Health Communication - دانشکده بهداشتsoh.iums.ac.ir/uploads/health_communication_book1.pdf · 2016-08-30 · health communication theory and practice. The need for this

HealthCommunicationFrom Theory to Practice

Renata Schiavo

John Wiley & Sons, Inc.

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Health CommunicationFrom Theory to Practice

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HealthCommunicationFrom Theory to Practice

Renata Schiavo

John Wiley & Sons, Inc.

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Copyright © 2007 by Renata Schiavo. All rights reserved.

Published by Jossey-BassA Wiley Imprint989 Market Street, San Francisco, CA 94103-1741 www.josseybass.com

No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any formor by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except aspermitted under Section 107 or 108 of the 1976 United States Copyright Act, without either the priorwritten permission of the publisher, or authorization through payment of the appropriate per-copyfee to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400,fax 978-646-8600, or on the Web at www.copyright.com. Requests to the publisher for permissionshould be addressed to the Permissions Department, John Wiley & Sons, Inc., 111 River Street, Hoboken,NJ 07030, 201-748-6011, fax 201-748-6008, or online at http://www.wiley.com/go/permissions.

Limit of Liability/Disclaimer of Warranty: While the publisher and author have used their best effortsin preparing this book, they make no representations or warranties with respect to the accuracy orcompleteness of the contents of this book and specifically disclaim any implied warranties ofmerchantability or fitness for a particular purpose. No warranty may be created or extended by salesrepresentatives or written sales materials. The advice and strategies contained herein may not besuitable for your situation. You should consult with a professional where appropriate. Neither thepublisher nor author shall be liable for any loss of profit or any other commercial damages, includingbut not limited to special, incidental, consequential, or other damages.

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Library of Congress Cataloging-in-Publication Data

Schiavo, Renata.Health communication : from theory to practice / Renata Schiavo. — 1st ed.

p.; cm.Includes bibliographical references and index.ISBN 978-0-7879-8205-8 (pbk.)

1. Communication in medicine—United States. 2. Health promotion—United States. 3. Healthplanning—United States. I. Title.[DNLM: 1. Delivery of Health Care. 2. Communication. 3. Health Planning. 4. Program

Development. W 84.1 S329h 2007]R118.S33 2007610.1'4—dc22

2006101792

Printed in the United States of AmericaFIRST EDITION

PB Printing 10 9 8 7 6 5 4 3 2 1

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www.josseybass.com

Contents

Tables, Figures, Exhibits, and Numbered Boxes viiPreface xiAcknowledgments xvAbout the Author xviiIntroduction xix

P A R T O N E : I N T R O D U C T I O N T OH E A L T H C O M M U N I C A T I O N 11 What Is Health Communication? 32 Current Health Communication Theories and Issues 303 Cultural, Gender, Ethnic, Religious,

and Geographical Influences on Conceptions ofHealth and Illness 71

P A R T T W O : H E A L T H C O M M U N I C A T I O NA P P R O A C H E S A N D A C T I O N A R E A S 8 94 Interpersonal Communications 915 Public Relations and Public Advocacy 1216 Community Mobilization 1477 Professional Medical Communications 1758 Constituency Relations in Health Communication 198

P A R T T H R E E : P L A N N I N G , I M P L E M E N T I N G , A N DE V A L U A T I N G A H E A L T H C O M M U N I C A T I O N P R O G R A M 2 1 39 Overview of the Health Communication

Planning Process 21510 Situation Analysis and Audience Profile 237

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11 Identifying Program Objectives and Strategies 28112 Developing Tactical and Evaluation Plans 29813 Implementing, Monitoring, and Evaluating

a Health Communication Program 336Appendix A: Examples of Worksheets and Resources

on Health Communication Planning 353Appendix B: Selected Online Resources on Health

Communication 363Glossary 371References 379Name Index 413Subject Index 419

vi CONTENTS

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Tables, Figures, Exhibits,and Numbered Boxes

Tables1.1 Health Communication Definitions 81.2 Key Characteristics of Health Communication 121.3 What Health Communication Can and Cannot Do 273.1 A Comparative Overview of Ideas

of Health and Illness 793.2 Examples of Disease-Specific Ideas of Illness 834.1 Comparing Cultural Norms and Values 944.2 Barriers to Effective Provider-Patient

Communications: Patient Factors 1115.1 Public Relations Functions in Health Care 1235.2 Characteristics of Types Relevant to Public Relations 1255.3 Key Characteristics of Ethical Public

Relations Programs 1305.4 Dos and Don’ts of Media Relations 1365.5 Mass Media Channels and Related

Public Relations Tools 1397.1 Key Audiences of Professional Medical

Communications 1787.2 Key Obstacles to Clinician Change 1847.3 Communication Approaches and Tools

and Their Effects 1887.4 Key Communications Tools and Channels

in Professional Communications 193

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8.1 Guidelines for Establishing and PreservingLong-Term Relationships 205

8.2 Potential Drawbacks of Partnerships 2089.1 Key Elements of an Effective Health

Communication Program 22710.1 Qualitative Versus Quantitative Research Methods 26610.2 Frequency of Explicit Criteria for Evaluation of

Health-Related Web Sites by Criteria Groups 27112.1 Examples of Communication Concepts for a

Program on Childhood Immunization 30912.2 Key Elements of a Partnership Plan 32112.3 Drawbacks of Evaluation 32813.1 Examples of Areas of Monitoring with Related

Data Collection and Reporting Methods 344

Figures1.1 Health Communication Environment 232.1 Attributes of the Audience 342.2 Ideation Theory 424.1 The Potential Impact of Interpersonal

