Cancer Institute at the National Institutes of Health, 2002, p. 226). The theory identifies and defines five subgroups on the basis of their characteristics and propensity to accept and adopt innovation (Beal and Rogers, 1960):

• Innovators • Early adopters • Early majority • Late majority • Laggards

The overall premise of this theory is that change occurs over time and is dependent on the following stages (Rogers, 1962, 1983, 1995; Waisbord, 2001; Health Communication Partnership, 2005c):

• Awareness • Knowledge and interest • Decision • Trial or implementation • Confirmation or rejection of the behavior

KEY THEORETICAL INFLUENCES IN HEALTH COMMUNICATION 37

Innovators

Early adopters

Early majority

Late majority

Laggards

0 1 2 3 4 5

Length of the innovation-decision period (in years)

2.34

1.14

0.55

0.40

4.65

Figure 2.2 Attributes of the Audience Source: Beal, G. M., and Rogers, E. M. The adoption of two farm practices in a central Iowa community. Special report no. 26, p. 14. Ames, Iowa: Agricultural and Home Economics Experiment Station, Iowa State University, 1960. Used by permission.

It also observes that innovators usually decide much faster than any other subgroup on whether to adopt new ideas, concepts, or practices (Beal and Rogers, 1960; see Figure 2.2). Therefore, innovators can act as role models and persuade other subgroups (including laggards) to accept and adopt new behaviors and social practices.

Similar to many other theories in any field, diffusion of innovation has been misused and misinterpreted at times (Health Communication Partnership, 2005c). Some critics have observed that the trickle-down approach, from the innovators to the laggards,may notwork in all situations (Waisbord, 2001). Rogers himself modified the theory to change the focus from “a persuasion approach (transmission of information between individuals andgroups)” to “aprocess bywhichparticipants create and share information with one another in order to reach a mutual understanding” (Waisbord, 2001, p. 5; Rogers, 1976).

Nevertheless, diffusion of innovation still plays a key role in health communication research, evaluation, andplanning. Themajor contribution of the theory is its early audience segmentation model, which supports the importance of looking at intended audiences as a complex puzzle of different subgroups, stages, needs, and priorities that should be considered in developing communication messages and activities. The theory can also provide a valid framework for “innovator studies” that seek to assess program impact within an initial group of adopters (Schiavo, Gonzalez- Flores, Ramesh, and Estrada-Portales, 2011).

38 CHAPTER 2: CURRENT HEALTH COMMUNICATION THEORIES AND ISSUES

Finally, the individuals’ stage model provides a perspective on the time and the external conditions that are needed to achieve behavioral or social change. It is a useful tool in thinking about the levels of awareness, knowl- edge, and interest among key groups (Health Communication Partnership, 2005c). It is also a valid reminder that continuing to engage innovators and early adopters, or their representatives, in program planning and evaluation is essential to program sustainability as well as to the involvement of larger segments of the intended population in promoting innovative behaviors or social practices. For a practical example about the application of this theory, see Box 2.1.

BOX 2.1. DIFFUSION OF INNOVATION THEORY: A PRACTICAL EXAMPLE

Luciana, a nineteen-year-old college student, lives in a coastal town in southern Italy and loves

going to the beach. During her summer vacation and many of the late spring weekends, she

spends four to six hours each day basking in the sun while talking with her friends or playing

beach volleyball or swimming. She uses sunscreen lotion with a low sunscreen protection

factor (SPF), and only at the beginning of the season, to avoid sunburn. Once she is tanned,

she may not use it at all. Most of her friends rarely use any sunscreen protection and, if they do,

use the same kind with a low SPF. During the winter, Luciana keeps her tan by using artificial

ultraviolet sunlamps.

In the summer, getting a nice tintarella, the Italian word for suntan, is one of Italians’

favorite pastimes and is considered very attractive. People compliment each other on their

tintarella. Although Luciana and some of her friends may be somewhat aware that prolonged

and continual sun exposure is a risk factor for skin cancer, the aesthetic appeal and social

approval of a tanned skin allay their doubts about sun exposure. Luciana also feels she is too

young to worry about skin cancer, does not know enough about it, and therefore does not feel

the need to use much stronger sunscreen protection.

A reviewof the literatureonthesubject (forexample,Monfrecola, Fabbrocini, Posteraro,and

Pini, 2000) shows that Luciana’s fictional profile is somewhat representative of frequent beliefs

andbehavior amongapercentageof Italian youngpeoplewho live on theMediterranean coast.

According to thediffusion of innovations theory, Luciana could be considered an innovator

or early adopter in her peer group if she starts using higher sunscreen protection and limiting

her use of sunlamps. Ideally, she could talk with her peers and circle of friends about following

her example. In fact, most of them do not use any sunscreen andmay be slower to change than

Luciana.

There are a few facts that are good indicators that she could become an innovator or early

adopter: her education level (she is a college student), socioeconomic background (both of

KEY THEORETICAL INFLUENCES IN HEALTH COMMUNICATION 39

her parents hold advanced degrees and professional jobs and have raised Luciana to question

existing behaviors in light of new information), personality (she is rational, resourceful, and

charming, andoftenperceived as a leader in her peer group), exposure tomedia (she iswell read

and relies on a variety of media for information and entertainment), attitude toward change

(she is willing to experiment with new things and behaviors if she understands them and

perceives their benefits), and social involvement (she is an active member of several student

organizations and other social and political groups).

If we look at the different stages of the diffusion of innovation theory (awareness,

knowledge and interest, decision, trial or implementation, confirmation or rejection of the

behavior), the first step is to make Luciana aware of skin cancer’s severity, recent increase, and

strong link to sun exposure and sunlamp use. Recent facts and incidence data should be used

to reinforce her awareness and to point to the need for sunscreen use.

If research shows that Luciana is already aware of the disease severity and related risk

factors, communicationmessages and interactions should focus onmaking skin cancer relevant

to her and her peers (the second stage of the diffusion theory). Knowledge that skin cancer

can also occur among young people, and that the sun’s damaging effects begin at an early age

(National Cancer Institute, 2005b) may help increase Luciana’s concern about sun exposure.

Still, her perception that a tanned body is more attractive than an untanned one may prevent

her from taking action and should be addressed early as part of the overall intervention.

Focusing on the damaging effects of sun exposure on the skin’s appearance and overall aging

process may appeal to Luciana’s aesthetic values.

Social support as well as the ability to sustain the recommended behavior should be

encouraged by using adequate communication tools and activities while Luciana goes through

the three remaining stages of the diffusion of innovation theory as she decides, tries, and,

ideally, continues to use sunscreen and limit her use of sunlamps. In these stages, Luciana will

need to perceive the advantages of behavioral change, find it acceptable for her lifestyle, and

find it easy to implement and sustain. Sunscreen samples and detailed instructions on when

to apply the sunscreen (not only to prevent skin burning) can facilitate early use, but social

support and peer validation is critical to sustainability.

The program should also address her other concerns: the appeal of an untanned or lightly

tanned body (Broadstock, Borland, and Gason, 1992; Monfrecola, Fabbrocini, Posteraro, and

Pini, 2000), which could be reinforced by celebrities, institutions, older family members, or

others who could act as role models; and the reduced risk for a potentially life-threatening

disease. Change would occur only if all tools and activities are designed to take into account

Luciana’s needs and rely on her input as a key actor in the overall change process. If these needs

are adequately met, Luciana may become an ambassador (innovator) for the importance of

sunscreen use among her circle of friends, peers, and social groups. (An example on the topic

of skin cancer is given in Weinreich [1999].)

40 CHAPTER 2: CURRENT HEALTH COMMUNICATION THEORIES AND ISSUES

In approaching the rest of this chapter, readers may find it helpful to apply Luciana’s

fictional example or other examples to all theories and models that are discussed in it. At a

minimum, this would prompt awareness of different ways of organizing one’s thoughts when

dealing with the same health issue using different theoretical frameworks. It will also provide a

tool to organize audience-related research.

Health Belief Model The health belief model (HBM) (Becker, Haefner, and Maiman, 1977; Janz and Becker, 1984; Strecher and Rosenstock, 1997) was originally intended to explain why people did not participate in programs that could help them diagnose or prevent diseases (National Cancer Institute at the National Institutes of Health, 2002). The major assumption of this model is that in order to engage in healthy behaviors, key groups need to be aware of their risk for severe or life-threatening diseases and perceive that the benefits of behavior change outweigh potential barriers or other negative aspects of recommended actions. HBM is one of the first theories developed to explain the process of change in relation to health behavior. It has also inspired—among many other models—the field of health education. Health education is defined in Healthy People 2010 as “any planned combination of learning experiences designed to predispose, enable, and reinforce voluntary behavior conducive to health in individuals, groups, or communities” (US Department of Health and Human Services, 2005, p. 11–20; Green and Kreuter, 1999).

HBM has the following key components:

• Perceived susceptibility: The individual’s perception of whether he or she is at risk for contracting a specific illness or health problem

• Perceived severity:The subjective feeling onwhether the specific illness or health problem can be severe (for example, permanently impair physical or mental functions) or is life threatening, and therefore worthy of one’s attention

• Perceived benefits: The individual’s perceptions of the advantages of adopting recommended actions that would eventually reduce the risk for disease severity, morbidity, and mortality

• Perceived barriers: The individual’s perceptions of the costs of and obstacles to adopting recommended actions (includes economic costs as well as other kinds of lifestyle sacrifices)

KEY THEORETICAL INFLUENCES IN HEALTH COMMUNICATION 41

• Cues to action: Public or social events that can signal the importance of taking action (for example, a neighbor who is diagnosed with the same disease or a mass media campaign)

• Self-efficacy:The individual’s confidence in his or her ability to perform and sustain the recommended behavior with little or no help from others

In describing the HBM, Pechmann (2001) referred to it as a “risk learning model because the goal is to teach new information about health risks and the behaviors that minimize those risks” (p. 189). The overall premise of the HBM is that knowledge will bring change. Knowledge is brought to intended groups through an educational approach that primarily focuses on messages, channels, and spokespeople (Andreasen, 1995).

“Some authors caution that the HBM does not pre-suppose or imply a strategy for change” (Rosenstock and Kirscht, 1974, p. 472; Andreasen, 1995, p. 10). Nevertheless, the major contribution of the HBM to the health communication field is its emphasis on the importance of knowledge, a necessary but not sufficient step to change. HBM can also be used for audience-related research because it provides a useful framework to organize one’s thoughts in developing an audience profile and refining health communication programs as part of research and evaluation. Box 2.2 provides a case study on how the health belief model was used to evaluate a mass media campaign for HIV prevention.

BOX 2.2. THE ADDED-VALUE OF THEORETICALMODELS IN EVALUATING

MASSMEDIA CAMPAIGNS

Situation and ProgramDescription

In 1988, the National AIDS Program (NAP) of the Ministry of Health of Peru conducted a

household survey on knowledge, attitudes, and practices related to sexual behavior and HIV

transmission with technical and financial support from Johns Hopkins University, Population

Communication Services, and the Population Council. The results showed high levels of

misconceptions about HIV transmission routes and a low percentage of respondents (13

percent) reporting condom use in the last month before the survey (Saba and others, 1992).

In order to educate the public on HIV transmission and prevention, the NAP and its partners

agreed to conduct a six-week mass media campaign using TV spots, radio spots, and movie

theater advertisements.

42 CHAPTER 2: CURRENT HEALTH COMMUNICATION THEORIES AND ISSUES

Theory-Based Evaluation

The impact of the campaignwas evaluated by comparing the baselinewith a follow-up survey.1

The evaluation team created a rating scale (health belief model [HBM] index) and related

evaluation parameters based on the constructs of the HBM (Jette and others, 1981). The rating

scale ranged from 0 to 3 depending on the individual’s perception of none, one, two, or three

of the following variables: (1) susceptibility to HIV infection, (2) severity of the disease, and

(3) perceived benefits of condoms as effective protection against HIV. Thus, respondents who

consider themselves as susceptible to HIV infection, consider AIDS as a severe disease, and

perceived condoms effective for prevention got a score of 3. Those who did not have any of

these three beliefs were given a score of 0. There were values of 1 and 2 in between.

The evaluation showed an increase in perceived susceptibility, perceived severity, and

perceived benefits of condom use after exposure to the mass media campaign. Self-reported

condom use increased from 13 to 16 percent (a difference of 3 percentage points). To better

understand the profile of the respondents who changed their behavior, the HBM index was

correlated with self-reported condom use. It was observed that for individuals exposed to

the campaign, the proportion of high scorers on the HBM index who used condoms was

significantly greater than low scorers on the HBM index. In fact, 20 percent of the respondents

who scored high in the HBM index used condoms after exposure to the campaign, compared

with only 9 percent of the individuals who scored low in the HBM index2 (a difference of

11 percentage points). High scorers were clearly the most susceptible to change.

Conclusions

As for this case study, the use of a theoretical model guides and organizes data interpretation

when evaluating the mass media campaign. Theory guides assumptions about the profile

of the population who are more susceptible to change if exposed to a “cue to action” such

as an educational campaign. The “predictability” offered by the theoretical model can be

very valuable for audience segmentation, message design, and campaign evaluation so that

program efforts can be tailored to address existing perceptions, attitudes, needs, and behaviors

among key audiences.

Notes 1The pre- and postcampaign survey consisted of structured questionnaires applied to two samples of 1,913 and

2,443 men and women aged fifteen to forty-four from middle, lower middle, and lower socioeconomic strata

before and after the six-week campaign. 2Scores of 2 or 3 in the HBM index were considered high whereas scores of 0 or 1 were considered low.

KEY THEORETICAL INFLUENCES IN HEALTH COMMUNICATION 43

References

Jette, A. M., and others. “The Structure and Reliability of Health Belief Indices.” Health Services

Research, 1981, 16(1), 81–98.

Saba, W., and others. “The Mass Media and Health Beliefs: Using Media Campaigns to Promote

Preventive Behavior.” Unpublished case study, 1992, 1–25.

Source: Saba, W. “The Added-Value of Theoretical Models in Evaluating Mass Media Campaigns.” Unpublished

case study, 2012a. Used by permission.

Social Cognitive Theory Also knownas social learning theory, social cognitive theory (SCT; Bandura, 1977, 1986, 1997) explains behavior as the result of three reciprocal factors: behavior, personal factors, and outside events. Any change in any of these three factors is expected to determine changes in the remaining ones (National Cancer Institute at the National Institutes of Health, 2002). Behavior is viewed as influenced by a combination of personal and outside factors and events.

One of SCT’s key premises is its emphasis on the outside environment, which becomes a source of observational learning. According to SCT, the environment is a place where individuals can observe an action, understand its consequences, and, as a result of personal and interpersonal influences, become motivated to repeat and adopt it. SCT has these key components (Bandura, 1977, 1986, 1997; National Cancer Institute at the National Institutes of Health, 2002; Health Communication Partnership, 2005d):

• Attention: People’s awareness of the action being modeled and observed.

• Retention: People’s ability to remember the action being modeled and observed.

• Reproduction (trial): People’s ability to reproduce the action being modeled and observed.

• Motivation: People’s internal impulse and intention to perform the action. Motivation depends on a number of social, affective, and physiological influences (for example, the support of peers and family

44 CHAPTER 2: CURRENT HEALTH COMMUNICATION THEORIES AND ISSUES

members to perform the action, the knowledge that the action will improve physical performance), as well as the perception of self- efficacy.

• Performance:The individual’s ability to perform the action on a regular basis.

• Self-efficacy:The individual’s confidence in his or her ability to perform and sustain the action with little or no help from others, which plays a major role in actual performance.

SCT can provide a framework to approach several different questions in program research and planning, but its major contribution to health communications is to understand the mechanisms and factors that can influence retention, reproduction, andmotivation (Health Communication Partnership, 2005d) on a given behavior.

Theory of Reasoned Action The theory of reasoned action (TRA; Ajzen and Fishbein, 1980) suggests that behavioral performance is primarily determined by the strength of the person’s intention to perform a specific behavior. It identifies two major factors that contribute to such intentions (Ajzen and Fishbein, 1980; Health Communication Partnership, 2005e; Coffman, 2002):

• A person’s attitude toward the behavior. In general, attitudes can be defined as positive or negative emotions or feelings toward a behavior, a person, a concept, or an idea (for example: “I ___ eating fruit and vegetables”; “I ___ my friend’s boyfriend”).

• A person’s subjective norms about the behavior. In the TRA, subjective norms are defined as the opinion or judgment, positive or negative, that loved ones, friends, family, colleagues, professional organizations, or others may have about a potential behavior (for example, “My friends do not approve that I smokemarijuana”; “My doctor recommends that I exercise at least twice per week”).

Under theTRA, attitudes towarda specificbehavior are a functionof the person’s own beliefs about the consequences of such behavior (for example, “smoking marijuana may have a negative impact on my concentration and work performance”). These are called behavioral beliefs.

behavioral beliefs A term usedwithin the theory of reasoned action that refers to a person’s own beliefs about the consequences of a given behavior

Subjective norms are influenced by normative beliefs, which refer to

normative beliefs A term usedwithin the theory of reasoned action that refers towhether a person may believe significant otherswill approve or not of his or her behavior

whether a person may think significant others will approve or not of his or her behavior (for example, “I think that if I start to smoke marijuana, some

KEY THEORETICAL INFLUENCES IN HEALTH COMMUNICATION 45

of my friends may not approve of it”). Another component of normative beliefs is the person’s motivation to comply with other people’s ideas and potential approval (Coffman, 2002). For example, if one’s normative belief is, “I think that if I start to smoke marijuana, some of my friends may not approve it,” the person’s motivation to comply can be assessed by asking the following question: “Do I care enough about these specific friends to avoid smoking marijuana?” In other words, “Do I care about what people may expect of me?”

TRA is an influential theory in health communication and is frequently used also in program evaluation (Coffman, 2002). However, it is important to be cautious about concluding that the intention of adopting a certain behavior may always translate in actual behavior adoption. Communica- tion can play an important role in supporting behavioral intentions and increasing the likelihood that they would become actual behaviors. This requires the development of interventions and tools that would increase social support and community engagement as well as make it easy for people to try, adopt, and integrate new health behaviors in their lifestyle.

TRA is particularly useful in analyzing and identifying reasons for action and what may change people’s attitudes toward a health or social behavior. It is also a good tool in profiling primary audiences (people

primary audiences The peoplewhom the program seeks to engage more directly andwould most benefit from change

whom the program seeks to engage more directly and would most benefit from change) and secondary audiences (individuals and groups who

secondary audiences All individuals, groups, communities, and organizations that may influence the decisions and behaviors of the primary audiences

may have an influence on the primary audience) (Health Communication Partnership, 2005e).

Social Norms Theory Several theories address the influence of social norms (group-held beliefs

social norms Group-held beliefs on how people should behave in a social situation or group setting

on how people should behave in a social situation or group setting) on behaviors. This is of particular importance for health communication interventions because understanding and influencing such norms via a community- or population-centered process is often critical to attaining behavioral and social results. Social norms–centric theories predicate that most people may be willing to adopt or sustain a specific behavior not only if they are able to see a definite benefit in that change but also if they are convinced that other people will do the same.

Several authors have developed social norms theories. Among them, Bicchieri’s (2006) new theory of social norms challenges key assumptions from the field of social sciences by arguing that people conform to social norms as an automatic response to cues they receive in a specific social situ- ation. According to this theory, toomuch emphasis is placed on the rational

46 CHAPTER 2: CURRENT HEALTH COMMUNICATION THEORIES AND ISSUES

process of decisionmaking because decisions are oftenmade withoutmuch deliberation, (1) as a result of people’s understanding of social expectations or (2)—in the case of “moral norms”—as an unconditional response to emotional reactions to a situation (Bicchieri, 2006).

That is why, in order to achieve almost any kind of behavioral or social result in health or community development settings, it is necessary to con- sider, understand, and influence existing social norms. For example, we have case study–based evidence that in pandemic flu or other emergency settings, social norms may prevent the implementation of recommended emergency response measures, such as social distancing, avoiding crowded places, safely caring for lovedones, orhandlingdeadbodies (Schiavo, 2009b).

Yet, in applying social norms theories it may be equally important to research and develop a key influentials roadmap (identifying and

key influentials roadmap Identifying and mapping groups and stakeholders whose opinions,moral values, and expectations actually matter in the eyes of specific groups or populations

mapping groups and stakeholders whose opinions, moral values, and expectations actually matter in the eyes of specific groups or populations) for each intended group. Although social norms theories rightly assume a horizontal and participatory process to addressing and influencing current norms, the moral and social authority of specific gatekeepers (for example, elderly, community, or religious leaders, etc.) or other stakeholders should not be underestimated. Social cues and emotional reactions to situations are dependent on cultural values and the specific peer groups with whom people interact. Therefore, it’s important that gatekeepers and other relevant groups are engaged in the process of influencing social norms.

Ideation The ideation theory (Kincaid, Figueroa, Storey, and Underwood, 2001; Rimon, 2002; Cleland and Wilson, 1987) refers to “new ways of thinking anddiffusionof thosewaysof thinkingbymeansof social interaction in local, culturally homogenous communities” (O’Sullivan, Yonkler, Morgan, and Merritt, 2003, pp. 1–3; Bongaarts and Watkins, 1996). This theory is used in strategic behavior communications to identify and influence ideational elements (Rimon, 2002; Kincaid, Figueroa, Storey, and Underwood, 2001), such as attitudes, knowledge, self-efficacy, social and peer approval, and other factors that can affect and determine health behavior (see Figure 2.3).

One of the key premises of the ideation theory is “that the more ideational elements that apply to someone, the greater the probability that they will adopt a healthy behavior” (Kincaid and Figueroa, 2004). In other words, individual and community behaviors are influenced by the social contexts in which people live and work.

KEY THEORETICAL INFLUENCES IN HEALTH COMMUNICATION 47

Knowledge

Emotions

Norms

Self-image

Attitudes

Behavior

Perceived risk

Self- efficacy

Social support and

influence

Personal advocacy

Implies simultaneous effect of all influences

Implies communication can affect all influences

Figure 2.3 Ideation Theory Sources: Kincaid, D. L., and Figueroa,M. E. Ideation and Communication for Social Change. Health Communication Partnership Seminar, April 23, 2004. Used by permission. Rimon, J. G. Behaviour Change Communication in Public Health. Beyond Dialogue: Moving Toward Convergence. The Communication Initiative, 2002.www.comminit.com/strategicthinking/stnicroundtable/sld-1744.html. Retrieved Nov. 2005. Used by permission.

Convergence Theory Similar to other theories in the social process category (O’Sullivan, Yonkler, Morgan, andMerritt, 2003), the convergence theory (Kincaid, 1979; Rogers and Kincaid, 1981) emphasizes the importance “of information sharing, mutual understanding and mutual agreement” on any collective or group action that would bring social change (Figueroa, Kincaid, Rani, and Lewis, 2002, p. 4). It is based on the perspective that individual perceptions and behavior are influenced by the perceptions and behaviors of members of the same group, such as members of professional associations, colleagues, and family members, and by people “in one’s personal networks,” such as peers, friends, or personal or professional acquaintances (O’Sullivan, Yonkler, Morgan, and Merritt, 2003, p. 1-4).

This theory is characterized by three distinctive features (Kincaid, 1979; Rogers and Kincaid, 1981; Figueroa, Kincaid, Rani, and Lewis, 2002):

• Information is shared using a participatory process in which there is no sender or receiver but everyone creates and shares information. Participants in this process include individuals, community groups and organizations, and different kinds of institutions, such as professional associations, churches, and schools.

48 CHAPTER 2: CURRENT HEALTH COMMUNICATION THEORIES AND ISSUES

• Communication emphasizes individual perceptions and interpreta- tions of the information being shared, encourages an ongoing dia- logue, and fosters mutual understanding and agreement on common meanings.

• Communication is horizontal and involves two or more participants. In a horizontal model of communication, all participants are equal and aim to reach mutual agreement that may stimulate a group action.

This theory has contributed to redefining communication as a process inwhich all participants need to respect and take into account other people’s feelings, emotions, and beliefs. It has also highlighted the importance of social networks and key influentials in defining the path to social change.

Stages of Behavior Change Model The stages of behavior change model, also known as the transtheoretical model (Prochaska and DiClemente, 1983; Grimley, Gabrielle, Bellis, and Prochaska, 1993; Prochaska and Vellicer, 1997), defines behavioral change as a process that goes through different stages or steps. Each stage describes different “levels of motivation or readiness to change” (National Cancer Institute at the National Institutes of Health, 2002, p. 221; Prochaska and Vellicer, 1997). The model identifies five stages of change (Prochaska and Vellicer, 1997; Weinreich, 2011): 1. Precontemplation, in which individuals have no intention of adopting a

recommended health behavior but are learning about it 2. Contemplation, in which individuals are considering adopting the

recommended behavior 3. Decision, in which people decide to adopt the recommended health

behavior 4. Action, in which people try to adopt the recommended behavior for a

short period of time 5. Maintenance, in which people continue to perform the recommended

health behavior for a long period of time (at least over six months) and, ideally, incorporate it in their routine and lifestyle In health communication, these stages of change can be used in the

phase in which intended audiences are segmented (see Chapter Ten) to identify key groups that, among other related characteristics, will also have similar levels of motivation and readiness for behavioral change (Weinreich, 1999). Therefore, this theory can be instrumental in designing

KEY THEORETICAL INFLUENCES IN HEALTH COMMUNICATION 49

communication objectives, messages, and strategies for each of these groups (National Cancer Institute at the National Institutes of Health, 2002).

Communication for Persuasion Theory This theory was developed by social psychologist William McGuire and focuses on how people process information. McGuire (1984) highlighted twelve interdependent steps in the process of persuasive communication (McGuire, 1984; National Cancer Institute at the National Institutes of Health, 2002; Alcalay and Bell, 2000). He suggested that in order to assimilate and perform a new behavior, a person should do the following (McGuire, 1984; National Cancer Institute at the National Institutes of Health, 2002): 1. Be exposed to the message. 2. Pay attention to it. 3. Find it interesting or personally relevant. 4. Understand it. 5. Figure out how the new behavior could fit in his or her life. 6. Accept the change that is being proposed. 7. Remember and validate the message. 8. Be able to think of the message in relevant contexts or situations. 9. Make decisions on the basis of the retrieved information or message.

10. Behave in line with that decision. 11. Receive positive reinforcement for that behavior. 12. Integrate the new behavior into his or her life.

This model also suggests that these twelve steps are interdependent. Achieving any of them is strictly contingent on success at all prior steps. Message design, messenger credibility, communication channels, and the characteristics of both the intended audiences and the recommended behavior, which should be intended to fit easily in people’s lives, all influence behavioral outcomes.

Although the current focus of health communication ismore on engag- ing intended groups than persuading them, keeping in mind McGuire’s steps for persuasion can provide a valid framework for approaching key groups and stakeholders to secure their initial involvement and input in the health issue. In doing so, it is also important to remember that key values and needs may change over time. This should prompt communicators to

50 CHAPTER 2: CURRENT HEALTH COMMUNICATION THEORIES AND ISSUES

incorporate these changes in communication planning and evaluation as well as redefine recommended behaviors depending on people’s lifestyles, preferences, and needs.

Intergroup Theories Intergroup theories seek to explain intergroup behavior within the context of communication and decision-making settings and may provide useful constructs for the development of intercultural communication interven- tions and message design strategies. A comprehensive discussion of all theories in this group goes beyond the scope of this book. Yet, sample contemporary intergroup theories that continue to influence the field of health communication include the anxiety and uncertainty management (AUM) theory and the problematic integration theory.

Developed by William B. Gudykunst, AUM theory assumes that at least one person in an intercultural or group encounter is a stranger. The theory explains how intergroup communication’s effectiveness may be enhanced by “the mindful management of anxiety and uncertainty levels of interaction” (Littlejohn and Foss, 2009a). AUM explores the roles of motivation, knowledge, skills, and cultural differences in effective com- munication as well as people’s ability to manage anxiety and uncertainty (Gudykunst, 1993). The theory also has implications for risk commu- nication in epidemics and emergency settings where managing people’s psychological reaction to crisis is strictly dependent on the ability of key professional and community groups and leaders to adequately manage the anxiety and uncertainties that accompany the process of communicating about risk.

Similarly, problematic integration theory (PI) (Babrow, 1992, 2007) also examines “the role of communication in producing and copying with subjective uncertainty” (Bradac, 2011, p. 456). PI theory analyzes the pro- cess through which people receive, process, and react to communication and life’s experiences. “Although PI theory is a general perspective on communication in difficult situations, many applications have been made in the area of health communication” (Littlejohn and Foss, 2009b). Some of the main premises of PI theory is that communication processing and integration is related to social and cultural beliefs and constructs, which determine people’s ability to integrate new information and experiences within their existing beliefs and cultural identity, either in harmony with them or in a problematic way. Babrow (1992) identified several different manifestations of problematic integration, which may be symptomatic of cognitive, emotional, communicative, ormotivational discomfort. PI theory

KEY THEORETICAL INFLUENCES IN HEALTH COMMUNICATION 51

has great implications for cross-cultural health communication interven- tions because it points to the importance of identifying and adequately addressing cultural and social constructs among groups and stakeholders we seek to engage in the health communication process.

Mass and NewMedia Communication Theories This section includes sample mass media and new media theories that influence the practice of health communication and provides useful guid- ance on communication principles as they relate tomedia use and influence within the context of health communication interventions. Many of these principles transcend mass media and new media and also apply to other action areas of health communication.

Mass Media No one can dispute the ability of the mass media to reach significant per- centages of interested groups and audiences. If adequately used and selected in response to audience’s needs and preferences, radio, television, printed media, and the Internet are powerful connectors between communicators and their audiences.

Mass communication theories include research and studies that focus on the impact of the mass media on intended populations. However, many of their key principles and observations can apply in general to the overall field of global health communication. The following definitions are important when looking at this family of theories:

• Media effects are simply the consequences [on the groups they reach] of what the mass media do, whether intended or not.

• Media power, on the other hand, refers to a general potential on the part of the media to have effects, especially of a planned kind.

• Media effectiveness is a statement about the efficiency of media in achieving a given aim and always implies intention or some planned communication goal. (McQuail, 1994, p. 333)

Although several authors divide mass communication theories into different eras and subgroups (McQuail, 1994; Health Communication Partnership, 2005b), a comprehensive discussion of all of them is beyond the scope of this book. Therefore, the theory presented next represents only an example of models and studies in this category.

52 CHAPTER 2: CURRENT HEALTH COMMUNICATION THEORIES AND ISSUES

Cultivation Theory of Mass Media Developed by George Gerbner, the cultivation theory “specifies that repeated, intense exposure to deviant definitions of ‘reality’ in the mass media leads to perceptions of the ‘real- ity’ as normal” (Communication Initiative, 2003a; Gerbner, 1969; Gerbner, Gross, Morgan, and Signorielle, 1980). “The result is a social legitimization of the reality depicted in the mass media, which can influence behavior” (Communication Initiative, 2003a;Gerbner,Gross,Morgan, andSignorielle, 1980). In other words, the media have the power to portray a behavior to make it socially acceptable by shaping public perceptions and feelings toward that behavior. Cultivation refers to the ability of the mass media to produce long-term effects on intended audiences by nurturing their feelings through continual message exposure. This process also relies on the ability of themassmedia to “transcend traditional barriers of time, space and social grouping” (Communication Initiative, 2003a; Gerbner, 1969).

Cultivation is a concept that transcends the mass media and applies to the overall field of health communication. In fact, nurturing the feelings of key stakeholders and groups through continual message exposure, using all kinds of communication channels including the mass media, is a practice that frequently helps secure their involvement in the health issue and its solutions.

NewMedia Theories There is a lot of excitement about the widespread use of new media

newmedia “Those media that are based on the use of digital technologies, such as the Internet, computer games, digital television, and mobile devices, as well as the remaking of more traditionalmedia forms to adopt and adapt to newmedia technologies” (Williams and others, 2008; Flew, 2002)

(“those media that are based on the use of digital technologies, such as the Internet, computer games, digital television, and mobile devices, as well as ‘the remaking of more traditional media forms to adopt and adapt to new media technologies,’” Williams, Zraik, Schiavo, and Hatz, 2008, p. 161; Flew, 2002, p. 11) and their ever increasing potential in health communication. Emerging new media theories have been focusing primarily on attempting to explain the process through which new media may help build community around a health or social issue, influence people’s participation, share knowledge, expand one’s social networks, test messages and strategies, and ultimately influence behavior and social change (Dholakia, Bagozzi, and Pearo, 2004;Hsu, Ju, Yen, andChang, 2007).

Of interest, Dholakia, Bagozzi, and Pearo (2004) developed a social influence model to connect and identify personal and social motives for people’s participation in virtual communities. According to this model, many of the motivating factors (for example, social enhancement, enter- tainment value, and self-discovery) for participation in virtual communities mirror those that play a key role in motivating people to participate in real-world communities.

KEY THEORETICAL INFLUENCES IN HEALTH COMMUNICATION 53

Yet, the lackof visual cues and theoverall anonymity thatnewmedia and social media (a subgroup of new media and social sites that aim primarily

social media A subgroup of newmedia and social sites that aim primarily to create community and connect people. Socialmedia (for example, YouTube) are tools for sharing and discussing information (Stelzner, 2009)

to create community and connect people, such as Facebook [Stelzner, 2009]) provide users, may change group dynamics and, depending on the health or social topic, may also shift perceptions of others “from being primarily interpersonal to being group-based perceptions (stereotyping)” (Lea, Spears, and de Groot, 2001, p. 527). In health communication, the appeal of the anonymous connotation of new media may vary depending on cultural values of specific groups and health and social issues.

Although a comprehensive discussion on the use of new media among different groups and kinds of organizations, as well as planning and evaluation methodologies for new media–based interventions is included in Chapters Five and Fourteen, it is worth mentioning here that—as with other communication channels—new media–based approaches should be integrated with the many other forms of communication we discuss in this book (and others) in order to maximize behavioral and social impact of all programs.

Marketing-Based Models In the private (commercial and nonprofit) sector, the field of marketing refers to strategic activities that encourage the use of products or ser- vices by consumers or special groups. Over time, marketing-based models have also inspired public health, health care, and community development interventions that encourage the adoption of new or existing health prod- ucts, services, or behaviors. The two models that are presented next have many similar features and contribute to the theoretical basis of health communication.

Social Marketing Social marketing has been defined as “the application of commercial marketing technologies to the analysis, planning, execution, and evaluation of programs designed to influence the voluntary behavior of intended audiences in order to improve their personal welfare and that of their society” (Andreasen, 1995, p. 7). Similar to commercial marketing, behavior change is the ultimate goal of social marketing. However, in commercial marketing, behavior change is sought primarily to benefit the sponsoring organizations (Andreasen, 1995), even if, in some cases,marketing activities also encourage the adoption of healthy behaviors, such as immunization or compliance to medication, which can improve the health conditions of intended populations.

54 CHAPTER 2: CURRENT HEALTH COMMUNICATION THEORIES AND ISSUES

Social marketing practices are consumer centered (Andreasen, 1995; Kotler and Roberto, 1989; Lefebvre, 2007) and stress the importance of four elements, referred to as the four Ps of social marketing:

• Product: The behavior, service, product, or policy that the orga- nization or program seeks to see adopted by intended audiences. In social marketing, products can be tangible (for example, con- doms or mosquito nets being sold and distributed as part of a social marketing campaign) or intangible (for example, the behavior being recommended and adopted by intended audiences).

• Price:The price of the product that is being promoted or the emotional, physical, community, or social cost of adopting the new behavior, policy, or practice.

• Place:Theproduct distribution channels (for example, point-of-service locations, wholesale distributors) or the place where it is most likely to reach intended audiences with communication messages and tools to facilitate the adoption of the new behavior.

• Promotion:Howamessage is conveyed. It thus refers tohowtomotivate intendedaudiences so they try andperformthe recommendedbehavior or adopt a new policy or practice.

Social marketing is also considered a planning framework to be used with other theories and models in health communication plan- ning (National Cancer Institute at the National Institutes of Health, 2002). Additional theoretical constructs should closely fit the specific health issue and its potential solutions and, most important, sustain community participation and involvement (Waisbord, 2001).

Critics of social marketing view this approach as a top-down model that does not allow the level of community participation required for effective change, especially in the case of developing countries: “For them, social marketing is a non-participatory strategy because it treats most people as consumers rather than protagonists” (Waisbord, 2001, p. 9). Yet, social marketing models and interventions over the years have been incorporating community engagement and mobilization and other partici- patory strategies. In several of its applications, social marketing has evolved into a theoretical and practice-based model that may also apply to social change (Lefebvre, 2013). Moreover, Healthy People 2020 includes social marketing–specific objectives as part of the health communication and health information technology topic area (US Department of Health and Human Resources, 2012b).

KEY THEORETICAL INFLUENCES IN HEALTH COMMUNICATION 55

One of social marketing’s key contributions to the health communica- tion field is a systematic people-centered and market-driven approach to program research. Social marketing techniques and tools are particularly helpful in developing key group profiles, situation and marketing analyses, and defining the health problem and potential solutions. Although these analyses occur in a participatory context, which involves members of key groups and should be always encouraged, many research tools and tech- niques are imported from social marketing and marketing practices (see Chapter Eleven).

Another contribution is related to the importance of cost-effectiveness and competitive analyses. The social marketing approach to competition encourages the analysis and understanding of all alternatives, such as alternative behaviors or programs or products that people may have (Andreasen, 1995). This helps develop a desirable “product” that is likely to be adopted and to fit people’s lifestyle, beliefs, and needs.However, in health communication, “products” are always intangible and should coincide with behavioral or social outcomes (for example, changes in immunization or AIDS prevention practices or policies).

Finally, social marketing strategies have been shown to be helpful in raising disease and risk awareness (see the example in Box 2.3) as well as contributing to achieving behavioral and social results among different groups and populations. In public health, other models and techniques complement and integrate social marketing theory and practice in order to further encourage program sustainability as well as a long- lasting community involvement (Waisbord, 2001) and the building of local capacity to address health and development issues.

BOX 2.3. RAISING AWARENESS OF INFANTMORTALITY DISPARITIES

IN SAN FRANCISCO

In San Francisco, African American infants suffer a mortality rate two to three times higher

than white infants. In an attempt to address this disparity, the San Francisco Public Health

Department (SFDPH) partnered with community-based organizations and the Family Health

Outcomes Project at the University of California, San Francisco, and with funding from the

Centers for Disease Control (CDC) REACH 2010 initiative, created the Seven Principles Project.

The project included a social marketing campaign aimed at (1) raising awareness of the gap

in infant mortality rates among African Americans who live in San Francisco, (2) increasing

knowledgeof specific practices and risk factors that havebeen associatedwith higher incidence

of sudden infant death syndrome (SIDS), and (3) encouraging families to take action.

56 CHAPTER 2: CURRENT HEALTH COMMUNICATION THEORIES AND ISSUES

Methods

Working together with African American residents and using focus groups to secure program

feedback, the Seven Principles Project developed three multimedia campaigns. The three

campaigns all used the same media to disseminate information. These included advertorials

on buses and at bus stops in the neighborhoods where the majority of African Americans

reside, as well as posters, cards, brochures, handouts, church fans, and radio public service

announcements on radio stations that are popular with the African American community. Main

messages included the information that (1) black babies die at twice the rate of all babies in

San Francisco; (2) to reduce the chance of SIDS, babies sleep best on their backs; and (3) stop

black babies from dying—take action. The campaign also provided a telephone number that

people could call to get involved with the project.

The campaign’s main concepts and activities were based on research findings on knowl-

edge, attitudes, and beliefs about infant mortality and SIDS among African Americans. Prior to

the design of the Seven Principles Project, the SFDPH conducted several focus groups to assess

existing awareness levels and to help develop effective intervention strategies. Focus groups

included 250 African American community members. Focus group findings revealed that prior

to the campaign, over half of the participants did not know about any disparity in infant

mortality in San Francisco. In addition, a baseline telephone survey of 804 African Americans

ages eighteen to sixty-four showed that only 39.6 percent knew about the disparity. Moreover,

28.5 percent of survey respondents were not aware that placing an infant on his or her back to

sleep may reduce the risk of SIDS. Because the disparity in infant mortality rates has persisted

for years, clearly this message had not been effectively communicated to the African American

community. The Seven Principles Project aimed to address this information gap.

Results

A follow-up telephone survey conducted with 654 African Americans indicated substantial

community exposure to the awareness campaign. It also revealed a statistically significant

increase in awareness about the existing disparity in infant mortality when compared to

the data collected prior to the campaign (62.7 percent of respondents who participated in

the postsurvey were aware of the disparity versus only 39.6 percent of respondents in the

precampaign survey). Although there was no overall significant increase (70.4 percent versus

71.7 percent) in knowledge about proper sleep positions to prevent SIDS, respondents who

reported any exposure to this campaignweremore likely to know about proper sleep positions

(79.7 percent versus 64.3 percent).

Source: Rienks, J., and others. “Evidence That Social Marketing Campaigns Can Effectively Increase Awareness of

Infant Mortality Disparities.” Paper presented at the Annual Meeting of the American Public Health Association,

Philadelphia, Dec. 13, 2005. Used by permission.

SELECTMODELS FOR STRATEGIC BEHAVIOR AND SOCIAL CHANGE COMMUNICATION 57

Integrated Marketing Communications Integrated marketing communications (IMC), a planning concept “that recognizes the added value of a comprehensive plan that evaluates the strategic roles of a variety of communication disciplines and combines these disciplines to provide clarity, consistency, and maximum communication impact” (Belch and Belch, 2004), is a strategic approach used in the private sector to develop, implement, and evaluate brand communication programs. It takes into account and addresses the consumer’s perspective, needs, beliefs, and perceptions and relies on the strategic integration of measurable objectives and approaches (Schultz and Schultz, 2003; Nowak and others, 1998). It is considered an avant-garde marketing approach, has been incorporated in several academic programs, and forms part of the curricula of many departments (New York University, 2013; University of Utah, 2013; Emerson College, 2013). IMC principles are also reflected in some models for strategic behavior communications.