Communications on Behavior: A Practical Example 999.1 Health Communication Cycle 2219.2 Key Steps of Health Communication Planning 223

10.1 Key Steps of Situation Analysis 241

Exhibits9.1 Examples of Outcome Objectives for a

Program on Pediatric Asthma 23410.1 Audience Segmentation Example 25010.2 SWOT Analysis for the Caribbean Cervical

Cancer Prevention and Control Project 264

viii TABLES, FIGURES, EXHIBITS, AND NUMBERED BOXES

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11.1 Sample Communication Objectives: Understandingthe Connection with Other Program Elements 286

Numbered Boxes2.1 Diffusion of Innovation Theory: A Practical Example 352.2 Raising Awareness of Infant Mortality Disparities

in San Francisco 484.1 Personal Selling Case Study 1024.2 The Impact of Effective Provider-Patient

Communications on Patient Outcomes:A Pediatric Nurse Practitioner’s Perspective 106

4.3 Impact of Physician Attitudes on Patient Behavior:A True Story 108

5.1 Johnson & Johnson’s Campaign for Nursing’sFuture Initiative 127

5.2 Using the Internet as a Key Public Relations Channel:The Schepens Eye Research Institute 131

6.1 Social Mobilization to Fight Ebola in Yambio,Southern Sudan 155

6.2 How Bingwa Changed His Ways 1586.3 Gay Men’s Health Crisis HIV/AIDS Timeline 1627.1 National Foundation for Infectious Diseases Flu

Fight for Kids: Case Study 1898.1 How Constituency Relations Can Help Advance an

Organization’s Mission: A Practice-Based Perspective 2068.2 National Cancer Institute Guidelines for Considering

Commercial Partners 21010.1 Audience Profile: Got a Minute? Give It to Your Kids! 25212.1 NCI’s Cancer Research Awareness Initiative:

From Message Concepts to Final Message 31112.2 Community Theater in Benin: Taking the Show on

the Road 315

TABLES, FIGURES, EXHIBITS, AND NUMBERED BOXES ix

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For my daughters, Oriana and Talia, and,of course, my husband, Roger Ullman

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Preface

When my child will grow up, he will walk on his own, hewill walk on his own two feet, and that is the greatest giftof all.A MOTHER WHOSE CHILD RECEIVED THE POLIO VACCINEAS PART OF THE ONGOING POLIO ERADICATION CAMPAIGN

IN INDIA (WORLD HEALTH ORGANIZATION AND GLOBALPOLIO ERADICATION INITIATIVE, 2004A)

“I first became familiar with the importance and impact of healthcommunication while working on the polio eradication campaignin India,” relates one of my students, Prarthana Shukla, who holdsa medical degree from Ahmedabad, India, and moved to the UnitedStates to complete a master’s in public health at New York Univer-sity (interview with the author, 2006). As a member of one of themedical teams that administered the oral polio vaccine to infantsand unimmunized children in India, she attributes the long linesof people waiting to be immunized to a widespread and well-designed communication campaign that used multiple channelsto convey the importance and safety of immunization. Despite herlack of experience in health communication, several analyses andpostintervention evaluations (Waisbord, 2004; Favin, 2004) agreewith her observation and contribute to the bulk of evidence inmany disease areas that has recently propelled health communi-cation to the forefront of the public health arena.

Health communication has been defined as “the main currencyof healthcare in the 21st century” (Clancy, quoted in Krisberg,2004). Ready access to relevant, reliable, and culturally appropri-ate information enables the general public, patients, health care

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providers, public health professionals, and others to address per-sonal and public health concerns far more effectively than in thepast (U.S. Department of Health and Human Services, 2001). Inthe wake of the anthrax crisis in 2001, communication was definedby the U.S. Centers for Disease Control (CDC) and other federalauthorities as the most important health-care-related science of thetwenty-first century (White House, 2004; Prue, Lackey, Swenarski,and Gantt, 2003). For the first time, health communication is partof the Healthy People 2010 objectives, the official public healthagenda of the U.S. federal government.

Health communication courses as well as specific health com-munication programs have been flourishing in the United Statesand around the rest of the world. This has created the need forcomprehensive and up-to-date tools to train students and staff onhealth communication theory and practice.

The need for this book became clear while I was looking for atextbook for my health communication course. I wanted a bookthat combined a theoretical and practice-based overview of currentissues and topics in health communication with a step-by-step prac-tical section that would help readers acquire technical skills in pro-gram planning, implementation, and evaluation. Conversationswith other health communication practitioners and colleagues con-firmed the need for this kind of book.

For the past eighteen years, I have been focusing on interna-tional health care. I have had the opportunity to work on staff oras a consultant for nonprofit organizations, pharmaceutical com-panies, communication agencies, governments, universities, andresearch laboratories in the United States and several countries inEurope, Latin America, and Africa. I know that health communi-cation is a powerful tool that can help improve health outcomes,contribute to eliminating health disparities, and promote behav-ioral and social change. I wanted this book to reflect my practice-based perspective and convey to readers my enthusiasm and trustin the enormous potential of well-designed and well-implementedhealth communication programs to improve individual and pub-lic health outcomes.