IMC recognizes that the flow and volume of information is constantly increasing for most audiences around the world (Schultz, Tannerbaum, and Lauterborn, 1994; Renganathan and others, 2005). Therefore, message clarity and consistency as well as “an integrated and coordinated approach with credibility is vital” (Renganathan and others, 2005, p. 310). The most important contribution of IMC to health communication is its emphasis on the significance of a multifaceted and strategic approach, which is based on people’s point of view, and address their key needs.

Select Models for Strategic Behavior and Social Change Communication

Several models incorporate or combine behavioral, social, mass media, new media, or marketing theories described in this chapter. Select examples of these models and planning frameworks are described next.

Communication for Development (C4D) The concept of development communication (DW communication) was born over half a century ago to address key issues and lessons learned from the developing world. The field of DW communication has been evolving since the 1970s and strongly emphasizes community ownership and participation. It has been defined as “the art and science of human communication linked to a society’s planned transformation from a state of poverty to one of dynamic socio-economic growth that makes for greater

58 CHAPTER 2: CURRENT HEALTH COMMUNICATION THEORIES AND ISSUES

equity and the larger unfolding of individual potential” (Quebral, 1971, 1972, 2001).

Inspired byDWtheories and lessons learned, communication for devel- opment (C4D) is a broad term that refers to all kinds of communications that need to take place in society—and within different levels of society—if sustainable democratic development and behavioral and social change are to occur.

Several international and multilateral organizations have been using C4D as a planning framework for communication interventions aiming to achieve behavioral and social change. At UNICEF, for example, “C4D is defined as a systematic, planned and evidence-based strategic process to promote positive and measurable individual behavior and social change that is an integral part of development programs, policy advocacy and humanitarian work. C4D ensures dialogue and consultation with, and par- ticipation of children, their families and communities. In other words, C4D privileges local contexts and relies on a mix of communication tools, channels and approaches” (UNICEF, 2012, 2013a).

Although some of these concepts (for example, focus on participa- tion, horizontal communication, and collective action) have been already incorporated by a variety of other communication models and planning frameworks, C4D further embraces them via its human rights–based approach to programming and by ultimately seeking to create equality of distribution of social benefits, which in turn may help sustain long-term behavioral and social changes. At UNICEF, C4D has been used to improve “health, nutrition, and other key social outcomes for children, their fami- lies” and their communities (UNICEF, 2012). Several academic programs in the United States and internationally (Ohio University, 2013; Malmo University, 2013 [Sweden]) specifically focus on the theory and practice of communication for development.

Communication for Behavioral Impact Communication for behavioral impact (COMBI) is an integrated model and planning framework for social mobilization and strategic behavior communication interventions (Parks and Lloyd, 2004; Renganathan et al., 2005; Schiavo, 2007b; Hosein, Parks, and Schiavo, 2009). COMBI’s theo- retical foundation and “ten-step planning methodology have progressively matured from work started in 1994 at New York University on integrated marketing communication applied to social development challenges, with the input also of UNICEF and UNFPA” (Hosein, 2008; Hosein, Parks, and Schiavo, 2009). It was later absorbed by WHO in its social mobilization

SELECTMODELS FOR STRATEGIC BEHAVIOR AND SOCIAL CHANGE COMMUNICATION 59

work inGeneva in 2000. “Todate,WHOand its partners have trained public health professionals and government agencies in COMBI from more than fifty countries inAfrica,Asia, EasternEurope, LatinAmerica, theCaribbean, and North America. This training has increased local strategic communi- cation capacity and resulted in the development and implementation of more than sixty COMBI programs worldwide” (Hosein, 2008).

Although COMBI has been applied primarily in the health care field, its key principles and methodologies may be relevant to other areas. For example, COMBI has been used as part of UNICEF’s programs on child protection and juvenile justice in Moldova (E. Hosein, personal communication, 2005, 2006). Similar efforts were undertakenwithUNICEF in Albania and Jordan. A very successful program also using COMBI for antenatal care was carried out by UNICEF in Cambodia in 2009 (E. Hosein, personal communication, 2012, 2013). “Moreover, COMBI has been used and has the potential to be used in combination with other strategic communication models . . . of other U.S. and international organizations for the development of tools and planning resources” (Hosein, Parks, & Schiavo, 2009, p. 547; Johns Hopkins University, 2005; UNICEF, 2006c).

With its emphasis on behavioral impact, COMBI uses a research-based, participatory approach to identify and address behavioral issues that may have an impact on health outcomes (Renganathan and others, 2005; E. Hosein, personal communication, 2005, 2006). COMBI is based on two fundamental principles. “First:Donothing—producenoT-shirt, noposters, no leaflets, no videos, until youhave set out clear, precise, specific behavioral objectives (SBOs). Second: Do nothing—produce no T-shirts, no posters, no leaflets, no videos, until you have successfully undertaken a situational ‘market’ analysis in relation to preliminary behavioral objectives” (Schiavo, 2007b, p. 51;Renganathanandothers, 2005).The situationalmarket analysis calls for taking the recommended behavior back into the community and listening to its members to identify the “communication keys” to help secure their involvement (E. Hosein, personal communication, 2005, 2006). The key marketing principle here is to listen to the consumer. According to COMBI principles, an example of behavioral objectives is to prompt X number of people to swallow four to six tablets a day at home in the presence of filaria prevention assistant (or go to the distribution point) on filaria day (Renganathan and others, 2005). Evaluation of COMBI programs is specific to the achievement of the behavioral objectives specified early in program planning.

COMBI focuses on addressing specific diseases and related health behaviors, but it may also have an impact on social change. For example, the initial focus of COMBI primarily has been on communicable diseases

60 CHAPTER 2: CURRENT HEALTH COMMUNICATION THEORIES AND ISSUES

that have been jeopardizing the socioeconomic development of entire communities andcountries, especially in thedevelopingworld (WHO,2003; Renganathan and others, 2005). With this in mind, COMBI’s contribution to development and social change is its potential to “remove a significant obstacle that keeps people in poverty” (Renganathan and others, 2005, p. 318), as well as to reduce the mortality rates of diseases that affect entire families and communities. It also contributes to strengthen people’s health literacy and disease-related self-reliance.

As with most other kinds of interventions and models, COMBI alone is not sufficient to address development issues (Renganathan and others, 2005) and public health deficiencies. Yet, it can help make a difference. Addressing broader social issues such as health disparities, poverty, and injustice, all factors contributing to poor health, requires many different kinds of public health strategies and interventions, which should all rely on long-term commitment, a step-by-step approach, people’s participation, and a series of behavioral changes at the policymaker, stakeholder, funding agency, population, community, and individual levels. COMBI operates within this larger context as an approach to minimize the burden of disease and strengthen health services. In doing so, it supports one of the fundamental goals of public health.

COMBI integrates principles and methodologies from multiple disci- plines, including marketing, mass communications, information education communication, socialmobilization, anthropology, and sociology. Itmodels its integrated approach on recent developments and lessons learned from IMC,which iswidely used in the private and commercial sectors. As in IMC, COMBI uses a strategic blend of activities, channels, and audience-specific messages to address people’s perceptions, attitudes, and behaviors (WHO, 2003; Renganathan and others, 2005; Hosein, Parks, and Schiavo, 2009).

COMBI takes into account key IMC learnings, including what the influence of people’s perceptions—in other words, what people “believe to be important or true” (Renganathan and others, 2005, p. 309)—have on attitudes andbehaviors. It also stresses the importance of clear, credible, and consistent communication messages in relation to the healthy behaviors, products, or services that people are asked to endorse and use (WHO, 2003; Renganathan and others, 2005).

Precede-Proceed Model Designed by Lawrence Green and Marshall Kreuter (Green and Kreuter, 1991, 1999; Green and Ottoson, 1999), the precede-proceed model “is an approach to planning that analyzes the factors contributing to behavior

SELECTMODELS FOR STRATEGIC BEHAVIOR AND SOCIAL CHANGE COMMUNICATION 61

change” (National Cancer Institute at the National Institutes of Health, 2002, p. 219). The model assumes that long-lasting change always occurs voluntarily (Communication Initiative, 2003b; National Cancer Institute, 2005a) and is determined by the individual motivation to become directly involved with the process of change. Individuals need to feel empowered to change their quality of life (National Cancer Institute, 2005a), and in doing so are influenced by their community and social structure.

The key factors influencing behavior change are divided in three categories (National Cancer Institute at the National Institutes of Health, 2002, p. 219):

• Predisposing factors—the individual’s knowledge, attitudes, behavior, beliefs, and values before intervention that affect willingness to change

• Enabling factors—factors in the environment or community of an individual that facilitate or present obstacles to change

• Reinforcing factors—the positive or negative effects of adopting the behavior (including social support) that influence continuing the behavior

This model reinforces the importance of considering the individual as part of the social environment. It also supports the notion of individual empowerment and capacity building at both the individual and community levels, one of the most important components of sustainable behavior and social change. In some ways, this model is in contrast with social norms theories previously discussed in this chapter, which assume that people usually take decisions without too much deliberation in response to social expectations. In real life, a combination of both processes is likely to occur depending on the specific group and issue.

Communication for Social Change Communication for social change (CFSC) is a participatory model for com- munication planning, implementation, and evaluation. It was developed with the original input and sponsorship of the Rockefeller Foundation, which in 1997 convened a conference to explore the connection between communication and social change. The actual model was developed on the basis of the recommendations from all participants at this initial conference as well as follow-up meetings (Figueroa, Kincaid, Rani, and Lewis, 2002).

CFSC is defined as “a process of public and private dialogue through which people define who they are, what they want and how they can get it” (Gray-Felder and Dean, 1999, p. 15). It is an integrated model that

62 CHAPTER 2: CURRENT HEALTH COMMUNICATION THEORIES AND ISSUES

describes an “iterative process” to community dialogue that “starts with a catalyst/stimulus that can be external or internal to the community,” and “when effective, leads to collective action and the resolution of a common problem” (Figueroa, Kincaid, Rani, and Lewis, 2002, p. iii).

In this model, outcome indicators of social change include “leadership, degree and equity of participation, information equity, collective self- efficacy, sense of ownership, and social cohesion” (Figueroa, Kincaid, Rani, and Lewis, 2002, p. iv). In applying this model, it is important to recognize that social change (for example, less poverty, less HIV/AIDS) can take a long time and demands intermediate evaluation parameters to assess progress (Rockefeller Foundation Communication and Social Change Network, 2001). Social change is always the result of a series of gradual behavioral changes at the individual, group, and community levels. Therefore, behavioral outcomes should remain an important evaluation parameter in health communication even in the context of social change models.

Other Theoretical Influences and Planning Frameworks

Several other models and planning frameworks influence the theory and practice of health communication. A few examples, including medical models and logic models, are discussed next.

Medical Models Communication is also influenced by general beliefs about the intrinsic causes of health and illness. Over time, two medical models have been influencing communication in the provider-patient setting as well as how health organizations and professionals perceive what kinds of topics and factors should be addressed as part of a public health intervention.

The first of the two models, the biomedical model, has been around for many centuries and is based on the assumption that poor health is a physical phenomenon that “can be explained, identified, and treated with physical means” (du Pré, 2000, p. 8; Twaddle and Hessler, 1987). Therefore, the biomedical model does not take into account the person’s psychological conditions, individual and social beliefs, attitudes and norms, or other factors that can affect health and illness. As a result, communication efforts that are based on this model tend to be informative, strictly scientific, doctrinarian, authoritarian, “efficient,” and “focused” (du Pré, 2000, p. 9). Communication relies on a top-down approach in whichmedical providers

OTHER THEORETICAL INFLUENCES AND PLANNING FRAMEWORKS 63

or health organizations limit their efforts to transferring their knowledge on the medical and scientific causes of an illness and to prescribing a solution.

This approach lacks empathy with the patient or intended group’s feelings and social experiences (Friedman and DiMatteo, 1979; Laine and Davidoff, 1996; du Pré, 2000). Moreover, it does not take into account current knowledge that most diseases and their prognoses are heavily influ- enced by social and cultural habits, as well as the individual’s psychological status. For example, health conditions such as obesity, diabetes, and depres- sion are clearly influenced by external factors, which can include lifestyle issues, emotional stress, and cultural beliefs and preferences. Finally, dis- ease prevention is not considered under this model because its practice is closely related to the ability of health professionals and organizations to engage interested individuals and communities in the act of prioritizing a recommended behavior by reaching out to their core beliefs, feelings, and needs.

The second model, the biopsychosocial model, is based on the premise that poor health is not only a physical phenomenon but “is also influenced by people’s feelings, their ideas about health, and the events of their lives” (du Pré, 2000, p. 9; Engel, 1977). Given current emphasis on a patient-centered approach to health, the biopsychosocial model has been gradually substituting the biomedical model in most settings, also thanks to the work of many professional societies (for example, the American Medical Association and the American Academy of Family Physicians) and several hospitals and universities, which have guidelines and courses on provider-patient communications and highlight the importance of relating to patients’ feelings, culture, literacy levels, needs, and other key factors that may help improve patient compliance and outcomes. More broadly, the model also fits well with many of the current practices and theories in health communication. Under this model, communication tends to be empathetic, sensible to people’s needs and feelings, motivational, truly interdependent, and also aims to generate understanding of scientific and medical issues.

Logic Modeling Logic modeling is a flexible framework that has been used for program

logic modeling A flexible framework that has been used for program planning and evaluation in the fields of education, public-private partnerships, health education, and many other programmatic areas

planning and evaluation in the fields of education (Harvard Family Research Project, 2002), public-private partnerships (Watson, 2000), health educa- tion (University ofWisconsin, Extension ProgramDevelopment, 2005), and many other programmatic areas. In general, it is a one-page summary of

64 CHAPTER 2: CURRENT HEALTH COMMUNICATION THEORIES AND ISSUES

key factors that contribute to a specific health or social issue, the program’s key components, the rationale used in defining program strategies, objec- tives, and key activities, and expected program outcomes andmeasurement parameters that will be used in evaluating them. In sum, logic models are used to explain the relationship among key factors contributing to a health or social issue, program components, and related outcomes.

Logic models are considered helpful tools in the planning and eval- uation of public communication campaigns (Coffman, 2002) and other health communication interventions. They are tools for organizing one’s thoughts in considering all program-related options as well as to provide key stakeholders, partners, and team members with a quick snapshot of a specific program and its rationale. Logic models can be constructed using different theories and assumptions so they fit the health issues and the needs of the audiences under consideration. Yet, the first step in logic modeling is always analyzing the situation, its contributing factors, and the environment we seek to influence (Morzinski and Montagnini, 2002) in order to develop adequate strategies and activities and establish realistic outcome objectives.

Appendix A provides a list of online resources for the development of logic models for health communication planning. See Figure 2.4 for an example of a logic model we developed to evaluate the impact of a national infant mortality prevention program (Schiavo and others, 2011). This program was developed and implemented by the Office of Minority Health Resource Center (OMHRC), Department of Health and Human Services (DHHS) Office of Minority Health (OMH).

Current Issues and Topics in Public Health and Health Care: Implications for Health Communication

In addition to theories and models, a number of issues influence the theory and practice of health communication. Many of them are specific to a certain country, environment, political situation, health issue, or population, among other factors. Because of the large variety and number of such issues, a comprehensive discussion of all of them is beyond the reach of this book. Therefore, the topics explored next are just examples of some of the issues that are currently influencing the field of health communication.

CURRENT ISSUES AND TOPICS IN PUBLIC HEALTH AND HEALTH CARE 65

Project name: A Healthy Baby Begins with You

High rate of preventable infant mortality (defined as death of an infant before age one) among African Americans

Reduced incidence of infant mortality in the United States and more specifically among African Americans

• Lack of awareness of disproportionate infant mortality rates among African Americans

• Engagement of college-age African- American population via

• Message retention at key events re: core program information • Increased awareness of high burden of infant mortality among African Americans and related risk factors and causes • Increased awareness of link between infant mortality prevention and preconception care • Increased awareness of key behaviors that are part of preconception care • Increased number of people reporting having the intention of adopting and sustaining preconception health behaviors • Increased community engagement and number of community-based outreach efforts on this topic • Increased focus and support on preconception care within the provider-patient setting • Increased number of local and statewide partnerships on this topic

• Increased number of women and men who adopt and sustain at least three to four recommended behaviors that are part of preconception health and care • Increased number of health care providers who discuss preconception care at routine visits • Increased number of community-based and other health organizations that would develop programs to address infant mortality prevention and preconception care and regard them as a key organizational priority

• Establishment of partnerships with health departments and programs and other local and state health organizations • Faith-based community outreach • High school outreach • Community canvassing and health fairs • Mass media communications • Education of health care providers

Tailored health messages Development of pool of health ambassadors and peer educators via preconception peer education training Increased OMH involvement with (minority-serving) colleges and institutions

• Poor understanding of link between infant mortality prevention and preconception care • Lack of understanding of timing, importance, and definition of preconception care as well as related behaviors • Impact of chronic stress re: history of discrimination on health outcomes among African Americans, including infant mortality rates • Limited community engagement and social support especially in most affected cities and neighborhoods • Limited support and involvement of men and other family members • Lack of focus on preconception health within provider-patient settings • Conflicting priorities, access to care, and other obstacles to healthy lifestyle and preconception health

Long-term health issue and problem:

Long-term goal:

Contributing Factors

Strategies and Tactics Outcomes and Impact

Short-term/intermediate process- related parameters

Summative evaluation outcomes

Figure 2.4 Logic Model and Evaluation Design for a National Program for Infant Mortality Prevention by the Office ofMinority Health, Department of Health and Human Services

Source: Schiavo, R., Gonzalez-Flores,M., Ramesh, R., and Estrada-Portales, I. “Taking the Pulse of Progress Toward Preconception Health: Preliminary Assessment of a National OMH Program for Infant Mortality Prevention.” Journal of Communication in Healthcare, 2011, 4(2), 106, Figure 1.CW. S. Maney & Son Ltd. 2011. Used by permission.

66 CHAPTER 2: CURRENT HEALTH COMMUNICATION THEORIES AND ISSUES

Health Disparities As previously discussed, the concept of health equity has rightly emerged worldwide as one of the guiding principles for the work of many organiza- tions in the public health, health care, and community development fields. Health equity addresses the importance of eliminating health disparities (see Chapter One for definitions of health equity and health disparities) by minimizing or removing differences in the well-being and health status of diverse populations and groups. As Dr. Martin Luther King Jr. is often quoted to have said, “Of all forms of inequality, injustice in health is the most shocking and the most inhuman” (Randall, 2002).

“The United States National Institutes of Health (NIH) defines health disparities as the ‘differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the United States’” (Center for Health Equity Research and Promotion, 2005). Unfortunately, “health disparities continue to undermine opportunities for economic and social development of too many communities in the United States and globally” (Health Equity Initiative, 2012b). They are “linked to diverse factors that are likely to be community-specific, including socio-economic conditions, race, ethnicity and culture, as well as having access to health care services, a built environment that supports physical activity, neighborhoods with accessible and affordable nutritious food, well-designed housing that is sited to minimize community exposure to environmental and other health hazards, efficient transportation that enable vulnerable groups to connect with services and support systems, culturally appropriate health information that accurately reflects literacy levels, and caring and friendly clinical settings” (Health Equity Initiative, 2012b). Some health disparities are also related to “genetic and biological differences among ethnic groups or between men and women” (Center for Health Equity Research and Promotion, 2005).

Although “health is the foundation for civil society, for social and cultural growth, for political stability, and for economic sustainability” (Families USA, 2012), only 59 percent of US adults are aware of health disparities, and this includes the ethnic and social groups that are most affected by such differences in health status and outcomes (Benz, Espinosa, Welsh, and Fontes, 2011). Over one decade, awareness of health disparities has increased only a mere 5 percent (Benz, Espinosa, Welsh, and Fontes, 2011), whereas disparities have increased or stayed the same among many disadvantaged groups. Health communication can contribute to reducing or eliminating health disparities by doing the following, for example:

CURRENT ISSUES AND TOPICS IN PUBLIC HEALTH AND HEALTH CARE 67

• Raising awareness of health disparities and their root causes (for example, social determinants of health)

• Encouraging community action and multisectoral partnerships to identify, design, and implement community-specific solutions

• Reaching disadvantaged groups across cultures, socioeconomic con- ditions, geographic boundaries, and other factors that may influence health outcomes

• Developing programs, tools, and resources that would result in behav- ioral, social, and organizational results in support of health equity

• Creating a professional and social movement in support of health equity

• Ultimately, facilitating the long-term social change process that is needed to achieve health equity

Patient and Community Empowerment Patient empowerment is an important concept inmodernmedicine andone of the central pillars of health communication strategies within health care settings. However, definitions and expectations generated by this term vary by health settings, contexts, and environments. For example, the term can refer to patient awareness about a disease and its treatment, which allows patients to engage in informed discussions with their health care providers, and therefore participate in treatment and prevention decisions. It can imply the patient’s ability to feel competent to adhere to recommended treatment or prevention measures, or to engage in behaviors that may improve health outcomes. And it can include the patient’s involvement in the public debate about policies, health care regulations, medical practices, research funding, and social change.

Partnering for Patient Empowerment Through Community Awareness (2005) and the Standing Committee of European Doctors (2004) are two organizations that focus on expanding consumer awareness about diseases and health resources or improving patient-provider communications. Oth- ers have effectively mobilized and engaged patient groups in the process of policy and social change. AIDS and other life-threatening conditions have taught important lessons to patients around the world. Over time, AIDS activists have had a tremendous impact on drug approval regulations, research funding, policies, and access to AIDS drugs, as well as public perception of AIDS, just to name a few topics.

Because of the different levels of patient involvement, it is important to refrain from using the term patient empowerment in a general way.

68 CHAPTER 2: CURRENT HEALTH COMMUNICATION THEORIES AND ISSUES

When a planned health communication intervention is seeking to engage patients or the general public, consideration should be given to what patients ideally should be able to do and what kind of empowerment may help advance patient outcomes. This should inform all capacity building and outreach efforts.

Similarly, community engagement, participation, and empowerment form a central mantra of effective health communication interventions. It is only when communities get together and understand the connection among health, community development and the availability of a variety of services (within and outside of health care) as it relates to improving community health and well-being that communication interventions have an actual opportunity to generate sustainable results and to mediate the kind of social support that is needed to implement and maintain complex health and social behaviors. Community mobilization and engagement are further discussed in Chapter Six.

The Rise of Chronic Diseases Over the past few decades, the burden of chronic diseases (for example, obesity, diabetes, cardiovascular disease, etc.) has exponentially increased. In many settings, chronic diseases have now replaced infectious diseases as the predominant cause of death. In New York City, for example, chronic diseases account for 75 percent of all deaths versus the 9 percent of deaths that can be attributed to infectious diseases (Lee, 2012). The trend has been growing since the 1940s and sharply differs from data from the year 1880 in which only 13 percent of all deaths occurring in New York City could be attributed to chronic diseases and 57 percent to infectious diseases (Lee, 2012). Worldwide, chronic diseases are the largest cause of death (WHO, 2005c).

Because chronic diseases are influenced by multiple factors and shaped by the environment in which people live, work, and play, a social deter- minants of health-based perspective needs to be incorporated in all interventions. Health behaviors to prevent and manage chronic diseases need to be implemented during a person’s lifetime, which also adds to the complexity of communication interventions that seek to address them. Health communication interventions can help prevent and manage chronic diseases at different levels (Halpin, Morales-Suárez-Varela, and Martin-Moreno, 2010):

• Social level: By advocating for policies, bans, adequate urban planning, access to services and information (including, but not limited to, health care services) that would help create a healthy social context and environment

CURRENT ISSUES AND TOPICS IN PUBLIC HEALTH AND HEALTH CARE 69

• Community level:By encouraging community action andmultisectoral partnerships to promote social support for healthy behaviors, iden- tify solutions to community-specific needs and issues, and mobilize communities around this issue

• Health care level: By encouraging widespread use of best clinical practices, building capacity for cultural competence (defined as the

cultural competence The ability to relate to other people’s values, feelings, and beliefs across different cultures, and effectively address such differences as part of all interactions

ability to relate to other people’s values, feelings, and beliefs across different cultures, and effectively address such differences as part of all interactions) among health care providers, addressing health literacy issues, promoting community and patient participation in clinical care, and continuing to build awareness of the importance of preventive care

• Individual level: By promoting healthy behaviors and routine medical checkups among different populations and groups

Given the complexity and multifactoral nature of chronic diseases, only sustainable and multilevel communication interventions are likely to produce long-term results.

Limits of Preventive Medicine and Behaviors Despite the medical and scientific advances of the past few centuries, pre- ventive medicine cannot eliminate disease. However, preventive medicine and behaviors have contributed to extending life expectancy and improving the overall quality of life for many populations.

Still, preventive medicine does not work all the time. This concept may be troublesome for some people and therefore should be considered in designing health communication interventions. Consider the example of Eduardo, a fifty-year-old low- to middle-class Puerto Rican man who smokes and is being pressured by his family to quit because of the risk of oral cancer. They also want him to have regular checkups with his doctor and break his habit of seeking medical help only when he is seriously ill. The family has been alarmed by the recent death of a close cousin who was a heavy smoker and developed oral cancer. However, Eduardo has a very good friend who never smoked in his life and still developed oral cancer. He makes several arguments against his family’s request to change his health-related habits:

• Quitting smoking will not guarantee that he will not get cancer. • He enjoys smoking and drinking alcohol. • Why is his family worried about oral cancer? What happened to their

cousin is a rare event. • He is too busy for regular checkups with his doctor.

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Eduardo is right about the limits of preventive medicine and habits. However, there are a few facts that may help him see his family’s point of view if discussed as part of a comprehensive and culturally competent health communication intervention:

• Oral cancer incidence is two times higher among men in Puerto Rico than among mainland US Hispanics (Hayes and others, 1999) and higher than that observed in white males living on the mainland United States (Ho and others, 2009; Parkin and others, 1997; Suarez and others, 2009).

• Together with alcohol consumption, tobacco use is a primary risk factor for oral cancer (Blot and others, 1988; Mashberg and others, 2006). Actually, their joint effect appears to be more than additive, if not multiplicative. The risk for oral and pharyngeal cancers is between six and fifteen times greater for smokers who are also heavy drinkers compared to individuals who neither smoke nor drink (Mashberg and Samit, 1995).

• Smoking cessation is a standard preventivemeasure against the risk for oral cancer (Lewin and others, 2000; Matiella, Middleton, and Thaker 1991; US Department of Health and Human Services, 1986, 1994).

• Social support (for example, from friends, peers, and others) help people quit smoking (Mermelstein and others, 1986), so talking with family and friends about one’s intention and the benefits of quitting smoking, and seeking their support and involvement, may help people succeed in adopting new behaviors.

Of course, many other issues need to be considered and addressed in order to motivate Eduardo to quit smoking—for example, his social context, the potential difficulty of succeeding in quitting smoking, the priority assigned by his health care provider to oral cancer screening, and the friendliness and support of clinical settings and peers. Still, it is important to remember that most people are not aware of disease risk factors and other relevant information. Incorporating disease statistics and information in health communication interventions legitimizes the quest for behavior and social change. It also helps attract people’s attention by positioning the health issue in a larger context than the family and circle of friends in which they live. Finally, it may help people accept the limits of preventive medicine and behavior by showcasing whenever possible the high percentage of cases in which disease can be prevented. Prevention does not work in all cases, but it still works in most cases.

CURRENT ISSUES AND TOPICS IN PUBLIC HEALTH AND HEALTH CARE 71

AMobile, On-Demand, and Audience-Driven Communication Environment The Internet, mobile technology, and other advances have significantly extended “the scope of health care beyond its traditional boundaries” (Eysenbach, 2001, p. e20) and consequently have changed the practice of health communication. Increasingly, patients, health care professionals, the general public, and the overall health care community rely on the Internet andmobile technology for a variety of services and communications, which include advice on health issues, virtual pharmacies, distance learning for practitioners, medical or public health information systems (for example, disease surveillance systems), patient support groups, and health records, to name a few applications (Gantenbein, 2001; Eysenbach, 2001).

E-health has emerged as “a field in the intersection ofmedical informat- ics, public health and business, referring to health services and information delivered or enhanced through the Internet and related technologies” (Eysenbach, 2001, p. e20). In health communication, the increasing reliance on the Internet and mobile technology by consumers and professionals has opened the way to the use of interactive health communication tools (for example, websites, Internet-based games, mobile applications, online press rooms, disease symptoms simulations, opinion polls, seminars), which are often designed as part of larger health communication interventions. It has also prompted several initiatives and research studies that attempt to analyze the impact of the Internet and mobile technology on health beliefs, behaviors, outcomes, and policies, as well as health-related encoun- ters and communications such as provider-patient interactions. Finally, it has raised questions about the accuracy of sources of information on all kinds of new media as well as the importance of understanding the implications of Internet and mobile technology use in relation to issues of patient privacy and equal access to information by those who may not have the resources or skills to take advantage of new technologies, espe- cially in relation to health matters (Eysenbach, 2001; Cline and Haynes, 2001). Most important, the advent of new technology has created a mobile, on-demand, and audience-driven communication environment, which in integration with other communication areas and channels is quick to cre- ate community around health issues, and has also been used to validate ideas and new interventions, secure audience feedback on variety of issues, support people who want to quit smoking, and remind pregnant women to see their health care providers, among other initiatives (Abroms, Pad- manabhan, Thaweethai, and Phillips, 2011; Evans and others, 2012). These topics as well as the use of the Internet, mobile technology, and new media

72 CHAPTER 2: CURRENT HEALTH COMMUNICATION THEORIES AND ISSUES

and their implications in health communication are discussed in detail in Chapter Five.

Interactive health communication has been defined as the “interaction of an individual—consumer, patient, caregiver or professional—with or through an electronic device or communication technology to access or transmit health information or to receive guidance and support on a health- related issue” (Robinson, Patrick, Eng, andGustafson, 1998, p. 1264). Several other disciplines influence or contribute to interactive health communica- tion (Gantenbein, 2001). These include areas of public health informatics, defined as “the systematic application of information and computer sci- ence and technology to public health practice, research and learning” (US Department of Health and Human Services, 2005, p. 23); medical informatics, “the field that concerns itself with the cognitive, information processing, and communication tasks of medical practice, education and research” (Greenes and Shortliffe, 1990, p. 1114); and consumer health informatics, “the branch of medical informatics that analyzes consumers’ needs for information; studies and implements methods of making infor- mation accessible to consumers; and models and integrates consumers’ preferences into medical information systems” (Eysenbach, 2000, p. 1713).

In addition to extending the outreach of health communication pro- grams, the use of the Internet, mobile technology, and other new platforms provides health communication practitioners with an opportunity to advo- cate for policy efforts on expanding access and new media literacy among disadvantaged communities both in the United States and globally, as well as helping people evaluate the accuracy, credibility, and relevance of the information found on different kinds of new media. As “health communi- cation and health information technology (IT) are central to health care, public health, and the way our society views health” (US Department of Health and Human Services, 2012b), health communication research and practice canprove instrumental in promotingunderstanding, and expanded and effective use of, technological advances.

Low Health Literacy Low health literacy is the inability to read, understand, and act on health information, options, and services (Zagaria, 2004; Zarcadoolas, Pleasant, and Greer, 2006). Health literacy is a significant prerequisite to the effec- tiveness of howpeoplemake health-related decisions in a variety of contexts and communication settings (Schiavo, 2009d) and one of the most impor- tant issues in health communication. No matter how accurate, compelling,

CURRENT ISSUES AND TOPICS IN PUBLIC HEALTH AND HEALTH CARE 73

or graphically appealing information appears to be, the purpose of any material or verbal communication is defeated if people cannot understand it. Health literacy levels affect howwe communicate about health and illness in a variety of settings and countries, and also have a well-documented impact on several health issues (Schiavo, 2009d).

Low health literacy affects all different age groups and ethnic back- grounds. “Nearly half of all American adults—90 million people—have difficulty understanding and acting upon health information” (Institute of Medicine, 2004, p. 1). In Canada, a significant percentage of the population lacks basic literacy skills (for example, the ability to work well with words and numbers or read and understand printed materials) that are needed to process complex information, including health information (Gillis, 2005).

In addition to inadequate reading, writing, or math skills, other factors may contribute to low health literacy (Institute of Medicine, 2004; Zorn, Allen, and Horowitz, 2004; Schiavo, 2009d):

• Poor or insufficient speaking, listening, or comprehension ability • Language barriers and skills • Low ability to advocate for oneself and navigate the health care system • Inadequate background information • Low socioeconomic status • Lack of Internet access, computer skills, and new media literacy • Gender and cultural roles • Overall level of engagement in health decisions

Healthy People 2010 describes health literacy as “the degree to which health literacy “The degree towhich individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (US Department of Health and Human Services, 2005, p. 11–20; Selden and others, 2000)

individuals have the capacity to obtain, process, andunderstandbasic health information and services needed to make appropriate health decisions” (US Department of Health and Human Services, 2005, p. 11–20; Selden and others, 2000). Health communication can help improve this capacity by taking into account health literacy levels in all phases of strategic planning and program implementation. Health communication interventions should be designed to address different areas, including culture and society, health care and public health systems, and education (Institute ofMedicine, 2004). Health communication can also contribute to breaking down barriers by relying on culturally relevant messages, materials, and activities that reflect the language ability and preferences of intended groups. Specific health

74 CHAPTER 2: CURRENT HEALTH COMMUNICATION THEORIES AND ISSUES

literacy objectives included as part of Healthy People 2020 “to improve the health literacy of the population” include the following (US Department of Health and Human Services, 2012b):

• Increase the proportion of persons who report their health care provider always gave them easy-to-understand instructions about what to do to take care of their illness or health condition

• Increase the proportion of persons who report their health care provider always ask them to describe how they will follow the instruc- tions

• Increase the proportion of persons who report their health care providers’ office always offered help in filling out a form

Becausehealth literacyhas implications for different kinds of communi- cation areas within and outside clinical settings (including provider-patient communication, community engagement and mobilization, and mass media and new media communication), a strong focus should be placed on people’s needs and preferences, as well as on the health literacy–health communication continuum (health literacy improves communication

health literacy–health communication continuum Health literacy improves communication and at the same time communication improves health literacy levels (Schiavo, 2009d)

and at the same time communication improves health literacy levels) (Schiavo, 2009d).

Health communication interventions can also play a key role in building the skills needed to improve overall health literacy levels. They can help sensitize health care providers, public health officers, community leaders, industry representatives, and others in the health care field about the need to reach out to patients and the general public in these groups’ own terms. Sample online resources on health literacy are included in Appendix A. Health literacy is considered and mentioned throughout this book.

Impact of Managed Care and Other Cost-Cutting Interventions on Health The advent of managed care in the United States has had an overall impact on provider-patient relationships as well as the way health care may be perceived by the media, the general public, and health care providers. This is not only a US-based phenomenon. Cost-cutting interventions are being implemented in many places around the world. For example, several countries in Asia are increasingly adopting managed care plans (Gross, 2001), and the UK health care reform has been gradually opening doors for the managed care industry (Royce, 2012).

CURRENT ISSUES AND TOPICS IN PUBLIC HEALTH AND HEALTH CARE 75

Managed care organizations essentially manage the costs and the delivery of health services to patients. Many aspects of health care (for example, the choice of a primary care physician, the eligibility for medical tests and other procedures) that traditionally were decided only by the health care provider or the patient are now scrutinized and influenced by managed care. Other worldwide cost-cutting interventions are part of the same trend that over the past few decades has been shifting responsibilities for health care from the government to companies (such as managed care organizations) or individuals.

The time that providers can dedicate to an individual patient has been reduced by the need to see an increasing number of patients each workday. From the patient’s perspective, the quality of care may seem inferior and lacking the human touch that much longer conversations with physicians and indiscriminate access to tests and other medical procedures may provide.

Although the debate on the pros and cons of cost-cutting interventions is beyond the scope of this book, it may be worth considering the impli- cations of the current health care environment for health communication interventions:

• Health communication planning should take into account both the provider’s and patient’s opinion on cost-saving interventions and their perceived impact on their professional and personal lives.

• Health communication activities can help health care providers improve their communication skills and optimize their time with patients by managing expectations, addressing questions in a brief but efficient manner, and showing empathy with patients’ needs and worries.

• Through advocacy, mass media campaigns, professional and govern- ment relations, and other strategic activities, health communication can help create a climate in which managed care organizations, legis- lators, and other key groups would feel compelled to preserve the right balance between quality of care and cost-saving measures.

These are just a few examples of the kinds of considerations that should be given to the current cost-saving environment and how this could be incorporated in strategic health communication planning.

Reemergence of Communicable Diseases The reemergence of many infectious diseases that had started to decline or disappear has influenced health communication in two different but

76 CHAPTER 2: CURRENT HEALTH COMMUNICATION THEORIES AND ISSUES

related ways. First, it is one of the reasons for the health communication renaissance. Because of the rising incidence of several reemerging diseases such as tuberculosis (CDC, 1994a), many authors and organizations have pointed to the need to raise awareness of the ongoing risk for communicable diseases by using the health communication approach (Freimuth, Cole, and Kirby, 2000).

In fact,many infectious diseasesmay again becomeapublic threat in the absence of effective prevention and communication strategies. For example, pediatricians in the United States and many other countries have been witnessing increasing parental complacency about the need for childhood vaccines (Macartney and Durrheim, 2011). Vaccines have become victims of their own success becausemany parents and young health care providers mayhavenever seen thedevastatingeffectsofdiseases (NationalFoundation for Infectious Diseases, 1997; Vernon, 2003), such as polio orHaemophilus influenzae type B, the leading cause of bacterial meningitis and acquired mental retardation in US children before the vaccine was introduced (National Association of Pediatric Nurse Practitioners, 2005).

Still, five cases of polio among children in an Amish dairy farm com- munity in Minnesota in 2005 (Harris, 2005) are a powerful reminder that even vaccine-preventable infectious diseases remain a threat everywhere, including in the developed world. In most cases, they are just a train ride or flight away. Communicating about the ongoing risk for infectious diseases has become a strategic imperative.

The second implication of this topic in health communication is related to the attempt by the health care community to redefine risk communi- cation, which is assuming greater prominence, and also incorporating principles and strategies from crisis and emergency communication. Risk communication has been identified by Healthy People 2010 as one of the relevant contexts of health communication. It is defined as “the dissemina- tion of individual and population health risk information” (US Department of Health and Human Services, 2005, p. 11-13). Health People 2020 also includes a specific objective on risk communication: “Increase the propor- tion of crisis and emergency risk messages intended to protect the public’s health that demonstrate the use of best practices” (US Department of Health and Human Services, 2012b).

Health communication has traditionally used strategies that raise awareness of disease severity and risk among interested groups and pop- ulations so that people can relate to this risk and learn how to minimize it. Now, a more systematic approach to risk communications has been dictated by new attitudes toward disease prevention (or the lack of) that have led to the reemergence of many infectious diseases, as well as the need

CURRENT ISSUES AND TOPICS IN PUBLIC HEALTH AND HEALTH CARE 77

to engage relevant communities in all steps related to the preparedness and response phases of public health and humanitarian emergencies. To this end, several related fields have been converging to harness best practices and models. These include risk communication (which traditionally has been long-term, frequent, behavior-centered, expert-led, and focused on “hazards, consequences and cultural beliefs and attitudes” [Schiavo, 2009c] among other distinguishing features); and crisis communication (which traditionally has been reactive, nonroutine, focused on crisis update and status, led by authority figures, and short term) (Schiavo, 2009c; Reynolds and Seeger, 2005). Crisis and emergency risk communication integrates

crisis and emergency risk communication Integrates risk and crisis communication in preparing for, responding to, and recovering from epidemics, emerging disease outbreaks, and other hazards

approaches from both fields (risk and crisis communication) in prepar- ing for, responding to, and recovering from epidemics, emerging disease outbreaks, and other hazards (CDC, 2013b).

A definition of risk communication that attempts to represent the complexity of the process related to communicating and managing risk during public health emergencies is the one offered by the US Department of Health and Human Services (2002, p. 4), which defines risk communi- cation as “an interactive process of exchange of information and opinion

risk communication “An interactive process of exchange of information and opinion among individuals, groups, and institutions” (US Department of Health and Human Services, 2002). “The dissemination of individual and population health risk information” (US Department of Health and Human Services, 2005, pp. 11–13)

among individuals, groups, and institutions.” The definition also includes a discussion and related actions about risk types and levels aswell asmethods, strategies, and activities for managing risks in a variety of settings. Given the complexity of risk communication in public health emergency (also called emergency risk communication) and other settings, this process

emergency risk communication Risk communication as applied to public health and humanitarian emergency settings

is or should be characterized by the participation of different key groups, communities, stakeholders, and segments of society so that risk—and its social determinants—can be adequately addressed by effective, multisec- toral, and integrated communication interventions, which rely on multiple action areas (for example, mass media and new media communication, community mobilization and citizen engagement, policy communication and public advocacy) and strategies.

Worldwide Urbanization Cities and urban living have assumed greater relevance in relation to overall public health outcomes. “In 2008, for the first time in history, more than half of the world’s population will be living in towns and cities. By 2030 this number will swell to almost 5 billion, with urban growth concentrated in Africa and Asia” (UNFPA, 2012). Strategic health communication interventions in urban settings present many similarities with health communication planning, implementation, and evaluation in other settings. However, a specific set of issues, trends, and challenges may

78 CHAPTER 2: CURRENT HEALTH COMMUNICATION THEORIES AND ISSUES

influence interventions in urban settings and should be addressed as part of training modules and sessions intended for public health, health care, and community development professionals, nonprofit organizations, and government agencies.

For example, a 2009–2010 exploratory survey revealed several areas of need for capacity-building efforts on strategic communication in urban health settings (Schiavo and Ramesh, 2010; Communication Initiative, 2010; Schiavo, 2010b). Key findings from this survey emphasize the need for “training modules and sessions that address the issues of diversity and health disparities, which are very prominent in urban settings. Respondents pointed to the need for tools and strategies that would help them tailor communication interventions to different populations (both in relation to different racial and ethnic groups as well as various socioeconomic levels) within highly diverse contexts and given potential limitation of resources. Specific training needs were primarily related to the following topics: health disparities, diversity, communication framing and tailoring, and communi- cation planning and evaluation methods” (Schiavo and Ramesh, 2010). As urban areas continue to grow—and to pose new challenges and opportu- nities regarding the way we communicate on health and illness—research and capacity-building efforts on strategic health communication in urban settings will intensify to address the needs and preferences of urban com- munities. This theme will be further explored throughout relevant sections of this book.

The Threat of Bioterrorism The threat of bioterrorism has forced public health officials, governments, and key community leaders and organizations to revisit their communi- cation strategy in light of the possibility of an emergency situation. A few general principles about the key characteristics of communications efforts aimed at averting a potential public health disaster have emerged from the lessons learned from the 2001 anthrax-by-mail bioterrorist attacks in the United States (see Chapter One):

• Clear, timely, accurate, and audience-specific messages • Credible spokespeople • Strategic planning • Coordinated efforts • Adequate channels • Culturally competent attitude to communication

CURRENT ISSUES AND TOPICS IN PUBLIC HEALTH AND HEALTH CARE 79

Although all of these elements are standard attributes of well-designed and well-implemented health communication programs, the issue of preparedness assumes a greater importance in emergencies. In health communication, preparedness relates to the following (Schiavo, 2009b, 2010a):

• Clarity of behavioral results • A standard protocol that different organizations andmultilateral agen-

cies can use in a coordinated effort within countries and globally • Risk assessment and related preparedness measures that are specific

for each at-risk group • Community dialogue and consultations to secure community buy-

in on emergency mitigation measures and assess existing obstacles, community-specific preferences, and needs that may jeopardize their implementation

• Involvement and training of social mobilization partners (for example, teachers, religious leaders, community leaders, health care providers, etc.)

• Early selection and training of key spokespeople who can address intended groups

• Advance preparation to address potential questions from different groups or from the mass media

• Other group- and issue-specific tools and activities

International Access to Essential Drugs TheHIV/AIDS crisis inAfrica and other developing regions, where the high incidence of AIDS has been threatening not only lives but also the regions’ economic and social development, dramatically pointed to the importance of equal access to life-saving medications (Ruxin and others, 2005). It would certainly be a failure of modern medicine if treatment could not be delivered to those most in need of it.

In developing countries, access to medications is primarily influenced by cost, capacity for storage and drug delivery, adequate medical training, local infrastructure for drug distribution, hospital and treatment center conditions, and political willingness (Ruxin and others, 2005). All of these factors are equally important in ensuring that medications are available to people and can be effectively used to treat them.

Different efforts and campaigns have been developed and implemented by several organizations in the AIDS and public health fields (for example,

80 CHAPTER 2: CURRENT HEALTH COMMUNICATION THEORIES AND ISSUES

Doctors Without Borders, Medicus Mundi, World Health Organization). Yet, multisectoral partnerships are emerging as suitable models to work in multiple countries and bring together local governments, companies, local nongovernmental organizations, and other key stakeholders in sharing responsibility for guaranteeing access. This is a complex issue that deserves a book of its own and has been shaping interactions among different key players in the health care, public health, and community development fields as well as government or organizational policies. The overall point is that health communication, together with other kinds of interventions, can help advance this debate by creating consensus and raising awareness about adequate strategies, lessons learned from previous experiences, as well as the importance of a cohesive approach in which different stakeholders would assume their share of responsibility. It is a topic that those who enter the health care field cannot ignore, and one that is being greatly emphasized by global health interventions. It is also strictly interconnected to access to health services and adequately trained health workers, which is discussed in the next section.

Global Health Workers Brain Drain and Other Capacity-Building Needs in Developing Countries Health communication cannot replace the lack of adequate local capacity, training, or infrastructure. When health services are unavailable or too distant from specific groups, health communication interventions should help create the political and social willingness that is needed to build hospitals, recruit and train local health care providers, and make health products available.

This is a major issue in developing countries. Nevertheless, lack of capability or training often affects health care in developed countries, too. For example, underserved populations around the world are faced with a shortage of medical supplies in local hospitals or inadequate numbers of nurses or physicians per number of patients (Physicians for Human Rights, 2004; Colwill and Cultice, 2003). Among others, health communication can play a role in the process of expanding local capacity and infrastructure in these ways:

• Increasing understanding of the key factors contributing to brain drain • Advocating for increased funds for health care provider training

and retention strategies, patient clinical care, and task-shifting inter- ventions that incorporate community engagement and peer-to-peer communication strategies into clinical care

KEY CONCEPTS 81

• Engaging local leaders and government officers in the process of assess- ing local needs and subsequently creating or updating health services

• Raising awareness among local health care providers of standard medical practices they may not use routinely

• Training patients and family caregivers so they can ask the right questions in physicians’ offices, local meetings, and all other venues where health care–related decisions are made

• Increasing the visibility of leaders and organizations that focus on a specific health issue, disease, or local need

• Creating local awareness of disease severity and risk so that the issue can be prioritized and addressed in the community through adequate services and training

Lack of local capacity and training should force communicators to reflect on the limits of communication interventions. It should make them prioritize those strategies that together with other public health interventions would help develop critical masses, political willingness, and innovative processes to address existing deficiencies.

Key Concepts

• The theoretical basis of health communication is influenced by the behavioral and social sciences, health education, social marketing, mass and speech communication, new media theory, medical models, anthropology, and sociology.

• In this chapter, the most prominent theories and models are divided into the following categories: behavioral and social science theo- ries, mass and new media communication theories, marketing-based models, and other theoretical influences and planning frameworks, including medical models and logic modeling.

• There is recognition of the multidisciplinary nature of health commu- nication.

• Theories, models, and planning frameworks can influence different aspects and phases of health communication planning, evaluation, and management. They should all be considered as part of a comprehensive tool kit and selected in response to situational and group-related issues and needs.

• A number of issues and topics influence the practice of health com- munication and need to be considered in the analysis of the current health care environment.

82 CHAPTER 2: CURRENT HEALTH COMMUNICATION THEORIES AND ISSUES

FOR DISCUSSION AND PRACTICE

1. Select a theory addressed in this chapter and use a practical example on a health issue

of your choice to illustrate how changes in health behaviors may occur according to the

steps highlighted by the theory you selected. Box 2.1 provides a practical example on the

diffusion of innovation theory. This example can be used as a model for this exercise.

2. In your opinion, what is the main benefit of using theoretical frameworks and planning

models in health communication? Do you have experience with any theory-based health

communication interventions? If yes, identify your key learnings.

3. Which of the current issues highlighted in this chapter do you think most affect health

communication practice, and why? Do you have any experience in addressing these issues

or participating in health-related programs that focus on them?What, if anything, have you

recently heard in the news about these topics? Is there any other issue that you think may

shape the practice of health communication in the near future?

4. Using the logic model featured in this chapter (see Figure 2.4), research and discuss with

your fellow students key contributing factors to a health issue or condition you are aware

of either professionally or personally.

5. Analyze and present on common elements of different theories within the same category

or compare key elements of theories in two different categories (or family of theories) as

described in this chapter.

KEY TERMS

behavioral beliefs

crisis and emergency risk

communication

cultural competence

emergency risk communication

health literacy

health literacy–health

communication continuum

key influentials roadmap

logic modeling

newmedia

normative beliefs

primary audiences

risk communication

secondary audiences

social media

social norms

CHAPTER 3

CULTURE AND OTHER INFLUENCES ON CONCEPTIONS OF HEALTH AND ILLNESS

IN THIS CHAPTER

• What Is Culture?

• Approaches in Defining Health and Illness

• Understanding Health in Different Contexts: A Comparative Overview

• Gender Influences on Health Behaviors and Conceptions of Health and Illness

• Health Beliefs Versus Desires: Implications for Health Communication

• Cultural Competence and Implications for Health Communication

• Key Concepts

• For Discussion and Practice

• Key Terms

In 1976, as the United States celebrated its Bicenten- nial, the US Congress passed the American Folklife Preservation Act (Public Law 94–201) [1976]. In writing the legislation, Congress had to define folk- life. Here is what the law says: “American folklife” means the traditional expressive culture shared within the various groups in the United States: familial, ethnic, occupational, religious, regional; expressive culture includes a wide range of cre- ative and symbolic forms such as custom, belief, technical skill, language, literature, art, architecture, music, play, dance, drama, ritual, pageantry, hand- icraft; these expressions are mainly learned orally, by imitation, or in performance, and are generally maintained without benefit of formal instruction or institutional direction. (Hufford, 1991)

Traditional expressions of any culture influence every- day decisions, both big and small. They are reflected in the choice of the cake people have for their children’s birthday, and also in major decisions related to child rearing. They influence the slang children and doctors or handymen use to address their peers or others (Hufford, 1991). They are recalled when grandparents come to visit through tales and stories they transmit to the next generation. They are verbal and nonverbal cues that affect how information on any topic is received, accepted, and elaborated.

These traditions, habits, and beliefs also influence ideas of health and illness among different groups. The reality is that conceptions of health and illness are related to people’s upbringing as well as their cultural, religious,

84 CULTURE AND OTHER INFLUENCES ON CONCEPTIONS OF HEALTH AND ILLNESS

ethnic, and gender-related values and beliefs, to name just a few compo- nents. In health communication, these values and beliefs assume a critical importance in the design and implementation of programs that can reach across cultural boundaries and produce behavioral and social results.

CHAPTER OBJECTIVES

Through a comparative review of examples of different religious, ethnic, cultural, age, and

gender-related influences on the concepts of health and illness, this chapter (1) establishes the

need for research-based communication interventions that always take into account audience-

specific beliefs, behaviors, and characteristics and (2) provides information and reflections

that would help readers “assess cultural, environmental, and social justice influences on the

health of communities” (Association of Schools of Public Health, ASPH Education Committee,

2009, p. 11) and “engage communities in creating evidence-based, culturally competent

programs” (p. 11).

What Is Culture?

Culture has been rightly compared to an iceberg (Peace Corps, 2011). “Just as an iceberg has a smaller visible section above the waterline and a larger, invisible section, below the waterline” (Peace Corps, 2011, p. 10), so culture has some observable aspects (observable behaviors) and others that can only be intuited, imagined, and ultimately researched (see Figure 3.1). Culture is both influencing and influenced by universal values (emotions

universal values Emotions and feelings that people may share across different groups within the same culture or in some cases across cultures

and feelings that people may share across different groups within the same

INVISIBLE

VISIBLE

Figure 3.1 Comparing Culture to an Iceberg

APPROACHES IN DEFINING HEALTH AND ILLNESS 85

culture or in some cases across cultures) andpersonal values (emotions and personal values Emotions and feelings that derive from personal, group, or community past experiences

feelings that derive from personal, group, or community past experiences) (Peace Corps, 2011). As previously mentioned, culture is one important dimension of human behavior and, along with other factors (for example, age, religious beliefs, geographic location) influences people’s concepts of health and illness.

Approaches in Defining Health and Illness

Defining the meanings of health and illness may appear to be an easy task. After all, in Western countries, people seem to know when they are sick with a cold or other illness. Why should it be so complicated? Yet, in reality, health and illness have been defined in different ways across cultures around the world. Most authors agree that individual ideas on health and illness have a tremendous impact on people’s attitudes toward healthy behaviors as well as disease prevention and treatment.

Following are two of the many models that over time have been used to define health. Although the models need to be considered in the context of the cultural and geographical attributes of key groups and stakeholders, they can still help us comprehend the evolution of the definitions of health and illness over time.

Medical Concept of Health Under the medical concept of health, health is strictly defined as the lack of disease (Balog, 1978; Boruchovitch and Mednick, 2002) and, more specifically, the absence of physical symptoms and signs associated with illness. This concept mirrors the biomedical model discussed in Chapter Two and takes into account only the physiological nature of health and illness. It was particularly popular among physicians and other health care professionals in the first half of the twentieth century (Boruchovitch and Mednick, 2002).

However, as with the biomedical model, the medical concept of health neglects to consider the influence that other factors, such as psychological or lifestyle issues, have on many diseases. Moreover, it defines health by highlighting illness (Boruchovitch and Mednick, 2002) and therefore does not take into account that often a healthy status is more of a general condition of well-being.

Several studies have shown that people tend to feel “healthy” when they are happy, energetic, and feel invulnerable to disease (Andersen and

86 CULTURE AND OTHER INFLUENCES ON CONCEPTIONS OF HEALTH AND ILLNESS

Lobel, 1995; Campbell, 1975; Pew Research Center, 2006; Veenhoven, 2008). At times, this applies also to cases in which they are “concurrently ill” (Andersen and Lobel, 1995, p. 132). Healthy people tend to bounce back from illness faster and with better outcomes than unhealthy ones (for example, peoplewhoareunder a lot of physical or emotional stress) (Dougall and Baum, 2012; Gouin and Kiecolt-Glaser, 2011; Godbout and Glaser, 2006), so there is somethingmore to a healthy status than just being disease free. For example, chronic stress associated with low socioeconomics or a history of social discrimination may be linked to higher incidence of preterm births and higher infant mortality rates among African Americans (California Newsreel, 2008; Lu and Lu, 2007).

World Health Organization Concept of Health and Its Connection to the Social Determinants of Health One of the key principles of the World Health Organization (WHO) Con- stitution (1946) is a definition of health, which in the past few decades has changed the perspective of many health care and public health profession- als on the concepts of health and illness. “Health is a state of complete physical, mental and social well-being and not merely the absence of dis- ease and infirmity” (p. 2). This concept of health refers to the need for a balanced interaction among different physical, medical, psychological, social, and lifestyle-related factors. Balance, and the need for a balanced life that may help achieve good health, becomes a key principle in this defini- tion, which also somewhat reflects the biopsychosocial model discussed in Chapter Two.

In fact several factors—or determinants of health—affect health out- comes. Such factors (see Figure 3.2) pertain to different categories: the living, working, and aging environment; community-, population-, or group-specific factors, such as culture, gender, race, and other social influences, including the kind of social support people are used to giving and receiving as it relates to health and social behaviors they currently practice or plan to change; socioeconomic opportunities and related poli- cies; access to services and information as they relate not only to health care but also to other essential services such as transportation, recreational facilities and parks, community centers, and others.

The concept of balance is also echoed in the definition of health in many populations and cultures. For example, health beliefs of traditional Southeast Asians, such asmost Chinese people, revolve around the concept of balance between yin and yang, the two life forces (Matsunaga, Yamada, and Macabeo, 1998). Yin is the female force and is described as dark,

APPROACHES IN DEFINING HEALTH AND ILLNESS 87

Living and working environment

Culture, gender, race,

age, and other social influences,

and support

Socio- economic

opportunities and policies

Access to services, culturally

competent information

Individual, community, and social behaviors and norms

Health outcomes

Figure 3.2 Health Outcomes as a Complex and Multidimensional Construct

Source: Adapted from Schiavo, R., Boahemaa, O., Watts, B., and Hoeppner, E. “Raising the Influence of Community Voices on Health Equity: Introducing Health Equity Exchange.” Journal of Communication in Healthcare, Aug. 2012a. http://maneypublishing.com/images/pdf_site/Health_Equity_Exchange_-_Renata_Schiavo.pdf.

cold, and wet. Yin illnesses need to be treated with yang (hot) to restore health and the right balance. Hot foods such as chicken or herbal mixtures may be recommended to treat yin illnesses (Rhode Island Department of Health, 2005d; Raven, Chen, Tolhurst, and Garner, 2007). Yang is the male force and is considered “light, hot and dry” (Matsunaga, Yamada, and Macabeo, 1998, p. 49). Yang diseases may be treated with cold foods, such as vegetables (Rhode Island Department of Health, 2005d) or herbs. In traditional Chinese culture, hot and cold do not refer to actual temperature but areused todefineandcharacterizeopposite forces (Matsunaga,Yamada, and Macabeo, 1998). Cancer is an example of a yin disease, whereas an ear infection is considered a yang disease (Rhode Island Department of Health, 2005d).

As another example, drinking a lot of coldfluids, such aswater or orange juice, to nurture a bad coldmay appear strange in some traditional Hispanic cultures, because illness, treatment, and foods are also viewed in terms of seeking a balance between hot and cold (Rhode Island Department of Health, 2005b), this time referring to actual temperature. AmongHispanics, hot soups or teas may be viewed as an option to becoming healthy. In the

88 CULTURE AND OTHER INFLUENCES ON CONCEPTIONS OF HEALTH AND ILLNESS

United States, Hispanics include many different groups that differ in terms of cultural beliefs and ethnic and geographical backgrounds. However, many Hispanics also look at health as the result of a balance between the ability to function well in society and within one’s family, feelings of happiness and well-being, being clean, and having time to rest and sleep well (Rhode Island Department of Health, 2005b).

Even given this information, it would be false to imply that Hispanics or Chinese are unaware of the medical basis of diseases and the role germs may play at the onset of many illnesses; they are actually aware. However, as with many other cultures, health is viewed as the result of a sense of well-being with oneself and others, which goes beyond being disease free.

One of the potential limitations of the WHO model of health is its lack of specificity (Lewis, 1953; Boruchovitch and Mednick, 2002) and measurable parameters. This may complicate the evaluation of medical, behavioral, and social results. Also, it is important to take into account that although conditions such as obesity, diabetes, and depression are more heavily influenced by a number of social and individual factors, a sudden stroke or a head trauma needs immediate and urgent medical intervention that at least initially is limited to addressing medical causes and symptoms. This intervention focuses on restoring health by addressing only physical symptoms, which is the key assumption of the medical model.

Understanding Health in Different Contexts: A Comparative Overview

The definition of healthy varies from culture to culture and region to region. Ethnic, religious, socioeconomic, and age-related factors influence perceptions about health and healthy behaviors. For example, in some countries where malnutrition and poverty may be predominant, a large body size is considered a sign of a healthy lifestyle because it is associated withwealth and enough food (Mokhtar and others, 2001). InmanyWestern countries, however, people often regard heavy weight as a sign of an unhealthy lifestyle (for example, lack of exercise or poor eating habits).

Religious and spiritual factors are also relevant in medicine because they influence beliefs about the nature of illness as well as the ability to cope with disease or adhere to recommended treatments. Several questionnaires and standard models, such as the Royal Free Interview for Religious and Spiritual Beliefs, have been developed and translated in many languages to assess religious and spiritual ideas and their potential influence on patients’ behaviors and outcomes. Among other things, the Royal Free Interview is designed to investigate the extent to which people attribute sickness to

UNDERSTANDING HEALTH IN DIFFERENT CONTEXTS: A COMPARATIVE OVERVIEW 89

God’s will or rely on religious beliefs and practices to cope with the stress of an illness (Pernice and others, 2005).

In assessing the impact of religion and spirituality on ideas of health and illness, it is important to distinguish between the two terms because they refer to different levels of involvement in organized religious practices.Reli- gion is usually defined as a series of spiritual practices and behaviors within an organized religious structure (for example, the Catholic church), which in some cases may also recommend or inspire specific health behaviors; spirituality is a larger concept that includes people’s values, questions about the meaning of life, and, potentially, some level of involvement in orga- nized religious activities (Emblen, 1992; Mueller, Plevak, and Rummans, 2001; Hill and Pargament, 2003; Pernice and others, 2005). “Spirituality is expressed through art, poetry and myth, as well as religious practice. Both religion and spirituality typically emphasize the depth of meaning and purpose in life. One does not, of course, have to be religious for life to be deeply meaningful, as atheists will avow. Yet, although some atheists might not consider themselves spiritual,many do. Spirituality is thus amore inclu- sive concept than religion” (Dein, Cook, Powell, and Eagger, 2010, p. 63). Both can play a key role in the way disease is perceived and addressed in different cultures. In fact, religion and spirituality include traditions and values that may affect people’s understanding of the causes of illness, compliance to treatment and physician recommendations, or feelings of optimism or fatalism about disease outcomes, to name just a few examples. Religious beliefs have been reported to overrule clinical recommendations in influencing patients’ decisions (Coward and Sidhu, 2000). This points to the need for a culturally competent approach to disease prevention and management in which intended groups’ religious or spiritual assumptions should be respected and understood.

Age is another contributing factor in defining health and healthy behaviors. For example, inCanada, awareness of the importanceof adequate nutritional habits in relation to health tends to increase with age. When choosing food to eat, older Canadians “place more emphasis on nutrition” than younger Canadians (Health Canada, 2002). As another example, some authors have shown that even within a sample representing different ethnic backgrounds, a significant number of older people in the United States are fatalistic about the cause of many diseases, feel powerless about treatment, and tend to consider disease “a normal part of aging” (Goodwin, Black, and Satish, 1999). In general, concepts of health and illness change over time and often become increasingly more complex with older age.

Finally, access to recent advances in technology has also contributed to defining what people think it means to be healthy. For those who have

90 CULTURE AND OTHER INFLUENCES ON CONCEPTIONS OF HEALTH AND ILLNESS

regular access to it, the Internet and mobile technology have contributed to the merging of cultural perspectives and the understanding of many diseases. Similarly, radio and television have brought into many homes across the world images of models and lifestyles from different countries andcultures that over timecanbeassimilatedor emulatedbyagivenculture. However, it would be naive to expect that people will not incorporate their traditional beliefs and social values in redefining health as a result of new information and models. For any given culture, new ideas of health and illness tend to be the result of a carefully balanced combination of preexisting and new concepts.

Health communicators should be aware that programs designed to achieve awareness of a specific health issue and its solutions may also have an impact on existing concepts of health and illness because of people’s exposure to new models and beliefs. This potential impact should be con- sidered early in program design as well as monitored and evaluated over time. Cross-cultural communication efforts should always be envisioned as an opportunity to integrate cultures and not to convince people of the rightness of a single culture. Adequate resources and tools should be devel- oped to support people who initially adhere to new concepts and behaviors so they can be encouraged in their new beliefs by their social and family circles. Consider the following story that exemplifies how miscommunica- tion about the ideas of health and illness, and the consequential clash of two different cultures, may produce disastrous results (Fadiman, 1997):

Lia Lee was a three-month-old Hmong child with epilepsy. Her doc- tors prescribed a complex regimen of medication designed to control her seizures. However, her parents felt that the epilepsy was a result of Lia “losing her soul” and did not give her medication as indicated because of the complexity of the drug therapy and the adverse side effects. Instead, they did everything logical in terms of their Hmong beliefs to help her. They took her to a clan leader and shaman, sacri- ficed animals and bought expensive amulets to guide her soul’s return. Lia’s doctors felt her parents were endangering her life by not giving her themedication so they called Child Protective Services and Lia was placed in foster care. Lia was a victim of a misunderstanding between these two cultures that were both intent on saving her. The results were disastrous: a close family was separated and Hmong commu- nity faith inWestern doctors was shaken. (American Medical Student Association, 2005)

GENDER INFLUENCES ON HEALTH BEHAVIORS AND CONCEPTIONS OF HEALTH AND ILLNESS 91

Table 3.1 provides a comparative overview of ideas of health and illness among different populations and groups. This table offers a useful perspective on the many variations of these two fundamental concepts that need to be considered in researching and approaching any key group or community. The information in the table includes only sample facts, which come from published data and reviews in this field and may not apply to all people in the groups being featured. In fact, people in these groupsmay have individual conceptions that are shaped not only by sociocultural factors but also by their family upbringing, gender, educational level, life experiences, and living environment. Moreover, many other audience- or issue-specific factors that are not highlighted here may influence conceptions of health and illness and should be analyzed on a case-by-case basis.

Gender Influences on Health Behaviors and Conceptions of Health and Illness

Gender refers to the role and responsibilities that men and women respec- tively assume in their society and family. It is distinguished from sex, which is a biological trait (Zaman and Underwood, 2003). Although these two terms are often used interchangeably, only gender refers to cultural values that are associated with a given sex. Communication, culture, and gender are interconnected, and communication needs to take into account what gender means and how meanings of gender change in relation to cultural values, organizations, and activities through which such meanings are expressed (Wood, 2009).

In many cultures, gender roles and responsibilities tend to be different. Conceptions of health and illness often reflect this diversity. However, in approaching gender communication, it is important to refrain from applying gender-related stereotypes. The right approach is to research how gender attributes have evolved over time in a given culture and have influenced health care–related decisions and definitions.

In many settings, women’s ideas of health and illness have been influenced by their role as wives and mothers in providing health care for the rest of the family. This role has also traditionally influenced the epidemiology and control ofmany diseases (Vlassoff andManderson, 1998). For example, Finerman (1989) reports that in rural Ecuador, women may be reluctant to defer medical care to professionals or other people outside their home. They aremotivated by their need to protect their privileged and well-respected role as the family’s caretaker, which could be questioned by

92 CULTURE AND OTHER INFLUENCES ON CONCEPTIONS OF HEALTH AND ILLNESS

Table 3.1 A Comparative Overview of Ideas of Health and Illness

Population or ethnic group Good health is Illness is

African Americans (United States) The result of “keeping spiritual harmony [among]mind, body and soul” (University of Michigan Health System, 2005) “Feelings of well-being” and the

capacity “to fulfill one’s role” in society without excessive pain or stress (Rhode Island Department of Health, 2005a)

The consequence of natural causes, inad- equate diet, too much wind or cold (University of Michigan Health System, 2005)

God’s punishment for bad conduct (University of Michigan Health System, 2005)

…………………………………………………………………………………………………………………………………………………………………………… Vietnamese (country of origin and United States)

The proper balance between am and duong opposing forces, which are the same as yin and yang in Chinese cul- ture (Matsunaga, Yamada, and Macabeo, 1998; Rhode IslandDepartmentofHealth, 2005d)

An indication that “the body is out of balance” (Rhode Island Department of Health, 2005d)

…………………………………………………………………………………………………………………………………………………………………………… Koreans (country of origin and United States)

A balance between organic and inorganic elements, mind and body (Matsunaga, Yamada, andMacabeo, 1998;Pang, 1980)

Imbalanceamongthemanyelementsthat make a person (Matsunaga, Yamada, and Macabeo, 1998)……………………………………………………………………………………………………………………………………………………………………………

Hispanics (United States)

A feeling of bienestar (well-being), which is related to achieving balance in the emotional, physical, and social spheres; a balance between hot and cold body humors (Rhode Island Department of Health, 2005b)

An imbalanceamongemotional, physical, andsocial factors;anunevennessbetween hot and cold in the body (Rhode Island Department of Health, 2005b)

…………………………………………………………………………………………………………………………………………………………………………… Native Americans (United States)

A cycle that symbolizes perfection and equality; a balancing act among mind, body, spirit, and nature (Rhode Island Department of Health, 2005c)……………………………………………………………………………………………………………………………………………………………………………

Chinese (country of origin and United States)

Balance among body, mind, and spirit, commonly expressed as yin and yang (Centers for Disease Control [CDC], 2008a)

Imbalance of yin and yang, unbalanced qi (life energy), lack of emotional har- mony, or because of fate, interference from ancestors and others in the spirit world who seek revenge (CDC, 2008a)……………………………………………………………………………………………………………………………………………………………………………

Somali (country of origin and United States)

“Caused by angry spirits or ‘evil eye,’ which can stem from excessive praise of someone (i.e., flattery about a person’s beauty can curse the person receiving the compliment)” (CDC, 2008b)……………………………………………………………………………………………………………………………………………………………………………

Religious groups…………………………………………………………………………………………………………………………………………………………………………… Catholics A reflection of fallen nature and some-

thing evil; a result of the sin of Adam (Ukrainian Catholic Church in Australia, New Zealand, and Oceania, 2006)……………………………………………………………………………………………………………………………………………………………………………

Muslims Astateofdynamicequilibrium(AI-Khayat, 1997)

Apunishment;awayofwashingsinsaway (CancerBACKUP, 2006)……………………………………………………………………………………………………………………………………………………………………………

GENDER INFLUENCES ON HEALTH BEHAVIORS AND CONCEPTIONS OF HEALTH AND ILLNESS 93

Table 3.1 A Comparative Overview of Ideas of Health and Illness (Continued)

Population or ethnic group Good health is Illness is

Hindus and Sikhs Theresultofgoodkarma(“thecyclicalpro- cess of life and rebirth,” Sheikh, 1999, p. 600),which is the total effect of a person’s actions and determines the person’s des- tiny (Sheikh, 1999; CancerBACKUP, 2006)

A punishment for wrongdoings in the currentandpreviouslives(CancerBACKUP, 2006)

…………………………………………………………………………………………………………………………………………………………………………… Age groups…………………………………………………………………………………………………………………………………………………………………………… Children (Brazil) “Positive feelings” (Boruchovitch and

Mednick, 1997) “Negative feelings associated with being ill”; “not being healthy” (Boruchovitch and Mednick, 1997)……………………………………………………………………………………………………………………………………………………………………………

Elderly (Mexico) Something to be grateful to God for; dependent on the situations one lives in (Zunker, Rutt, and Meza, 2005)

Normal at their age; because of lack of knowledge about how to keep healthy during youth (Zunker, Rutt, and Meza, 2005)……………………………………………………………………………………………………………………………………………………………………………

Elderly (United States) A normal part of aging (Goodwin, Black, and Satish, 1999)

outside interventions. The desire to preserve a woman’s role as a primary caretaker has an important impact on the way diseases are managed, controlled, and prevented.

Gender also affects women’s access to health information, financial resources for treatment interventions, and ways to respond to disease in comparison with men (Vlassoff and Manderson, 1998). Moreover, in the case of diseases that are highly stigmatized, such as AIDS or tuberculosis, women tend to bemarginalizedmore thanmen by family and social circles.

In addition, in many cultures, the imbalance of power between men and women has created the need for developing different role models and recommended behaviors that are specific to each gender (Zaman and Underwood, 2003). For example, there are gender-related differences in talking with adolescents about sex and risky behaviors. Teaching girls about being assertive and demanding that their partners use condoms to prevent sexually transmitted diseases (STDs) is an additional but funda- mental gender-specific element of most STD awareness efforts intended for adolescent girls.

More recently, the advent of the Internet and other technologies has left women behind and created a large gender divide in many countries or communities across the world. For example, Obayelu and Ogunlade (2006) report that in Nigeria some women are influenced by local culture and other kinds of social pressures to believe that “working with ICTs (Information-Communication-Technologies) would drive women mad.”

94 CULTURE AND OTHER INFLUENCES ON CONCEPTIONS OF HEALTH AND ILLNESS

Others “considered the word ‘technology’ to have male connotations, even though ‘information’ seemed more feminine” (Obayelu and Ogun- lade, 2006, p. 55). In developing countries, access to ICT training and literacy is connected to economic and social opportunities, as well as the ability to network across regions and genders. “ICTs also provide options for women, including overcoming illiteracy, creating opportunities for entrepreneurship, allowing women to work from home and care for their families, accessing ICTs from rural locations, and enhancing and enriching their quality of life” (Obayelu and Ogunlade, 2006, p. 55). Therefore, one of the priorities for health communication in the twenty-first century is to close the gender divide as it relates to the understanding and use of technological advances and to create the cultural change that is needed to empower women and include them.

As for concepts of health and illness, changes in gender-related roles and responsibilities may be one of the effects of a health communica- tion program on a particular health issue (Zaman and Underwood, 2003). Therefore, gender attributes in the health care setting need to be under- stood, monitored, and evaluated over time in relation to the influence that health communication programs may have on them. These changes could potentially influence gender-related concepts of health and illness and become one of the many examples of how different elements of the health communication environment are interconnected.

Health Beliefs Versus Desires: Implications for Health Communication

Meeting and managing expectations is a critical attribute of most pro- fessional and personal interactions in result-oriented societies such as Western cultures. However, achieving what has been promised to others is important in all cultures.

In the public health and health care fields, when one asks others to changebehaviors, it is usually for better health. But the concept of health and illness varies across cultures and groups, and so are culturally related and group-specific health beliefs. Health beliefs influence how people estimate the likelihood that different outcomes may be linked to the recommended behavior. If people feel competent about managing their health, they are more likely to feel optimistic about their ability to reverse negative patterns and become healthier. If instead they feel that illness is God’s punishment for some past wrongdoing (as in the case of a few cultural or religious groups), they may be more pessimistic about their ability to change what they view as their fate, or they may rely on prayer to seek help. Table 3.2

HEALTH BELIEFS VERSUS DESIRES: IMPLICATIONS FOR HEALTH COMMUNICATION 95

Table 3.2 Examples of Disease-Specific Ideas of Illness Epilepsy is a “loss of soul” (American Medical Student Association, 2005; Fadiman, 1997)—Hmong

Tuberculosis is due to God’s curse, evil spirits, or sin (Kapoor, 1996)—Indians

Mental retardation isduetothe“spiritofdeadhorse” (Chan,1986;Erickson,Devlieger,andSung,1999)—Koreans

“Malaria is caused by mosquito bite and when the child walks or spends too much time in the hot sun, his blood becomes hot and this causes malaria” (Ahorlu and others, 1997, p. 492)—Igbo in Nigeria

“Diabetes is permanent in the body leading to [a] terrible, pessimistic and hard future resulting in loss of independence” (Meeto and Meeto, 2005)—Asians

“Schizophrenia is split personality or multiple personality. People with schizophrenia are violent and dangerous” (Health Canada and Schizophrenia Society of Canada, 1991)—North America

Some types of TB are caused by hard work, too much worrying, or passed down from older generations to younger (Le and Nguyen, 2013)—Vietnamese

“. . . people get the ‘shaking illness [Parkinson’s disease] through witchcraft after taking forcefully something belonging to other people . . . ” (Mshana, Dotchin, and Walker, 2011, p. 5)—rural northern Tanzania

HIV is a punishment from God and condoms cannot be trusted; HIV/AIDS can be caused by sorcery; . . . HIV is added to the lubricant in condoms (Bogart and others, 2011)—South Africa

provides a few examples of disease-specific definitions of illness that may affect how people from different cultures view specific diseases. These ideas have been reported in existing literature on the topic and may evolve over time.

Beliefs also affect how people rate the desirability of a certain outcome. In evaluating potential outcomes and their individual, social, and cultural appeals, people are influenced by logical and emotional arguments. It is important to understand and rate the level of priority and appeal placed on potential consequences of recommended behaviors.

Take the example of Julie, a fifty-two-year-old woman who is severely overweight. At her annual checkup, her physician finds out that she has type 2 diabetes, which is frequently associated with obesity and characterized by high blood sugar (glucose) levels. So far, Julie does not have any of the major symptoms of diabetes, with the exception of feeling tired and having a few episodes of blurred vision. She has attributed these symptoms to the long hours she spends working in a local manufacturing company and to recent personal events that “make her feel she wants to sleep more.” Therefore, when her physician recommends that she lose weight because of the potential long-term effects of diabetes, which include eye complications, kidney disease, and an increased risk for heart attack, stroke, and poor circulation problems (American Diabetes Association, 2005), she does not see the need to follow these instructions. She has no interest in minimizing the potential impact of her diabetes because she does not have any obvious symptoms.

96 CULTURE AND OTHER INFLUENCES ON CONCEPTIONS OF HEALTH AND ILLNESS

Diabetes prevention and control is only one of the many benefits of weight loss in obese or severely overweight patients. Others are the potential reduction of the psychological effects of obesity, which is a highly stigmatized condition and often limits opportunities in education, employment, personal relationships, and other areas (Wang, Brownell, and Wadden, 2004), and a lower risk for many other conditions associated with obesity, including some forms of cancer, alterations in pulmonary function, hypertension, and cardiovascular disease (Bray, 2004).

Well-planned health communication programs should consider all of these potential outcomes and evaluate their level of importance to key groups. In order to convince people to prioritize weight loss (as in Julie’s case), communicators and health care providers should identify the most desirable outcomes to the patient. This should become the entry message of all interactions and communication efforts, which creates a receptive environment to introduce and discuss the benefits of other potential outcomes and relate to and address patients’ needs and preferences.

Regardless of the context in which they take place (for example, the physician’s office or a public forum), communication interactions and related health practices should be effective and efficient. Effective refers to the ability to achieve desired outcomes (for example, in Julie’s case, diabetes control or reduction of psychological effect). Efficient refers to the ability of achieving these outcomes with minimal time and cost (both economic and emotional).

Of equal importance are people’s expectations about the overall quality of the experience. Factors that may influence the quality of the experience are the level of difficulty in complying with recommended activities (for example, limiting consumption of sweets), the kind of support received by friends and family, access to healthy food in one’s neighborhood, and many others that are social, community, or individual-specific. Potentially negative consequences of weight loss should also be considered in order to assess the overall appeal of the recommended behavior and its outcomes.

Many experiences have emphasized the importance of understanding and managing health beliefs and desires. As Babrow (1991) reports on the topic of smoking cessation, the probability of achieving expected outcomes, as well as the value placed on positive (for example, “improve health, quit successfully, save money”) and negative (for example, potential “weight gain, stress, loss of time”) consequences of smoking cessation strongly relate to the intention of smokers to participate in programs that would help them quit (Babrow, 1991, p. 102).

CULTURAL COMPETENCE AND IMPLICATIONS FOR HEALTH COMMUNICATION 97

Health communication programs can highlight the cause-and-effect relationship between desirable outcomes and recommended behaviors. They can also contribute to the development of tools and resources that will recommend easy-to-achieve steps for recommended behaviors and set realistic expectations. Finally, as Babrow (1991, p. 96) suggests, communi- cation messages “might inculcate optimism, hope or faith,” depending on people’s health beliefs and related cultural values.

Cultural Competence and Implications for Health Communication

Cultural competence has been defined as “the capacity to function effec- cultural competence The ability to relate to other people’s values, feelings, and beliefs across different cultures, and effectively address such differences as part of all interactions

tively as an individual and an organization within the context of the cultural beliefs, behaviors and needs presented by consumers and their communi- ties” (US Department of Health and Human Services, 2006b). In simpler terms, cultural competence is the ability to relate to the unique characteris- tics and values of each population, community, or ethnic group and address them in an efficient way that would create bridges across cultures and dif- ferent opinions. Culturally appropriate care, defined as the ability of health care professionals to provide medical care within a socially and culturally acceptable framework that may vary from patient to patient, can actually lead to enhanced patient outcomes (Frable, Wallace, and Ellison, 2004) and can also help reduce health disparities. In health communication and, more broadly, public health and health care, cultural competence is increasingly important, given the diversity of most urban and other settings.

Recent consensus among public health and health communication experts and organizations has highlighted the role culture plays in health outcomes and behaviors, as well as in increasing the effectiveness of health communication interventions (Kreuter and McClure, 2004; Institute of Medicine, 2002, 2003b; Liu and Chen, 2010). Well-designed and well- executed health communication programs should rely on an in-depth understanding of intended groups and be tailored to their needs and beliefs. This implies a true knowledge of cultural values that inspire the people with whom we interact.

In fact, although shared values and other cultural expressions are often related to age, race, religion, gender, and geographical boundaries, it is likely that even within the same racial or age group, there may be different sub- groups with specific cultural connotations or different stages in terms of their understanding and involvement in a certain health issue. For example, it would be naive to believe that a single smoking cessation program could

98 CULTURE AND OTHER INFLUENCES ON CONCEPTIONS OF HEALTH AND ILLNESS

be designed for teenagers who live in the inner city and affluent neighbor- hoods of a metropolitan area and have different smoking-related habits and beliefs. Some of the program’s key elements may be the same, but others should address the unique characteristics and preferences of these different groups.

Audience segmentation, which is defined as the practice of under- audience segmentation The practice of understanding large groups and populations as part of smaller groups (segments) that have similar characteristics, preferences, and needs; one of the key steps of the situation and audience analysis and completes the audience profile

standing large groups and populations as part of smaller groups (segments) that have similar characteristics, preferences, and needs (Boslaugh, Kreuter, Nicholson, and Naleid, 2005; Moss, Kirby, and Donodeo, 2009), is a well-established process in health communication as well as in related disciplines. Although a detailed discussion of audience segmentation is included in Chapter Eleven, readers should start thinking about the poten- tial uniqueness of the cultural, behavioral, psychological, demographic, socioeconomic, and geographical characteristics and risk factors of differ- ent audience segments and try to apply them to a recent health situation they encountered. For example, would you use just one approach to help your friends quit smoking, regardless of whether they are aware of the potential risk for smoking-related complications and diseases? What about the approach you would take to help a friend who is surrounded by peers who regard smoking as cool versus someone who feels guilty about not being able to quit and lives with people who disapprove of smoking? There are many variables in approaching audience segmentation, and culture is one of them (Kreuter and McClure, 2004).

Although audience segmentation is a term that health communica- tion borrows from marketing disciplines, our emphasis on a participatory approach to communication planning, implementation, and evaluation demand innovative methods, including community consultation and dia- logue and community-driven assessments to understand the uniqueness of each group with whom we interact.

The concept of cultural competence establishes the need for tailored communication interventions, which usually use a multifaceted approach to address the concerns, preferences, and needs of a specific group (Kreuter and Skinner, 2000; Slater, 1996; Kreuter and McClure, 2004). Cultural competence is key to a program’s success and is strictly related to how information is exchanged, processed, and evaluated by intended groups. It also points to the importance of tailoring language and cultural references to the specific audience, customizing message delivery to different learning styles, and using credible messengers. (For additional discussion on the role that culture and cultural competence should play in message development and delivery, as well as in the selection of appropriate communication channels and spokespeople, see Chapter Thirteen.)

KEY CONCEPTS 99

Key Concepts

• Culture has been rightly compared to an iceberg (Peace Corps, 2011). Just as an iceberg has some visible sections and others are below the waterline, culture has some observable aspects (observable behav- iors) and others that can only be intuited, imagined, and ultimately researched.

• Conceptions of health and illness are influenced by culture, race, ethnicity, age, gender, socioeconomic conditions, and geographical boundaries, among other factors.

• Gender influences not only ideas of health and illness but also access to health information, financial resources for treatment interventions, and ways to respond to disease. In many cultures, it may also deter- mine differences in the level of social marginalization experienced by those who suffer from highly stigmatized diseases, such as AIDS or tuberculosis.

• Health communication interventions should analyze and take into account different ideas of health and illness in order to be effective in reaching out to intended groups.