The recent health communication “renaissance,” as it has beencalled by a few authors (including Bernhardt, 2004, p. 2051), hasalso been accompanied by a passionate attempt to redefine health

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communication and its role in public health, as well as to encour-age health professionals around the world to take advantage of thistool whenever possible. In doing so, most authors and practition-ers seem to agree that health communication is an approach draw-ing on multiple disciplines, including mass communication, socialmarketing, health education, anthropology, and sociology (Bern-hardt, 2004; Institute of Medicine, 2003; World Health Organiza-tion, 2003). I wanted this book to contribute to this debate bycapturing and summarizing recent trends and opinions, as well asmy own practical and teaching experience. Ultimately the goal isto help create new generations of health communication expertsand contribute to expanding the pool of health professionals whowill use this approach.

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Acknowledgments

A great number of colleagues, friends, and family members havecontributed to the creation of this book. My first heartfelt thanksgo to my editors, Andy Pasternack and Seth Schwartz of Jossey-Bass,for their invaluable help and guidance with the many questions re-lated to this project. Special thanks also to Sally Guttmacher ofNew York University for her encouragement when the idea of thisbook was in its infancy.

Thanks to my anonymous reviewers for their invaluable sug-gestions that have considerably contributed to the significance ofthis book. My appreciation also goes to all professional friends andcolleagues who provided suggestions on early drafts or helped se-cure relevant case studies and interviews. Among them are DougArbesfeld, Joe Casey, Lenore Cooney, Amanda Crowe, GustavoCruz, Chris Elias, Everold Hosein, Sherry Michelstein, Elil Ren-ganathan, and Lisa Weiss. I am very grateful to Prarthana Shukla,one of my students who worked as a research assistant for this pro-ject, for her dedication and hard work. Thanks to other studentswho have contributed feedback, most notably Lawrence Fung andEllen Sowala.

There are many people to whom I owe my practical experiencein health communication. These include my colleagues, clients, andpartners with whom I have had the privilege to work over the years.I spent endless nights with many of them brainstorming about newor old projects and learned a great deal from all of them.

Finally, many thanks to my husband, Roger Ullman, for hisendless support and lifetime partnership, and to our daughters,Oriana and Talia, for inspiring my work ethics and life. And to mymother, Amalia Ronchi, many thanks for understanding that I hadno time to chat during the many months dedicated to this project.

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About the Author

Renata Schiavo, Ph.D., M.A., is a senior health communicationsconsultant. She is also an adjunct assistant professor of publichealth at New York University’s Steinhardt School of Education,Department of Nutrition, Food Studies and Public Health, whereshe teaches health communication.

Schiavo has over eighteen years of international health care ex-perience in the United States and several countries in Europe, LatinAmerica, and Africa. She has worked on staff or as a consultant fornonprofit organizations, universities, pharmaceutical companies,communications agencies, research laboratories, and governments.Her communication work has focused on oncology, HIV/AIDS,malaria, leishmaniasis, central nervous system disorders, cardio-vascular diseases, women’s health, respiratory diseases, obesity,biotechnology, infectious diseases, childhood immunization, Lymedisease, and primary nocturnal enuresis.

Schiavo’s fields of expertise include strategic planning, behav-ior communications, marketing communications, communicationtraining, patient and professional medical communications, con-stituency relations, public relations, media relations, audience andmarket research, corporate communications, Internet-based com-munications, and strategic partnerships.

Schiavo served as an executive vice president at the Cooney/Waters Group (CWG), one of the largest independent health carecommunications agencies in the United States. Prior to joiningCWG, she formed and headed the corporate and marketing com-munications department of Rhodia Farma, the Brazilian affiliateof Rhone-Poulenc Rorer (now Sanofi-Aventis). Previously sheworked in the health care divisions of the New York–based com-munications agencies Manning Selvage & Lee and Noonan/Russo

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Communications. She also worked as a senior consultant to UNICEF-Angola and the local ministry of health on malaria preventionstrategies as well as evaluating local communications programs.

Formerly, Schiavo was a postdoctoral research scientist at Co-lumbia University and New York University, where she worked onnumerous molecular and cell biology projects.

Schiavo is a member of the American Public Health Associa-tion as well as the Steering Committee of its Health CommunicationWorking Group. She serves on the advisory board of Cases in PublicHealth Communication and Marketing, an online peer-reviewed jour-nal. Schiavo has also contributed with articles and opinions to theCommunication Initiative and is a member of the Communicationfor Behavioral Impact Global Technical Network, which is main-tained by the World Health Organization.

xviii ABOUT THE AUTHOR

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Introduction

Convincing people to adopt healthy behaviors or policymakers andprofessionals to introduce and change practices in support of bet-ter health has never been an easy task. Childhood immunization,for example, is one of the greatest medical and scientific successesof recent times. Because of immunization, many diseases that wereonce a threat to the life and well-being of children have becomerare or have been eradicated in many countries in the world. Yetas for most other health-related issues and interventions, chang-ing public and professional minds and convincing parents to im-munize their healthy children against diseases that may occur hastaken a worldwide multidisciplinary effort. Health communicationhas played a fundamental role in this effort since the introduction ofthe first childhood vaccine. Consider the case of Bonnie, the motherof a newborn child, who is offered a vaccine for her baby at birth ora few days after.

Bonnie, an American, is the twenty-five-year-old mother of abeautiful baby girl. She is thrilled about her child but quite fearfulbecause parenting is new to her. She has read about the benefitsof immunization but is too young to remember any of the diseasesagainst which she should immunize her child. She does not knowanyone who had polio or whooping cough or Hib (Haemophilus in-fluenzae type B) disease. She has also heard conflicting informationabout the potential adverse events or risks that may be associatedwith immunization and is unsure about which of the available in-formation is correct. She is confused and does not know whethershe wants to immunize her child.