• Tensions between health beliefs and desires influence people’s will- ingness to adopt and sustain health behaviors and are influenced by culture. Health communication can highlight the cause-and- effect relationship between recommended behaviors and desirable outcomes.

• Cultural competence is critical in health communication. • Major implications of cultural competence in health communication

include the need for audience segmentation and capacity building in a variety of professional and community settings, as well as the development of group-specific messages, channels, and messengers.

FOR DISCUSSION AND PRACTICE

1. While reflecting on the chapter’s definitions, list some universal values and personal

values that influence your culture. Please provide examples of how such values may have

influenced your own health-related decisions.

2. What is your reaction to the section in this chapter about Lia Lee, a Hmong child? What (if

anything) do you think should have happened differently?

100 CULTURE AND OTHER INFLUENCES ON CONCEPTIONS OF HEALTH AND ILLNESS

3. When can you say that you feel in good health? Do any family or cultural beliefs affect your

ideas of health and illness? Does your family or ethnic group have any special way to deal

with illness? Can you think of an experience in which your health was affected by physical

as well as mental and social factors?

4. Describe a personal experiencewith cross-cultural communication—for example, a health-

related encounterwith a health care provider fromadifferent cultural or ethnic background

or participation in research studies or programs that involved different groups or popula-

tions.

5. In health communication, what are themajor implications of the potential tension between

patients’ health beliefs and desires? Can you provide a practical example or personal

experience that illustrates how culturally competent communications can help address

such issues?

KEY TERMS

audience segmentation

cultural competence

personal values

universal values

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PART TWO

HEALTH COMMUNICATION APPROACHES AND ACTION AREAS

By the time readers approach Part Two, they have probably already had an opportunity to discuss different topics in health communication with peers, colleagues, and others. In most cases readers have had a chance to practice or reflect on how some of the concepts and theories we discussed in Part One may apply to their current or future endeavors. Because Part Two focuses on the different areas of health communication defined in Part One, some of you may come directly to this section of the book for special topics on a specific communication area.

PartTwo focuses on thedifferent action areas of health communication, related theoretical and practical approaches, and case studies. Key areas in this section include interpersonal communication (Chapter Four), mass media and new media communication and public relations (Chapter Five), community mobilization and citizen engagement (Chapter Six), profes- sional medical communications (Chapter Seven), constituency relations and strategic partnerships in health communication (Chapter Eight), and policy communication and public advocacy (Chapter Nine). Although each chapter focuses on a specific action area, all six chapters in this section also reinforce the importance of an integrated approach to health communi- cation interventions, which relies on a strategic blend of communication areas (and related media channels) to mirror how people talk about health and illness—in public forums, and with family members, at the doctor’s office and over the Internet, via new media and in community settings, just to cite a few examples—and to encourage behavioral and social change in support of improved patient, community, and public health outcomes.

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CHAPTER 4

INTERPERSONAL COMMUNICATION

IN THIS CHAPTER

• The Dynamics of Interpersonal Behavior

• Social and Cognitive Processes of Interpersonal Communication

• Community Dialogue as an Example of Interpersonal Communication at Scale

• The Power of Personal Selling and Counseling

• Communication as a Core Clinical Competency

• Implications of Interpersonal Communication for Technology-Mediated Communications

• Key Concepts

• For Discussion and Practice

• Key Terms

In 1999, Harry Depew, the 2000 Family Physician of the Year of the American Academy of Family Physicians (AAFP), began his comments to the AAFP Congress of Delegates by first addressing the audience in sign language: “If you were a hearing person in a deaf world, where you could not understand sign language, how would you feel communicatingwith yourdoctor?”Thenhe askedout loud (AAFP, 1999). His question refers to a specific commu- nication need and area of interpersonal communication (provider-patient communication). Still, the feelings of isolation and frustration that may be elicited by the sit- uation Depew describes are likely quite similar to those we may feel in all instances in which health informa- tion, or another kind of information, is misunderstood or blocked out because we cannot relate to the person who is speaking.

Interpersonal communication is an important action area of health communication programs aimed at behav- ioral (World Health Organization [WHO], 2003) or social change. It includes provider-patient communications as well as community dialogue (interpersonal communica- tion at scale) and counseling and personal selling (the one-on-one engagement of key groups in their ownhomes, offices, or places of work and leisure), which are activities that find applicability inmany different phases and aspects of the communication process.

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CHAPTER OBJECTIVES

This chapter reviews some of the key factors in the dynamics of interpersonal behavior

and communication. It also focuses on practical aspects of community dialogue, counseling,

personal selling, and provider-patient communications, which are all key areas of interpersonal

communication. In doing so, it highlights the importance of considering all encounters as

an opportunity for a two-way exchange of information and ideas, as well as the potential

beginning of a long-lasting partnership.

The Dynamics of Interpersonal Behavior

Interpersonal behavior is influenced by several cultural factors. Although each individual has his or her own style of interacting with others, social conventions or norms, as well as traditions and values in a given group or community, play an important role in how behavior and communication take place and are interpreted and perceived.

All interactions comprise both verbal and nonverbal signs and symbols that contribute to the meanings of behavior and communication actions. Social psychologists tend to consider signs to be involuntary behaviors. Symbols are defined as voluntary acts, such as using verbal expressions to describe one’s feelings (Krauss and Fussell, 1996). According to these definitions, saying “I am embarrassed” is a symbol, whereas blushing in response to feelings of embarrassment is a sign.

Symbols are the result of social conventions and agreement (Sebeok, 2001; Lim, Liu, and Lee, 2011). For example, the significance of the word embarrassed is well known and shared by all English-language users (Krauss and Fussell, 1996). Therefore, using it in this context is supported by social norms and conventions.

A number of so-called signs may be controlled and therefore assume a symbolic value (Krauss and Fussell, 1996). For example, facial expressions can be controlled and modified to induce others to believe what we want them to believe and disguise what we are really feeling (Kraut, 1979; Porter and ten Brinke, 2008). Most people can recall situations in which they met a colleague or attended a business party immediately after a painful disagreement with a loved one. Chances are that facial expressions were controlled to disguise all feelings related to the recent disagreement. As this example demonstrates, it is difficult to strictly apply the theoretical distinction between signs and symbols (Krauss and Fussell, 1996). Still,

THE DYNAMICS OF INTERPERSONAL BEHAVIOR 105

this distinction can provide a useful framework to explain some of the components of interpersonal behavior and communication.

It is also critical to take into account the impact of culture on the interpretation of signs and symbols. Culture starts influencing meanings quite early in life. In fact, the process of socialization that begins within the family, and aims at preparing children for their adult role, is influenced by social norms and cultural factors of a given population or group (Moment and Zaleznik, 1964; Grusec, 2011; Berns, 2013). How a child will address teachers and elderly members of his or her family and community depends on the educational level, cultural values, age, and traditions of the parents, as well as their social environment.

Differences in power and social status also affect the dynamics of interpersonal behavior and the potential intimacy or level of formality of relationships (Hwa-Froelich and Vigil, 2004; Hofstede, 1984, 2001). In some cultures, people are assigned a higher social status in relation to their age, economic wealth, education, profession, or birth order (Hwa-Froelich and Vigil, 2004). For example, in the Chinese language, the eldest sister is addressed with a special word that conveys respect (Hwa-Froelich and Vigil, 2004).

Signs and symbols often assume different meanings in different cul- tures. Posture, social cues, and facial and idiomatic expressions all influence interpersonal relationships. In interpreting people’s behavior, it is impor- tant to be aware of cultural differences thatmayhave a powerful effect on the dynamics of interpersonal behavior. Lack of understanding of these differ- ences often undermines the impact of well-meant communication efforts.

In the public health and health care fields, understanding how cultural variables and interpretations affect interpersonal behavior has a positive influence on communication that may lead to better patient outcomes, increased patient compliance to treatment, or a better chance for disease control in a given group or population, to name just a few potential positive effects. Table 4.1 compares examples of different aspects of culture that may influence interpersonal relationships and communication during a health care–related encounter. Because these are just sample cultural norms and values, they may not apply to all situations or may evolve over time. As previously mentioned in Chapters Two and Three, cultural competence is essential to effective health communication within the context of interpersonal behavior and interactions as well as in a variety of organizational and professional settings. Table 4.1 provides useful insights to manage diversity in the interpersonal setting but also applies to other communication areas and settings.

106 CHAPTER 4: INTERPERSONAL COMMUNICATION

Table 4.1 Comparing Cultural Norms and Values

Aspects of culture US health care culture Other cultures

Sense of self and space Informal Handshake

Formal Hugs, bows, handshakes……………………………………………………………………………………………………………………………………………………………………………

Communication and language Explicit, direct communication Emphasis on content; meaning found in words

Implicit, indirect communication Emphasis on context; meaning found around words……………………………………………………………………………………………………………………………………………………………………………

Dress and appearance “Dress for success” ideal Wide range in accepted dress More casual

Dress seen as a sign of position, wealth, and prestige Religious rules More formal……………………………………………………………………………………………………………………………………………………………………………

Food and eating habits Eating as a necessity; fast food Dining as a social experience Religious rules……………………………………………………………………………………………………………………………………………………………………………

Time and time consciousness Linear and exact time consciousness Value on promptness Time equals money

Elastic and relative time consciousness Time spent on enjoyment of relationships

…………………………………………………………………………………………………………………………………………………………………………… Relationship, family, friends Focus on nuclear family

Responsibility for self Value on youth; age seen as handicap

Focus on extended family Loyalty and responsibility to family Age given status and respect……………………………………………………………………………………………………………………………………………………………………………

Values and norms Individual orientation Independence Preference for direct confrontation of conflict Emphasis on task

Group orientation Conformity Preference for harmony Emphasis on relationships……………………………………………………………………………………………………………………………………………………………………………

Beliefs and attitudes Egalitarian Challenging of authority Gender equity Behavior and action affect and determine the future

Hierarchical Respect for authority and social order Different roles for men and women Fate controls and predetermines the future

…………………………………………………………………………………………………………………………………………………………………………… Mental processes and learning style

Linear, logical Problem-solving focus Internal locus of control Individuals control their destiny

Lateral, holistic, simultaneous Accepting of life’s difficulties External locus of control Individuals accept their destiny

…………………………………………………………………………………………………………………………………………………………………………… Work habits and practices Reward based on individual achievement

Work has intrinsic value Rewards based on seniority, relationships Work is a necessity of life

Source: Gardenswartz, L., and Rowe, A.Managing Diversity: A Complete Desk Reference and Planning Guide. New York: McGraw-Hill, 1993, p. 57.C The McGraw-Hill Companies, Inc. Reprinted with permission.

Social and Cognitive Processes of Interpersonal Communication

Interpersonal behavior is usually affected by social cues, preferences, needs, and factors as well as cognitive processes that may vary at the individual

SOCIAL AND COGNITIVE PROCESSES OF INTERPERSONAL COMMUNICATION 107

level. Social and cognitive factors play a key role in how information is shared, evaluated, processed, and absorbed.

Social Cues, Needs, and Factors Change occurs when people are able to share common meanings and understand each other. In health communication, messages affect attitudes only when people understand, process, and remember them (Krauss and Fussell, 1996) and feel motivated to apply them in their everyday life.

In order to be effective, communication needs to respond to specific social cues and needs. This general principle also applies to different types of interpersonal communication, such as one-on-one teaching, counseling, personal selling, and provider-patient communications.

Several authors explain people’s behavior in the interpersonal commu- nication context in terms of the desire to satisfy a specific need (Step and Finucane, 2002; Kellerman and Reynolds, 1990; Roloff, 1987; Schutz, 1966; Frisby and Martin, 2010). Rubin, Perse, and Barbato (1988) developed the Interpersonal Communication Motives scale to explain the dynamics and motivation of interpersonal communication. Based on this model, people interact and speak with each other to satisfy specific needs:

• Being part of a social group or including others in one’s group • Appreciating others • Controlling other people’s actions and increasing behavioral

compliance • Being amused and entertained • Escaping and being distracted from routine activities • Relaxing and relieving stress

In their analysis, Rubin, Perse, and Barbato (1988) also showed that people tend to be less anxious when their motivation to communicate is to include others or to feel included. Having a good life, which entails overall satisfaction, good health, economic security, and social gratification, among other factors, also influences the reasons for which people communicate (Barbato and Perse, 1992; Step and Finucane, 2002).

Age and gender also influence motives for interpersonal communica- tion. For example, young people between eighteen and twenty-five years old often use communication as ameans for having fun, relaxing, feeling part of a social group, or escaping from routine activities (Javidi and others, 1990; Step and Finucane, 2002; Barbato, Graham, and Perse, 2003). Alternatively,

108 CHAPTER 4: INTERPERSONAL COMMUNICATION

middle-aged or older adults tend to communicate more to express appreci- ation or feel appreciated (Javidi and others, 1990; Step and Finucane, 2002). Barbato and Perse (1992) found that elders with greater life satisfaction and higher levels of social activity reported pleasure and affection asmotives for communication, whereas those who were less healthy, mobile, and socially active communicated for control or comfort. There are gender differences in interpersonal communication as well: women seem to communicate more “to express emotions” or appreciation, whereas men’s motivation is primarily control (Step and Finucane, 2002, p. 95; Barbato and Perse, 1992). To this effect, for example, gender communication interventions need to rely on an in-depth understanding of the communication styles and attitudes different genders bring to all interactions. These may include dif- ferences in the way of processing information, attitudes toward tasks and relationships, gender-specific values, leadership styles, and motivational factors. Yet, this kind of analysis is needed not only for different genders but also should expand to all groups and stakeholders we seek to reach and engage in the communication process.

Manyother elements contribute to the quality and tone of interpersonal interactions. Some obvious factors are common cultural references: similar upbringing, level of intimacy and mutual trust, level of competence about the topic being discussed, openness to new ideas, and individual states of mind.

Most people can relate to the feeling of recognizing themselves in the values and expressions of thosewhowere born in the samepart of theworld. This is a good predictor of potentially good interpersonal interactions but needs to be complemented by feelings of trust and respect about the other person’s competence or level of empathy on the subject being addressed.

Personal experiences can also affect interpersonal communication and influence relationships with those who previously shared one’s cultural values and beliefs. For example, a couple from a conservative country where women are not allowed to participate with men in any kind of social event may reevaluate their beliefs and interact differently with their fellow citizens after living in a country where the concept of equality between men and women is widely accepted. When travelers return from such a trip, their interpersonal relationships may be affected by the urge to change beliefs, whereas before such beliefs were based on shared values and the need to conform to them.

This example points to the importance of cultural and social factors in interpersonal interactions and communication. It also suggests that inter- actions and communication may change over time according to people’s beliefs and values. Therefore, communication needs to be sensitive to belief

SOCIAL AND COGNITIVE PROCESSES OF INTERPERSONAL COMMUNICATION 109

and attitude changes and recognize that these changes are often the result of other interpersonal relationships and communications. It is important to acknowledge the cause-and-effect impact of interpersonal communication and promptly adapt to change.

Cognitive Processes The process of acquiring knowledge by the use of reasoning, intuition, or perception is strictly related to communication and its modalities. Every time people interact with others, they share information. How new or existing information is acknowledged and processed depends on the approach one takes to communication.

For example, psychologists have long pointed out that people’s perfor- mance in trying to solve a problem is influenced by the way the problem is presented (Glucksberg and Weisberg, 1963; Chiu, Krauss, and Lau, 1998). In theUnited States, an “I-can-do” attitude toward professional tasks is con- sidered amajor asset. Can-do people feel that all tasks are within their reach and competence, and there is no such thing to them as an insurmountable problem. They also tend to transmit their enthusiasm and confidence to subordinates and colleagues. They present problems and situations with an optimistic flair. This is likely to make people feel competent and able to solve problems and may enhance their performance. By contrast, if a problem is presented by highlighting all the worst scenarios and expressing doubts about the possibility of addressing it, chances are that people may feel that whatever they do may not work.

Knowledge and attitude change are also influenced by the way informa- tion is presented. Establishing open and trusting communication is often the first step in creating a receptive environment in which information can be perceived as reliable and worthy of consideration. All successful communications and interactions usually require a reasonably good under- standing of the other person’s point of view (Brown, 1965; Park and Raile, 2010). Openness and trust are usually contagious. People can induce the same kind of open and trusting communications in others just by beginning first. Cooperation creates and is created by, among other things, openness in communication and trusting and friendly attitudes (Deutsch, 2012). Figure 4.1 shows two different scenarios and their potential impact on knowledge, attitude, and behavior after a mother’s conversation with her infant daughter’s pediatrician.

Still, it is important to remember that the sole or singular use of verbal expressions has been shown to have only a temporary impact on attitude change (Chiu, Krauss, and Lau, 1998). Eiser and Pancer (1979) studied the

110 CHAPTER 4: INTERPERSONAL COMMUNICATION

I understand that everything looks new and scary. I know you are afraid for your daughter. However, vaccines are safe and effective. We immunize many newborns every day.

I am quite uncomfortable with the idea of vaccinating my baby just two days after she is

born. Why should I immunize her against Hepatitis B (HepB) right now?

But why do we need to do it now?

The first dose of the HepB vaccine is recommended at birth. Also, the sooner you do it, the faster you will get used to the idea of immunization. This would be better for your baby. You want her to be protected from serious diseases as soon as possible. What else can I tell you to address your concerns? Would you like to speak with someone else, as for example one of our nurse practitioners who also handles a lot of vaccinations?

I am sure you are right but I prefer to wait on this.

No, it’s OK. You convinced me. Thank you for taking the time. Let’s vaccinate her.

But she is so small and fragile.

We immunize newborns all the time. There is nothing to worry about.

She can actually endure more than you think.

Beth

Beth

Beth

Beth

Physician 1

Physician 1 Physician 2

Physician 2

Figure 4.1 The Potential Impact of Interpersonal Communication on Behavior: A Practical Example

effect of biased language on attitudinal changes by asking study partic- ipants to write their views on capital punishment. Some of the subjects were directed to use words in their essays that were pro–capital punish- ment. Others were told to use words that were anti–capital punishment. Although the attitude of study participants toward capital punishment initially changed to reflect the words they had used in their essays, they

COMMUNITY DIALOGUE AS AN EXAMPLE OF INTERPERSONAL COMMUNICATION AT SCALE 111

had reverted to their original perspectives within six days from when they wrote their papers (Eiser and Pancer, 1979; Chiu, Krauss, and Lau, 1998).

In health communication, it is not enough to define a recommended behavior as “healthy” or “life-saving.” In order to determine a more perma- nent attitude change, all statements need to reflect local cultural values, be supported by evidence (Chiu, Krauss, and Lau, 1998), and translated into tools to facilitate their practical application. This is an important concept in message development in both interpersonal communication and other action areas of health communication. Facts and tools are critical to lend credibility to verbal expressions and motivate people to change.

Community Dialogue as an Example of Interpersonal Communication at Scale

Listening to communities and theirmembers and responding to their needs by encouraging action and partnerships across sectors are or should be key cornerstones of any kind of health communication intervention. Commu- nity dialogue is a process that seeks to create a favorable environment in

community dialogue A process that seeks to create a favorable environment in which communities feel comfortable putting forward their ideas and interests and providing input and opinions on specific matters on which they are consulted

which communities feel comfortable putting forward their ideas and inter- ests and providing input and opinions on specific matters on which they are consulted. “Unlike debate, dialogue emphasizes listening to deepen understanding. It develops common perspectives and goals, and allows participants to express their own interests” (Agriculture and Agri-Food Canada, 2012). Dialogue is a conversation that takes place at the commu- nity level and can take many forms: from a small group of people around a kitchen table, to a large consensus process in a community center, to dialogues over the Internet and other kinds of new media, and workshops or polling. In this way, community dialogue is a form of interpersonal communication at scale to which all of the principles of interpersonal communication as well as the dynamics of interpersonal behavior rightly apply. As some other authors have also suggested community dialogue pro- cesses “are based on the belief that such inclusion is a citizen’s right, may improve the accuracy of decisionmaking andmay assist in the community’s acceptance of decisions” (Duignan and Parker, 2005, p. 2).

Community dialogue methods and tools have been incorporated in a variety of communication planning frameworks (including communication for development, communication for behavioral impact, and others; see Chapter Two), and have been used by different kinds of community organizations, citizens, and institutions. Because community dialogue is an integral component of community mobilization and citizen engagement,

112 CHAPTER 4: INTERPERSONAL COMMUNICATION

further discussion of this topic and its practical applications is included in Chapter Six.

The Power of Personal Selling and Counseling

Personal selling is a well-established practice in the commercial sector personal selling Refers to (1) one-on-one engagement of different groups in their own homes, offices, or places of work and leisure and (2) the ability to sell one’s image and expertise, an important skill in most counseling activities

that also has many applications in public health, health care, and health communication. In the commercial sector, it refers to the one-on-one, “door-to-door engagement” (WHO, 2005b, p. 27) of potential customers or special groups in their own homes, offices, or places of work and leisure. In the health care industry, the figure that comes tomind is the pharmaceutical sales representative who goes to physicians’ offices to present a product.

Personal selling is also widely used for nonprofit causes and to spread theword about recommended newhealth behaviors and practices. In public health and health communication, personal sellers are usually volunteers, social workers, trainers, health professionals, or representatives of com- munity development organizations who go door-to-door or attend events where health services are provided. Their role is to engage key groups in interpersonal interactions to explain, recommend, and show benefits of a specific health behavior or practice. Often this role is coupled with actual service delivery. It also serves the purpose of answering questions and addressing fears and concerns about recommended health services and practices.

Door-to-door immunization is considered a core strategy of the world- wide polio eradication campaign, for example (Joyner, 2001;WHO, 2012b). House-to-house “mop-up” campaigns were part of a four-pronged strategy employed to eliminate polio in theAmericas (Aylward andHeymann, 2005). WHO, UNICEF, and their partners in the polio-eradication effort organize national immunization days in which thousands of volunteers and health professionals travel to remote villages and poor areas in the developing world to set up one-day clinics in schools, markets, and other places where they can reach a large number of people and persuade them to vaccinate their children. In India alone, during National Immunization Day in 1999, “2.5 million volunteers and health professionals traveled by any available means, including by camel and on foot following dry riverbed[s], carrying the vaccine on ice to their immunization posts” (Joyner, 2001). Another door-to-door campaign aiming to immunize seventy-seven million African children against polio in one year was launched by UNICEF and its partners

THE POWER OF PERSONAL SELLING AND COUNSELING 113

in 2005 (Li, 2005). Polio immunization campaigns in South Sudan targeted 3.2 million children under the age of five and conducted door-to-door national immunization days in all ten states of South Sudan in February and March 2012 (WHO, 2013b).

Personal selling does not work in a vacuum. In most cases, per- sonal selling efforts need to be complemented by other communication interventions, such as new media and mass media outreach, community mobilization, and other communication approaches discussed later in this book (see the example in Box 4.1). All of these other activities help create social consensus and support about the importance of responding to the call for action of volunteers, health workers, or school children who would knock on people’s doors. Without creating a supportive environment in which people feel motivated to listen to the recommendations of the so- called agents of change, most personal selling efforts may fail or produce only minimal results. Still, in the case of polio, door-to-door immunization enables the vaccination of millions of children in areas where war, lack of infrastructures, and poverty would otherwise make vaccine access and delivery impossible (Joyner, 2001). Similarly, personal selling was one of the key success factors in a WHO effort to prevent lymphatic filariasis in several endemic countries (see Box 4.1).

BOX 4.1. PERSONAL SELLING AND COUNSELING CASE STUDY

Lymphatic Filariasis

India, Kenya, Nepal, Philippines, Sri Lanka, and Zanzibar

Lymphatic filariasis (LF) is a painful and disfiguring disease caused by threadlike worms that

live in the human lymphatic system. LF is transmitted from person to person by mosquitoes.

Around 120 million are affected by LF, with more than one billion people at risk of infection.

LF is one of seven diseases targeted for elimination by WHO. The strategy adopted for

elimination in 1997 at the World Health Assembly is to treat entire endemic communities once

a year, for five to six years, with two coadministered antiparasitic drugs. For the strategy ofmass

drug administrations to be successful over 70 percent of the total population should take the

prescribed number of LF prevention pills. The other fundamental aspect of the program is to

provide support for those already suffering from LF-related disabilities.

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Impact

Country

Total population

targeted

Coverage rate achieved

(% of total population)

India: Tamil Nadu 28 million 74

Kenya 1.2 million 81

Philippines 4.5 million 87

Sri Lanka 9.5 million 86

Zanzibar 1 million 83

Thebehavioral objective: Take your LFpills fromyour filaria preventionassistants on filaria day.

COMBI plans were designed for India (the state of Tamil Nadu), Kenya, Nepal, Philippines,

Sri Lanka, and Zanzibar. The campaigns had a sharp, singular focus on the behavioral result

expected: the ready acceptance and swallowing of the tablets on a chosen day.

Theheartof theentireeffortwereagroupofdedicated individuals (healthworkers, teachers,

and volunteers) called filaria prevention assistants, going door-to-door hand-delivering a set of

tablets to all eligible individuals. They also carried out two preparatory visits to households

explaining the elimination program, showing the tablets, describing what was expected, and

answering any queries or concerns. The filaria prevention assistants were supported by intense

community mobilization, massive advertising, highmedia coverage, and political and religious

leadership backing.

Source:World Health Organization. Mediterranean Center for Vulnerability Reduction. “COMBI in Action: Country

Highlights.” 2004a. http://wmc.who.int/pdf/COMBI_in_Action_04.pdf. Used by permission.

Still, the practice of personal selling is an acquired communication skill that relies on many of the principles of interpersonal communication discussed so far in this chapter, as well as on individual characteristics and strengths. It requires training, awareness of people’s needs, strong listening skills, and the ability to engage others, as well as to counter objections by acknowledging the other person’s perspective and empathizing with it. It involves the ability to resolve conflicts by brainstorming and finding com- mon ground. In the case of a specific health communication campaign or public health intervention, it requires a level of competence and knowledge on the subject matter that, at a minimum, should be sufficient to elicit trust among the groups and communities we may reach.

Furthermore, the term personal selling can refer to the ability to sell one’s image and expertise, a helpful skill in most kinds of consulting activities. This second definition refers primarily to a communication skill,

THE POWER OF PERSONAL SELLING AND COUNSELING 115

whereas the first definition is related to a key area of interpersonal commu- nication. These two meanings are strongly connected and interdependent in their practical application.

Personal selling (the ability to sell one’s image and expertise but also a skill that is needed in the one-on-one engagement of key groups and stakeholders) is dependent on a number of verbal and nonverbal signals that should be recognizable by such groups. Among others, these include posture, overall confidence, speech and expressions, dress code (casual versus formal), and the ability to relate to others and express genuine concern. However, signs and symbols are not the same across differing populations and cultures. As previously discussed (see Table 4.1), several cultural and social factors may influence people’s ability to sell their image, competence, and expertise among members of different key groups and populations.

In counseling, which could be defined as the help provided by a profes- counseling The help provided by a professional on personal, psychological, health, or professional matters, including via one-on-one interactions, personal selling, and other interpersonal communication approaches

sional on personal, psychological, health, or professional matters, personal selling skills are a powerful determinant of one’s ability to have an impact on the beliefs, attitudes, and behavior of the person who is seeking counsel. In fact, personal selling skills may affect the ability of health communication practitioners to counsel others on communication strategies or engage opinion leaders in prioritizing a given health issue. Personal selling also influences patient-provider relationships and treatment compliance.

Because of their special role in giving advice and shaping other people’s professional or personal lives, counselors, whether they are physi- cians, nurses, psychologists, lawyers, health communication practitioners, community organizers, health science librarians, or other public health, community development, or health care professionals, need to be trusted and respected by the people they seek to reach. The audiences (whether they are patients or nonprofit organizations or others) need to have faith in the counselors’ commitment to a common cause (for example, a patient’s well-being or the success of a communication intervention) in order to relate to them and follow their advice.

Most important, people need to feel a sense of ownership of the issue on which they are being advised. And how could it be otherwise? Even if health professionals are knowledgeable about a given disease or health problem, it is the patient’s life that is directly affected by its symptoms and potential consequences. And what about key stakeholders, such as professional organizations, senior government officials, community development organization, foundations, or top physicians who decide to endorse a health issue after being solicited by health communication practitioners or other public healthprofessionals?Given their busy schedule

116 CHAPTER 4: INTERPERSONAL COMMUNICATION

and conflicting priorities, they are likely to dedicate significant portions of their time to addressing a specific issue only if they feel needed and can make a significant contribution to the problem’s solution.

Several cultural nuances may affect these general concepts. In some cultures, patients tend to defermore to their physicians or donot participate as much in treatment and prevention decisions because of their views of illness as God’s will or punishment or other cultural beliefs. Nevertheless, in all situations, the role of counselors, including health care providers, is to reach out, bridge cultural differences, and try to transform each encounter into a productive partnership.

Because of the documented impact of provider-patient communica- tions on patient outcomes and overall satisfaction, the rest of this chapter focuses primarily on this important form of interpersonal communication in health care. In doing so, it provides a practical and research-based perspective on how to transform ordinary relationships into successful partnerships that may lead to improved disease outcomes.

Communication as a Core Clinical Competency

Being sick is among one of the most vulnerable times in people’s lives, especially in the case of severe, chronic, or life-threatening diseases. It is also a time in which patients need to understand and feel comfortable with the information their provider shares with them. From a patient’s perspective, it is important to feel that their case is a key priority for the health care provider they have selected. From a provider’s perspective, conflicting priorities, managed care requirements (see Chapter Two), time barriers, or insufficient communication training may limit the ability to establish trusting and open relationships with patients.

Still, effective communication has been shown to have a positive impact on patient compliance to health recommendations, patient satisfaction, patient retention rates, overall health outcomes, and even a reducednumber of malpractice suits (DiMatteo and others, 1993; Garrity, Haynes, Mattson, and Engebretson, 1998; Lipkin, 1996; Lukoschek, Fazzari, and Marantz, 2003; Belzer, 1999; Zolnierek and DiMatteo, 2009). As Lukoschek, Fazzari, and Marantz (2003) highlighted, the patient-provider encounter offers one of the most important opportunities “to have a major impact on reducingmorbidity andmortality of chronic diseases, through personalized information exchange” (p. 209). Box 4.2 provides a health care provider’s perspective on the impact of effective communication on patient outcomes and well-being, as well as on key social determinants of health (for example, the level of social support and the kind of interactions with peers and others that people experience in their living and working environment).

COMMUNICATION AS A CORE CLINICAL COMPETENCY 117

BOX 4.2. THE IMPACT OF EFFECTIVE PROVIDER-PATIENT COMMUNICATION ON

PATIENT OUTCOMES: A PEDIATRIC NURSE PRACTITIONER’S PERSPECTIVE

MaryBethKoslapPetraco,CPNP, is the coordinator for childhealth in theSuffolkCountyDepartment

of Health Services, New York; chair of the Immunization Special Interest Group of the National

Association of Pediatric Nurse Practitioners; and a clinical assistant professor at the State University

of New York at Stony Brook. Her thoughts on the importance of provider-patient communications

(interview and other personal communications with the author, 2006) reflect her extensive patient-

related experience.

Cultural competence is very important in nursing. US nurses are specifically educated to

put aside their cultural bias andworkwith the patient’s cultural beliefs. This is a unique attribute

of US-educated nurses and helps establish effective relationships with patients.

Good provider-patient communications are very important in changing patients’ attitudes

toward disease, helping them use their culture in a positive way, and empowering them to

make the changes in their lives that are associated with better health outcomes.

I learned a long time ago that the parents of the children I see knowmore than I do. When

I acknowledge this fact, it’s much easier to guide parents to make the changes that are needed

for their children as well as to reinforce the positive things they are already doing.

There are a number of key factors that help establish a good provider-patient relationship.

First, give patients respect. Introduce yourself and explain the role you will play in their care.

Don’t talk down to them. Use language the patient understands. Acknowledge positive points

and accomplishments. Always think of them as people with their unique needs and beliefs.

Nurses are well positioned to establish good provider-patient relationships because of

their education and training. Nursing is at the same time an art and a science and is based on

the same key steps (assessment, implementation, and evaluation) of effective communication.

Patient-provider encounters should be used not only to determine the physical fitness of

the patient and treat potential illnesses but also to assess the patient’s overall well-being. For

example, when a twelve-year-old Hispanic girl presented with vague stomach complaints that

were preventing her from attending school, we discovered that physical symptoms and causes

had nothing to do with her condition. The girl was happy at home and loved her mother, who

was a domestic worker and spoke only Spanish. She was also a very good student. Yet, recently

she had refused to go to school. By talking with her and her mother, we discovered that she

had been bullied and threatened with physical assault by a group of children in the school.

We taught both her and her mother to talk to the school counselor, request a Spanish

translator, and speak with the families of the other children. We did a role-play with themother

so she would feel comfortable once at school. We also recommended she mention that the

police would get involved if this would not stop.

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It was priceless to see the smile on the mother’s face when she came back to our office a

few weeks later for a follow-up visit. It is also priceless to know that the girl is now happy in

school and doing very well academically.

Nurses canmake a difference in their patients’ lives. This is why I think nurses should always

advocate for their patients’ rights, especially in the case of underserved populations.

In all disease areas, effective communication is part of the cure. So, what is the best way to make it happen and overcome existing barriers to good patient-provider relationships?

One important step is to recognize that communication is a core clinical competence that can help improve effective use of time and help patients comply with recommended treatment and healthy behaviors, as well as optimize overall patient satisfaction and outcomes. As with other kinds of interpersonal interactions, understanding the patient’s cultural values, language preferences, differences in style, living andworking environments, life stressors, and specific meanings attributed to verbal and nonverbal expressions (see Table 4.1) are fundamental in establishing a satisfactory relationship.

It all starts with training. Some studies have shown that a patient’s comprehension of health information is highly influenced by physicians’ attitudes toward the importance of sharing information with their patients, which is shaped by their experience during medical training (Lukoschek, Fazzari, and Marantz, 2003; Eisenberg, Kitz, and Webber, 1983). For example, after three years of training, most medical residents tend to maintain a participatory attitude toward the decision-making process related to treatment and other recommendations. But after the same time period, surgical residents have switched to a more authoritarian attitude, even if they started with similar views as those of medical residents. This may reflect the hierarchical status and the task-oriented characteristics of surgeons’ medical training (Eisenberg, Kitz, and Webber, 1983). Still, it would be unfair to generalize these findings without taking into account personal and cultural factors and experiences.

The example in Box 4.3 shows how different physician attitudes toward communication may result in different outcomes. It also points to the importance of an empathetic and participatory approach to provider- patient communications, which may be better suited to motivate patient compliance and establish true partnerships.

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BOX 4.3. IMPACT OF PHYSICIAN ATTITUDES ON PATIENT BEHAVIOR: A TRUE STORY

Carmen was a sixty-one-year-old Spanish woman visiting her relatives in the United States.

(The name of the patient and some other facts have been changed to protect the patient’s

and physicians’ privacy.) During her trip, she was hospitalized for emergency spine surgery.

She had been suffering from excruciating back pain that her physicians in Spain had mis-

diagnosed. While in the United States, her pain had worsened, and it turned out that a

major infection had almost destroyed two of her vertebrae and was threatening her ability

to walk.

The surgery was successful. However, Carmen felt isolated in a foreign hospital where she

could not communicate with physicians and nurses. She spoke no English. Her relatives visited

her as often as they could, but they also needed to deal with work and family obligations. They

hired an interpreter for a few hours each day so Carmen could communicate with the hospital

staff and perhaps feel a little less lonely.

Approximately fifteen days after the surgery, one of Carmen’s physicians recommended

that she try to stand up and sit on a chair. When he went to visit Carmen, he did not speak to

her through the interpreter. He just instructed the nurse to help her and did not show much

empathy for Carmen’s pain. Carmen tried to get out of bed, but her pain was really bothering

her. After the first attempt, she asked her interpreter to tell the physician that she was tired; she

needed to rest and might try later.

A few hours later, her internal medicine specialist came by. She had been alerted about

the earlier events and had called Carmen’s relatives to discuss how to approach this issue. She

greeted Carmen warmly and started to speak with her through her interpreter. Carmen talked

about her attempt to stand up. She was still in a lot of pain. Despite the words of reassurance

by her relatives who had just telephoned her, she was not sure she wanted to try again. After

all, in most countries, patients who have this kind of surgery, or even less invasive surgery, are

confined to bed rest for much longer. Carmen found the request unreasonable.

The internist explained to Carmen that this was a common procedure in the United States

and helped improve and accelerate a patient’s rehabilitation. She highlighted the benefits of

early ambulation. She also showed empathy for Carmen’s pain. She mentioned that she would

consult pain specialists to see whether they could do something to reduce her pain while she

tried to regain mobility. Through the interpreter, she made sure that Carmen understood all

the information and also asked if she had additional questions.

Carmen decided to try again with the help of the nurse and her interpreter. After a few

attempts, she stood up and managed to sit on a chair. The entire team—the physician, the

nurse, and the interpreter—encouraged and congratulated her for trying. She was still in a lot

of pain, but she was happy about having succeeded. After all, this was a sign that things might

go back to normal soon.

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The physicians’ recommendations proved to be effective. Less than a month after her

surgery, Carmen was able to walk with the aid of a cane. Without the skillful communication

intervention of the internal medicine specialist, this story might have had a different outcome.

Carmen might have taken longer to stand up and perhaps suffered some of the medical

consequences of prolonged immobility.

Finally, it is also important to remember thatmost health care providers care about communicating well with their patients. For most physicians, nurses, and other care providers, helping others is one of the primary reasons they chose their professions. However, lack of communication training or other patient- or physician-related barriers may prevent some of them from being effective in establishing productive partnerships with their patients.

Prioritizing Health Disparities in Clinical Education Health and health care disparities continue to exist and, in some cases to increase, for many populations in the United States and globally. For example, “recent studies have shown that despite the steady improvements in the overall health of the United States, racial and ethnic minorities expe- rience a lower quality of health services and are less likely to receive routine medical procedures and have higher rates of morbidity and mortality than non-minorities. Disparities in health care exist even when controlling for gender, condition, age and socio-economic status” (American Medical Association, 2013).

The issue of quality and equality of care has assumed greater promi- nence in the era of urbanization and increasing diversity, both at the general population and patient levels. At the same time, diversity and inclusion have been recognized as core elements to the pursuit of excellence in clinical care, and ultimately, to addressing institutional and community priorities (Nivet, 2012). Several prominent organizations and authors (New York Academy of Sciences, 2012; Lunn and Sanchez, 2011; American Medical Association, 2013) have been encouraging physicians and other health care providers to look at their own practices to eliminate inequalities in clinical care, and medical schools to prioritize health disparities in clinical education.

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Among others, cross-cultural health communication (which refers cross-cultural health communication A systematic approach to health communication programming and interpersonal communication that emphasizes one key aspect of the health communication process: the ability to communicate across cultures, be culturally competent, be inclusive and mindful of diversity, as well as to bridge cultural differences so that community and patient voices are heard and properly addressed

to a systematic approach to health communication programming and interpersonal communication that emphasizes one key aspect of the health communication process: the ability to communicate across cultures, be culturally competent, be inclusive and mindful of diversity, and to bridge cultural differences so that community and patient voices are heard and properly addressed) has emerged as a prominent field also in clinical education on health disparities. In clinical settings, the importance of cross-cultural health communication strategies and skills continues to grow since the Institute of Medicine report Unequal Treatment (2003a) recommended cultural competence training for health care professionals as one of the key activities toward attaining health care equality.

Of great importance in the development of cultural competence and cross-cultural communication training curricula is the inclusion of infor- mation, resources, and easy-to-implement tools for physicians, nurses, and other health care providers to assess the socioeconomic and living environment of patients so that barriers to patient compliance can be readily identified and addressed. Health care providers as well as the insti- tutions they serve can play a key role in developing and implementing new community-driven models for the provisions of health care services so that peer-to-peer communication and community engagement strategies can help reinforce clinical recommendations, increase cultural competence in clinical settings, and address key social determinants of health that affect patient outcomes. As the journey toward quality and equality of care progresses, it is important to make sure that clinical education also addresses key barriers to effective provider-patient communications that are discussed in the following section.

Barriers to Effective Provider-Patient Communication Although many health care providers and public health professionals believe in the importance of optimal provider-patient communications, data suggest that many interactions could be improved. For example, in the United States, studies have shown that the average patient speaks for eighteen to twenty-two seconds before the physician interrupts (Belzer, 1999; American Medical Association, 2005c). Additional research shows that “if allowed to speak freely, the average patient would initially speak for less than 2 minutes” (American Medical Association, 2005a). Most important, in this short period of time, the patient would be able to

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Table 4.2 Barriers to Effective Provider-Patient Communication: Patient Factors Education level……………………………………………………………………………………………………………………………………….. Health literacy level……………………………………………………………………………………………………………………………………….. Language barriers……………………………………………………………………………………………………………………………………….. Cultural or ethnic differences……………………………………………………………………………………………………………………………………….. Age……………………………………………………………………………………………………………………………………….. Cognitive limitations……………………………………………………………………………………………………………………………………….. Lack of understanding of medical jargon and scientific terms……………………………………………………………………………………………………………………………………….. Disease-related stress……………………………………………………………………………………………………………………………………….. Power imbalance compared to health care providers……………………………………………………………………………………………………………………………………….. Socioeconomic conditions (including living and working environment)

express most of his or her concerns and symptoms (Belzer, 1999). This is likely to translate to a better provider-patient relationship as well as to “less follow-up visits, and shorter, more focused, interactions” (American Medical Association, 2005c).

Time is not the only barrier that could be addressed by effective communication. Most of the patient-related barriers in Table 4.2 could be removedby improved interactions and simplified information. For example, research shows that education level and language barriers may lead to low comprehension of medical information among patients (Lukoschek, Fazzari, and Marantz, 2003), so the use of jargon and complex medical terms negatively affects patients’ comprehension. As the AmericanMedical Association (2005d) suggests, most patients, regardless of their education level, prefer health information that is simple and easy to understand. In fact, most people can relate to the feelings of vulnerability and stress associated with the diagnosis of a chronic or life-threatening disease or the fear that a temporary medical condition may jeopardize imminent events in their life. In these situations, even well-educated patients may prefer not having to deal with the additional burden of making an effort to understand their provider’s suggestions.