Bonnie’s case is a typical example of issues or informationalneeds that health communication interventions can successfullyaddress. These include:

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• Providing Bonnie with research-based and reliable informa-tion that will reassure her about the importance of immuni-zation and its low risk

• Improving communication with her pediatrician or healthcare provider by teaching her what questions to ask and rais-ing awareness among health care providers of patients’ needsand most frequent concerns

• Developing tools such as brochures, posters, Web pages, andother informational vehicles from reputable sources that willreinforce the information Bonnie will hear from her healthcare provider

• Encouraging peer-to-peer support by establishing venues andevents where new mothers can discuss immunization

• Raising disease awareness by targeting consumer media, par-enting publications, and other vehicles so that Bonnie andother parents can become familiar with the severity of vaccine-preventable diseases and the benefits of immunization

Health communication approaches will work only if they relyon an in-depth understanding of Bonnie’s and other new moth-ers’ lifestyles, concerns, beliefs, attitudes, barriers to change, andsources of information about newborns and immunization. Itwould also be important to research and understand the cultural,social, and ethnic environment in which Bonnie lives. What kindof support does she get from family, friends, and her working en-vironment? Who most influences her decisions on her child’s well-being and upbringing? What does she fear about immunization?Is there any existing program in her community that focuses onchildhood immunization? What are the lessons learned? These arejust some of the many questions that need to be answered beforedeveloping a health communication program intended for Bonnieand her peers.

About This BookThe example about Bonnie should make clear that health com-munication is “a part of everyday life” (du Pré, 2000, p. 3). There-fore, health communication programs should be based oninformation and facts that draw on the everyday lives of their au-

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diences, as well as the environment where they live and work. Oneof the fundamental premises of this book is the importance of aresearch- and practice-based approach to developing theories,models, and methods that should guide and inform health com-munication planning and management.

The goal of this book is to provide a comprehensive intro-duction to health communication by combining the theory andpractice of this field with a hands-on guide to program develop-ment and implementation. This book is a much-needed intro-ductory text on health communication that addresses the needsof students and professionals who are pursuing a career in healthcare. It also incorporates many advanced topics that can helphealth communication practitioners and researchers, as well asexperts in related areas, reflect on current issues and trends andadvance their behavioral, practice, or policy change goals in amore efficient manner.

One of the primary themes of this book is the evolving natureof health communication and the importance of recognizing thatthere is no single magical health communication intervention. Onthe contrary, health communication is a multidisciplinary approachthat relies on different action areas, such as interpersonal com-munications, public relations, public advocacy, community mobi-lization, professional communications, and constituency relations,among others (see Chapter One or the Glossary for a definition ofall these terms). It is the blend of these areas that allows practi-tioners to involve communities, individuals, professional audiences,policymakers, and the general public with communication inter-ventions that will prompt them to consider, analyze, and eventu-ally adopt the behavior, policy, or practice suggested by a givenhealth communication program or approach.

Over the years I have developed a practice-based definition ofhealth communication that has inspired my work for this book. Ibelieve that health communication is a multifaceted and multidis-ciplinary approach to reach different audiences and share health-related information with the goal of influencing, engaging, andsupporting individuals, communities, health professionals, specialgroups, policymakers, and the public to champion, introduce,adopt, or sustain a behavior, practice, or policy that will ultimatelyimprove health outcomes.

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Who Should Read This BookThis book is primarily aimed at two audiences. The first of theseaudiences includes all professionals and individuals who are newto this field, such as graduate and undergraduate students inhealth communication, public health, public health education,public health nursing, community health and preventive medicine,communication, marketing, or nursing, as well as young and middle-career practitioners and researchers in this field. It also includeshealth and medical professionals, public health experts, funders,nonprofit board members and staff, physicians, nurses, and otherhealth care providers with experience in related disciplines and aprofessional interest in health communication.

In the second audience are practicing managers, researchers,and instructors who can benefit from the strategic and step-by-stepapproach this book offers to implement health communicationprograms and train students and staff on this topic in a more effi-cient, effectual, and time-saving manner.

Overview of the ContentsTwo of the fundamental premises of this book are the multidisci-plinary and multifaceted nature of health communication, as wellas the interdependence of the individual, social, political, anddisease-related factors that influence health communication in-terventions, and health care in general. With these premises inmind, the division of topics in parts and chapters is only instru-mental to the text’s readability and clarity. Readers should alwaysconsider the connection among the different theoretical and prac-tical aspects of health communication as well as all external factors(political, social, cultural, economic, market, and other influencesthat shape or contribute to a specific situation or health problemas well as influence key program audiences) that influence thisfield. This introduction is an essential part of the book and is in-strumental to maximize use and understanding of the text.

This book is divided in three parts. Part One focuses on defin-ing health communication—its theoretical basis as well as its con-texts and key action areas. Part One also establishes the importanceof considering cultural, geographical, socioeconomic, ethnic, age,

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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 inpublic health as well as in the marketing or private sector contexts.

Part Two focuses on the different areas of health communica-tion defined in Part One: interpersonal communications, publicrelations and public advocacy, community mobilization, profes-sional medical communications, and constituency relations.

In all chapters in Part Two, key health communication issuesare raised in the form of a question or brought to life in a casestudy. This is followed by a discussion of a specific communicationapproach or area. All chapters discuss specific communication areasin the context of the multidisciplinary nature of health communi-cation and the need for an integrated approach. Special emphasisis placed on the importance of selecting and adapting health com-munication tools to a fast-changing social, political, market, andpublic health environment. Case studies and testimonials from ex-perts and practitioners in the field are included in many of thechapters in Part Two.