As previously discussed in Chapter Two, health literacy is another key issue that affects quality and equality of care and should be prioritized in addressing barriers to provider-patient communication. Providers who are aware of, and able to address, different health literacy levels, and at the same time be culturally competent, are more likely to do the following (Schiavo, 2009b):

• Contribute to building andmaintaining a caring, engaging, and friendly clinical environment

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• Use simple and direct language • Listen to patient’s concerns • Have a proactive attitude toward asking questions • Have the ability to recognize nonverbal clues • Use repetition, feedback, and follow-upmechanisms to increasepatient

recollection of medical information, assess patient comprehension levels, and motivate patient compliance

Similarly, language and cultural barriers can be addressed by the use of interpreters as well as an increased emphasis on cultural sensitivity and competence during medical training and cross-cultural communication training sessions (both before and after graduation), which should engage and provide physicians and other health care providers with essential concepts and skills in this area. Research shows that patients may attribute different connotations to words that are used interchangeably by health professionals (Lukoschek, Fazzari, andMarantz, 2003;Heurtin-Roberts and Reisin, 1992). For example, AfricanAmericans attribute a differentmeaning to the words hypertension and high blood pressure (Lukoschek, Fazzari, and Marantz, 2003;Heurtin-Roberts, 1993), and thismayaffect their compliance to providers’ suggestions (Heurtin-Roberts and Reisin, 1992).

As Heurtin-Roberts (1993) reports, the term hypertension is often replaced by “high-pertension, a chronic folk illness related to the biomed- ical hypertension and involving blood and nerves” (p. 285). A percentage of African Americans consider hyper-tension (or high-pertension) differ- ent from high blood pressure. High-pertension is regarded as a chronic condition that may become worse with older age and may be related to being “high tempered” (p. 290). Because it is considered a chronic illness, high-pertension is often a way to cope with difficult living conditions and is “one of the few means of controlling the behavioral environment available to the individual” (p. 285).

Some health care providers are quite savvy about cultural differences andother kinds of barriers, whereas othersmaynot have had anopportunity to focus on them throughout their careers. From the provider’s perspective, the demands and long hours of most health care professions are often too burdensome to leave time forpleasantry andmore effective communication. Physicians in the primary care or pediatric environment are being required to see an increasing number of patients to satisfy managed care policies and other cost-cutting interventions (see Chapter Two).

In the United States, the number of office visits per year has increased by more than 40 percent, rising from 581 million in 1980 to approximately

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838 million in 2003 (Robert Graham Center, 2005). Pediatricians, for example, see an average of 93.6 patients per week (American Academy of Pediatrics, 2005a). In addition, only 30 percent of them feel they have received adequate training in counseling and behavior modification techniques. Most are fulfilled by many elements of their professional life, but more than half feel “stressed trying to balance work and personal responsibilities” (American Academy of Pediatrics, 2005b).

Still,whenmosthealth careproviders are given anopportunity to attend a communication training session, a most common reaction is pleasant surprise about skills, methods, and facts they may not have considered but that may help save time, improve overall patient satisfaction, and avoid conflicting or stressful patient-related situations. After some initial reluctance and skepticism, most providers enjoy testing their knowledge about communication methodologies as well as their skills as effective communicators. For many of them, hearing that most physicians do not let their patients speak for more than eighteen to twenty-two seconds without interrupting is often a surprise.

Trends in Provider-Patient Communication For several decades, people in Western countries have witnessed an ongo- ing shift in provider-patient relationships. Patients have become more involved with their own care and are more educated about health issues. Several patient organizations have worked to reinforce patients’ rights and to create networks and tools that contribute to patient education and empowerment. Patient activism and lessons learned from the AIDS crisis, which have shown the importance of patient and public participation in health care decisions and policies, have contributed a new perspective on more traditional provider-patient communications. At least among the most affluent segments of society, the Internet and other new media have also contributed to a variety of new forums where medical information is discussed, questioned, and analyzed with peers, experts, and others.

Physicians, nurses, and other health care providers have been adapting to, and in many cases encouraging, a new kind of relationship in which the power balance weighs less heavily on the physician’s side. Although many providers have been enjoying and adapting to this new trend, others have been struggling to find the time to accommodate patients’ increasing requests anddemands. Providerswhohavemade successful transitionshave thriving practices (patients like physicians who are good communicators and personable) and have relied on a number of tools developed by their professional associations.

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Recent initiatives by the American Medical Association (2005a), the American Academy of Family Physicians (1999), and the Association of American Medical Colleges (AAMC) (1999) highlight the importance of provider-patient communications and aim to equip physicians with skills and tools to communicate effectively with patients and incorporate communication as a core competency at all levels of medical education.

Among them, the AAMC (1999), which represents all 141 accredited medical schools in the United States, 17 medical schools in Canada, and more than 400 teaching hospitals, has identified several communication- related goals for medical students. Also, the AMA Foundation (2005b) has become a member of the Partnership for Clear Health Communication, which includes several organizations and industry leaders, in an attempt to address the problem of low health literacy. In 2007, the Partnership for Clear Health Communication joined forces with the National Patient Safety Foundation (2007).

Health care providers are increasingly learning communication skills that may help them break bad news. For example, special communica- tion courses teach oncologists how to talk with cancer patients about their diagnosis, life expectancy, treatment, and other sensitive issues in an empathetic and effective way. Some of these courses use standard commu- nication techniques, such as role-playing, to help providers practice their communication approach with actors who pose as patients (Zuger, 2006).

Moreover, some professional organizations have been focusing on equipping practitioners and patients with communication skills and tips. AskMe 3, an initiative of the Partnership for Clear Health Communication, teaches patients to ask their providers three questions that will help them understand their problem and recommended solutions (AmericanMedical Association, 2005d). This approach may help patients stay focused, ask the right questions, and minimize miscommunication with their providers if integrated with broader health literacy interventions. At the same time, it is a service to health care providers because it may lead to shorter andmore focused conversations.

Although there is still a lot to do in the area of provider-patient communication, new trends and initiatives in Western countries have established a path for a more participatory attitude to health care. The hope is that this will teach patients to make the best use of encounters with providers and help providers to bemore effective at conveying information. In most developing countries, as well as in many traditional cultures where the power balance has not shifted yet, health communication training and other kinds of interventions can help encourage people to become more responsible for health care decisions by communicating better with

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their physicians. In doing so, it is important to remember that models that have worked in Western countries may not work in other regions of the world or among members of different ethnic groups. For example, “many Asian Indians (especially older patients) prefer their doctors tomake health-related decisions on their behalf, as opposed to a more participatory style of decision making where the doctor presents them with options to be discussed. They often consider doctors to be authority figures and are more accustomed to answering questions than asking them. Asian Indian patients may thus be more inclined to play a passive role and may hesitate to express their concerns” (Health Equity Initiative, 2011). These kinds of examples further support the need for understanding patients’ preferences and culture as well as the importance of cross-cultural communication training in clinical education.

Transforming Provider-Patient Relationships into Partnerships By definition, partnerships require that all partners are equally committed to pursuing a common cause and are aware of their role. In the provider- patient relationship, the common cause is the patient’s health.

Health communication can help improve provider-patient relation- ships by raising awareness of common communication issues as well as roles and responsibilities in achieving good health outcomes. Training in communication methodology and message development may help health care providers sharpen their communication skills and address patients’ questions and concerns in a more effective way. It may also help physicians conduct conversations in a way so that patients will stay on topic and feel that their provider is truly concerned about their health.

In summarizing many of the ideas discussed in this chapter, ideally, communication training for health care providers should focus on these topics:

• A brief overview on communication methodologies and how to affect behavioral change

• How communication skills can help make effective use of time • Benefits of effective communication • Common barriers and how to address them • Differences in cultural and ethnic factors, age, and gender as they relate

to health beliefs and attitudes

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• Impact of the social determinants of health on patient outcomes (including practical tips on how to discuss with patients how their living and working environment may affect their health)

• Practical tips and examples on all topics • Interactive session in which health care providers practice and test

their communication skills in different potential scenarios

Some practical tips that may help providers establish good and trusting relationships with their patients are common to all human interactions:

• Greet patients properly and according to their cultural and ethnic preferences. For example, calling patients by their first name is appro- priate in many Western countries and can help break down barriers but is not advisable when addressing Korean patients, who prefer to be called by their full name (Matsunaga, Yamada, and Macabeo, 1998).

• Put patients at ease by smiling, asking about the patient’s family, and establishing good eye contact (if culturally appropriate).

• Do notmake patients feel that the next patient may bemore important by looking at the watch or at the door (Belzer, 1999).

• Show empathy about patients’ concerns and needs. • Listen and avoid interrupting. • Help patients stay focused on their medical issues. • Recognize nonverbal clues. • Reinforce key messages and recommendations by providing written

materials and scheduling follow-up visits or contacts.

Focusing on only the communication skills of health care providers may not be sufficient to achieve an effective provider-patient partnership. As patients’ participation in health decisions increases, communication tools and events intended for patients may help them do their share in establishing a true partnership with their providers. Primarily, training can help patients in several ways:

• Asking the right questions • Staying focused • Becoming familiar with common medical terms • Understanding how to differentiate between credible and noncredible

informational sources (on the Internet as well as in other settings)

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• Dealing with conflicts or other kinds of impediments that may prevent them from following or trusting a provider’s recommendations

• Showing respect for the provider’s time and experience • Identifying and discussing key factors in their living and working

environments that may affect their health or ability to comply with clinician recommendations

Communication specialists can help address issues in provider-patient relationships by helping professional associations, patient groups, and individual health care providers understand the issues at stake as well as improve overall communication skills. They can also help influence policies and medical curricula to recognize the central role that effective communication can have on health outcomes.

Implications of Interpersonal Communication for Technology-Mediated Communications

A discussion about interpersonal communication would not be complete without acknowledging the impact that the advent of the Internet, video technology, telephone, mobile technology, and other media has had on interpersonal relationships over several decades. Increasingly, many inter- actions are mediated by technology and take place using e-mail, voice mail, videoconferencing, texting, or other media channels. This may shape the quality and implications of communication by depriving it of non- verbal expressions (for example, facial expressions, gestures) and other influences (for example, the potential impact of different venues—formal versus informal venues—on health care or business conversations) that are usually common in face-to-face encounters.

Still, as several authors report, even when people rely on electronic media, they continue to engage in the process of grounding, which refers to the ability to find, understand, and share common meanings (Brennan and Lockridge, 2006; Brennan, 1990, 2004; Clark and Brennan, 1991; Clark and Schaefer, 1989; Clark and Wilkes-Gibbs, 1986; Schober and Clark, 1989). Take the example of an e-mail in which a mother asks a close friend to pick her child up from school. If the e-mail states only, “Could you please pick my child up from school?” the request may not be clear unless the recipient already knows the school’s address, the dismissal time, the names of the child and the teacher, aswell aswhere he or she should bring the child. These additional facts will allow the recipient to evaluate and eventually rule out the existence of potential conflicts (for example, previous work

KEY CONCEPTS 129

commitments) or other impediments. Still, the mother would have to wait for her friend’s reply. This dynamic is quite similar to what occurs in face- to-face encounters. As other authors highlight, the interpersonal exchange in both cases has two phases: the presentation phase, when the mother asks her friend for help and describes the task’s requirements, and the acceptance phase, which implies the need for the friend’s reply to confirm that he or she understood and accepted the task (Brennan and Lockridge, 2006; Clark and Schaefer, 1989).

As it related to health, technology-mediated communications have provided a private forum to discuss sensitive matters, connect with others who may have experienced similar health issues, network, and learn about new medical solutions, among other actions. They have also affected provider-patient relationships. For example, somephysiciansmay complain about the number of unnecessary questions and concerns that patients raise because of noncrediblemedical facts found on the Internet. Yet the Internet and other technology advances have improved the ability of patients and the general public to participate in personal and public health decisions.

In the case of life-threatening conditions such as HIV/AIDS, the use of the Internet has increased people’s ability to deal with their illness. For example, the use of the Internet has influenced the coping skills of people living with HIV by promoting individual empowerment, increasing social support, and helping them help others (Reeves, 2000; Coursaris and Liu, 2009).

The influence of media technology on interpersonal communication and other aspects of health communication varies from population to population and group to group. It is related to media access, socioeco- nomic conditions, media literacy levels, as well as specific media uses and preferences that may vary from group to group. A more comprehensive discussion on new media communication is included in Chapter Five.

Still, when using any form of technology to communicate about health matters, it is important to remember and apply all general principles and values that pertain to interpersonal communication. Gender, age, and cultural, ethnic, and geographical factors as well as literacy levels still influence technology-mediated communications and should be considered. This is about using one of the many kinds of media to have a heart-to-heart discussion about health and health behaviors.

Key Concepts

• Interpersonal communication is an important action area of health communication.

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• Interpersonal behavior and communication are highly influenced by cultural-, social-, age-, and gender-related aspects, as well as literacy and health literacy levels and individual factors and attitudes.

• The dynamics of interpersonal communication are determined by signs (for example, involuntary acts) and symbols (for example, use of verbal expressions) that may differ among cultures and groups.

• Examples of interpersonal communication are community dialogue, personal selling, counseling, and provider-patient communication.

• Community dialogue is an example of interpersonal communication at scale. It is a process that seeks to create a favorable environment in which communities feel comfortable putting forward their ideas and interests and providing input and opinions on specific matters on which they are consulted.

• Personal selling refers to (1) one-on-one engagement of different groups in their own homes, offices, or places of work and leisure and (2) the ability to sell one’s image and expertise, an important skill in most counseling activities. It is an acquired communication skill that requires training but is also dependent on individual, social, and cultural factors. The two definitions are strongly connected and interdependent in their practical application.

• Personal selling interventions may not be very effective in the absence of other communication activities (for example, public relations, com- munity mobilization) that would help create a receptive environment for door-to-door interventions.

• In counseling, which could be defined as the help provided by a professional onpersonal, psychological, health, orprofessionalmatters, personal selling is a powerful determinant of one’s ability to have an impact on the beliefs, attitudes, and behavior of the person who is seeking counsel.

• Provider-patient communications is an important area of interpersonal communication and has been shown to affect patient satisfaction, retention, and overall health outcomes.

• Further emphasis should be placed on prioritizing health dispari- ties in clinical education—including training in cross-cultural health communication—to address differences in quality and equality of care.

• Effective communication in the provider-patient setting depends on several patient- and physician-related factors as well as external factors (for example, time constraints and managed care requirements).

KEY CONCEPTS 131

• Communication specialists can help improve provider-patient com- munications. They can help health care providers and patients under- stand the issues at stake and improve their communication skills. They can also work with professional associations, patient groups, and individual health care providers to help them influence policies and university curricula, including communication as a core clinical competency.

• Technology advances have had a tremendous impact on interpersonal communication. Many types of interpersonal communication are now mediated by technology and take place using e-mail, videoconferenc- ing, telephone, texting, and other media.

• Technology-mediated communications are influenced by many of the same factors that rule other types of interpersonal communication, such as literacy and health literacy levels and age, gender, cultural, ethnic, and individual factors.

FOR DISCUSSION AND PRACTICE

1. Describe the most common verbal and nonverbal clues that, according to your culture,

age group, gender, family values, personal preferences, or other factors, may affect your

level of satisfaction with health-related encounters and communications and prompt you

or your peers to comply with the health care provider’s recommendations. For example,

how do you like to be greeted by your physician? Is there any specific personal or cultural

value or belief that you need to have acknowledged in order to trust and comply with the

health information being presented to you? Is there any nonverbal clue that you may find

confusing or offensive?

2. Maria is a forty-one-year-old Caucasianwomanwho is expecting her first baby. Eight weeks

into the pregnancy, it becomes clear that she is likely to have amiscarriage. She really wants

the baby and may be very upset at the idea of a miscarriage, especially because she fears

she may not become pregnant again. Think of how her physician should break the bad

news in a way that would acknowledge Maria’s feelings and set realistic expectations. Use

role-playing to simulate the actual discussion, and try to envision some of Maria’s potential

questions. Evaluate the pros and cons of potential physician approaches and attitudes

toward communication on this matter.

132 CHAPTER 4: INTERPERSONAL COMMUNICATION

3. Have you ever participated in any kind of community dialogue or read about it in the

media? Use your own experience or research an example of community dialogue to discuss

how this process helped a community identify key priorities and next steps on a health

issue.

4. In this chapter, personal selling is defined as (1) one-on-one, door-to-door engagement of

key groups and stakeholders and (2) the ability to sell one’s image and expertise. Discuss

practical examples from your professional or personal experience or recent readings that

illustrate these two definitions.

5. Review Figure 4.1 and use five to ten adjectives to describe the style and communication

approaches of physicians 1 and 2. Then discuss key factors that in your opinion influenced

the mother’s decision in both scenarios.

6. Reflect on and discuss when the use of technology (e-mail, texting, etc.) is appropriate

within clinical settings. Provide examples of when, in your opinion, health care providers

should or should not communicate with their patients via e-mail.

KEY TERMS

community dialogue

counseling

cross-cultural health communication

personal selling

CHAPTER 5

MASS MEDIA AND NEW MEDIA COMMUNICATION, AND PUBLIC RELATIONS

IN THIS CHAPTER

• Health Communication in the New Media Age: What Has Changed and What Should Not Change

• The Media of Mass Communication and Public Relations

• Public Relations Defined: Theory and Practice

• Mass Media, Health-Related Decisions, and Public Health

• NewMedia and Health

• Reaching the Underserved with Integrated New Media Communication

• Mass Media– and New Media–Specific Evaluation Parameters

• Key Concepts

• For Discussion and Practice

• Key Terms

“Years ago, Americans grabbed toast and coffee for break- fast. Public relations pioneer Edward Bernays changed that” (Spiegel, 2005). Bernays, whom many regard as the historical father of public relations, referred to many the- ories of his uncle, Sigmund Freud, in developing a public relations campaign to help convince Americans that “ba- con and eggs was the true all American breakfast” (Spiegel, 2005; Museum of Public Relations, 2005) and that it was ultimately healthier. Bernays’s campaign in the mid-1920s was successful at changing the public’s mind (Museum of Public Relations, 2005). Although bacon and eggs have been somewhat eclipsed by new habits, such as eating cold cereals or not eating breakfast at all (ABC News, 2005), they remain a very popular breakfast: only one in ten Americans usually eats toast or some other kind of bread or pastry (ABC News, 2005).

Outside the breakfast setting, public relations strate- gies and activities are usually used for mass communica- tion or to create interest among multiple publics about an idea, a new policy, a product or service, a recommended behavior, a professional field, a company, an institution, or a nonprofit organization. Ethical public relations relies on reputable facts and figures, and has found many appli- cations as part of health communication interventions in the commercial, nonprofit, health care, and public health sectors. Yet, in the new media age, public relations the- ory and practice has evolved to develop new models and strategies for the use of new and social media as part of health communication programs.

134 CHAPTER 5: MASS MEDIA AND NEW MEDIA COMMUNICATION, AND PUBLIC RELATIONS

CHAPTER OBJECTIVES

This chapter reviews the relationships among mass communication, public relations, mass

media, and newmedia, and discusses themwithin the context of health communication in the

new media age, establishes public relations as a key action area in mass communication and

other health communication interventions, and provides an overview of mass media and new

media use and strategies. Finally, it also provides practical suggestions on key success factors

of mass media and new media communication programs, and discusses select mass media–

and newmedia–specific evaluation parameters.

Health Communication in the NewMedia Age: What Has Changed andWhat Should Not Change

We live in an exciting time for health communication. Communication- related technologies (Internet, mobile, etc.) have been fast advancing at an unprecedented pace, and have been adopted by different groups and populations across the world. Technology provides communicators with myriad new channels and strategic options, which can no longer be ignored and need to be efficiently integrated as part of comprehensive multimedia health communication interventions. Through a variety of media (for example, professional and personal blogs, social media sites, podcasts, chat rooms, and mobile applications, among others), e-health (see definition in Chapter Two and the Glossary) and mHealth (the use of mobile and

mHealth The use of mobile and wireless technology devices for health-related interventions that seek to improve patient and public health outcomes

wireless technology devices for health-related interventions that seek to improve patient and public health outcomes) have been rising to provide innovativeways to communicate abouthealth andcommunity development issues with many different groups.

In this multimedia environment the distinction between mass media

massmedia Means of communication to reach large audiences or percentages of a given population; what can act as mass media may vary in different countries or groups

(means of communication reaching large audiences or percentages of a given population; what can act as mass media may vary in different countries or groups) and new media is always evolving and being debated. For example, for some of its information-related applications (for example, websites, online journals, and libraries) and related functions (for example, health information seeking and retrieving), the Internet acts—and in many cases substitutes—more traditional mass media, such as print and broadcast media and books (Flanagin and Metzger, 2001; Schiavo, 2008, 2009a). Yet, this is primarily true in North America, Europe, and several Asian countries. In fact, several developing countries and underserved and vulnerable groups in developed countries continue to lag behind in

HEALTH COMMUNICATION IN THE NEW MEDIA AGE 135

this technological revolution despite several initiatives that are underway to bridge the digital divide. Depending on the country and the specific group or population, such a digital divide occurs because of a combination of technology access and quality, costs of Internet connectivity—which in someAfrican countriesmay be hundreds of times higher than in the United States or most European countries (World Health Organization [WHO], 2007)—and most important, media and health literacy.

In several African countries, for example, “even where institutions and individuals have Internet access, the connection often has little practical value for more than a few elite users” and “tests of actual Internet speeds indicate that, while users at large European or American universities enjoy Internet connections which deliver 17 million bits per second, users at African institutions operate at speeds that are 500 to 600 times slower” (WHO, 2007). In the United States, many groups may still lack the capacity to retrieve, assess, and understand health information. About one-third of Americans lack health literacy (National Opinion Research Center, 2010). Lack of health and media literacy as well as cultural preferences in relation to the use of online tools or limited access to computer skills and technology may negatively affect the use of online media among underserved groups and communities with significant health disparities. For all of these groups, it may be a bit of stretch to say that the information-related features of the Internet can be considered to act in the same way as mass media, at least for the time being.

New media (see Chapter Two and the Glossary for a relevant def- inition) and social media penetration has been exponentially increasing (see Table 5.1), and is projected to continue to increase, and helps people connect on many different issues, create online communities, and work together across geographic boundaries. Yet, the use of interactive functions of the Internet and mobile technology—such as social media, texting, and online forums—cannot yet be considered the same as mass media in their application to health issues, at least not across different socioeconomic, age, and ethnic groups. In fact, “Web 2.0 is not familiar ground for the majority of the US population . . . When you hear the phrase ‘2.0’ you are hearing about an online world that is familiar to what we call the ‘Elite Tech Users,’ who make up one-third of all adults” (Fox, 2008). Similarly, although “social network sites are popular, they are used only sparingly for health updates and queries” (Pew Internet & American Life Project, 2011e). Although these trends will continue to evolve, technology-mediated mes- sages tend to reach those segments of the population that are already highly motivated about their health, therefore leading to “increasing gaps between the health haves and the have-nots” (Dutta, 2009, p. 71) and to the need for

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Table 5.1 Internet and NewMedia Penetration

United States International

Eighty-one percent of US adults use the Internet. • Seventy-onepercent visit video-sharing sites (YouTube/

Vimeo).

• One in three read blogs. • Sixty-nine percent use social networking sites

(Facebook, Twitter, LinkedIn, Instagram, Pinterest).

Ninety-five percent of US teenagers use the Internet. Fifty-three percent of US adults sixty-five and older use the Internet and e-mail. Seventy-two percent of Internet users admitted looking for health information online. Eighty-seven percent of US adults have cell phones.

• Fifty-five percent use the Internet on their mobile phones.

Thirty-two and one-half percent of the world uses the Internet. North America, Oceania, and Europe have the highest Internet penetration. Asia is the leading world region for Internet use. Ninety-six percent of Canadian households own a computer. Africa is becoming a fast-growing mobile market:

• Mobile phone penetration rate of 62 percent in 2011. • Penetration expected to grow to 84 percent by 2015. • Nigeria,Egypt,andSouthAfricaare the fastest-growingmarkets.

Source: GSMA (2011); International Telecommunication Union (2012); Internet World Stats (2012); Pew Internet & American Life Project (2011b, 2011c, 2012a, 2012b, 2013a, 2013b, 2013c, 2013d).

developing adequate strategies to bridge the digital divide, increase overall media literacy, and continue to integrate the use of new media with other health communication areas and channels.

Yet, new media are increasingly used in mass communication and community-based communication. In approaching health communication planning, implementation, and evaluation, it is important to take into account what has changed and what should not change in this new media age so that we continue to stay focused on achieving behavioral, social, and organizational results that ultimately help improve population and community health outcomes.

This chapter focuses on mass media and new media communication as they relate to practical applications for mass communication (a field

mass communication A field of research and practice that is concerned with communication with large segments of the population and the general public, which is also a key action area in health communication

of research and practice that is concerned with communication with large segments of the population and the general public, which is also a key action area in health communication) as well as other kinds of interventions intended for specific communities, populations, and groups. Given the prominence of new media in the twenty-first century, this brief overview identifies key elements of what has changed and what should not change in the new media age (see Table 5.2), and serves as a premise for discussing the relationship among mass communication, multiple kinds of media, and public relations.

HEALTH COMMUNICATION IN THE NEW MEDIA AGE 137

Table 5.2 Health Communication in the Media Age: What Has Changed andWhat Should Not Change

What has changed . . . What should not change . . .

It is an exciting time for newmedia and health communication. Communication environment has become mobile, searchable, customizable, and on-demand. Now is a horizontal media environment in which every reader is a publisher; every click contributes to whether a new idea, product, or service will make or break it. • There is increased participation and real-time feedback from

different groups.

• Online communities provide opportunity for feeling part of a group and help people cope with disease and crisis.

Convergence of computer, Internet, telecommunications, televisual technologies presents users with myriad choices.

• Information overload: There is more total media time but less information time.

Digital divide and computer skills are key factors in health literacy and the ability to navigate health systems.

• Vulnerable populations are still excluded from new media revolution.

• New media is English-dominated; non-English speakers also largely excluded.

Newmedia–based interventions “need to be part of an integrated approach with other health communication areas” (Schiavo, 2008).

• Integration supports effectiveness, expanded reach, and mirrors how people communicate every day.

“A technology-based revolution more than a health communications revolution” (Schiavo, 2008)

• Interventions should still be designed to achieve group- specific behavioral and social objectives.

• Theory- and strategy-driven communication principles should continue to inform newmedia–based interven- tions.

Each key group and stakeholder have specificity, needs, and preferences that are central to intervention design.

• As with other communication areas, evaluation also essential to newmedia–based interventions.

• Need to go beyond counting and tracking and assess real-life effectiveness.

News spreads fast, so do communication hoaxes and cyberbullying.

There are new challenges and opportunities for a variety of key groups and stakeholders.

References: Schiavo, R. “The Rise of E-Health: Current Topics and Trends on Online Health Communications.” Journal of Medical Marketing, 2008, 8, 9–18. Schiavo, R. “E-Health: Current Trends, Strategies, and Tools for Online Health Communications.” Presented at the Office of Minority Health Resource Center, Rockville, MD, Mar. 24–25, 2009a. Schiavo, R. “Health Communication in the NewMedia Age: What Has Changed andWhat Should Not Change.”Workshop presented at Health Equity Initiative, 2012b.

Although many of the topics listed in Table 5.2 are discussed in further detail in the “New Media and Health” section of this chapter and other relevant sections of the book, the table seeks to establish the need to use this exciting new channel strategically and in integration with other kinds of health communication interventions and areas. Newmedia–based interventions should continue tobegrounded in communication theory and rigorous planning frameworks, and, most important, be people-centered. After all, these same mantras apply to all other communication areas, media, and channels, because there is no magic way to promote health and

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social change. This is also relevant for mass communication, a key area of health communication, which relies on public relations strategies and multimedia platforms to communicate with large segments of the US and global populations about health and social matters of public interest.

TheMedia of Mass Communication and Public Relations

In general terms, the basic function of mass communication is to inform, educate, entertain, motivate action, and build community on issues of public interest. As it relates to health and social development, purposeful mass communication is instrumental to creating a favorable environment on new or recurring health issues or social determinants of health, policies, products, and services, which may support and open the way to other kinds of communication areas and activities. In turn, this may motivate people to participate in community events or new social movements, and to adopt new health and social behaviors.

Creating the feeling of “I heard this frommany places” among intended groups and populations is strictly related to the main challenge of mass communication, which is to reach as many people as possible. To do so, communication should rely on common meanings and styles to which large segments of the population may relate. Yet, mass communication is increasingly multicultural and no longer knows geographic boundaries. As mass communication at the global scale has become a recent cultural phenomenon (ISeek Education, 2013), the challenges of finding common meanings have increased and evolved, and so has the demand for a stronger understanding of the theory and practice of mass communication and the specific characteristics and current or potential use of different kinds of media among students and practitioners.

Within and outside health communication, the media of mass com- munication are composed of a strategic blend of what some people may define as “old” media (print, radio, broadcast, entertainment and motion media, which have been evolving over the years and look nothing like “old”) and new media, which include blogs, wikis, videocasts, podcasts, social networking sites, mobile technology, and texting, just to name a few examples. These media are being used in innovative ways across issues and sectors. In this scenario, media literacy—both as consumers and purveyors of media—is an increasingly important skill within most health-related and professional sectors.

PUBLIC RELATIONS DEFINED: THEORY AND PRACTICE 139

Public relations (PR), which is defined as “the art and science of estab- public relations “The art and science of establishing and promoting a favorable relationship with the public” (American Heritage Dictionary of the English Language, 2011)

lishing and promoting a favorable relationship with the public” (American Heritage Dictionary of the English Language, 2011) has been the backbone of mass communication for several decades. Yet, the conceptualization and models of public relations have evolved over time to mirror not only new communication theories and trends but also the characteristics of available media and the evolution of journalism’s standards and practice (Duhe, 2007).

Without any doubt, the advent of new media has also been changing the practice of public relations. If nothing else, as “large, hierarchical entities, tend to lag behind smaller, more nimble organizations in the adoption and applications of new media technologies . . . dominant voices are now accompanied, challenged, and sometimes overshadowed by voices previously marginalized” (Duhe, 2007, p. x). The new media have created an interactive environment in which organizations and their public can tell and compare their stories from beginning to end. Whether relying on mass media, new media, or other communication channels, public relationships continue to be part of the communication process, because there is no way to replace the human factor.

Public Relations Defined: Theory and Practice

The word relationship is fundamental to all definitions of PR as well as their practical applications. As with other action areas of health communication, PR is a relationship-based discipline. Similarly, health care or public health PR is based on an in-depth understanding of its publics as well as their needs, wants, and desires. This overall concept applies to all functions of PR listed and defined in Table 5.3: public affairs, community relations, issues or crisis management, media relations, and marketing PR.

Public Relations Theory Historically, the theoretical basis of PR has been influenced not only by Bernays’s relationship with Sigmund Freud, the father of psychoanalysis, but also by many other observations and models. Nevertheless, some of Bernays’s theoretical assumptions still apply to the modern practice of PR. If you want people to do what you want, “you don’t hook into what they say. You try to find out what they really want” (National Public Radio, 2005), according to Bernays. This concept recognizes the importance of psychological, emotional, and subconscious factors in human behavior, one

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Table 5.3 Public Relations Functions in Public Health and Health Care Public affairs A strategic approach to promote public discussion and, eventually, agreement on health

policies or administrative procedures that may be practiced by a given organization or its key stakeholders and intended audiences…………………………………………………………………………………………………………………………………………

Community relations Anareaof PRpractice throughwhichpractitioners andorganizations establish, cultivate, and strive tomaintainmutuallybeneficial relationshipswith the communities (defined asgroupswithcommonvalues,causes,needs,andsharingthesamegeographic location) that can affect or are affected by their actions. Community relations is one of the many aspects of constituency relations and building (see Chapter Eight) and a component of all other health communication areas…………………………………………………………………………………………………………………………………………

Issues management A multifaceted and “formal management process to anticipate and take appropriate action on emerging trends, concerns, or issues likely to affect an organization and its stakeholders” (Issue Management Council, 2005)…………………………………………………………………………………………………………………………………………

Crisis management A proactive approach based on the advance development of contingency plans and activities to anticipate, avert, and deal with potential crises. It often includes a strong focus on the use ofmassmedia to help organizations ensure their publics that a solution is being implemented and a specific concern or issue is being addressed…………………………………………………………………………………………………………………………………………

Media relations A proactive and reactive approach that aims at interacting with key health journalists, bloggers, and offline and online pundits, and makes “use of the media in a planned way” (Economic and Social Research Council, 2005a). This includes print, broadcast, entertainment, and online journalists, bloggers, and writers…………………………………………………………………………………………………………………………………………

Marketing public relations

An area of PR that focuses on developing strategic programs and relationships that would support endorsement and use of the organization’s health products and services among its key stakeholders and publics.

of the main ideas Freud developed (National Public Radio, 2005; Museum

communities A variety of social, ethnic, cultural, or geographical associations, for example, a school, workplace, city, neighborhood, organized patient or professional group, or association of peer leaders; groups with common values, causes, and needs

of Public Relations, 2005), which is also more recently supported by social norms theory (see Chapter Two).

Some of the theories in PR also highlighted the relevance of psycho- logical aspects of human personality in moving intended groups through the three desirable effects of PR interventions: “attention, acceptance and action” (Smith, 1993, p. 193). For example, some authors advocate the use of the psychological type theory in public relations practice (Smith, 1993). This theory has been primarily used in education, religion, and business to understand and predict “patterns of human interaction” (p. 177). According to Smith, if applied in PR, it could help practitioners tailor their messages to key groups and stakeholders by taking into account their personal psy- chological type and learning preferences. As Table 5.4 shows, Smith (1993) identified four primary types:

ST: Sensitive/thinking SF: Sensitive/feeling NT: Intuitive/thinking NF: Intuitive/feeling

PUBLIC RELATIONS DEFINED: THEORY AND PRACTICE 141

Table 5.4 Characteristics of Psychological Types Relevant to Public Relations

ST SF NT NF

People who prefer . . . Sensing and thinking Sensing and feeling Intuition and thinking Intuition and feeling…………………………………………………………………………………………………………………………………………………………………………… Focus on . . . Facts: What is . . . Facts: What is . . . Possibility: What

could be Possibility: What could be……………………………………………………………………………………………………………………………………………………………………………

Make decisions based on . . .

Impersonal analysis; reason

Personal warmth; emotion

Personal warmth; reason

Impersonal analysis; emotion……………………………………………………………………………………………………………………………………………………………………………

Tend toward . . . Practical and pragmatic

Sympathetic and friendly

Logical and ingenious Enthusiastic and insightful……………………………………………………………………………………………………………………………………………………………………………

Adept at . . . Applying facts and experience

Meeting daily needs of people

Developing theoretical concepts

Recognizing aspirations of people……………………………………………………………………………………………………………………………………………………………………………

Sensitive to . . . Cause and effect Feelings of others Technique and theory Possibility for people

Note: ST: Sensitive thinking; SF: Sensitive feeling; NT: Intuitive thinking; NF: Intuitive feeling. Source: Smith, R. D. “Psychological Type and Public Relations: Theory, Research, and Applications.” Journal of Public Relations Research, 1993, 5(3), 177–199. C Lawrence Erlbaum Associates. Used by permission.

Each of these types has distinct characteristics and learning habits (listed in Table 5.4) that influence their decision-making process, as well as the way they may react to different ways that information is presented (for example, factual information versus information that appeals primarily to emotions).

Although the psychological type theory may be difficult to apply rigorously to actual PR practice (in fact, data on psychological types exist for only select audiences and may be too expensive to collect in a timely and statistically significant manner), keeping in mind the influence of both “reason and sentiment” (Smith, 1993, p. 195) on people’s beliefs and behavior is quite common among PR practitioners. Understanding people’s learning styles and other preferences is part of the process of preparing for the development of a PR program. This is equally important in new media communication in which people’s action (both in sharing information via social networking sites and other media and actually acting on the information being shared) is immediate and messages need to have an emotional and graphic appeal to resonate with the groups we intend to engage and ultimately to be shared on others’ social networks and media.

Similarly, the notion of multiple publics and the need to address them differently in response to their characteristics, needs, desires, and issue- specific beliefs has been historically addressed by PR theory and practice. It is also one of the main assumptions of field dynamics models and methods, which, in their application to PR, attempt to explain the relationship between an organization and its different publics, as well as the mutual

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interaction among such publics. For example, one method describes and compares this interaction in terms of “dominance-submissiveness, friendly-unfriendly, and group versus personal orientation” (Springston, Keyton, Leichty, andMetzger, 1992, p. 81). In practice, when there is public debate about an organization, an idea, a product, or a behavior, it is quite common to find a variety of opinions, levels of involvement (for example, leaders versus followers), and interest and attitudes among multiple audiences. PR interventions often tip the preexisting balance and prompt a shift in the attitudes and opinions of multiple key groups. As a result, they may also change the dynamics of the relationship among such groups.

Within this perspective, PR is considered “the management function that establishes and maintains mutually beneficial relationships between an organization and the publics on whom its success or failure depends” (Cutlip, Center, and Broom, 1994, p. 2). The concept of PR as a relationship management discipline has emerged as a fundamental part of its theoretical basis (Ledingham, 2003) and finds application in actual PR practice. As Center and Jackson (1995) observe, “the proper term for the desired out- comes of public relations practice is public relationships. An organization with effective public relations will attain positive public relationships” (p. 2).

In thenewmedia era, notmuchhas changed in relation toPR’s emphasis on relationships. “Public relations specialistswere someof the first people to embrace the power of socialmedia, and as a result are often the ones leading the way in the social space, whether they are consulting with clients from an agency point of view or strategizing on an in-house PR team” (Swallow, 2010). No matter which tools PR professionals use to connect with media members, most agree and emphasize “the fact that personal relationships will continue to propel the bond between social media and PR,” and also report spending “80% of their time talking with journalists, bloggers and other influencers about issues and macro topics” (Swallow, 2010). In other words, “the critical step has historically been, and will remain, the human element” (Swallow, 2010). Online relationship and reputationmanagement is only one of the many areas in which PR has been reinventing itself and applying the field’s relationship-based theory and practice.

The valueof PRpractitioners to the general public and theorganizations they serve is often determined by the extent and closeness of their contacts with the media and community representatives, as well as other key stake- holders. In this way, PR strategies and activities become a fundamental tool of larger health communication, health care, and public health interven- tions by expanding the reach of health messages as well as using the power of mutually beneficial relationships to advance the discussion and solution of a given health issue. In order to be effective, PR practitioners ought to

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read, understand, and follow their audiences (whether online or offline), and then use the power of mass and new media as well as community relations to talk to and with them. Several other authors or organizations also include PR among communication’s key action areas (WHO, 2003) or recognize, among other fields, the role or influence of PR in health communication and mass communication (Springston and Lariscy, 2001).

Public Relations Practice Although the practice of public relations is less than a hundred years old, PR is now employed by a broad variety of organizations beyond companies that sell products, including universities, foundations, nonprofit organizations, schools, hospitals, and associations. In fact, the official definition of PR by the Public Relations Society of America (PRSA) highlights the widespread use of PR by different types of organizations and the existence of multiple publics from which these organizations “must earn consent and support” (PRSA, 2005b). PRSA (2005b) also notes that “public relations helps an organization and its publics adapt mutually to each other.” In most cases, PR also helps organizations and their publics discuss and eventually come to an agreement on ideas, recommended behaviors, products, or services—a process increasingly common in the newmedia era. In this way, it becomes an essential area of mass and health communication.

Over the past few decades, PR growth has been related to the diver- sification of mass media and its increasing influence on society, with the Internet having a huge impact on the work of PR professionals in the last decade. More recently, social media have pretty much changed the face of PR in relation to some of the tools being used as well as the constant evolution of social platforms and need for connectivity among all of them. New media and social media have kept PR professionals on their toes and fostered an evolution that the PR world seems to have enjoyed (see later sections of this chapter for a discussion of tools and specific media).

Yet, PR strategies have, for the most part, remained unchanged. In the commercial world, PR helps create market share and secure product endorsement and use. In the public health world, it helps create a receptive public environment that can motivate people to change their health or social behavior and act on community needs. In doing so, it provides the public with widespread access to information and helps build support for behavioral, social, and policy changes.

Nonprofit and commercial efforts to feature a specific disease area or health issue sometimes complement each other. For example, in promoting aproduct through themassmedia, companies oftendiscuss other important

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facts, such as awareness about a disease, disease incidence, or risk factors. If the information is based on reputable sources and scientifically relevant data, these efforts may contribute to the disease awareness endeavors of many nonprofit and government organizations in the same field. In some cases (see Box 5.1), corporations have helped tackle a general public health or health care–related problem by providing resources, funds, and programs to elicit interest in the subject.

BOX 5.1. JOHNSON& JOHNSON’S CAMPAIGN FOR NURSING’S FUTURE INITIATIVE

Recognizing that the United States was experiencing the most severe nursing shortage in

history, Johnson & Johnson, a multinational health care company, launched the Johnson &

Johnson Campaign for Nursing’s Future in 2002. This is a multiyear, nationwide effort to

enhance the image of the nursing profession, recruit new nurses, and retain nurses currently in

the system.

Campaign elements have included a national television, print, and interactive advertising

campaign in English and Spanish celebrating nursing professionals and their contributions to

health care; a multifaceted and highly visible public relations campaign with press releases,

video news releases, and satellite radio tours available to hundreds of media outlets across

the country; recruitment materials including brochures, pins, posters, and videos in English

and Spanish distributed free of charge to hospitals, high schools, nursing schools, and nursing

organizations; fundraising efforts for student scholarships, faculty fellowships, and grants to

nursing schools to expand their program capacity; celebrations at regional nursing events to

create enthusiasm and feelings of empowerment among local nursing communities; a website

(www.discovernursing.com) about the benefits of a nursing career featuring searchable links to

hundreds of nursing scholarships andmore than one thousand accredited nursing educational

programs; and activities to create and fund retention programs designed to improve the

nursing work environment. Numerous organizations, including the White House, with the

Ron Brown Award for Corporate Leadership, the American Hospital Association, the American

OrganizationofNurseExecutives, theNational StudentNursesAssociation, theAmericanNurses

Association, and NurseWeek, have honored Johnson & Johnson for this campaign and their

overall contribution to addressing the current nursing shortage.