Part Three provides a step-by-step guide to the developmentand implementation of a health communication plan. Each chap-ter covers specific steps of the health communication planning pro-cess or implementation and evaluation phases. Case studies, practicaltips, and specific examples aim to facilitate readers’ understand-ing of the planning process, as well as to build technical skills inhealth communication planning. Recent methodologies andtrends in measuring and evaluating results of health communica-tion programs are explored here.

Appendix A contains resources and worksheets on health com-munication planning. Online resources listed in Appendix B pointto job listings, conferences, journals, organizations, centers, andprograms in the health communication field.

The Glossary of key health communication planning terms atthe end of the text should be used as a reference while reading thisbook, as well as a way to recap key definitions in health communi-cation planning. Some of the key terms from the glossary are high-lighted in bold type and briefly defined the first time they arementioned in the text, so that readers can become familiar withthem before approaching the chapters in Part Three that more

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specifically cover these topics. Other topic-specific definitions areincluded in relevant chapters.

Many chapters start with a practical example or case study. Thisis often used to establish the need for communication approachesthat should be based on an in-depth understanding of intendedaudiences’ perceptions, beliefs, attitudes, behavior, and barriers tochange, as well as the cultural, social, and ethnic context in whichthey live. While referring to current theories and models, the bookalso reinforces the importance of the experience of health com-munication practitioners in developing theories, models, and ap-proaches that should guide and inform health communicationplanning and management.

Each chapter ends with discussion questions for readers to re-flect on, practice, and implement key concepts. Finally, all chap-ters are interconnected but are also designed to stand alone andprovide a comprehensive overview on the topic they cover.

Author’s NoteAs a health communication practitioner and instructor, I fully un-derstand the complexity of communicating about health and ill-ness. Changing human and social behavior to attain better healthoutcomes is often a lifetime endeavor.

My heartfelt appreciation and admiration go to all profession-als, students, patients, policymakers, and ordinary people whoevery day dedicate their time to make a difference on their ownhealth outcomes or those of their families, communities, specialgroups, or populations. These include all professionals and re-searchers in the health care and public health fields, the studentsor young practitioners who have committed themselves to a re-warding but demanding career, the patients who strive to keepthemselves informed and make the right health decisions, thehealth care providers who dedicate their lives to alleviate and man-age human sufferance, the mass media, government officers, as-sociations, advocacy groups, and everyone else who may have animpact on health care.

I believe that being aware of current health communicationtheories and experiences may ease the process of communicat-ing about health and illness and make it more approachable forall of these groups and individuals. I hope this book will help.

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Health CommunicationFrom Theory to Practice

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Part One

Introductionto HealthCommunication

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Chapter One

What Is HealthCommunication?

In This Chapter• Defining Health Communication• Health Communication in the Twenty-First Century: Key

Characteristics and Defining Features• The Role of Health Communication in the Marketing Mix• Health Communication in Public Health• Overview of Key Communication Areas• What Health Communication Can and Cannot Do• Key Concepts• For Discussion and Practice

Health communication is an evolving and increasingly prominentfield in both public health and the nonprofit and commercialsectors. Therefore, many authors and organizations have been at-tempting to define or redefine it over time. Because of the mul-tidisciplinary nature of health communication, many of thedefinitions may appear somewhat different from each other. Nev-ertheless, when they are analyzed, most point to the role thathealth communication can play in influencing and supporting indi-viduals, communities, health care professionals, policymakers, orspecial groups to adopt and sustain a behavioral practice or a so-cial or policy change that will ultimately improve health outcomes.

Understanding the true meaning of health communicationand establishing the right context for its implementation may help

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communication managers and other health care professionalsidentify early on the training needs of staff and others who are in-volved in the communication process. It will also help create theright organizational mind-set and capability that should lead to asuccessful use of communication approaches to reach audience-specific goals.

This chapter sets the stage to discuss current health commu-nication contexts. It also positions the importance of health com-munication in public health as well as in the private sector. Finally,it describes key elements, action areas, and limitations of the healthcommunication approach.

Defining Health CommunicationThere are several definitions of health communication. For themost part, all of them point to a similar role of this approach inthe process of advocating for and improving individual or publichealth outcomes. This section analyzes and aims to consolidate dif-ferent definitions for health communication. This analysis startsfrom the literal and historical meaning of the word communication.

What Is Communication?An understanding of health communication theory and practice re-quires reflection on the literal meaning of the word communication.Communication is defined in this way: “1. Exchange of information, be-tween individuals, for example, by means of speaking, writing, orusing a common system of signs and behaviors; 2. Message—a spo-ken or written message; 3. Act of communicating ; 4. Rapport—a senseof mutual understanding and sympathy; 5. Access—a means of ac-cess or communication, for example, a connecting door” (EncartaDictionary: English, North America).

In fact, all of these meanings can help define the modalities ofwell-designed health communication programs. As with otherforms of communication, health communication should be basedon a two-way exchange of information that uses a “common systemof signs and behaviors.” It should be accessible and create “mutualfeelings of understanding and sympathy” among members of thecommunication team and intended audiences (all audiences the

4 HEALTH COMMUNICATION: FROM THEORY TO PRACTICE


health communication program is seeking to influence and en-gage in the communication process; also referred to as target au-diences). Finally, communication channels (the means or path usedto reach intended audiences with health communication messagesand materials, such as the mass media) and messages are the “con-necting doors” that allow health communication interventions toreach intended audiences.