Key Outcomes*

• Forty-six percent of eighteen- to twenty-four-year-olds who participated in a 2002 Harris Poll survey recalled the campaign.

• Sixty-two percent had discussed a nursing career for themselves or a friend. • Twenty-four percent of the respondents in this group said the campaign was a factor in

their consideration.

PUBLIC RELATIONS DEFINED: THEORY AND PRACTICE 145

• The discovernursing.com website traffic has tallied over three million unique visitors, spending an average of twelve to fifteen minutes exploring the site.

• Surveys show that recruitment materials are being used by 97 percent of high schools and 73 percent of nursing schools.

• Eighty-four percent of nursing schools that received the materials reported an increase in applications and enrollment for the fall 2004 semester.

• The campaign has raised over $8 million [up to the date of this case study] at regional fundraising events. These funds have been used to provide scholarships to thousands of

nursing students and nurse educators and have been complemented by more than one

hundred Johnson & Johnson grants to area nursing schools to help them expand their

program capacity and, therefore, accept more students.

• TheAmericanAssociation of Colleges of Nursing reported that baccalaureate nursing school enrollments have seen double-digit increases every year since the launch of the campaign

in 2002.

Key Success Factors

• Relevance of the issue to Johnson & Johnson’s key publics as well as the community at large and organizational competence to address it

• Strong relationship-building effort in support of the campaign with organizations including health care systems, nursing schools, and professional associations around the country

• Multimedia strategy with consistent messages in broadcast, print, publicity, special events, printed materials, videos, and the Internet

∗Outcomes include only results that had been analyzed at the time this case study was developed.

Source: Johnson & Johnson. “Campaign for Nursing’s Future Initiative.” Unpublished case study, 2005b. Used by

permission.

Although the issue of partnerships with commercial entities will be discussed in Chapters Eight and Thirteen as part of the broader subject of partnerships in health communication, it is worth mentioning here that many reputable nonprofit and government organizations, including the US National Cancer Institute (National Cancer Institute at the National Institutes ofHealth, 2002), consider collaborations or partnershipswith for- profit entities. In doing so, many of them have developed strict guidelines and criteria that help them protect the public interest and avoid endorsing specific products or services (see Chapter Eight).

PR practice must be held to high ethical standards. The ongoing debate on PR ethics and related dos and don’ts is legitimate and should never be

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abandoned. However, although it is fair to assume that themainmotivation of any industry is profit, it would be unfair to think that all companies would go to any length to sell their products.

Media power, on which PR relies, can be abused if facts are misrepresented or inflated. However, in the battle for free media coverage and the high number of social media followers, this is a risk that the general public may encounter with a variety of organizations (even those with the best intentions) if they become too enamored with an idea or the opportunity to raise their own profile and visibility. Because of the nature of their profession, PR practitioners need to meet the challenges of serving their client’s interests (whether their client is a business, a nonprofit, or a government organization) while preserving an honest and ethical relationship with the publics they cultivate and address. Most professional societies in this field, including the PRSA (2005a), have a comprehensive code of ethics for their members.

Table 5.5 lists some of the key characteristics of ethical PR programs. Many of them are common sense but should always be considered in designing and implementing a multimedia PR campaign.

In addition to promoting public discussion of ideas, policies, services, or behaviors, PR also contributes to increasing the visibility of nonprofit organizations, commercial entities, and other kinds of institutions, aswell as their mission, activities, and spokespeople. This is a fundamental function of PR that helps establish organizations and their experts as leaders in a field. Together with other kinds of activities, PR helps them gain the favorable reputation and the public respect that are needed to have an impact on behavioral and social change, as well as to encourage others to join the debate on a health issue and its potential solutions.

As an example of PR activities reaching out to multiple publics, Box 5.2 shows the media and public relations page of the website of the Schepens Eye Research Institute, an affiliate of Harvard Medical School.

Table 5.5 Key Characteristics of Ethical Public Relations Programs Based on research……………………………………………………………………………………………………………………………………….. Feature reputable and scientifically relevant facts and figures……………………………………………………………………………………………………………………………………….. Strive to maintain an honest and direct relationship with the publics they address……………………………………………………………………………………………………………………………………….. Adhere to general ethical principles such as identifying sources, conflicts of interest, and grant disclosures……………………………………………………………………………………………………………………………………….. Seek to establish trusting and long-term relationships between organizations and their publics and therefore discourage unethical approaches that may harm relationships……………………………………………………………………………………………………………………………………….. Include standard procedures to promptly correct potential mistakes and misinformation……………………………………………………………………………………………………………………………………….. Encourage free information exchange and seek to engage different publics……………………………………………………………………………………………………………………………………….. Preserve the public interest

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The page includes information that helps position the institute as a resource for the media about eye diseases and related research and treatment news. By providing resources on the institute’s history, mission, and activities, as well as the background and expertise of its faculty and spokespeople, the page appeals to journalists and bloggers in search of story ideas and resources on the subject, and experts interested in authoring guest edi- torials and blogs, and also provides news to feature on social media. In addition, it appeals to many different key groups and stakeholders (for example, health care providers, professional organizations, patient groups) that may have an interest in this field and may want to engage in collabo- rations or just participate in the public debate on eye disease research and treatment. Recently, this page, located at www.schepens.harvard.edu/news room/newsroom/newsroom.html, has evolved to include a much more comprehensive news section with posts that can be easily shared on dif- ferent media, versus the traditional press releases that were more often featured until 2011.

BOX 5.2. USING THE INTERNET AS A KEY PUBLIC RELATIONS CHANNEL:

THE SCHEPENS EYE RESEARCH INSTITUTE

Source: Schepens Eye Research Institute. “Media and Public Relations.” 2003. www.schepens.harvard.edu/news

room/newsroom/newsroom.html. Used by permission.

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PR Versus Advertising: The Differences Media coverage as well as the virality level and the number of social kudos of a post stemming from PR campaigns is free of charge, but placing a story requires an in-depth understanding of the media, journalists, bloggers, influentials, and audiences among PR practitioners and the organizations they represent. For example, faced with countless choices for story ideas, journalists select what they cover primarily on the basis of newsworthiness, which is what they think their audiences may find interesting (Fog, 1999; De Nies and others, 2012). Other parameters include level of comfort or knowledge about the topic, the way the information is framed and presented to them, and the relationship they have with their sources, such as PRpractitioners, organizations, andpoliticians. In this highly competitive environment, achieving national media coverage is a major endeavor.

In the new media era, PR practitioners can borrow from advertis- ing its experience in creating visual opportunities for complex concepts. Although PR practitioners already work in multidisciplinary teams includ- ing graphic designers and web and newmedia developers, further emphasis on advertising techniques may help increase people’s ability to connect and identify with new media sites and information via the power of imagery and evocative taglines.

Yet, the success of new media–based communication interventions is linked to several research- and relationship-centered factors, which are grounded in health communication and PR theory and practice and include the following actions (Schiavo, 2008; Kamateh, 2013):

• Identify groups who have an interest in your specific health issue and research what kinds of social media they usually engage with. This would increase opportunities for public debate and engagement on the topic of interest as well as to make sure you reach the people you intend to reach.

• Create multiple opportunities to share the information by making it easy to share and posting it on multiple platforms that are also linked with each other.

• “Identify campaign ambassadors” (Kamateh, 2013) by encouraging new media partners, bloggers, and others in your network to share information on their own social media. Alert them in advance of the campaign and send them relevant links at launch and throughout the campaign.

• “Encourage message co-creation” by identifying opportunities for the groups you seek to engage “not only to repost your materials but

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convey the message in their unique and perhaps more relatable way” (Kamateh, 2013). Take into account that this is not very different from the other communication areas discussed in this book in which the role of influencers and community leaders has a major impact on the trust, significance, and transparency of all communications.

• Use an integrated approach that relies on a variety of media and communication settings and areas to maximize impact.

• Go beyond tracking and counting in evaluating results. Create mea- surable behavioral, social, and organizational objectives for all inter- ventions.

• Update your media frequently to continue to engage online commu- nities.

Whether offline or online, PR is a less controlled but more credible way to approach the media than advertising. In advertising, organizations pay for the print, online, or broadcast space to place their ads, so the media have no editorial power on the ad content. The ad content is immediately recognized and identified with a specific health organization by the media’s audiences. In PR, the media placement is free of charge, but its final tone and content are determined by the journalist or the new media publics who author or contribute to the story. In the absence of breakthrough news, achieving media coverage using PR strategies is not easy and requires strategic efforts and tools, long-term relationships with the media, and a true understanding of the concept of newsworthiness and community engagement, as well as the ability to track online communities and listen to their needs, concerns, and preferences.Most important, it requires patience and perseverance.

Mass Media, Health-Related Decisions, and Public Health

No one can dispute the power of mass media. Part of this power stems from the media’s influence on public opinion and everyday decisions. Often the general public views the mass media as an objective source of information. Another important factor is related to the media’s relationships with important decision makers and stakeholders around the world, including governments and multilateral organizations as well as the nonprofit and business sectors. In addition to the entertainment appeal of themedia, both of these factors have contributed to the increasing power of themassmedia.

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In the Internet era—andmore specifically in theUnited States, Canada, and several countries in Europe—mass media also include websites, blogs, online libraries, magazines, and journals, prerecorded webcasts and pod- casts, and all other information-related functions of the Internet. In these contexts, health information–seeking behavior has dramatically changed since the advent of the Internet, which is functioning as other established mass media. For example, in the United States, eight out of ten (80 per- cent) of Internet users look online for medical or health information (Pew Internet & American Life Project, 2011c). Similarly, more than one-third of Canadian adults searched for health information online (Underhill and Mckeown, 2008), with these numbers continuing to increase. As previously discussed, this does not apply tomany disadvantaged and lowhealth literacy groups in both developed and developing countries, and therefore supports the need for a research-based approach to health communication planning, which includes the selectionof adequate group-specificmedia andchannels.

Yet, becausemassmedia are themain channels ofmass communication, competition formedia coverage and to stand out in the online space is quite fierce. People rely onmassmedia as their main source of news and informa- tion, and their health, political, and life choices are increasingly conditioned by what they hear or read. For example, a well-documented impact of the Internet is on the quality and nature of patient-provider communications, because the Internet has enabled additional patient participation in clin- ical settings and decisions (Pew Internet & American Life Project, 2007). Similarly, mass media campaigns that use other kinds of mass media, more specifically television, radio, and newspapers, have been shown to produce positive changes or to prevent negative changes within the context of health-risk behaviors (for example, “use of tobacco, alcohol, and other drugs, heart disease risk factors, sex-related behaviors, road safety, cancer screening and prevention, child survival, and organ or blood donation”) across large populations (Wakefield, Loken, and Hornik, 2010, p. 1261).

One of the major accomplishments of many successful organizations from a variety of sectors, other than the programs, services, or goods they manufacture and provide, is the success of their advertising and media coverage efforts as well as their online reputation and reach, which helps strengthen their credibility and stake on key issues and increase their visibility. In public health, the media can influence people’s perception of disease severity, their views about the potential risk of contracting the disease, or their feelings about the need for prevention or treatment. Media coverage can also affect what people eat or do in their leisure time. It can help reduce the stigma associated with many diseases or break the cycle of misinformation and silence about health conditions that are underdiag- nosed, undertreated, or underreported. It can help convince policymakers

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to develop new prevention or treatment policies or address specific social determinants of health to benefit large segments of the population.

In summary, especially in the United States and most of Europe, where there is a widespread media culture, mass media can have an enormous impact on people’s health behaviors. The typical American watches over thirty-five hours of TV every week (Nielsen, 2010). Also, Americans spend an average of thirty-two hours amonth online versus sixteen hours amonth globally (GoGulf, 2012). People do not see their best friends that often, so the media may become more influential than actual people.

Massmedia campaignshaveproven tobe effective inhelping to increase immunization rates (Porter and others, 2000; Paunio and others, 1991), vaccination knowledge (McDivitt, Zimicki, and Hornik, 1997), cervical cancer screening among Hispanic women (Ramirez and others, 1999), people’s ability to cope with disease (Pew Internet & American Life Project, 2007), and dieting and fitness regimens (Pew Internet & American Life Project, 2007). The list of media influences (positive or negative) on health beliefs and behaviors is enormous. Most important, mass media have been defining the concept of health and fitness by bringing into everyone’s homes seductive images ofmen andwomen, such as healthy and fit celebrities with whom average people would like to identify. Sometimes these images are used for the right purpose (for example, encouraging people to exercise or remember their annual medical checkup), but at other times they promote unhealthy behaviors such as smoking. The power of mass media is such that not everyone can understand what is really behind a seductive image and make the right health decision.

Vulnerability to the power of themassmedia and some of the unhealthy behaviors the media may consciously or subconsciously promote is related to many factors, including educational level, prior knowledge, or experi- ence on the subject, age, socioeconomic conditions, personal experience, psychological status, and health and media literacy. For example, in 1998, recognizing the vulnerability of young adults and adolescents to media messages that encourage smoking, the US government limited forms of advertisement or PR activities that would directly target this age group with positive messages on smoking (Centers for Disease Control [CDC], 1999; Advertising Law Resource Center, 2006). Similarly, in many countries, direct-to-consumer advertising is prohibited for prescription drugs and other kinds of products that are used for the treatment or prevention of serious diseases (DES Action Canada and Working Group on Women and Health Protection, 2006; Mintzes and Baraldi, 2006; Ventola, 2011).

This brings us back to the discussion on the ethics of PR as well as the importance of following the code of ethics highlighted by many professional societies, keeping in mind the suggestions in Table 5.5.

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Fortunately, most PR practitioners think that preserving the ethics of their actions is in the best interest of their own practice as well as the publics and organizations they serve.

Dos and Don’ts of Media Relations Interacting with the media is an acquired skill. Because of limited time and conflicting priorities, journalists do not like to be approached by people who sound incompetent about the story they are trying to place or show little awareness of the media industry and its rules. This also applies to news websites and popular blogs in search of guest bloggers or information on an issue of interest. It is not very different (other than the format of the tools being used) to pitch theHuffington Post (www.huffingtonpost.com), a very popular US news website, content aggregator, and blog, which covers US politics, entertainment, style, world news, and comedy, than pitching a popular newspaper or television station. It requires the same understanding of what they may be interested in covering, the right contact person at the selected media outlet, and ultimately a great and newsworthy story.

In an attempt to help junior PR practitioners approach the media in the way the media want to be approached, several professional societies, including the Public Relations Society of America, organize workshops and lunch meetings in which journalists speak about their daily routine, their preferred communication channels (for example, e-mail, telephone, social media), and the kind of health issues and stories they may be interested in covering. More recently, such events also include popular bloggers and journalists from online news websites so that PR practitioners can develop relevant skills. Because PR is increasingly recognized as an important skill in public health as well as a key area of health communication, one of the sessions of the 2005 annual meeting of the American Public Health Association focused on media advocacy and featured journalists from broadcast and print media who discussed the dos and don’ts of media and press relations with public health professionals.

In approaching the media, it is essential to remember that they are just another audience, so it is important to know them well. Because of their influence on many of the publics of PR and larger health communication interventions, knowing them and understanding how to spur their interest in a story and its core messages is even more critical than with many other audiences.

The average US reporter now receives approximately two hundred e-mails each day, and some receive as many as five hundred per day (101PublicRelations, 2005). “Their Twitter networks churn out an endless stream of updates, links, and photos. Their RSS (really simple syndication)

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feeds offer innumerable stories from their favorite blogs and websites” (Phillips, 2012). Also, given recent changes in the media industry, some journalists who work in some kinds of media outlets (for example, print media) are gradually being replaced by online reporters and therefore work within limited human resources settings. They have time to read only a small portion of their e-mails, and usually it is the first few lines. The media pitch—defined as a brief summary statement or e-mail message that

media pitch A brief summary statement, letter, or e-mail message that explains why a piece of information is new, relevant to a journalist’s intended audience, and worth covering

explains why the information is new, relevant to the journalist’s intended audience, and worth covering—should be the focus of these first few lines. Only stories that stand out for their newsworthiness and relevance to the publication’s audience are actually published; each reporter files no more than one to three stories on any given day.

Using the mass media to publicize the core messages and activities of a larger health communication or public health intervention can help expand the reach of the program to different key groups and publics. It can also help create a critical mass in support of the recommended health behavior or social change. However, getting there, and seeing a story published, is a process in itself. Once the first stories are published, it is still important to secure ongoing attention from multiple media to reach new audiences or reinforce the message over time. Table 5.6 highlights some of the dos and don’ts of media relations as they apply to more traditional mass media (print, broadcast, and radio) and online media sites and outlets. All of them are based on PR practice. Others may apply to specific situations, countries, reporters, or media channels.

What Makes a Story Newsworthy The concept of newsworthiness is strictly related to the preferences, needs, and interests of the intended audience of a given publication or media outlet. For example, it is not a surprise that most parenting magazines in the United States and Europe dedicate a lot of space to stories on babies or toddlers and their sleeping habits. Sleep deprivation is a common problem among new parents as well as parents of toddlers who struggle to teach their children how to go to sleep on their own and stay asleep for the entire night. Parentingmagazines and other consumer publications perceive the topic as something that sells the magazine to their audience. In fact, in 2005 alone, there were at least seventy-four articles on “getting your baby to sleep” or related topics in different kinds of consumer publications (LexisNexis, 2006). Over time, “babies and sleep” continues to be a popular topic with at least seventy-eight articles in US magazines and newspapers from January 2012 to April 2013 (ProQuest, 2013).

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Table 5.6 Dos and Don’ts of Media Relations

DO DON’T

Identify the names and interests of journalists, bloggers, or online reporters who usually cover health generally or specific health topics Establish long-term relationships or cultivate media interest in a specific topic by posting frequently on media they may follow Be aware of reporters’ and bloggers’ deadlines and respond in a timely fashion Be polite, accurate, and helpful, and most important, responsive; for example, prime time on television fills up quickly, so reply as fast as you can Understand why reporters are calling; determine whether they are seeking to quote you, do they want only a background briefing (Economic and Social Research Council, 2005a), or do they want to ask you to author a guest blog or a piece for a news site Make yourself available for a few days after issuing any kind of news Make sure all partners in your program are aware of their media- related roles and responsibilities (Economic and Social Research Council, 2005a) Media train key spokespeople Use media tools that are specific to the kind of media and can be easily shared offline and online Learn when reporters are on deadline and don’t call at that time Read the news (online and offline) and relevant blogs; it is the best way to understand the media and what they may cover

Waste reporters’ or bloggers’ time by pitching them randomly regardless of their specific interests Use jargon or technical terms in writing news pieces and speakingwith reporters (EconomicandSocialResearchCouncil, 2005a) Agree to disclose information off the record unless you have a special relationship with a reporter; you are always at risk of seeing that information in print Call repeatedly or leave multiple voice messages or send multiple e-mails on the same topic

Sometimes newsworthy topics for specific publications can be found in the publication name. For example, the Chapel Hill News (both online and print versions) looks primarily for stories that appeal to the residents of Chapel Hill, North Carolina. Infectious Diseases News includes breaking news, editorials, and feature articles that appeal primarily to infectious disease specialists, and also to other health care providers (for example, family physicians, pediatricians, and internal medicine specialists) who are involved in preventing and managing infectious diseases among their patients. The type of media (print, radio, television, or online publications) influences the concept of newsworthiness as well.

Understanding the relevance of a story to the media’s intended audi- ences is only the first step in definingwhether the storymay be newsworthy. Many other criteria need to be met to maximize the chances for media coverage of an organization’s data, information, and messages:

• The story’s time line: it just happened or is about to happen

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• The existence of new data or information from clinical trials, opinion surveys, and other kinds of studies and their potential impact on the media’s intended publics

• The presentation of these new data or information at a major profes- sional, community, or interdisciplinary meeting or their publication in a prestigious peer-reviewed journal, which would legitimize the public impact and relevance of the information

• Reputable spokespeople, such as opinion leaders (for example, top physicians, researchers, and community leaders), top executives, ath- letes, or other celebrities who appeal to themedia’s intended audiences

• A new angle to a story of current interest or to an issue that has not been covered for a while; reading the news is the best way to find new media hooks

• Human interest stories, such as the testimonial of a mother who decided not to immunize her child who then died or almost died of a vaccine-preventable disease or the personal story that is behind a celebrity’s endorsement of a specific cause

• The announcement of a new large program or event for the media’s intended audiences and either providing a unique health-related ser- vice or social benefit or conveying big names in the field

• The use of appropriatemedia tools, which are developed to create con- nections and to reach and engage intended groups, whether virtually or offline

The following PR tools are the ones most commonly used for mass media communication.

• Press release: A written announcement of an event, program, or other newsworthy items for distribution to the media. It includes information on the details of the event, program, or news item and the organization that issues the press release; facts and data on the topic being featured; telephone and e-mail of a media contact person; and the name and credentials of an expert or celebrity spokesperson to interview. In the new media era, press releases are often substituted by virtual newsrooms (see, for example, Cooney Waters Group,

virtual newsrooms Dedicated webpages where the event announcements or other newsworthy items are linked to videos and other resources that can help reporters, online newsletter editors, and bloggers write the story or just link to it

2013), dedicated webpages where the announcement is linked to videos and other resources that can help reporters, online newsletter editors, and bloggers write the story or just link to it. In some other cases the announcement is featured in the news or media section of the organization’s website. Yet, copies of press releases and other

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information are still being sent as PDFfiles to some reporters. Although in the United States and many other countries the emphasis is on making sure that the news release is sharable on a variety of social media, standard techniques to approach reporters and online gurus to secure media coverage are often country- and media-specific.

• Media alert: A one-page announcement including information on the what, when, where, and who of a specific event and the telephone number and e-mail address of a media contact. It is used for media distribution to announce press conferences, speakers’ availability for telephone interviews, and program kick-off events, for example. This is often included as part of the virtual newsroom in the newmedia era.

• Op-ed article: A signed article expressing a personal opinion and the viewpoint of a specific group or organization. It is usually published on the page opposite the editorial page of a newspaper and is targeted to one publication and not sent to multiple publications simultaneously. In the online space, the equivalent of an op-ed article is often a guest blog or an opinion piece submitted to a news website.

• Public service announcement:Noncommercial advertising for distribu- tion to radio, broadcast, or print media that includes information and a call to action for the public good. The format varies to accommodate the characteristics of print, radio, online, and broadcast media. It can also be sent to multiple media outlets for free and unrestricted use.

• Radio news release: The radio version of the press release, sent to radio stations for free use, and lasting forty-five to sixty seconds. It includes a sound bite from one of the PR program’s spokespeople. In developing countries, where community and national radios are still one of the most valuable communication channels in terms of audience reach and influence, radio news releases are still widely used for a variety of health communication programs. Their use is now less frequent in the United States and other Western countries.

• Radio actuality: A recorded segment of a speech, statement, or other speaking engagement. It can be posted online or distributed as a media file to relevant radio stations. “Usually, the biggest news stations will not use actualities, as they consider them spoon-fed news. Some of the smallest stations do not have the equipment necessary to record actualities over the phone. This leaves a large number of mid-sized stations to target for actuality distribution” (Families USA, 2013).

• Video news release: A video segment designed in the style of a news report and distributed to local and national television and cable

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networks for free and unrestricted use. It is rarely used in the United States but remains somewhat common in some European countries. Media outlets often use only portions of the release.

• B-roll:A series of video shots on a specific topic, packaged in the format of unedited material (footage) and distributed to local and national televisions and cable networks. It is sometimes used in the United States to pitch a story to local TV news shows.

• Mat release: A ready-to-use feature story, usually including a photo- graph or some artwork, for distribution to community newspapers and other local and smaller publications. Digital mat releases are designed for online outlets and include backlinks to additional infor- mation and the source’s website. Mat releases are designed to be easily incorporated in print or online news outlets.

Selecting the right tools for targetmedia is not an optional step. Because all of these tools are designed to facilitate the reporter’s or blogger’s job and make it easy to cover the story, using the wrong tool sends a negative message to the media about the source’s knowledge of the media industry and, potentially, his or her level of competence in the issue at hand. Table 5.7 identifies the mass media channels and most common PR tools used to address each of them specifically.

NewMedia and Health

Young professionals just completing their studies or entering the workforce have never known a world without the Internet and, in most cases, new media. This is an important point to reflect on when we think about whether or not to include new media as part of health communication interventions in the public health, health care, or community development fields. The answer is an unmistakable yes!

Newmedia have changed the way we think about connecting with each other and are increasingly playing an important role in public health, health care, and community development interventions. They have broadened the traditional and more elitist notion of expert knowledge, connected people across disciplines and created collaborations beyond traditional geographic boundaries, enabled the development of strong online communities that help people copewith specific situations or just do their job better andmore effectively, and, depending on the issue and specific groups, also contributed to raising awareness of health and community development issues.

The opportunity new media provides to create groups and commu- nities that share the same interest in health or social topics has been

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Table 5.7 Mass Media Channels and Related Public Relations Tools

Media Tools

Print media (for example, national newspapers, magazines)

Press releases, op-ed articles, letters-to-editor, print public service announcement, media alerts………………………………………………………………………………………………………………………………………..

Radio (local and national radio stations) Radionews release, radiopublic serviceannounce- ment, radio actuality, media alerts, live interview with expert (by telephone or in a studio)………………………………………………………………………………………………………………………………………..

Broadcast (national and local TV stations) Press release, video news release, B-roll, pub- lic service announcement, media alerts, and videos—often packaged as part of virtual news- room on a dedicated page………………………………………………………………………………………………………………………………………..

Local publications and community newspapers Mat release……………………………………………………………………………………………………………………………………….. Online news websites Virtual newsrooms (including press releases or

news announcements, media alerts, video or audio files, and other relevant documents), opin- ion pieces (guest blogs, opinion pieces on news website), public service announcements, digitized mat releases, audio and video files (including podcasts, webcasts, and so on)

influencing not only information-seeking behavior but also treatment and research efforts in many areas. For example, “online patient groups have become an increasingly powerful voice . . . raising funds for research, and offering patient information and support. As the cumulative power of the membership grows, these groups are becoming invaluable partners to researchers and physicians searching for a cure” (Wall Street Journal, 2007). New media use is growing among a variety of different professional, patient, voluntary, and advocacy organizations, as illustrated in Table 5.8, which includes sample—and ever evolving—uses of the Internet and new media by health organizations.

Yet, are the new media the new magic tools? In this case, the answer is an unmistakable no! Although new media (and generally, the Internet) have created great opportunities for an increased democratization of the knowledge-sharing process and have changed power levels in many con- texts, both online and offline (including the patient-provider setting), they have also presented professional and lay communities with a variety of seri- ous challenges and, too often, hidden roadblocks and pitfalls. Think about themanypeoplewho, becauseof their lackofmethodological trainingor low health literacy status, may not know how to discern between real and mis- leading or fake data; or struggle to decidewhether they should followdieting and fitness advice from the American Dietetic Association—which bases

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Table 5.8 Most Common Uses of the Internet and NewMedia by Health Organizations Professional health organizations Voluntary, patient, and advocacy organizations

Continuing medical education (CME) Virtual support groups for patients and family caregivers………………………………………………………………………………………………………………………………………..

Professional networking Community building and organizing……………………………………………………………………………………………………………………………………….. Dissemination of new health policies and standards of care

Volunteer recruitment

……………………………………………………………………………………………………………………………………….. Online publications and reports Disease profiling and risk assessment tools

Publicity of ongoing activities, programs, events (online and offline)……………………………………………………………………………………………………………………………………….. Disease-specific resources……………………………………………………………………………………………………………………………………….. Organizational visibility……………………………………………………………………………………………………………………………………….. Media and press relations………………………………………………………………………………………………………………………………………..

Advocacy……………………………………………………………………………………………………………………………………….. Fundraising

Source: Adapted from Schiavo, R. “The Rise of E-Health: Current Topics and Trends on Online Health Communications.” Journal of Medical Marketing, 2008, 8, 15, Table 2.C Palgrave Macmillan, LTD. Used by permission.

its recommendations on lessons learned from research and clinical results among many people—or the Amazing Adventures of Dietgirl, which is a valuable one-person anecdotal experience that may not work for all, given the complexity of people’s body build, health status, or concurrent health conditions, social support levels, just to name a few reasons. Think about the opportunities newmedia have created for hoaxes, self-publicity, and instant celebrity, even when information or celebrity status may not be deserving attention and aims to trick people into buying harmful products or services.

Most important, think about the digital divide among the haves and have-nots because of differences in computer skills, access to new technol- ogy, and health and new media literacy. Technological advances may help reduce health disparities through the potential to make information avail- able to all, advocate for access to important services (within and outside health care), and support partnership building and management. However,

when new information is delivered indiscriminately via the mass media, it is acquired at a faster rate among those of higher socioe- conomic status. . . . Given that the wealth gap between white and non-white is widening, with the median wealth of white households now twenty times that of non-Hispanic black households and eighteen times that of Hispanic households, research is needed to examine the processes which give rise to communication equalities. . . . Given the constant evolution of the media landscape, comprehensive efforts will

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be needed to ensure that all groups are benefiting equally from health messages on the internet. If not, the rise of new media may serve only to exacerbate already apparent disparities in health. (Richardson, 2012) Although an important function of health communication interven-

tions is, or should be, to address and enhance health literacy and newmedia skills among underserved and vulnerable populations, the tension between the pace of capacity-building efforts on health and new media literacy and the advent of new technology will continue to exist for the foreseeable time. In other words, many disadvantaged groups may not be able to keep up with the pace of technological progress at all times. These are just some of the arguments in favor of continuing to use new media in integration with other communication areas, strategies, and activities so that our efforts will not only be more inclusive of cultural preferences and group-specific needs but will also mirror the way communication about health and illness actually happens: via myriad interpersonal, community, professional, mass media, and new media channels in a variety of settings.

Other authors have pointed to many of the lessons learned from Barack Obama’s campaign to become the forty-fourth president of the United States of America, and how these lessons may be relevant to public health or health care communication theory and practice. Obama’s cam- paign strategy, which relied heavily on new media, was able to rally an unprecedented level of public engagement that translated to donations, volunteers, and the kind of excitement in intensity and numbers not seen too often in US politics. In analyzing the campaign, although recognizing that very few public health campaigns may be funded at the same level as Obama’s presidential campaign, Abroms and Lefebvre (2009, p. 420) high- lighted the following take-away messages for public health interventions that use new media:

• Consider new media—social network sites, uploaded videos, mobile text messages, and blogs—as part of a comprehensive media mix.

• Encourage horizontal (i.e., peer-to-peer and social network) com- munications of campaign messages as social influence and mod- eling are important drivers of behavior.

• Embrace user-generated messages and content, especially in the case where top-down campaign messages are straightforward and translatable by the public.

• Use new media to encourage small acts of engagement. Small acts of engagement are important for relationship building and can

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lead to larger acts of engagement in the future. Additionally, small acts of engagement can have effects that ripple throughout a social network.

• Use social media to facilitate in-person grassroots activities, not to substitute for them.

Perhaps the most important lesson learned from the Obama campaign was the campaign’s ability to translate online engagement into offline action. This leads to another take-away message:

Make sure that the online and offline worlds actually support each other’s efforts via integrated and synergic activities and strategies that maximize their combined or individual impact.

So, we are back to the importance of integrating different action areas, strategies, activities, and channels of health communication. In doing so, it’s important to stay abreast of newmedia current use and future potential as well as factors that contribute to use and perceptions of new media tools among different groups, because these influence or should influence the selection of new media channels for specific health communication interventions (see Table 5.9 for sample factors in the public’s perception and use of new media–specific tools). As an example, Box. 5.3 includes information on a program that integrates different kinds of media and action areas.

Table 5.9 Sample Factors in Public Perception and Use of NewMedia–Specific Tools Task appropriateness……………………………………………………………………………………………………………………………………….. Organizing strategies; ease of navigation……………………………………………………………………………………………………………………………………….. Message content and complexity……………………………………………………………………………………………………………………………………….. Adequate health literacy levels and cultural competence of all information……………………………………………………………………………………………………………………………………….. User attitudes toward technology and newmedia literacy……………………………………………………………………………………………………………………………………….. Frequency of use of specific newmedia among key groups……………………………………………………………………………………………………………………………………….. Format, presentation style, visual appeal……………………………………………………………………………………………………………………………………….. Stage of illness……………………………………………………………………………………………………………………………………….. Size and composition of network and online community……………………………………………………………………………………………………………………………………….. Visibility of information, specific topic, organization……………………………………………………………………………………………………………………………………….. Level of comfort of your organization and partners with specific newmedia tool……………………………………………………………………………………………………………………………………….. Feasibility for integration with other communication areas and services……………………………………………………………………………………………………………………………………….. Can this be tailored to meet the needs of the end user?

References: Schiavo, R. “The Rise of E-Health: Current Topics and Trends on Online Health Communications.” Journal of Medical Marketing, 2008, 8, 9–18; George Mason University. “Review of Literature: Impact of Interactive Health Communications.” F. Alemi (ed.). 1999. http://gunston.gmu.edu/healthscience/722/Review.htm.

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BOX 5.3. SPORTS FOR HEALTH EQUITY: AMULTIFACETED NATIONAL PROGRAM

Health disparities continue to compromise the ability of vulnerable and underserved com-

munities across the United States to thrive. These disparities are linked to diverse factors,

including socioeconomic conditions, race, ethnicity, and culture, as well as access to health care

services, affordable and nutritious food, culturally appropriate health information, caring and

friendly clinical settings, and a built environment that supports physical activity. Communities

with greater disparities experience higher rates of infant mortality, higher incidence of several

diseases and health conditions, and lower life expectancy.

Any progress toward health equity is predicated on raising awareness that these inequities

exist. Studies have shown that there are low levels of awareness among racial and ethnic

minority groups regarding disparities that disproportionately affect their own communities

(Benz, Espinosa, Welsh, and Fontes, 2011), and that there have only been very modest gains in

awareness in the last decade among all Americans, despite the national goal to reduce health

disparities introduced by Healthy People 2000 and reemphasized by Healthy People 2010 and

Healthy People 2020. There is an urgent need for innovative approaches to educate people

about health disparities and encourage them to talk about health equity in their communities

with the goal of assessing their own health-related needs and working together across sectors

to achieve key changes.

Goals and Objectives

Sports for Health Equity is a national program launched in late 2012 by Health Equity Initiative

(HEI), a nonprofit organization, to raise awareness and promote community action about health

equity. The program uses sports as its central theme to engage young people and members

of their communities. The campaign has featured Essence Carson, WNBA All Star, NY Liberty

player, recording artist, writer, and producer as its Sports for Health Equity ambassador. The

program’sgoal is to increase theawareness andunderstandingof health equity, including social

determinants of health and how health disparities can negatively affect socioeconomic status

and opportunity, among teens, their families, their communities, and the general public. Other

key objectives include encouraging healthy behaviors and lifestyles and promoting youth as

key agents of change. The project aims to create increased community action on health equity

and to enable multiple sectors to join forces to develop long-term sustainable solutions to

reduce health disparities.

Communication Strategies and Activities

The campaign employs a multifaceted approach to enlist students, their families, teachers,

coaches, communities, community-basedbusinesses, andorganizations andprofessionals from

multiple sectors in the health equity movement. Current and future activities have included or

may include in the future a national media campaign to help create a receptive environment

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for community-based dialogue on health equity, awareness-raising basketball shoot-a-thons at

middle schools and high schools, virtual and community town hall meetings on health equity

and neighborhood involvement, a turnkey kit on how to organize a community town hall, a

pledge campaign that will encourage families to talk about health equity issues around the

kitchen table, a public information campaign of fact sheets, PowerPoint presentations that can

be used by teachers and coaches within middle and high school settings, and other sample

educational materials examining health equity and social determinants of health that can be

integrated into middle and high school social studies and health studies courses.

The campaign capitalizes on elements vital to sports and to achieving health equity, such

as teamwork, collaboration, focus, unity, and a sense of community, and emphasizes how sports

and themovement for health equity can bring together people from all different backgrounds,

ethnicities, and socioeconomic categories to work for the common goal of finding community-

specific solutions. Health Equity Initiative also conducted a new and social media outreach

campaign that included a video featuring Essence Carson, which was publicized on various

social media outlets and websites.

Program Launch Results

As a testimonial to the power of mass media and new media, in less than six months since its

launch, the program already reached over 1.24 million people via mass media, new and social

media, event-based outreach, and presentations of the video at national conferences and film

festivals. Celebrity endorsement and participation were key to media and event placement.

Other key elements in securing media coverage included the personal story appeal of the

program’s video, and preexisting experience with key media that cover this kind of topic.

Future evaluation efforts will focus on assessing results vis-à-vis the program’s key elements

and objectives.

Source: Health Equity Initiative. “Sports for Health Equity: A Multi-faceted National Program.” Unpublished Case

Study, 2013b. Used by permission.

NewMedia Use: Blogs, Podcasts, Social Networks, and More A comprehensive discussion of the use of different new media goes beyond the scope of this book. Yet, this section highlights how different groups are using select new media such as blogs, podcasts, and social networks. By the time this book is published, the new media discussed here as well as others that are still in their infancy may have further evolved. The main purpose of this section is primarily to make sure that practitioners and students

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approach the use of new media as part of health communication interven- tions with the same research- and evidence-based attitudes that we use or should use for all other communication channels and provide examples of current uses and facts that should be researched and understood in the planning phase. In considering any kind of existing or emerging newmedia, the key to integrating them strategically within health communication interventions is to understand how they are used and perceived by different groups.

Blogs Blogs (an abbreviation of the term web log and a discussion or an online

blog An abbreviation of the termweb log and a discussion or an online informational site consisting of brief and conversational entries called posts

informational site consisting of brief and conversational entries called posts) are often used to make public hallway conversations on health and illness and to publicize and discuss health-related experiences, news, studies, opinions, and statistics.Many blogs act as online journals or diaries, whereas others function as online branding forums for an organization, an individual, a service, or a product. Well-established blogs such as the Huffington Post (www.huffingtonpost.com) act primarily as news websites where readers go periodically to stay informed on a variety of news topics. Although their interactivity distinguishes them from other media, these kinds of blogs act as mass media because of their wide reach.

For the most part, blogs continue to focus on sharing personal expe- riences or practical knowledge or keeping in touch with friends and family (Pew Internet & American Life Project, 2006). Fewer blogs focus on larger themes or have reached the kind of popularity that is typical of more- established mass media. Yet, blogs, as a kind of media, have reached mainstream popularity and have accounted for some of the decline of print media, as well as for influencing political agendas and conveying different viewpoints, including, sometimes, opinions that do not have factual valida- tion (one of the main pitfalls of blogs and more, in general, of new media).

“Overall, bloggers are a highly educated and affluent group. Nearly half of all bloggers earned a graduate degree, and the majority have a household income of $75,000 per year or higher (Sussman, 2009). When considering influence, mommy bloggers are very powerful. Close to 71% of US female Internet users turned to them for useful information and 52% read them for product recommendations (eMarketer Digital Intelligence, 2010)” (CDC, 2011b, pp. 32–33). Bloggers are now 7 percent of US social media users (Knowledge Networks and MediaPost Communications, 2011) and more recently tend to team up to contribute to a specific multiauthor blog (MAB). MABs from universities, think tanks, popular newspapers, interest

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groups, and other organizations account for an increasing quantity of blog traffic (Wikipedia, 2013). Many bloggers have moved over to other media, whether they have appeared on popular television and radio programs, published a book on the content of their blog, or converted their blog into an online magazine. See, for example, the case of Street Fighters of Public Health in Box 5.4.

BOX 5.4. STREET FIGHTERSOF PUBLIC HEALTH:USING ONLINE TOOLS TO CREATE

NETWORKINGOPPORTUNITIES IN PUBLIC HEALTH

At a recent American Public Health Association annual meeting, public health professionals

wore bright orange badges on which they had written their strengths, or “super powers,”

in the field of public health. Produced and distributed by the blog Street Fighters of Public

Health (SFoPH), www.streetfightersofpublichealth.com, these badges became known as “sticky

ice breakers.” Designed to decrease barriers to networking among public health professionals,

the stickers showed off the wearer’s areas of interest and qualifications, thereby facilitating an

ice-breaking conversation with conference attendees and potential employers.

The blog Street Fighters of Public Health was founded in 2009 by Kate Swartz while

pursuing her master’s in public health degree in health communication at the Keck School of

Medicine of the University of Southern California. The blog started as a practice in simplifying

public health issues for the public with an approachable voice. However, while mentoring and

attending public healthmeetings, Swartz found that public health professionals were spending

enormous amounts of money attending conferences, only to leave with unpaid internships

and few valuable contacts. She found that these individuals in the field wanted to learn more

about career development, networking, and solutions in the public health workplace.

The innovative nature of Street Fighters of Public Health is twofold in both authorship and

content that diverts from conventional online publishing and academia. Authorship changed

when SFoPH transitioned from a blog to an online magazine in which professionals were given

the opportunity to self-promote by contributing and publishing articles on public health topics

online. In a formative evaluation of the contribution network, the first candidate contributor

was given the opportunity to research content andwritematerial and successfully published an

average of two articles every week. Unlike the traditionally objective and technical descriptions

of public health issues found in academic journals, the network of contributors at SFoPH are

encouraged to engage a public audience with stories about public health that relate to current

events or personal experience in addition to research citations.

“Public health professionals focus on improving thewell-being of the community. I wanted

to form the community that improves the well-being of the public health professional,”

says Swartz. In order to develop an “army of street fighters” the blog employs social media

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mechanisms such as Twitter, Facebook, and Blogger to attract public health professionals

who are new to the field. In order to help professionals better advocate for themselves, the

staff began hosting social hours and providing networking advice and mentoring services for

individuals in the field. “It is important to polish new talent, and make young professionals feel

welcome in public health; they’ll be running the show soon,” says Swartz. The site accepts blog

entries on public health topics from interested parties willing to subscribe.

Source: Swartz, K. “Street Fighters of Public Health: Using Online Tools to Create Networking Opportunities in

Public Health.” Interview and other personal communications with author, 2012 and 2013.

One of themost important features of blogs is their interactivity, which allows readers to leave comments and start new conversations. Yet, “inmost online communities [including blogs], 90% of users are lurkers who never contribute, 9%of users contribute a little, and 1%of users account for almost all the action” (Nielsen Norman Group, 2006). Also, in the United States, only one in three Internet users (Pew Internet & American Life Project, 2013a) and 12 percent of social media users age thirteen to eighty (Knowl- edge Networks and MediaPost Communications, 2011) read blogs, with Internet users under age thirty-four significantly more likely to read blogs.

So, what do the statistics we discussed so far tell us? That blogs may be best suited (at the least at the moment) to build awareness of health issues than engaging communities; that blogs still do not reach a significant segment of the US population so they should be used in combination with other culturally competent and audience-specific media; and that perhaps they may be best suited to reachmothers, affluent groups, online teens, and adults age eighteen to thirty-three when compared to other age or social groups. These and many other facts are the kinds of information that need to be researched and analyzed in considering and integrating blogs as a communication channel for any health communication intervention in the public health, community development, or health care fields.

Podcasts Podcasts (digital or audio files that can be downloaded from a website

podcasts Multimedia digital files made available on the Internet for downloading to a portable media player or computer

to a media player or a computer) are increasingly used by a variety of organizations and publications in the health field. For example, podcasts are commonly used to do the following:

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• Provide a valuable and user-friendly continuing medical education or continuing education “to-go” (Korioth, 2007) option, which can be usually downloaded from a members-only webpage.

• Bring to life complex issues, such as the role of scientists in health communication (Biotechnology Journal, 2007).

• Stir debate on recent medical advances and fuel innovation, as, for example, the podcast series by Solving Kids’ Cancer (2012), an organi- zation dedicated to find, fund, and manage therapeutic development for life-threatening kinds of pediatric cancer.

• Discuss health news and topics of public interest via a themed series or special podcasts.

• Be a part of new media and mass media news releases.

Podcasts are a cost-effective option to expand the reach of expert panels, conferences, and other professional and community-based events. Currently, they are an extremely common audio file on a variety of online resources in the Unites States and other Western countries. As technology evolves, the use of podcasts is expected to expand and change to include new applications and options.

Social Media and Social Networking It is difficult to think of a starting point to describe the use of social media and social networking in health communication. Although the two terms are often lumped together, “social media [emphasis added]

social media A subgroup of new media. “Social media (for example, YouTube) are tools for sharing and discussing information” (Stelzner, 2009)

(for example, YouTube) are tools for sharing and discussing information. Social networking [emphasis added] is the use of communities of interest

social networking A type of newmedia that uses “communities of interest to connect to others” (Stelzner, 2009)

to connect to others” (Stelzner, 2009). Some media (for example, Facebook and Twitter) combine both functions (Stelzner, 2009).

Perhaps, the most common uses of these media by different organi- zations, professionals, and lay people are to build community and raise awareness on specific health issues (for example, via Facebook or Twitter); validate ideas and organizational strategies via the number of social kudos or “likes” onemay receive on Facebook, or the number of followers onTwit- ter; expand event and meeting outreach; solicit opinions and ideas across geographic boundaries; mobilize communities in support of addressing specific health issues; build professional connections and relationships (for example, via LinkedIn); create virtual identities for oneself or test messages and strategies of health communication programs on virtual world net- works such asWhyville and Second Life; share photos (Flickr); or fundraise

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for organizational causes and special projects not only via social media and fundraising sites (for example, JustGive.org) but also via crowd-funding sites such as rockethub.com.

Socialmedia are constantly evolving and being used in newways. As the evaluation of social media impact is a relatively new and evolving practice, we can expect the next decade to add clarity on what social media actually can and cannot do within a variety of settings, groups, and health issues. Given the high number and variety of social media, a detailed description of the use of specific media is beyond the scope of this book. Therefore, this section is indicative only of the current and potential uses of social media. For additional case studies on social media and their use, see Chapters Fifteen and Sixteen.

mHealth Mobile health (mHealth) technologies have rapidly advanced and hold the promise to provide health information and services on the go. mHealth is the delivery of select public health and clinical information and services via mobile technologies (including texting, apps, and others). It is one of the many approaches that could help personalize and revolutionize health and medicine.

Several authors (Nilsen and others, 2012, p. 5) refer to mHealth’s “potential to greatly impact health research, health care, and health out- comes.” Recent experiences have already demonstrated the promise of mHealth within interventions on different but interconnected areas such as maternal and child health, chronic diseases, smoking cessation, and skilled delivery attendance (Evans andothers, 2012;Abromsandothers, 2012;Katz, Mesfin, and Barr, 2012; Lund and others, 2012). In Zanzibar, for example, a mobile phone intervention in twenty-four facilities (Lund and others, 2012) was associated with an increase in the number of women of urban residence who delivered their babies with skilled attendance (in other words with the help of a midwife, nurse, or physician or other health professional who had been educated and trained to proficiency to manage childbirth).

Yet, as technology progresses, so should be the science behindmHealth applications and evaluation. “mHealth requires a solid, interdisciplinary scientific approach that pairs the rapid change associatedwith technological progress with a rigorous evaluation approach” (Nilsen and others, 2012, p. 5). Several tools, trainings, and resources to strengthen research and evaluation capacity in this field as well as to encourage multidisciplinary collaborations are already underway and include work by the National Institutes of Health (Office of Behavioral and Social Sciences Research,

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2013) and the United Nations Foundation (2013). A proposed logic model for the evaluation of new media-based interventions, including mHealth, is featured in Chapter Fourteen.

As with other health communication areas and interventions, a list of the top ideal features of an mHealth intervention include the following:

• Integration within the socioeconomic and political contexts in which health communication operates, as well as other synergic communi- cation areas

• Clarity of expected behavioral and social results at the outset of the intervention

• Interdisciplinary collaborations and partnerships to maximize impact • Robust planning, research, and evaluation processes and efforts

The mHealth system is at the intersection of three different fields: health, technology, and grant-making philanthropy (with the last fueling innovation and providing adequate resources for scaling up and replication in a variety of settings). It is also influenced by local, national, and inter- national policies and regulations. There are a large number of groups and stakeholders involved in the mHealth system who are invested in realizing the promise of new technology. Research and evaluation are core functions of this system as well as critical to guaranteeing a sound review of lessons learned and their applicability in a variety of real-life settings.

Therefore, as mHealth evolves, of equal importance is the continual monitoring of actual and perceived uses of mobile technology as a channel for health information and services among different groups, as well as in relation to their culture, gender, and age-related preferences, health and media literacy levels, and access to technology, among others. For example, although mobile application popularity continues to increase in the United States and many other countries, smartphones—which are essential to applications functioning—are only owned by 35 percent of the US adult population (Pew Internet &American Life Project, 2011d) and about one in four American teens (Pew Internet & American Life Project, 2012c), with the majority of users under the age of forty-five (Pew Internet & American Life Project, 2011d). This kind of analysis is needed every time that we approach a new mHealth intervention to ensure maximum reach and impact in integration with other mHealth interventions, such as texting, and communication areas.

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Reaching the Underserved with Integrated NewMedia Communication

As previously noted, underserved and vulnerable populations are essential beneficiaries of the new media and other technological revolutions to address health disparities. As with all technological advances (including new treatment and prevention options), new media have the potential to help mitigate gaps in services and information that may lead to better health outcomes among disadvantaged groups. It definitely would be a failure of public health, health care, and, more in general, of community development, if those groupsmost in need of progress won’t benefit from it.

As with all other group-specific communication, reaching the under- served with integrated new media communication starts with listening, building trust, and understanding current needs, preferences, and priori- ties of specific groups. Whether the new media intervention is engaging mothers from ethnic minorities, the elderly, or communities from low- income countries or affected by social discrimination and stigma, or other vulnerable groups, all interventions should be grounded in a rigorous communication process and inspired by models for behavioral and social change. Formative research is crucial and should also include a compre- hensive health literacy assessment and health issue–specific risk mapping, as well as rely on a combination of quantitative and qualitative methods (see Chapter Fourteen for more details) to uncover unknown insights into health and community development issues. Most important, no interven- tion should be designed without the participation and active engagement of representatives from vulnerable and underserved populations.

In order to help bridge the digital divide and effectively reach the underserved, new media communication interventions need to focus on the following key factors and features, among others:

• Integration of community voices in all phases of program planning, implementation, and evaluation aswell as relevant and culture-friendly visual pieces, including the use of online and offline videos to moti- vate change and mobilize communities. For example, The Waiting Room, a documentary and social media project, features the stories of patients and their families and friends who attend an overcrowded emergency room in Oakland, California. People in the waiting room speak about community, language barriers, family violence, chronic diseases, poverty, access to care, taking action, andmany other relevant subjects in addressing health disparities (The Waiting Room, 2012). The film has won several awards and is the central piece of screenings

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and community outreach efforts throughout the United States (The Waiting Room, 2012).

• Community-specific role models and champions who are recognized by underserved communities.

• Culture- and user-friendly selection of new media channels. For example, mobile technology is by far more common than Web. 2.0 in underserved and minority communities in the United States. Adults from underserved communities “use a much wider range of their cell phones’ capabilities,” with text messaging, for example, being used by “70% of all African-Americans and English-speaking Latinos vs. just over half of whites” (Smith, 2010).

• Tailored risk-assessment tools and messages for change, which seek to showcase risk and health outcomes as they relate to family, genera- tional, and group-specific facts and time periods.

• Focus on increasing new media literacy via a variety of programs that use public libraries and other “usual suspect” kinds of contexts (for example, clinical settings) as key venues for training sessions and programs, and show, instead of telling, how to use new media.

• Integration of new media activities with community-based and other offline interventions. For example, in the research and issue assess- ment phase, focus groups including low literate and underserved groups could be turned into long-term support groups for interested participants, which could also include a social media component to spread their impact. Similarly, online communities can be connected to resources and local groups in relevant cities and neighborhoods.

These and other key features of new media interventions may help expand new media reach to include vulnerable and underserved popula- tions and realize the promise of this technological revolution as it relates to improved access to care, health outcomes, patient engagement, and management of chronic diseases, among many other actions, also within low-income and other disadvantaged settings.

Mass Media– and NewMedia–Specific Evaluation Parameters

Although the results of mass media and new media–based interventions should be evaluated as part of the larger behavioral and social outcomes of the health communication program for which the strategies and activities

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are designed, a few specific parameters are commonly used to measure quantitative and qualitative results of mass media campaigns that rely on traditionalmassmedia such as print, radio, andbroadcast. Similarly, specific parameters apply to the counting and tracking of new media campaign results. (Acomplete discussionof evaluationparameters andmethodologies of health communication interventions is included in Chapters Twelve, Thirteen, and Fourteen. The methodologies discussed here apply more specifically only tomassmedia and newmedia and reflect current practice.)

As with all other areas of health communication, evaluation and measurement of themassmedia component of a program should be related to the specific and measurable goals and objectives defined at the outset of the program. Some of these measures are defined by PR theory and practice, especially in the context of mass media campaigns (Institute for Public Relations, 1997, 2003; Yaxley, 2013). In other words, what was the mass media component of the program trying to accomplish? What are or were the specific objectives of each strategy or activity? Which of them were accomplished?

The Institute for Public Relations (1997, 2003) and Yaxley (2013) define three categories to measure PR-driven mass media programs:

• PR outputs: Short-term and process-oriented measurements, such as the number of stories published by the media, the number of times a specific spokesperson is quoted, the tone and content of the media coverage, and the number of Internet hits, likes, or shares received by

hits Total number of downloads (photos, text, HTML, etc.) on all the pages, including all times users came in contact with any of the different elements and components on all pages of a given site

an online article • PR outtakes: The way the PR program is received by the media and

other target key groups and stakeholders as well as overall message recall and retention. For example, did the media find the design and content of press materials or the virtual newsroom appealing and easy to use? Was the language used in press releases, virtual newsrooms, and other materials received favorably, or did the media have prob- lems understanding and using it? Did the actual message recipients (for example, the media’s intended audiences such as consumers or professionals) respond positively to the message? Did the recipients ask for more information by, for example, going to a recommended website? Did they write any letters to the editor or commentaries in response to media coverage, or did they comment on a specific blog post that was part of the mass media outreach?

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• PR outcomes: The evaluation and measurement of changes in the opinions, attitudes, behaviors, or levels of engagement in the media’s audiences regarding a given issue

Similar to some new media-specific measurements, PR outputs can be measured simply by “counting, tracking and observing” (Institute for Public Relations, 1997, 2003, p. 7). In media and press relations efforts, a common parameter to measure PR outputs is the number of media impressions, defined as “the number of people who might have had the opportunity to be exposed to a story that has appeared in the media” (Institute for Public Relations, 2006, p. 9). It is related to the total circulation (for example, number of copies sold by a newspaper or number of viewers of a TV news program) of a given publication or broadcast media outlet (Institute for Public Relations, 2002). For example, in 2010, the New York Times had an audited circulation of approximately 900,000 (daily issues) to 1.3 million (Sunday issue) readers (New York Times Company, 2013). Therefore, a story in the Times will generate 900,000 to 1.3 million media impressions, depending on whether it is published on a weekday or on a Sunday.

PR outcomes and to some extent PR outtakes (for example, for the part concerning the evaluation of message recall and retention by key groups and stakeholders) can be measured only through extensive pre- and postintervention studies (Institute for Public Relations, 1997, 2003; Macnamara, 2006; Futerra Sustainability Communications, 2010) and are difficult and expensive to assess. “Measurement of any process requires pre-activity measurement, followed by post-activity measurement . . . For instance how can you show you have increased employee understanding of company policies if you have not measured what they were before you implemented your communication?” (Macnamara, 2006, p. 14). Common methodologies for evaluating PR outcomes as well as some types of PR outtakes are similar to those generally used in health communication. (These are discussed in Chapters Twelve, Thirteen, and Fourteen.)

Similarly, new media–specific measurements often focus on the fol- lowing measurements (Williams, Zraik, Schiavo, and Hatz, 2008; Abroms, Schiavo, and Lefebvre, 2008):

• Uniquevisitors:The total countofhowmanydifferentpeople accessed

unique visitors The total count of how many different people accessed a specific website or media

a specific website or media • Visits: Total number of visits (including returning visitors and users

visits Total number of visits (including returning visitors and users who are no longer unique)

who are no longer unique) • Page views: Total number of times users viewed each unique page on

page views Total number of times users viewed each unique page on a given site, meaning the total number of pages users viewed when they visited a specific site

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a given site, meaning the total number of pages users viewed when they visited a specific site

• Hits: Total number of downloads (photos, text, HTML, etc.) on all the pages, including all times users came in contact with any of the different elements and components on all pages of a given site

• Keyword mentions: Total count of mentions of the program’s name

keywordmentions Total count of mentions of the program’s name or issue on the web (on websites, blogs, social media, and others) or issue on the web (on websites, blogs, social media, and others)

• Responses to text messages: Total number of mobile users who reply responses to text messages Total number of mobile users who reply to program texts or number of total responses per user received in reply to a text messaging program

to program texts or number of total responses per user received in reply to a text messaging program

• Textmessaging readership:Total number ofmobile users who report

text messaging readership Total number of mobile users who report reading messages from a text messaging program

reading messages from a text messaging program • Use of mobile interactive features: Total number of mobile users

use of mobile interactive features Total number of mobile users who use interactive features associated with the mHealth program

who use interactive features associated with the mHealth program (for example, apps, links to websites, and digital resources, etc.)

Ultimately, the contribution of the mass media and newmedia compo- nents of a health communication intervention should be measured as part of the overall evaluation of such interventions in relation to the impact on social and behavioral results of the overall program, and the attainment of its public health, patient-related, community development, or organi- zational goal. For a discussion of specific tools and models that apply to new media, see the section in Chapter Fourteen called “Evaluating New Media–Based Interventions: Emerging Trends and Models.”

Key Concepts

• Mass media and new media communications are important compo- nents of health communication interventions.

• Welive inanexciting time forhealthcommunication.Communication- related technologies (Internet, mobile, etc.) have been fast advancing at an unprecedented pace, and have been adopted by different groups and populations across the world.

• In approaching health communication planning in the new media age, special attention should be given to what has changed and what should not change as well as to analyzing specific opportunities and challenges.

• The media of mass communication include print, broadcast, radio, entertainment, and motion media, and information-related features

KEY CONCEPTS 175

of the Internet (for example, news websites, blogs, online journals, and libraries). Yet, the definition of mass media may be group-specific because it depends on several factors, including access to technology, cultural preferences, and health and new media literacy.

• The use of interactive functions of the Internet and mobile technology—such as social media, texting, and online forums—cannot yet be considered the same as mass media in their application to health issues, at least not across different socioeconomic, age, ethnic groups, and country settings. This will evolve over time and will continue to be group-specific.

• Public relations (PR), which is defined as “the art and science of establishing and promoting a favorable relationship with the public” (American Heritage Dictionary of the English Language, 2011), has been the backbone of mass communication for several decades.

• Whether relying on mass media, new media, or other communication channels, public relationships continue to be part of the commu- nication process, because there is no way to replace the human factor.

• Key theoretical constructs of PR recognize the importance of psy- chological, emotional, and subconscious factors in human behavior; understanding and addressing multiple publics in light of their unique characteristics as well as their mutual relationships and interaction; and understanding its role in relationship management. PR theory and practice has significantly evolved and adapted in the new media age.

• Because of the significant power of the mass media on public opinion and the potential risk for manipulation and misrepresentation, PR ethics should be always held to the highest standards. Professional codes of ethics as well as key characteristics of ethical PR programs should be considered in developing mass media and new media communication programs.

• The success of media-based campaigns depends on the story’s news- worthiness, ability to listen to and engage relevant groups, as well as the effectiveness of media relations and media-specific tools.

• Mass media and newmedia communications alone are not as effective in affecting and engaging the public, and encouraging behavioral and social change as larger and multifaceted interventions that rely on other action areas of health communication; use community-based strategies and activities; and complement existing or future public health, health care, and community development programs.

176 CHAPTER 5: MASS MEDIA AND NEW MEDIA COMMUNICATION, AND PUBLIC RELATIONS

• Underserved and vulnerable populations need to be included as essen- tial beneficiaries of the newmedia and other technological revolutions to address health disparities. Several factors and features of newmedia communication interventions may help bridge the digital divide and effectively reach the underserved.

• Overall outcomes of mass media and new media programs should be evaluated in the context of the health communication intervention for which they have been designed. Still, it is important to understand and take into account qualitative and quantitative parameters that specifically apply to mass media and new media.

FOR DISCUSSION AND PRACTICE

1. You are pitching consumer publications (for example, women’s magazines, local and

national newspapers, online publications) with a story that aims at raising awareness of

the importance of regular mammograms for breast cancer prevention in women over forty

years of age. List some potential elements and angles for your story in order to attract

reporters’ attention and secure media coverage.

2. This chapter lists some of the key factors in designing ethical PR programs and also refers

to existing guidelines. Share your reaction to each of these characteristics (see Table 5.5).

Can you recall any examples to which they may apply? Can you think of examples that do

the opposite? Is there anything else you would do to preserve public interest and ethics of

PR while designing the PR component of a health communication program?

3. Review the Street Fighters of Public Health case study in Box 5.4. Discuss what, in your

opinion, could be future directions in the use and potential impact of this kind of blog.

Compare with similar blogs you may know.

4. Research and discuss examples of key features of a new media communication program

intended to reach and engage vulnerable or underserved groups. Compare such features

and program-specific factors to those discussed in this chapter.

5. List and discuss key objectives and preliminary or projected results of an mHealth program

you may be familiar with or have researched.

6. Design, develop, and maintain a blog on a health-related topic of your interest. Discuss

lessons learned within the context of the specific health issue as well as the approach and

web-based platform you selected in developing your blog.

KEY CONCEPTS 177

KEY TERMS

blog

communities

hits

keyword mentions

mass communication

mass media

media pitch

mHealth

page views

podcasts

public relations (PR)

responses to text messages

social media

social networking

text messaging readership

unique visitors

use of mobile interactive features

virtual newsrooms

visits

CHAPTER 6

COMMUNITY MOBILIZATION AND CITIZEN ENGAGEMENT

IN THIS CHAPTER

• Community Mobilization and Citizen Engagement: A Bottom-Up Approach

• Community Mobilization as a Social Process

• Engaging Citizens in Policy Debates and Political Processes

• Implications of Different Theoretical and Practical Perspectives for Community Mobilization and Citizen Engagement Programs

• Impact of Community Mobilization on Health-Related Knowledge and Practices

• Key Steps of Community Mobilization Programs

• The Case for Community Mobilization and Citizen Engagement in Risk and Emergency Communication

• Key Concepts

• For Discussion and Practice

• Key Terms

“Ask Canadians what the name ParticipACTION conjures up, and the majority of adults will easily recall the 60- year-old Swede” (Costas-Bradstreet, 2004, p. S25). “Is it true that the average 30-year-old Canadian is only as fit as the average 60-year-old Swede?” (Canadian Public Health Association, 2004) was one of the many questions addressed by the early public service announcements of a health communication program that ran for more than thirty years and was established by ParticipACTION, a nonprofit organization.

Public service announcements were the main tool of ParticipACTION in the early days of its implementa- tion. Once the program’s name had been established and Canadians became increasingly aware of the importance of fitness, ParticipACTION also implemented innova- tive strategies to involve people at the community level. The program “used community mobilization as a way to empower communities and motivate individuals to get more active” (Costas-Bradstreet, 2004, p. S25).

Community mobilization efforts originally focused on the city of Saskatoon in central Canada. Soon the enthusiasm generated by ParticipACTION community events, including “Walk a Block a Day” and other mass participation activities, spread to several levels ofCanadian society, including other cities and regions, as well as provincial, territorial, and national governments (Costas- Bradstreet, 2004).

In 1992 alone, ParticipACTION trained fifty com- munity animators who “generated 21,000 registered community events involving over 1 million volunteer leaders” (Costas-Bradstreet, 2004, p. S26). Over the years,

180 CHAPTER 6: COMMUNITY MOBILIZATION AND CITIZEN ENGAGEMENT

the program attracted volunteers from all segments of society, including healthprofessionals, themedia, business communities, ordinarypeople, and government officials. It also developed partnerships with the federal gov- ernment, professional societies (for example, Ontario Physical and Health Education Association, College of Family Physicians), the commercial sec- tor (for example, theOntarioMilkMarketing Board,Merck Frosst Canada), and major health organizations, such as the Canadian Public Health Asso- ciation (Costas-Bradstreet, 2004). All partners contributed with funds, activities, and other resources that expanded the program’s reach.

The long-term impact of this program, which closed its doors in 2002 and was relaunched in 2009, are being assessed vis-à-vis a set of indicators that include organizational capacity building for physical exercise, part- nership development, funding process reform, and others (Faulkner and others, 2009). The growing prevalence of obesity in Canada (Canadian Pub- lic Health Association, 2004; Eisenberg and others, 2011) still points to the need for sustained efforts in this direction. Still, many of the success stories and lessons learned from ParticipACTION and other similar programs around the world demonstrate the importance of community mobilization as a fundamental strategy of health communication and, more broadly, public health, health care, and community development interventions.

CHAPTER OBJECTIVES

This chapter establishes community mobilization as a key area of health communication.

It also reviews some of the current theoretical assumptions and topics in relation to this

approach. Finally, it provides practical guidance on the key ingredients of community mobi-

lization programs and the need for considering this approach as part of a multifaceted and

multidisciplinary intervention. In doing so, the chapter also builds capacity and encourages

readers to “develop strategies to motivate others for collaborative problem-solving, decision

making, and evaluation” (Association of Schools of Public Health, 2007, p. 9), because these are

critical elements of effective health communication interventions.

Community Mobilization and Citizen Engagement: A Bottom-Up Approach

Definitions often provide a useful framework for understanding the platformand the key assumptions of any given approach. In the case of com- munitymobilization, the importance of community dialogue, participation,

COMMUNITYMOBILIZATION AND CITIZEN ENGAGEMENT: A BOTTOM-UP APPROACH 181

and self-reliance is emphasized in its theoretical definition and practical applications.

In fact, community mobilization is often defined as “empowering community mobilization One of the key areas of health communication. A bottom-up and participatory process. Using multiple communication channels, it seeks to involve community leaders and the community at large in addressing a health issue, becoming part of the key steps to behavioral or social change or practicing a desired behavior.

individuals to find their own solutions, whether or not the problem is solved” (Fishbein, Goldberg, and Middlestadt, 1997, p. 294). Although this definition does not and should not absolve community mobilization strategies fromthepressure and responsibility of producing results, it clearly indicates that local leaders and ordinary people are the key participants in this approach. At the same time, it places in their hands the potential for involving other levels of society (for example, governments, professional organizations, grant-makers, and the private sector) in the solutions they have found. In this way, community mobilization is a bottom-up approach because it tends to rely on people’s power to involve the upper hierarchical levels of society and to develop collaborative efforts to address community- specific issues.

For example, one of the main success factors of ParticipACTION was its community-driven approach, which helped secure “long-term gov- ernment and sponsor support” (Costas-Bradstreet, 2004, p. S25). Similar conclusions were drawn in regard to a community mobilization project in Cameroon that aimed at increasing knowledge and use of family planning methods and reproductive health services (Babalola and others, 2001). Babalola and others also highlight that once innovations were spread throughout local associations (called Njangi), they continued “to spread throughout the larger community, making community mobilization an effective tool for large-scale behavioral change communication” (p. 476). Effective communitymobilization fuses public health and social justice, and also seeks to change social norms to support behavioral and social results (Michau, 2012).

The term community can indicate a variety of social, ethnic, cultural, community A variety of social, ethnic, cultural, or geographical associations, for example, a school, workplace, city, neighborhood, organized patient or professional group, or association of peer leaders

or geographical associations, and it can refer to a school, workplace, city, neighborhood, or organized patient or professional group, or association of peer leaders, to name a few. As another example, Njangi are local socioeconomic associations that are quite common in most of Africa and “are formed on a geographic basis, by family structure, or through shared professions” (Babalola and others, 2001, p. 461). Communities always tend to share similar values, beliefs, and overall objectives and priorities. According toUNAIDS (2012, p. 14), a community is a “group of people with diverse characteristics who are linked by common ties including shared interests, social interaction or geographical location.” Communities are also made of groups of people from multiple sectors who share similar concerns and objectives and will act together in their common interest.

182 CHAPTER 6: COMMUNITY MOBILIZATION AND CITIZEN ENGAGEMENT

When communities drive public health or health communication inter- ventions, they are not merely consulted. They share power and decisions. Community mobilization may be initiated by leaders within the commu- nity or stimulated by external agencies, organizations, or consultants. Still, the role of external organizations, health communication practitioners, and other consultants is to facilitate and follow the mobilization process (Health Communication Partnership, 2006c).

In this context, one of the main objectives of health communication practitioners and other health professionals who may be involved in the community mobilization effort is to provide local leaders and their community with technical assistance to accomplish a number of goals:

• Find solutions that build on the community’s strengths and fit well within its overall context (Fishbein, Goldberg, and Middlestadt, 1997; Costas-Bradstreet, 2004).

• Facilitate partnerships with other segments of society (Costas- Bradstreet, 2004).

• Become aware of potential obstacles and ways to overcome them. • Resolve conflicts among community members and create a consensus

on potential solutions. • Establish a process for community involvement, including the develop-

ment of communication strategies, messages, materials, and activities, which can ultimately lead to social and behavioral changes.

• Point to resources and approaches that may facilitate long-term sus- tainability of all interventions and health solutions.

• Design a rigorous evaluation process, including community-relevant indicators so that the community can check on its own progress and accommodate changing needs.

• Keep the community focused on what it wants to accomplish.

It’s only by encouraging participation and ownership of the health communication process and its outcomes among community members and other key groups that communication interventions are likely to lead to sustainable behavioral and social results. This is why community mobilization is a core area of health communication.

Community Mobilization as a Social Process

The impact of community mobilization is greater when different com- munities interact with each other and create a social force for change. This concept is incorporated in the idea of social mobilization. Although

COMMUNITYMOBILIZATION AS A SOCIAL PROCESS 183

some of the premises of social mobilization may be different from those of community mobilization, the two terms are closely related and are used here interchangeably. Socialmobilization has been defined “as the process

social mobilization The “process of bringing together multisectoral community partners to raise awareness, demand, and progress for the initiative’s goals, processes and outcomes” (Patel, 2005, p. 53)

of bringing together multisectoral community partners to raise awareness, demand, and progress for the initiative’s goals, processes and outcomes” (Patel, 2005, p. 53). This definition is in agreement with the key elements of community mobilization as discussed in this chapter.

In the context of health communication, community mobilization tends to be disease specific and addresses behavioral issues that may help reduce the morbidity and mortality of a given condition. Still, there are a number of cases in which community mobilization is a component of health communication programs that complement larger public health interventions, and aim to guarantee or expand community access to health services and products or address social issues. In fact, community mobilization may entail and refer to different kinds of actions, from people marching to demonstrate their discontent about the paucity of research funds dedicated to a specific disease area, to community members connecting with others about the importance of disease prevention and leading the behavior change process.

Mobilizing local leaders and their communities is a long process that may vary according to the community’s makeup and needs. However, several success factors can be extrapolated from existing experiences and programs, and apply generally to this kind of effort:

• Evidence-based information, which is critical to attract attention to a health issue and convince people to prioritize it within a community. Moreover, it can help communities identify strategies and approaches that are likely to involve their members as well as other communities in the health behavior change process.

• An in-depth understanding of other conflicting community priorities coupled with efforts to effectively address them or showcase linkages with a specific health or social issue.

• A comprehensive analysis of social norms, key determinants of health, factors, and conditions that may prevent people from adopting and sustaining recommended health or social behaviors.

• A behavior-centered mind-set. In other words, what is it that commu- nities would like to do? What kind of progress indicators do they feel comfortable establishing and achieving toward their behavioral and social objectives?

• The inclusion of all influential groups in the planning, implementation, and evaluation of the community mobilization process.

184 CHAPTER 6: COMMUNITY MOBILIZATION AND CITIZEN ENGAGEMENT

• The quality of the technical assistance and training provided to local leaders and their communities by health communication practitioners and other key health professionals and facilitators. Outside support and technical assistance are critical to sustaining the effort over the long term (UNAIDS, 2005).

• The potential for community ownership and program sustainability. • The existence of complementary interventions (for example, mass

media campaigns, capacity building and training, widespread access to services) that reinforce community-based communication efforts, and encourage participants’ adherence to the process of change.

Most of these factors are common to the overall field of health communication and public health. Still, it is worth mentioning them here because of their critical importance in community mobilization programs.

Finally, facilitating a community-driven intervention requires good listening skills, a firm belief in the “value of collective action” (Costas- Bradstreet, 2004, p. S29), enthusiasm for the health or social cause, and a strong ability to transmit it. It also requires the application of many of the skills and theories previously discussed in relation to interper- sonal communication. As an example of the many different phases and steps of community mobilization, Box 6.1 features a case study from UNICEF on addressing oral polio vaccine refusal in northern Nigeria via the development and training of a community mobilizer network.

BOX 6.1. TACKLING ORAL POLIO VACCINE REFUSALS THROUGH VOLUNTEER

COMMUNITYMOBILIZER NETWORK IN NORTHERN NIGERIA

Current Situation

Nigeria remains one of the three polio-endemic countries in the world along with Pakistan and

Afghanistan. As of June 22, 2012, Nigeria had forty-five cases of wild poliovirus (WPV) in ten

states compared to twenty-five cases in six states for the same period in 2011 (see Figure 6.1). In

2011, Nigeria had sixty-two cases of WPV in eight states compared to twenty-one cases in eight

states in 2010. The number of cases in 2011 was three times higher than it was in 2010. Nigeria,

however, experienced 95 percent reduction of WPV cases in 2010 compared to the 388 WPV

COMMUNITYMOBILIZATION AS A SOCIAL PROCESS 185

cases in 2009. Further, the total number of circulating vaccine derived poliovirus (cVDPV2) was

thirty-five in ten states in 2011 whereas only one cVDPV2 case has been reported so far in 2012.

2009 2010

Nu m

be r o

f c on

fir m

ed W

PV ca

se s

2011

388

62 45

2012 (June)

21

Figure 6.1 Number of WPV Cases by Year in Nigeria

As of June 2012 two national immunization plus days (IPDs) and one subnational IPD have

been conducted covering ten very high-risk northern states. Fourmore IPDs are planned for this

year in Nigeria alongwithmop-up campaigns (door-to-door immunization) to be implemented

on detection of any new WPV cases. The proportion of missed children during campaigns has

fluctuated over time due to a multitude of social, religious, and political reasons as well as

campaign operational issues (June 2011—6.8 percent; November 2011—7.7 percent; and May

2012—7.2 percent). In terms of vaccine refusals, the goal is to keep actual noncompliance1

(vaccine refusals) in high-risk states under 2 percent. Actual noncompliance was reduced to 1.7

percent in May 2012 from 2.1 percent in February (see Figure 6.2).

IntensifiedWard Communication Strategy

Intensified ward communication strategy (IWCS) aims at addressing pockets of vaccine refusals

among caregivers in northern Nigeria by using targeted, data-driven communication interven-

tions through media, traditional institutions, religious leaders, and community volunteers in

the most high-risk settlements. Traditional and religious leaders play a key role in addressing

refusals driven by the men in the household, whereas different strategies need to be deployed

to empower women.

186 CHAPTER 6: COMMUNITY MOBILIZATION AND CITIZEN ENGAGEMENT

In 2011, UNICEF piloted few community-based communication initiatives as part of its

support to the IWCS in three northern states. These initiatives showed encouraging results

by reducing missed children and noncompliance through active community participation and

women’s empowerment.

0.0% Bauchi Borno Jigawa Kaduna Kano Katsina Kebbi Sokoto Yobe Zamfara HR

States

0.5%

1.0% 1.1%

1.9%

3.2%

2.2%

0.6%

1.7% 1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

1.0% 0.8%

1.4%

0.4%

3.4%

Figure 6.2 Proportion of Actual Noncompliance, High-Risk States, May 2012

With the support of Polio Eradication Initiative (PEI) partners and the Government of

Nigeria, UNICEF is now spearheading a rapid scale-up of a volunteer community mobilizer

network (VCMNet) targeting eight high-risk states: Kebbi, Kano, Sokoto, Zamfara, Jigawa, Yobe,

Katsina, and Borno. In total, more than 2,150 settlement-level VCMs are being recruited, trained,

equipped, and deployed in the settlements where missed children and refusals of oral polio

vaccine are still persistent. These VCMswill reach out to over six hundred thousand households

on a monthly basis to undertake communication interventions.

VCM Net is putting in place a targeted community-driven social mobilization effort and

a house-to-house behavior change communication approach in high-risk settlements that is

hoped to contribute to the reduction of the percentage of missed children in each campaign

(see Figure 6.3).

Selected from their settlement, the VCMs have been trained to work as change agents

in their respective communities. These women are trained to use simple pictorial materials

to engage caregivers in a dialogue around key household practices as well as routine and

polio immunization. It is hoped that the wider communication platform will create a positive

environment in which routine and polio immunization can be more effectively promoted,

eventually reversing the trend in vaccine refusals (see Figure 6.4).

COMMUNITYMOBILIZATION AS A SOCIAL PROCESS 187

Actual noncompliance

Missed children Households not visited

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0% 10.8%

12.3%

0.0%

12.8%

8.1%

9.8%

0.0%

11.9%

14.0%

Child absent

Mar 2012 May 2012

Figure 6.3 Preliminary Data, Sokoto VCMs Note: Data are from forty-seven Sokoto settlements. HH stands for households.

No felt need Oral polio vaccination safety

Nu m

be r o

f c hi

ld re

n m

iss ed

d ue

to no

nc om

pl ia

nc e

0

50

100

150

200

250

300

419

354

8.1% 241 209

112 107

350

400

450

Too many rounds

Mar 2012 May 2012

Figure 6.4 Main Reasons for Noncompliance Note: Data are from forty-seven Sokoto settlements.

Volunteer supervisors are engaged to support clusters of VCMs (maximum ten) to make

sure the mobilizers correctly use the IEC (information-education-communication) materials

provided and are sufficiently skilled at engaging with caregivers in a behavior-changing

dialogue. The supervisors also have to make sure all eligible children in the settlements are

tracked and that the monthly monitoring tools are properly filled out.

188 CHAPTER 6: COMMUNITY MOBILIZATION AND CITIZEN ENGAGEMENT

With data collected at settlement level from the project and correlated with campaign

data, the project will be in a position to accurately demonstrate the impact of the VCMs on

vaccine refusals and missed children in each settlement where a VCM has been engaged to

carry out behavior change communication.

Initial results from one of the target states, Sokoto, have shown some signs of positive

results and impact in reducing noncompliance and missed children. As the project proceeds,

more comprehensive data will be available for all the 2,150 settlements to confidently assess

the impact of the VCM Net on vaccine refusals and missed children.

Note 1Actual noncompliance is calculated as percentage of vaccine refusals out of total children seen.

Source: Laulajainen, T. “Tackling Oral Polio Vaccine Refusals Through Volunteer Community Mobilizer Network in

Northern Nigeria.” UNICEF, Nigeria. Unpublished case study, 2012. Used by permission.

Engaging Citizens in Policy Debates and Political Processes

Putting the public back into public health is a key goal of public health in the twenty-first century. Citizen engagement (or public engagement)

citizen engagement (or public engagement) The process of creating a better-informed citizenry so that people from different sectors and walks of life can effectively contribute to policy and economic decisions that ultimately affect their lives

is the process of creating a better-informed citizenry so that people from different sectors and walks of life can effectively contribute to policy and economic decisions that ultimately affect their lives. Given the social nature of community and social mobilization we discussed in this chapter, citizen engagement is community mobilization at scale, which more specifically aims to involve the general public in political processes and policy debates. In doing so, citizen engagement interventions also focus on increasing awareness among the general public of citizens’ rights and duties.

As inother communitymobilization efforts, public engagement is based on trust, transparency, and accountability of all actions and processes. “Ac- countability is often thought of in terms of government being accountable to citizens. In the context of mobilization, community members being accountable to each other is as important as government accountability. Those individuals elected to help lead projects are accountable to the wider community, their neighbors who are counting on them to implement projects in the best interest of everyone” (Mercy Corps, 2013, p. 8).

In community mobilization, every community and all citizens have the right to know the procedures, decision-making processes, and financial allocations and cash flow for programs, policies, and priorities that may affect all. Yet, as it relates to public health and health care systems, public

ENGAGING CITIZENS IN POLICY DEBATES AND POLITICAL PROCESSES 189

engagement is strongly dependent on building capacity to increase health literacy and media literacy levels among average citizens. It is only by enabling people to understand, evaluate, and act on health information that citizen engagement is actually possible. So, health and media literacy are fundamental premises for public engagement, and more in general community mobilization (Schiavo, 2009d).

Akeyoutcome indicatorof communitymobilizationandpublic engage- ment is, or should be, sustainability, especially because it relates to citizens’ ability to advocate for specific health policies or an equal distribution of resources, as well as to participate in political processes. As citizen engage- ment has proven to be effective in many different areas (see, for example, “The Case for Community Mobilization and Citizen Engagement in Risk and Emergency Communication” in this chapter), building capacity for mobilization should be a key priority in many countries and communities.

For example, a studyconducted forUNICEFoncommunity-basedcom- munication in pandemic flu settings revealed that identifying and building capacity of local social mobilization partners is one of the key priorities among UNICEF field staff, international organizations, and other profes- sional groups so that local partners can effectively contribute to prepare and respond to epidemics (an infectious disease affecting many people at the same time and spreading from person to person within a community or city) and emerging disease outbreaks (Schiavo, 2009b; Schiavo and Kapil, 2009). Emerging diseases are either appearing for the first time in a region or evolving from other past diseases. Building the capacity of civil society and other local community-based organizations to become effective partic- ipants in community development and engagement is also one of the key steps followed byMercy Corps (2013) as part of their community mobiliza- tion interventions. Other key elements of citizen engagement programming mirror the good practices andmethods of community mobilization that are discussed later in this chapter, and include community and citizen dialogue to assess needs, preferences, and strategies for government accountability, public surveys, and local or national community meetings, among others.

As public engagement is increasingly valued within and outside health communication settings, several universities, for example, The New School for Public Engagement (2013), government initiatives (White House, 2013), and programs strive to address the need to involve citizens in policy debates and others. Although a lot of good work is in process, top-down approaches are sadly still too prominent even in areas such as reducing health disparities where community action and public engagement across sectors is key to advancing the health equity agenda. Therefore, it is a challenge and a great opportunity for public health, health care, and community development professionals in the twenty-first century to

190 CHAPTER 6: COMMUNITY MOBILIZATION AND CITIZEN ENGAGEMENT

contribute to raising the influence of community and citizen voices on public matters.

Implications of Different Theoretical and Practical Perspectives for Community Mobilization and Citizen Engagement Programs

Over time, community mobilization has been influenced by many different fields (for example, behavioral and social sciences and social marketing) from both theoretical and practical perspectives. Yet, it is a different approach for behavioral and social change that perfectly fits the current emphasis on participatory strategies to communication.

For example, although community mobilization often uses social marketing strategies (see Chapter Two) as well as participatory research, “these terms are not synonymous” (Health Communication Partnership, 2006a).Communitymobilizationgoesbeyondparticipatory research,which involves key groups in the design, implementation, and analysis of research protocols and data related to the health issue and its audiences. Also, community mobilization is a different approach from social marketing.