Communication has its roots in people’s need to share andtransmit meanings and ideas. A review of the origin and interpre-tation of early forms of communication, such as writing, shows thatmany of the reasons for which people may have started developinggraphic notations and other early forms of writing are similar tothose we can list for health communication.

One of the most important questions about the origins of writ-ing is, “Why did writing begin and for what specific reasons?” (Hous-ton, 2004, p. 234). Although the answer is still being debated,many established theories suggest that writing developed becauseof state and ceremonial needs (Houston, 2004). More specifically,in ancient Mesoamerica, early forms of writing may have been in-troduced to help local rulers “control the underlings and impressrivals by means of propaganda” (Houston, 2004, p. 234; Marcus,1992) or “capture the dominant and dominating message withinself-interested declarations” (Houston, 2004, p. 234) with the in-tention of “advertising” (p. 235) such views. In other words, it ispossible to speculate that the desire and need to influence andconnect with others are among the most important reasons for theemergence of early forms of writing. This need is also evident inmany other forms of communication that seek to create feelingsof approval, recognition, or friendliness, among others.

Health Communication DefinedOne of the key objectives of health communication is to influenceindividuals and communities. The goal is admirable since healthcommunication aims to improve health outcomes by sharinghealth-related information. In fact, the Centers for Disease Con-trol and Prevention (CDC) define health communication as “thestudy and use of communication strategies to inform and influenceindividual and community decisions that enhance health” (2001;

WHAT IS HEALTH COMMUNICATION? 5


U.S. Department of Health and Human Services, 2005). The wordinfluence is also included in the Healthy People 2010 definition ofhealth communication as “the art and technique of informing, in-fluencing, and motivating individual, institutional, and public au-diences about important health issues” (U.S. Department ofHealth and Human Services, 2005, p. 11-2).

Another important role of communication is to create a re-ceptive and favorable environment in which information can beshared, understood, absorbed, and discussed by the program’s in-tended audiences. This requires an in-depth understanding of theneeds, beliefs, taboos, attitudes, lifestyle, and social norms of allkey communication audiences. It also demands that communica-tion is based on messages that are easily understood. This is wellcharacterized in the definition of communication by Pearson andNelson (1991), who view it as “the process of understanding and shar-ing meanings” (p. 6).

A practical example that illustrates this definition is the differ-ence between making an innocent joke about a friend’s personalitytrait and doing the same about a colleague or recent acquaintance.The friend would likely laugh at the joke, while the colleague orrecent acquaintance might be offended. In communication, un-derstanding the context of the communication effort is interde-pendent with becoming familiar with target audiences. Thisincreases the likelihood that all meanings are shared and under-stood in the way communicators intended them. Therefore, com-munication, especially about life-and-death matters such as inhealth care, is a long-term strategic process. It requires a true un-derstanding of target audiences as well as the communicator’s will-ingness and ability to adapt and redefine the goals, strategies, andactivities of communication on the basis of audience feedback.

Health communication interventions have been successfullyused for many years by nonprofit organizations, the commercial sec-tor, and others to advance public, corporate, or product-related goalsin relation to health. As many authors have noted, health com-munication draws from numerous disciplines, including healtheducation, mass and speech communication, marketing, socialmarketing, psychology, anthropology, and sociology (Bernhardt,2004; Institute of Medicine, 2003; World Health Organization, 2003).It relies on different communication activities or action areas, in-



cluding interpersonal communications, public relations, public ad-vocacy, community mobilization, and professional communications(World Health Organization, 2003; Bernhardt, 2004).

Table 1.1 provides some of the most recent definitions ofhealth communication and is organized by key words most com-monly used to characterize health communication and its role. Itis evident that “sharing meanings or information,” “influencing in-dividuals or communities,” “informing,” “motivating target audi-ences,” “exchanging information,” and “changing behaviors,” areamong the most common attributes of health communication.

Another important attribute of health communication shouldbe “to support and sustain change.” In fact, key elements of suc-cessful health communication programs or campaigns always in-clude long-term program sustainability, as well as the developmentof communication tools and steps that make it easy for individ-uals, communities, and other audiences to adopt or sustain a rec-ommended behavior, practice, or policy change. If we integratethis practice-based perspective with many of the definitions inTable 1.1, the following new definition emerges:

Health communication is a multifaceted and multidisciplinary approachto reach different audiences and share health-related information with thegoal of influencing, engaging, and supporting individuals, communities,health professionals, special groups, policymakers and the public to cham-pion, introduce, adopt, or sustain a behavior, practice, or policy that willultimately improve health outcomes.

Health Communication in the Twenty-First Century: Key Characteristicsand Defining FeaturesHealth communication is about improving health outcomes byencouraging behavior modification and social change. It is in-creasingly considered an integral part of most public health inter-ventions (U.S. Department of Health and Human Services, 2005;Bernhardt, 2004). It is a comprehensive approach that relies onthe full understanding and involvement of its target audiences.




Table 1.1. Health Communication Definitions

Key Words Definitions

To inform and “Health communication is a key strategy toinfluence (individual inform the public about health concerns andand community) to maintain important health issues on thedecisions public agenda” (New South Wales Department

of Health, Australia, 2006).

“The study or use of communication strategiesto inform and influence individual and communitydecisions that enhance health” (CDC, 2001; U.S.Department of Health and Human Services, 2005).