Fishbein, Goldberg, and Middlestadt (1997) point to the definitions of social marketing and community mobilization in order to highlight their differences. Social marketing is designed to “influence the behavior of target audiences to improve their personal welfare and that of the society of which they are part” (Fishbein, Goldberg, and Middlestadt, 1997, p. 294; Andreasen, 1995, p. 7). Community mobilization seeks to promote community empowerment by developing skills that can be used beyond addressing the specific problem or health issue (Fishbein, Goldberg, and Middlestadt, 1997). It works toward a long-term change in community skills that can be replicated within different communities and segments of society as well as in addressing other kinds of health issues. Community and social mobilization principles are incorporated in several models and planning frameworks (for example, communication for development, COMBI, communication for social change) described in Chapter Two. Also, as previously mentioned (see Chapter Two) social marketing authors and practitioners increasingly emphasize social change as a key outcome of social marketing (Lefebvre, 2013).

In planning a community mobilization effort, community participants are likely to analyze the situation by trying to define the best way for the community to address the health issue. Social marketers are likely to think about the behaviors that need to be influenced for social good and the strategies to accomplish that (Fishbein, Goldberg, and Middlestadt, 1997).

IMPLICATIONS OF DIFFERENT THEORETICAL AND PRACTICAL PERSPECTIVES 191

However, even in a participatory and community-driven approach, helping communities to define potential behavioral and social outcomes allows community participants to frame the health issue in a way that will respond to community needs and effectively address it. “A behavioral science orientation can help design interventions aimed at influencing behavioral determinants” (Fishbein, Goldberg, and Middlestadt, 1997, p. 298).

In fact, the influence of marketing models on community mobilization efforts may help community members define and pursue the changes they want toaddressusinga systematic approach.As inotherareasofhealthcom- munication, marketing’s major implication for community mobilization is its research-based and structured approach to planning. Still, the empha- sis of community mobilization efforts should be primarily on building the capacity of the community to address and prioritize its own problems.

Too often, it is possible to observe in the developing world the vacuum that is left when capacity building is not one of the key priorities of commu- nity mobilization as well as larger health communication or public health interventions. As soon as the outsiders leave, communities are left to man- age programs and priorities they are not prepared to address. Many times circumstances revert to the original situation shortly after international agencies leave. This is exactly what well-designed and well-implemented community mobilization programs should try to avoid in both the devel- oping and developed worlds. The recent emphasis on behavioral and social outcomes as well as increased community and key group participation in communication efforts is well positioned to accomplish that. As discussed in Chapter Two, several communication planning frameworks, such as UNICEF’s Communication for Development (C4D) and Communication for Behavioral Impact (COMBI), emphasize the importance of community participation, ownership, and empowerment.

Moreover, models such as the community action cycle draw on several social change theories and are designed to help communities “acquire the skills and resources to plan, implement and evaluate health-related actions and policies” (Lavery and others, 2005, p. 611). Under the community action cycle, outcomes are defined in terms of changes in “social norms, policies, culture, and the supporting environment” (HealthCommunication Partnership, 2006a) so that results can be sustainable and lead to new social norms in support of health behaviors. Instead, under COMBI, the model for communication for behavioral impact adopted and refined by the World Health Organization [WHO] (2003), community mobilization efforts, which are also participatory and aim at building community skills,

192 CHAPTER 6: COMMUNITY MOBILIZATION AND CITIZEN ENGAGEMENT

emphasize the importance of behavioral results as a key program outcome even when the program ultimately aims at social change.

Whether the emphasis is on behavioral or social outcomes should be determined by the unique characteristics of the health issue being addressed as well as those of the specific communities and audiences, and their existing health and social behaviors (see Chapter One). Yet, there are two importantmantras to remember, which are strictly interconnected and somewhat cyclical:

• Social change occurs only as a result of gradual behavioral changes at different levels of society.

• Sustainable behavioral results at the individual, community, or popu- lation levels can be achieved only by addressing barriers to behavior adoption and implementation, social norms, and key determinants of health.

Ideally, all interventions should aim at creating permanent changes in social rules and community or health system structure. This is also in agreement with some of the key premises of the larger public health field of community health. In fact, “the movement called community health means more than just access to health care. It’s strong families, good schools, safe neighborhoods, caring adults, and economic opportunities” (Emanoil, 2002, p. 16). Community health rightly regards disparities in health as going beyond individual behavior and actually being influenced by several socially determined factors as well as the kind of social support (or lack of) people receive throughout their lifetime, and more specifically at times of disease and crisis.

Box 6.2 offers a case study showing the correlation between behav- ior and disease burden and highlights how community mobilization can effectively address that. In reviewing this case study, readers should take into account that this intervention was aimed at reducing the impact of a sudden health crisis. Strategies used in this case may be different from more extensive interventions that would address and sus- tain a health behavior. Nevertheless, the case study provides a helpful example of the direct correlation among behavior, social engagement, and health outcomes, and how community mobilization, and, more generally, community-based interventions should be integrated also in epidemics, emerging diseases, and humanitarian emergency settings (see “The Case for Community Mobilization and Citizen Engagement in Risk and Emergency Communication” in this chapter for further discussion of this topic).

IMPLICATIONS OF DIFFERENT THEORETICAL AND PRACTICAL PERSPECTIVES 193

BOX 6.2. SOCIALMOBILIZATION TO FIGHT EBOLA IN YAMBIO, SOUTHERN SUDAN

Controlling communicable diseases demands not only medical expertise but also social

education. To meet this goal, WHO has adopted a type of social mobilization known as

communication for behavioral impact (COMBI) that focuses on influencing behavior at the

individual and community levels. This strategy was implemented in Yambio from late May to

June 2004 during an outbreak of Ebola hemorrhagic fever that resulted in seventeen confirmed

cases, including seven deaths.

In late May, WHO’s social mobilization experts from the WHO Mediterranean Centre

for Vulnerability Reduction (Tunis, Tunisia) were included among the international WHO-

coordinated Ebola response team. On arrival in Yambio, their first task was to determine what

changes in behavior were necessary to contain the Ebola outbreak.

The social mobilization teamwas immediately confronted with numerousmisconceptions

about the outbreak. For example, many people in Yambio were unconvinced that there was

actually an Ebola outbreak, and others believed that blood and skin samples were being

removed from patients and sold. There was also an unsubstantiated fear of the isolation ward,

wariness of the surveillance teams, and other irrational beliefs. For example, some people

refused to leave home between 5:00 and 7:00 pm, believing this would reduce their risk of

contracting Ebola.

To counter these misconceptions, the social mobilization team, which included pastors,

teachers, and community development workers (who wore uniforms to increase credibility),

spoke to villagers daily at their homes,marketplaces, restaurants, churches, and schools. Simple

measures were emphasized, such as asking sick individuals to contact the Ebola team within

twenty-four hours of the onset of symptoms, recommending to people that they avoid direct

contact with sick individuals, and suggesting that the community refrain from traditional

practices of sleeping next to or touching dead bodies for the duration of the outbreak.

A key element of the team’s strategy was the distribution of informational pamphlets,

which answered basic Ebola questions, as well as dispelling common rumors. Recognizing the

stigma that accompanies Ebola, the social mobilization team also worked to explain the need

for the isolation ward at Yambio Hospital, and included pictures of the ward in the pamphlet,

to show the local population that the fence around the ward was short enough for patients to

see and talk to their family and friends from a safe distance.

By placing communities at the center of the social mobilization program, the rapid

containment of the Ebola outbreak in Yambio can be attributed largely to the efforts of local

people themselves. As WHO and partners gain more experience in identifying and responding

to Ebola outbreaks, social mobilization will undoubtedly continue to play an important role in

the successful containment of future outbreaks.

Source: World Health Organization. “Social Mobilization to Fight Ebola in Yambio, Southern Sudan.” Action

Against Infection, 2004c. http://wmc.who.int/pdf/Action_Against_Infection.pdf. Used by permission.

194 CHAPTER 6: COMMUNITY MOBILIZATION AND CITIZEN ENGAGEMENT

Community (or social) mobilization has been positioned by several authors and organizations as a key component of global health commu- nication, especially in the context of behavior and social change models (WHO, 2003; Health Communication Partnership, 2006b; Patel, 2005; Ren- ganthan and others, 2005; Obregon and Waisbord, 2010; Schiavo, 2010a; UNICEF, 2013a). For example, in Namibia, one of the core elements of the Health Communication Partnership (2006a) communication program is a community mobilization effort aimed at increasing HIV community awareness as well as the use of HIV preventive measures and competent health services.

Still, community mobilization is not an all-inclusive tool to address community health issues. Its likelihood for success is related to the use of an integrated multifaceted approach in which other tools and areas of communication are used to reinforce the community change process. Mul- tiple channels (for example, mass media, new media, theater, interpersonal communication channels) should be used to share relevant information or reach out to specific key groups with tailored messages in order to create the kind of support needed for behavioral or social change within a commu- nity. Most important, community mobilization efforts should complement other relevant public health and community development interventions.

Impact of Community Mobilization on Health-Related Knowledge and Practices

As in other areas of health communication, communitymobilization efforts aim to influence health behavior as well as social norms and policies that may have an impact on health outcomes. This section reviews some of the key aspects and potential outcomes of the process of influencing health-related knowledge and practices through community mobilization interventions.

Reliance on Community Members Communicating ideas about health and behavior as well as social issues related to health outcomes is a long and difficult process. Using a peer-to- peer approach, such as relying on credible community members, to diffuse new ideas and prompt action may shorten this process (Babalola and others, 2001). For example, the Office of Minority Health Resource Center (OMHRC) of the Department of Health and Human Resources (DHHS) Office of Minority Health (OMH) has been successfully using a peer-to- peer communication approach for their preconception peer educator (PPE)

IMPACT OF COMMUNITYMOBILIZATION ONHEALTH-RELATED KNOWLEDGE AND PRACTICES 195

program, which seeks to raise awareness of high rates of infant mortality among African Americans and to encourage the adoption of preconception health behaviors among trained PPEs (college and graduate students) and the communities they reach (Office of Minority Health, 2013; Schiavo, Gonzales-Flores, Ramesh, and Estrada-Portales, 2011; Schiavo, 2012b).

Because of the involvement and leadership of community members in the different phases of program planning, implementation, and scaling up, community mobilization can be a time-saving and effective approach to influence health-related knowledge and practices. When external organi- zations, health communicators, and other kinds of facilitators approach a community, they should always identify, engage, and train local leaders who have an interest in the issue as well as in involving their communities and carrying on themobilization process. Thismay pass throughmany different stages, which include but are not limited to communication and disease- specific training. Several experiences have pointed to the importance of identifying an adequate number of social mobilization partners as well as training and engagement on interpersonal communication and community dialogue skills (Schiavo, 2009b; Schiavo and Kapil, 2009). Such partners can include women’s groups, teachers, community and religious leaders, community health workers, local government officials, and many others who feel passionate about a specific issue, and care about the well-being of their community.

Sometimes people who are well suited to become community leaders because of personal characteristics and social status lack specific knowl- edge and understanding of the health problem’s relevance within the community. Other times potential leaders need to go through a process of change themselves. Sometimes leaders already exist within a community and are ready to facilitate the process of change but may need techni- cal assistance in the planning and implementation of the process (as in the case study featured in Box 6.1). Other times people may become leaders because of life events or the exposure to engaging communica- tion tools and activities that influence their core beliefs and attitudes, prompt a personal change, and make them want to help others. The example in Box 6.3 shows the different phases of the process of per- sonal growth, disease awareness, and commitment to the prevention of sexually transmitted diseases (STDs) that a young man in Kenya experi- enced after attending a few community theater sessions on the topic, and engaging in a series of discussions with the health communication staff and the local coordinators from the Program for Appropriate Technology in Health, an international health organization that had developed the theater sessions.

196 CHAPTER 6: COMMUNITY MOBILIZATION AND CITIZEN ENGAGEMENT

BOX 6.3. HOWBINGWA CHANGED HISWAYS

At age twenty-four, Bingwa (not his real name) represents the typical Kenyan out-of-school

youth: unemployed and hot-blooded, but generally hopeful and lively. He had been a regular

attendee of the community theater sessions organized by Program for Appropriate Technology

in Health (PATH), an international nonprofit organization, in collaboration with the local

Rojo-Rojo troupe in Mumias, in Kenya’s western province.

BetweenJanuaryandSeptember2002,Bingwa’s lifeevolveddramatically. Thisveryaverage

young man—married, father of a fifteen-month-old son, sexually active outside his marriage

but insulated by a sense that hewas not at risk of any infection—became one of the first youths

to be stimulated by Magnet Theatre to navigate a course to new personal behavior that has

made him a community role model. He volunteered to go for voluntary counseling and testing

(VCT), learned for himself that he was not infected, and took serious steps to reduce his sexual

risk by taking charge of his personal life.

Bingwa made a living by taking care of his uncle’s four rental houses and eked out his

income by selling Coca-Cola and odds and ends from a kiosk. His buddies would hang around

at the kiosk, talking about politics, football, jobs, and girls. Bingwa, married and with a child,

was economically better off than his friends, and indeed the de facto group leader. There was a

time, in his bachelor days, when his house used to be known as “The Butchery” in recognition

of the fact that the young men in the estate would bring girls over there for sex. Bingwa was

always happy to make his house available and disappear for a while.

Bingwa’s first questions came on a Friday in January 2002, at the end of a session of

community theater by the Rojo-Rojo Magnet Theatre troupe. PATH’s theater coordinator,

Madiang, was looking forward to the weekend and was packing up after a Magnet Theatre

show.

Bingwa approached Madiang, and after a few moments of small talk, asked, “Say, is an STI

[sexually transmitted infection] the same as AIDS?”

Madiang answered in the negative. But Bingwa became pensive and launched a second

question: “Okay, then, if they are not the same, does an STI later become AIDS if it is not

treated?”

Madiang explained to Bingwa the difference between STI and HIV, and that HIV is just one

of various STIs. After citing some examples of other STIs, he offered an explanation on how

some STIs can pave the way to infection with HIV.

Bingwa now asked, rather hesitantly, “So which STIs are treatable?”

As they spoke, Madiangwas trying to understandwhy Bingwawas asking these questions.

He came to several assumptions: Bingwa could be infected with an STI; he might be seeking

treatment for that STI; he could be concerned about his HIV status. He possibly engaged in

multipartner or unprotected sex.

IMPACT OF COMMUNITYMOBILIZATION ONHEALTH-RELATED KNOWLEDGE AND PRACTICES 197

Ironically, Bingwa believed that he was not at risk for HIV at that time, even though he was

regularly having unprotected sex with multiple partners outside his marriage. Bingwa wrongly

believed that one could get HIV only from a sex worker.

Three weeks later, Bingwa had more questions, this time about VCT, which had been the

topic of the play. What was VCT? Does the test also check for the other STIs? Must someone

undergo the counseling in order to be tested?

In truth, Bingwa had already heard about VCT but did not understand it well. He confessed

that it was at the Magnet Theatre discussions that he had begun wondering if he might be a

candidate for VCT. The enactments had led him to start reflecting on his former life. He had

become convinced that he was probably infected with an STI and that it was only a matter of

time before this issue came to light. VCT seemed to him an opportunity to check his STI status.

These questions also seem to have been a turning point in Bingwa’s life. It was after asking

these questions that he “sat back alone in the kiosk and really looked at his life.” Every answer

he received only confirmed his fear that he was already infected. It was around this point that

he decided, in his words, to “stop engaging in sex, even with my wife. I was afraid!” Bingwa had

never met anyone who had gone for VCT and even doubted whether anyone actually did.

Not long after, Bingwa decided to go for VCT. He spoke to Madiang in private for nearly

one-and-a-half hours and asked him more questions than he ever had before. He would listen

to the answers keenly, be quiet for a while, and then launch another question. Two days later,

Bingwa became one of the first young men to go for VCT as a result of his exposure to the

Magnet Theatre process.

Bingwa’s life has not been the same since he went for VCT. He has already spoken out on

a popular Kenyan radio serial drama produced by PATH, Kati Yetu, strongly urging others to

go for VCT and reflect on their sexual lives and behaviors. Standing in front of his peers in a

Magnet Theatre session, Bingwa pledged that he would no longer engage in multipartner sex.

As of that year’s end, Bingwa affirmed that he had had neither extramarital nor unprotected

sex. That was six months after he adopted a new behavior. Today Bingwa has become a role

model in his community and has helped innumerable numbers of his peers to also go for VCT.

He is often asked to share his experience and the benefits of VCT, information he is always

willing to give out.

And his house is no longer called “The Butchery.”

Source: Program for Appropriate Technology in Health. “How Bingwa Changed His Ways.” Unpublished case

study, 2005b. Copyright C 2005, Program for Appropriate Technology in Health. The material in this case study may be freely used for educational or noncommercial purposes, provided that the material is accompanied by

this acknowledgment line. All rights reserved. Used by permission.

198 CHAPTER 6: COMMUNITY MOBILIZATION AND CITIZEN ENGAGEMENT

Advancing Knowledge and Changing Practices Regardless of how leaders decide to become engaged in the community mobilization process, this approach has proven to be effective in prompting changes in people’s health knowledge and practices. For example, one of the most important lessons learned in the past few decades is that “a fully mobilized and supportive environment is a crucial element of effective HIV prevention” (Amoah, 2001, p. 1).

In the United States, gay activists have played a fundamental role in controlling the AIDS epidemic. By speaking up, they have helped break the cycle of misinformation, shame, and stigma that is still an issue in too much of society, but was even more relevant in the early years of the epidemic, and risked paralyzing any form of progress. AIDS activists not only have ensured that “HIV prevention, treatment and care stayed a global, national and local priority” (Gay Men’s Health Crisis, 2006) but have also influenced disease awareness, drug approval regulations, work-related policies, prevention and treatment strategies, and access to medications, to name a few accomplishments. In doing so, the gay community, which started the overall AIDS activism movement in the United States, has involved different segments of society and contributed to show that AIDS is not only a gay disease. Box 6.4 presents a time line of AIDS events that summarizes some of the most important stages and results of this community mobilization process. The example also highlights that many of the policy and social changes were triggered by knowledge and behavioral changes at the legislative, general public, and scientific community levels.

BOX 6.4. GAYMEN’S HEALTH CRISIS HIV/AIDS TIME LINE

1981 CDC reports Kaposi’s sarcoma in healthy gay men.

New York Times announces “rare cancer” in forty-one gay men.

Eighty men gather in New York to address “gay cancer” and raise money for

research.

CDC declares the new disease an epidemic…………………………………………………………………………………………………………………………………………………………………………….

IMPACT OF COMMUNITYMOBILIZATION ONHEALTH-RELATED KNOWLEDGE AND PRACTICES 199

…………………………………………………………………………………………………………………………………………………………………………… 1982 GMHC (Gay Men’s Health Crisis) is officially established.

An answering machine, which acts as the world’s first AIDS hotline, receives

more than one hundred calls the first night.

GMHC holds its second AIDS fundraiser; produces and distributes fifty thousand

free copies of its first newsletter to doctors, hospitals, clinics, and the Library of

Congress and creates buddy program to assist PWAs (persons with AIDS).

CDC changes the name from gay cancer to AIDS……………………………………………………………………………………………………………………………………………………………………………. 1983 PWAs form National Association of People with AIDS (NAPWA).

GMHC funds litigation of first AIDS discrimination suit.

New York State (NYS) Department of Health AIDS Institute established……………………………………………………………………………………………………………………………………………………………………………. 1984 CDC requests GMHC’s help to plan public conferences on AIDS.

GMHC publishes its first safer sex guidelines.

The human immunodeficiency virus (HIV) is isolated in France and later in the

United States……………………………………………………………………………………………………………………………………………………………………………. 1985 Revelation that Rock Hudson, a US TV and movie star, has AIDS makes the

disease a household word.

FDA approves first test to screen for antibodies to HIV.

The American Association of Blood Banks and the Red Cross begin screening

blood for HIV antibodies and rejecting gay donors.

GMHC’s art auction is world’s first million-dollar AIDS fundraiser.

First international conference on AIDS held in Atlanta, Georgia.

CDC estimates one million HIV-infected people worldwide.

US military starts mandatory HIV testing.

First conference to discuss AIDS in communities of color held in New York City……………………………………………………………………………………………………………………………………………………………………………. 1986 New York City’s first anonymous testing site opens.

GMHC’s client base now includes heterosexual men and women, hemophiliacs,

intravenous drug users, and children.

US surgeon general calls for AIDS education for children of all ages.

GMHC holds first AIDS walk in New York City.

Several states pass bills to ban PWAs from food-handling and educational jobs,

making it a crime to transmit HIV, and force testing of prostitutes……………………………………………………………………………………………………………………………………………………………………………. 1987 AZT, the first drug approved to fight HIV, is marketed.

President Reagan uses the word AIDS in public for the first time.

CDC expands the definition of AIDS.

The United States shuts its doors to HIV-infected immigrants and travelers.

Political attacks against GMHC and educational efforts on safer sex that “encour-

age or promote homosexual sexual activity.”……………………………………………………………………………………………………………………………………………………………………………

200 CHAPTER 6: COMMUNITY MOBILIZATION AND CITIZEN ENGAGEMENT

…………………………………………………………………………………………………………………………………………………………………………… 1988 Condom use is shown to be effective in HIV prevention.

The first World AIDS Day held on December 1.

Surgeon general mails 107 million copies of “Understanding AIDS” to every

US household. The United States bans discrimination against federal workers

with HIV……………………………………………………………………………………………………………………………………………………………………………. 1989 GMHC leads successful effort to draft and pass New York State’s AIDS-Related

Information Bill, ensuring confidentiality. GMHC and other AIDS organizations

protest against US immigration policies……………………………………………………………………………………………………………………………………………………………………………. 1990 AIDS activist Ryan White’s death points to need for urgent funding legislation.

The Ryan White Comprehensive AIDS Resources Emergency (CARE) Act passes,

authorizing $881 million in emergency relief.

Americans with Disabilities Act (ADA) signed to protect people with disabilities,

including people with HIV, from discrimination.

The first book to talk about long-term survivors of AIDS is published.

The first GMHC dance-a-thon raises over $1 million.

US AIDS deaths pass the one hundred thousand mark……………………………………………………………………………………………………………………………………………………………………………. 1991 Earvin“Magic” Johnsonannounceshe isHIV-positive,becomingthefirstcelebrity

to admit contracting HIV via heterosexual sex.

Condoms become available in New York City high schools after months of

debate.

A Roper poll commissioned by GMHC finds that a majority of Americans believe

that more explicit AIDS education is needed……………………………………………………………………………………………………………………………………………………………………………. 1992 In response tomounting activism and protest, FDA starts “accelerated approval”

to get drugs to PWAs faster.

A federal court strikes down proposed “offensiveness” restrictions on AIDS

education materials.

First time that a US president is elected on a campaign platform that also

contains HIV and AIDS issues……………………………………………………………………………………………………………………………………………………………………………. 1993 CDC expands the definition of AIDS. New AIDS diagnoses expected to increase

by as much as 100 percent as a result of the change.

Over 13,800 PWAs have been clients of GMHC at this point.

The CDC, NIH, and FDA jointly declare that condoms are “highly effective” for

prevention of HIV infection……………………………………………………………………………………………………………………………………………………………………………. 1994 GMHC begins a New York City subway campaign aimed at gay, lesbian, and

heterosexual young adults.

WHO estimates 19.5 million HIV-infected people worldwide…………………………………………………………………………………………………………………………………………………………………………….

IMPACT OF COMMUNITYMOBILIZATION ONHEALTH-RELATED KNOWLEDGE AND PRACTICES 201

…………………………………………………………………………………………………………………………………………………………………………… 1995 CDC announces that AIDS is the leading cause of death among Americans aged

twenty-five to forty-four.

The FDA approves the first in a new class of drugs called protease inhibitors……………………………………………………………………………………………………………………………………………………………………………. 1996 The FDA approves the sale of first home HIV test kit.

GMHC launches its first prevention campaign for HIV-negative men.

The FDA approves HIV viral load test, used to track HIV progression and efficacy

of combination therapy.

Cover stories hailing AIDS breakthroughs and the “end” of the epidemic start

appearing in major US publications……………………………………………………………………………………………………………………………………………………………………………. 1997 The first human trials of an AIDS vaccine begin.

WHO estimates 30.6 million HIV-infected people worldwide.

GMHC begins providing on-site HIV testing and counseling services……………………………………………………………………………………………………………………………………………………………………………. 1998 GMHC launches the largest survey of gay and bisexual men, “Beyond 2000

Sexual Health Survey.”

New York State HIV Reporting and Partner Notification Act signed, requiring

that cases of HIV (not just AIDS) be reported to the Department of Health.

A GMHC study reports that an estimated 69,000 people in New York State have

HIV but remain unaware……………………………………………………………………………………………………………………………………………………………………………. 1999 First large-scale study of young gay men finds that large numbers have been

infected in the last two years, many of them black men……………………………………………………………………………………………………………………………………………………………………………. 2000 As the result of years of lobbying by HIV/AIDS organizations, New York State

passes legislation decriminalizing sale and possession of syringes without

prescription.

The CDC reports that black and Latino men now account for more AIDS cases

among gay men than white men.

The GMHC AIDS Hotline becomes accessible via e-mail……………………………………………………………………………………………………………………………………………………………………………. 2001 Twentieth year of AIDS epidemic.

In response to the arrest of participants in needle exchange program, federal

court rules that police may not interfere with public health initiatives that

combat disease through education and prevention.

UN General Assembly adopts global blueprint for action on HIV/AIDS and calls

for creation of $7 to $10 billion global fund for the developing world.

Abstinence-only HIV prevention programs begin to be promoted by US govern-

ment…………………………………………………………………………………………………………………………………………………………………………….

202 CHAPTER 6: COMMUNITY MOBILIZATION AND CITIZEN ENGAGEMENT

…………………………………………………………………………………………………………………………………………………………………………… 2002 The FDA approves a new rapid HIV testing device.

GMHC joins activists to protest US underfunding of domestic and global AIDS

programs.

GMHC begins offering on-site hepatitis C testing and launches new initiative

looking at gay men’s health in broader context……………………………………………………………………………………………………………………………………………………………………………. 2003 GMHC holds eighteenth annual New York AIDS Walk.

US bill authorizing up to $15 billion for global AIDS, TB, and malaria treatment

and prevention for twelve African and two Caribbean countries is signed.

Activists express doubts about provision that assigns abstinence-only programs

a third of USAID’s prevention funding……………………………………………………………………………………………………………………………………………………………………………. 2004 GMHC launches a new women’s institute to explore new approaches to HIV

prevention, particularly for women of color……………………………………………………………………………………………………………………………………………………………………………. 2006 About 38.6 million people are estimated to be living with HIV and AIDS

worldwide……………………………………………………………………………………………………………………………………………………………………………. 2009 President Obama and the Office of National AIDS Policy unveil the “91/2 Min-

utes” campaign. Every nine-and-a-half minutes, someone in the United States

becomes infectedwithHIV, equalingmore than fifty-six thousandnew infections

each year……………………………………………………………………………………………………………………………………………………………………………. 2011 GMHC celebrate its thirtieth anniversary and is recognized by the

White House as a pivotal organization in the HIV/AIDS field……………………………………………………………………………………………………………………………………………………………………………. 2012 AIDS Walk New York commemorates its twenty-seventh year as an event at the

forefront of the fight against HIV/AIDS.

Source: Gay Men’s Health Crisis. Gay Men’s Health Crisis HIV/AIDS Timeline. New York: Gay Men’s Health Crisis (GMHC), 2013. Used by permission.

As another example, in India and Armenia, a community mobilization effort thatwas implementedwithin amultichannel behavior change strategy was shown to improve knowledge and practices in many areas of childhood diseases management, including “improvements in births attended by skilledpractitioners, exclusive breastfeeding, immunization, andHIV/AIDS awareness and prevention knowledge” (Baranick and Ricca, 2005). Efficient mobilization requires regular and efficient information exchange, and new media and mobile technology have provided low-cost options for information exchange in many settings.

The list of disease areas andhealth issues inwhich communitymobiliza- tion has made or could make a difference is endless. By empowering people to take their lives and health in their own hands, community mobilization

KEY STEPS OF COMMUNITYMOBILIZATION PROGRAMS 203

can produce long-lasting results in health behaviors and practices as part of a multidisciplinary and multifaceted approach.

Key Steps of Community Mobilization Programs

There are several models and frameworks that describe the key steps of communitymobilization. Although some of the stages they describemay be different or use interchangeable terms, a few general criteria are common to all of them or reflect practical experience. These steps also apply to citizen engagement but need to be considered in a larger scale.

• The importance of understanding the community’s key characteristics, structure, values, needs, attitudes, social norms, health behaviors, and priorities

• A cross-cultural communication approach through which health com- municators and other community mobilizers should refrain from any form of cultural bias in exchanging information about health systems, beliefs, and behaviors, as well as other kinds of topics

• The need for engaging community members at the outset of the inter- vention, including during the community assessment or participatory research phase (and whenever possible, prior to that)

• A research-based planning process that should respond and evolve according to community needs and priorities

• An emphasis on capacity building and community autonomy, and ownership of the overall communication and goal-setting process

• An efficient information-exchange process that relies on culturally competent communication channels and venues

• A rigorous evaluation process that needs to be mutually agreed on by all community members and leaders, identifies behavioral or social outcomes as key evaluation parameters, and includes a number of other evaluation measurements to monitor progress and process at different stages

• The ability for the process to be replicated during the scaling-up phase (in which the program is expanded to reach other communities and regions) as well as to address similar issues within the community

Following are a few examples of models for community mobilization that incorporate all these criteria in different phases or by using slightly different terminologies. Methodologies used for most of these steps are

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common to the planning and implementation process of the overall field of health communication, and are described in further detail in Part Three of this book.

Common Terms and Steps in Community Mobilization Community mobilization is a long-term process that relies on a variety of sequential yet interdependent steps and activities. Some of the most common terms and phases of community mobilization are described next, starting with how to select and engage community organizations and leaders.

Engaging Community Organizations and Leaders Before conducting any community mobilization effort, health communi- cators and other community mobilizers need to identify communities that may have an interest in participating in such effort. The following key criteria should be considered:

• The community has expressed a preliminary interest in participating and places a high priority on the specific health issue.

• There are high rates of disease incidence, morbidity, and mortality within the community.

• Specific community characteristics can be used as a model for replica- tion of the effort.

• The health issue is relevant to the community’s health and develop- ment.

• There are relevant special needs or issues.

Engaging and equipping community leaders with potential new skills they may need to be effective participants in the overall communication process (including defining the key elements and initial steps of the intervention) are critical and should be part of the initial community engagement process.

This phase should be informed by preliminary formative research, including analysis of secondary data (literature, articles, and other infor- mation compiled by others) as well as stakeholders’ interviews, which will inform health communicators about how to approach the community regarding the specific health issue. At this stage, key stakeholders may include representatives of local nongovernmental organizations (NGOs), companies, international health agencies, local churches, women’s groups,

KEY STEPS OF COMMUNITYMOBILIZATION PROGRAMS 205

government, and everyone who can provide initial information on the community’s key characteristics, structure, and issues as well as existing interventions in the same health area. Formative research can also be instrumental in identifying potential community leaders.

Preliminary research findings and analysis should be shared with community members formally and informally. For example, as part of a joint malaria prevention effort in Angola by UNICEF and the local ministry of health, preliminary research findings were shared first with a team of government officers, and then with a larger group representing local NGOs, companies, universities, and other key stakeholders (Schiavo, 1998, 2000). This gave an opportunity to all participants to brainstorm about the findings, prioritize their relevance within the community, and develop preliminary strategies for a community outreach effort aimed at enhancing malaria awareness as well as the use of insecticide-treated mosquito nets for malaria protection (Schiavo and Robson, 1999). At the same time, this helped recruit and train communitymembers for the participatory research effort and other phases of the program.

Of great importance in approaching any community to share infor- mation and to initiate a dialogue on a specific health issue is to take into account community needs, preferences, and existing priorities. For example, in approaching a refugee camp in any underserved region of the world to discuss malaria prevention and potential interventions, facilitators should be prepared to hear that themain concern among communitymem- bersmay not bemalaria at all but actually food supplies, transportation, and others. Because these are very important priorities, health communication practitioners and community leaders should make all attempts to build trust, make sure community members feel they have been heard, provide links to resources and people who may address other priority issues, and make linkages between community-specific priorities and the health topic being discussed. Chances are that many different determinants of health, including those highlighted by the community, are contributing to disease severity and overall impact. For example, “malaria and poverty are inti- mately connected” (Gallup and Sachs, 2001, p. 85). Malaria exacerbates the impact of malnutrition, is a deterrent for foreign investment and tourism, and “has lifelong effects on cognitive development and education levels through the impact of chronic malaria-induced anemia and time lost or wasted in the classroom due to illness” (Gallup and Sachs, 2001, p. 85). As with other health conditions for which significant health disparities exist, malaria is a key determinant of socioeconomic development just as much as nutrition, transportation, education, and economic opportunities are

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key determinants of malaria severity and overall impact. This kind of anal- ysis should be part of community-based conversations when approaching community members to share information on any kind of health issue.

Participatory Research Participatory research, also referred to as community-driven assess-

participatory research (community-driven assessment, participatory needs assessment, community-needs assessment) A collaborative research effort that involves community members, researchers, community mobilizers, and interested agencies and organizations. It is a two-way dialogue that starts with the people, and through which the community understands and identifies key issues, priorities, and potential actions.

ment, participatory needs assessment (Centers for Disease Control [CDC], 2006i), and community-needs assessment, is a collaborative research effort that involves community members, researchers, commu- nity mobilizers, and interested agencies and organizations. It is a two-way dialogue that starts with the people, and through which the community understands and identifies key issues, priorities, and potential actions. Par- ticipatory research should inform and guide all phases of the community mobilization effort.

The US Agency for Healthcare Research and Quality (AHRQ) defines participatory research as “an approach to health and environmental research meant to increase the value of studies for both researchers and the community being studied” (Viswanathan and others, 2004, p. 1). Par- ticipatory research uses traditional research methodologies such as focus groups and one-on-one or group interviews. Another important method for participatory research is community dialogue, which is discussed in Chapter Four, because it is a form of interpersonal communication at scale.

Although the community should be involved in designing the research protocol and questions as well as recruiting research participants and analyzing research findings, experience shows that “participation levels vary” and depend on many factors, related to both the community and the health communication and research teams (Mercer, Potter, and Green, 2002). Also, the concept of participation may mean different things to different people and institutions.

Ideally, the community should be the main protagonist of this process. This phase should represent an opportunity to exchange information; understand community preferences, concerns, and priorities; and identify culturally appropriate communication activities, channels, messages, and spokespeople, as well as the behavioral or social outcomes that would need to be achieved through the intervention.

Community Group Meetings Community group meetings involve larger segments of the community in addition to the original members who have been recruited for the participa- tory research phase. They can be existing meetings (for example, monthly

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administrative meetings of a women’s group, hospital, or other kind of community) that are used to inform and engage community members in the communitymobilization efforts. They can also be specifically organized for other reasons:

• Sharing participatory research findings and securing feedback from a larger number of community members

• Informing about the health issue, its relevance to the community, and potential behavioral or social changes that have been identified during formative or participatory research, and then securing feedback and suggestions on all elements

• Advancing understanding of the community’s priorities and needs • Promoting an ongoing dialogue among community members on the

health issue and its potential solutions as well as other community priorities

• Motivating and engaging additional volunteers or community leaders to participate in the community mobilization effort

• Identifying roles and responsibilities of community members for pro- gram implementation

• Addressing other community- or issue-specific topics

Ideally, community leaders should conduct these meetings with the help, when necessary, of health communicators and other facilitators. Sometimes if local leaders are not ready or adequately trained to conduct such meetings, the community mobilization external team could take the lead, but only after discussing and agreeing on meeting strategies and agenda with relevant community leaders.

Partnership Meetings Once the community has identified its key priorities and actions, partner- ship meetings can be held to define and start establishing collaborations among community members, agencies, and organizations that have partic- ipated so far in the process or to introduce them to potential new partners and organizations. These kinds of meetings should attempt to achieve several goals:

• Define the roles and responsibilities of all different partners • Advance agreement on standard procedures and specific contributions

to the community mobilization effort • Develop strategies and action plans

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• Define and mutually agree on evaluation parameters • Discuss lessons learned • Provide an update on progress

A discussion on establishing and maintaining partnerships is included in Chapter Eight of this book.

Mobilization Tools for Urban Communities Although all the methods and tools discussed so far also apply to mobi- lization efforts in urban settings, some other methods may also be very helpful in mobilizing urban communities. Urban health settings present many similarities but also several distinguishing features from other geo- graphical, cultural, and physical contexts. Several authors have dwelled on the key characteristics of urban environments and their implications for public health, health care, and community development interventions and outcomes. Although some of these factors include social determinants of health that are not unique to urban environments, they are often “trans- formed when viewed through the characteristics of cities such as size, density, diversity, and complexity” (Vlahov and others, 2007, p. 16) and contribute to health challenges that may be unique to, or exacerbated by, urban environments, including “poverty, violence, social exclusion, pollu- tion, substandard housing, the unmet needs of elderly and young people, homeless people and migrants, unhealthy spatial planning, the lack of participatory practices and the need to seriously address inequality and sustainable development” (Waelkens and Greindl, 2001, p. 18).

In this context, mobilization tools may need to be expanded to be inclusive of different groups, to account for geographical distances, and to address perhaps higher levels of diversity than in smaller communities or rural areas. Some tools that may be helpful in urban settings include the following:

• Participatory influential road mapping, a participatory and

participatory influential road mapping A participatory and community-driven process to identify key stakeholders and other influentials who need to be engaged as part of the community mobilization and citizen engagement process

community-driven process to identify key stakeholders and other influentials who need to be engaged as part of the community mobilization and citizen engagement process. Although identifying key influentials is key to all kinds of mobilization efforts, it is perhaps even more relevant in urban settings where health communication practitioners and other team members may be faced with a large number of influencers that are specific to the different groups living in a given city.

KEY STEPS OF COMMUNITYMOBILIZATION PROGRAMS 209

• Strategic partnership training tomake sure that different communities and professionals understand key success factors and the dos and don’ts of successful multisectoral partnership and are well equipped to plan and execute them. A more detailed discussion on strategic partnerships and constituency relations is included in Chapter Eight. Thismaybedesignedaspreliminary to actionplanning andpartnership meetings.

• Consensus-building workshops, which may be embedded as part of consensus-building workshops Workshops that facilitate the building of consensus as well as momentum on key priority issues and innovative ways to address them

community meetings and facilitate the building of consensus as well as momentum on key priority issues and innovative ways to address them. These meetings should lead to a shared vision of the future that communities want to build for themselves and their children because it relates to a specific health or social issue.

Public Consultations Public consultation is a process in which the general public is asked to public consultation

A process in which the general public is asked to provide input on policies or other matters that may affect them

provide input on policies or othermatters thatmay affect them.An example of public consultation is the one conducted by the Canadian government in the prepandemic flu phase (prior to theH1NI flu outbreak of 2009) to assess citizen and stakeholders’ priorities on pandemic flu mitigation, including antiviral stockpile and prophylaxis (Schiavo, 2009b). Such consultation was implemented via several delivered dialogue sessions with citizens and health and nonhealth stakeholders. Delivered dialogue is a method for

delivered dialogue Amethod for public dialogue and consultation that usually relies on the use of specific discussion tools, including a discussion guide, sequence of questions, and briefing materials and instructions for dialogue facilitators

public dialogue and consultation that usually relies on the use of specific discussion tools, including a discussion guide, sequence of questions, and briefing materials and instructions for dialogue facilitators. The consul- tation empowered the Canadian public on deciding fund allocations for different pandemic flu interventions, and revealed that citizens regarded public health communication as a means of prevention (to be supported by adequate funding), and preferred to invest funds in antiviral supplies only as stockpiles for treatment interventions and not as a preventive measure (prophylaxis) (Schiavo, 2009b).

Another example of public consultations is the referendum (a vote referendum A vote on a ballot question in which the entire electorate is asked to accept or reject a policy change

on a ballot question in which the entire electorate is asked to accept or reject a policy change). Referendums on specific policy issues are conducted in many countries, including Italy. Yet, public costs of referen- dums are prohibitive for many developed and developing countries, thus delivered dialogue may be a more cost-effective method for public consul- tation (in addition to enabling qualitative assessment of public needs and preferences).

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Culturally Competent Communication Approaches, Channels, and Messengers Community mobilization is complemented by or relies on many different communication approaches and channels, such as theater, traditional media, new media, brochures, home visits, workshops, and rallies. (A detailed discussion about the development of communication messages and tools is included in Part Three of this book as part of the overall health communication planning and implementation processes.)

Nevertheless, it is important to note here that all strategies and action plans need to include community-based methodologies, channels, and venues (for example, existing meetings and communication vehicles), address community priorities and needs, and support behavioral or social outcomes. Most important, communication tools and messages need to be developed and delivered by and for the people.

All communication approaches, channels, and messengers or spokes- people should be carefully selected and evaluated vis-à-vis their cultural adequacy. As effective information exchange is key to the success of com- munity mobilization efforts, communication channels should be culturally competent. Yet, of equal importance is that such channels are traditionally used to share health-related information and not only to communicate on other topics.

For example, traditional media such as community radio have been successfully used to announce community meetings and reinforce health messages. Radio is a popular communication vehicle in many developing countries (and is still quite popular in manyWestern countries), which has been traditionally used also for health communication programs. In the new media era, mobile technology, which is fast advancing also in developing countries, has been used to communicate in between regular community meetings, to share information in disaster or public health emergency set- tings as well as to build people’s capacity to help each other, and to provide information to other teammembers on early signs and indicators that exter- nal factors may change and therefore affect programming (Mercy Corps, 2013).Althoughnewmediaarevaluablecommunicationtools incommunity mobilization, inmany parts of the world there is still no substitute for inter- personal communication venues and channels, because word-of-mouth, trusted community leaders and social mobilization partners, community- friendly venues, and ultimately human interactions continue to account for a large percentage of all kinds of communications on health and illness. Therefore, it is important to research and identify culturally competent communication channels to facilitate the exchange of information and ideas during the community mobilization or citizen engagement process.

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