Health communication is a “means to diseaseprevention through behavior modification”(Freimuth, Linnan, and Potter, 2000, p. 337).It has been defined as the study and use ofmethods to inform and influence [italics addedthroughout table] individual and communitydecisions that enhance health” (Freimuth,Linnan, and Potter, 2000, p. 338; Freimuth,Cole, and Kirby, 2000, p. 475).

“Health communication is a process for thedevelopment and diffusion of messages tospecific audiences in order to influence theirknowledge, attitudes and beliefs in favor ofhealthy behavioral choices” (Exchange, 2006;Smith and Hornik, 1999).

“Health communication is the use ofcommunication techniques and technologiesto (positively) influence individuals,populations, and organizations for thepurpose of promoting conditions conducive tohuman and environmental health” (Maibachand Holtgrave, 1995, pp. 219–220; HealthCommunication Unit, 2006). “It may includediverse activities such as clinician-patientinteractions, classes, self-help groups, mailings,hot lines, mass media campaigns, and events”(Health Communication Unit, 2006).

Motivating individuals “The art and technique of informing,influencing and motivating individual,



institutional, and public audiences aboutimportant health issues. Its scope includesdisease prevention, health promotion,health care policy, and business, as well asenhancement of the quality of life and healthof individuals within the community” (Ratzanand others, 1994, p. 361).

“Effective health communication is the art andtechnique of informing, influencing, andmotivating individuals, institutions, and largepublic audiences about important healthissues based on sound scientific and ethicalconsiderations” (Tufts University StudentServices, 2006).

Change behaviors “Health communication, like health education,is an approach which attempts to change a setof behaviors in a large-scale target audienceregarding a specific problem in a predefinedperiod of time” (Clift and Freimuth, 1995,p. 68).

Increase knowledge “The goal of health communication is toand understanding of increase knowledge and understanding of health-health-related issues related issues and to improve the health status

of the intended audience” (Muturi, 2005, p. 78).

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

Empowers people “Communication empowers people by providingthem with knowledge and understandingabout specific health problems andinterventions” (Muturi, 2005, p. 81).

Exchange, “A process for partnership and participationinterchange of that is based on two-way dialogue, where there is information, an interactive interchange of information, ideas,two-way dialogue techniques and knowledge between senders

and receivers of information on an equal

Table 1.1. Health Communication Definitions, Cont’d.



Health communication theory draws on a number of addi-tional disciplines and models. Health communication and its the-oretical basis have evolved and changed in the past fifty years(Piotrow, Kincaid, Rimon, and Rinehart, 2003; Bernhardt, 2004).With increasing frequency, it is considered “the avant-garde in sug-gesting and integrating new theoretical approaches and practices”(Drum Beat, 2005).

Most important, communicators are no longer viewed as thosewho write press releases and other media-related communications,but as fundamental members of the public health or health in-dustry teams. Communication is no longer considered a skill(Bernhardt, 2004) but a science-based discipline that requirestraining and passion and relies on the use of different vehicles(materials, activities, events, and other tools used to deliver a mes-sage through communication channels; Health CommunicationUnit, 2003b) and channels. According to Saba (2006):

In the past and this is probably the most prevalent trend eventoday, health communication practitioners were trained “on-the-job.” People from different fields (sociology, demography, publichealth, psychology, communication with all its different specialties,such as filmmaking, journalism and advertising) entered or werebrought into health communication programs to meet the need


footing, leading to improved understanding,shared knowledge, greater consensus, andidentification of possible effective action”(Exchange, 2005).

“Health communication is the scientificdevelopment, strategic dissemination, andcritical evaluation of relevant, accurate,accessible, and understandable healthinformation communicated to and from intendedaudiences to advance the health of the public”(Bernhardt, 2004, p. 2051).

Table 1.1. Health Communication Definitions, Cont’d.



for professional human resources in this field. By performing theirjob and working in teams, they learned how to adapt their skills tothe new field and were taught by other practitioners about thecommon practices and basic “lingo” of health communication.

In the mid 90s, and in response to the increasing demand forhealth communication professionals, several schools in the UnitedStates started their own curricular programs and/or “concentra-tions” in Health Communication. This helped bring more atten-tion from the academic world to this emerging field. The numberof peer-reviewed articles and several other types of health commu-nication publications increased. The field moved from in-servicetraining to pre-service education.

As a result, there is an increasing understanding that “the levelof technical competence of communication practitioners can af-fect outcomes. A structured approach to health communicationsplanning, a spotless program execution and a rigorous evaluationprocess are the result of adequate training. In health communica-tion, the learning process is a lifetime endeavor and should be fa-cilitated by the continuous development of new training initiativesand tools” (Schiavo, 2006). Training may start in the academic set-ting but should always be influenced and complemented by prac-tical experience and observations, as well as other learning andtraining opportunities, including in-service training and continu-ing professional education.

Health communication can reach its highest potential when itis discussed and applied within a team-oriented context that in-cludes many other health care and public health professionals.Teamwork and mutual agreement on the intervention’s ultimateobjectives 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 bul-let that can address health issues. Health communication is anevolving discipline and should always seek to incorporate lessonslearned as well to use a multidisciplinary approach to all interven-tions. This is in line with one of the fundamental premises of thisbook that recognizes the experience of practitioners as a key factorin developing theories, models, and approaches that should guideand inform health communication planning and management.



Table 1.2 lists the key elements of health communication,which are further analyzed below.

Audience CenteredHealth communication is a long-term process that begins and endswith the audience’s desires and needs. In health communication,the audience is not merely a target (even if this terminology is verywell established and used by practitioners around the world) butan active participant in the process of analyzing the health issueand finding culturally appropriate and cost-effective solutions. Itis a common practice in health communication not only to re-search intended audiences and other key constituencies but alsoto strive to engage them in defining and implementing key strate-gies and activities. This is often accomplished by working togetherwith organizations and leaders who represent them. For example,if a health communication program aims to reach breast cancersurvivors, all strategies and key program elements should be de-signed, discussed, tested, and implemented together with mem-bership organizations, patient groups, leaders, and audiencesamples representing this target audience. Most important, theseaudiences need to feel invested and well represented. They shouldbe the key protagonists of the action-oriented process that will leadto behavioral or social change.


Table 1.2. Key Characteristics of Health Communication

Audience-centered

Research-based

Multidisciplinary

Strategic

Process oriented

Cost-effective

Creative in support of strategy

Audience and media specific

Relationship building

Aimed at behavioral or social change


Research BasedHealth communication is grounded in research. Successful healthcommunication programs are based on a true understanding notonly of the intended audience but also of the situational environ-ment. This includes existing programs and lessons learned, poli-cies, social norms, key issues, and obstacles in addressing thespecific health problem.

The overall premise of health communication is that behav-ioral change is conditioned by the environment in which peoplelive, as well as by those who influence them. Creating a receptiveenvironment in which the target audience can discuss a healthissue and be supported in its intention to change by key influen-tials (for example, family members, health care providers) is oftenone of the aims of health communication programs. This requiresa comprehensive research approach that relies primarily on tradi-tional research techniques for the formal development of a situa-tion analysis (a planning term that describes the analysis ofindividual, social, political, and behavior-related factors that canaffect attitudes, behaviors, social norms, and policies about a healthissue) and audience profile (a comprehensive, research-based, andstrategic description of all key audiences’ characteristics, demo-graphics, needs, values, attitudes, and behavior). Situation analy-sis and audience profile are fundamental and interrelated steps ofhealth communication planning (the audience profile is describedin this book as a component of the situation analysis) and are de-scribed in detail in Chapter Ten.

MultidisciplinaryHealth communication is “transdisciplinary in nature” (Bernhardt,2004, p. 2051; Institute of Medicine, 2003) and draws on multipledisciplines (Bernhardt, 2004; World Health Organization, 2003).Health communication recognizes the complexity of attaining be-havioral and social change and uses a multifaceted approach thatis grounded in the application of several theoretical frameworksand disciplines, including health education, social marketing, andbehavioral and social change theories (see Chapter Two for a com-prehensive discussion of key theories and models). It draws on



principles successfully used in the private and commercial sectorsand also on the audience-centered approach of other disciplines,such as psychology, sociology, and anthropology (World Health Or-ganization, 2003). It is not anchored to a single specific theory ormodel. With the audience 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 people’s hearts; securetheir involvement in the health issue, and, most important, its so-lutions; and support and facilitate their journey on a path to bet-ter health.

Piotrow, Rimon, Payne Merritt, and Saffitz (2003) identify fourdifferent “eras” of health communication:

(1) The clinic era, based on a medical care model and the notionthat if people knew where services were located they would findtheir way to the clinics; (2) the field era, a more proactive approachemphasizing outreach workers, community-based distribution, anda variety of information, education, and communication (IEC)products; (3) the social marketing era, developed from the com-mercial concepts that consumers will buy the products they want atsubsidized prices; and, (4) today, the era of strategic behavior com-munications, founded on behavioral science models that empha-size the need to influence social norms and policy environments tofacilitate and empower the iterative and dynamic process of bothindividual and social change [pp. 1–2].

However, even in the context of strategic behavior communi-cations, many of the theoretical approaches of the different erasof health communication still find a use in program planning orexecution. For example, the situation analysis of a health commu-nication program uses primarily commercial and social marketingtools and models (see Chapters Two and Ten for a detailed de-scription) to analyze the environment in which change shouldoccur. Instead, in the early stages of approaching key opinion lead-ers and other key stakeholders (individuals and groups who havean interest or share responsibilities in a given health issue), keep-ing in mind McGuire’s communication for persuasion steps (1984;see Chapter Two) may help communicators gain stakeholder sup-port for the importance or the urgency of adequately addressinga health issue. This theoretical flexibility should keep communi-cators focused on their audiences and always on the lookout for



the best approach and planning framework to influence people’score beliefs and behaviors and engage them in the communica-tion process. In concert with the other features previously dis-cussed, it also enables the overall communication process to betruly fluid and suited to respond to audiences’ needs.

The importance of a somewhat flexible theoretical basis, whichshould be selected on a case-by-case basis (National Cancer Insti-tute, 2005a), is already supported by reputable organizations andauthors. For example, a publication by the U.S. Department ofHealth and Human Services, National Institutes of Health, Na-tional Cancer Institute (2002), points to the importance of select-ing planning frameworks that “can help [communicators] identifythe social sciences theories most appropriate for understandingthe problem and the situation” (p. 218). These theories, models,and constructs include several theoretical concepts and frame-works (see Chapter Two) that are also used in motivating changeat an individual level, interpersonal level, or organizational, com-munity, and societal level (National Cancer Institute, 2002) by re-lated or complementary disciplines.

The goal here is not to advocate for a lack of theoretical struc-ture in communication planning and execution. On the contrary,planning frameworks, models, and theories should be consistentat least until preliminary steps of the evaluation phase of a pro-gram are completed. This allows communicators to take advantageof lessons learned and redefine theoretical constructs and com-munication objectives (the intermediate steps that need to beachieved in order to meet program goals and outcome objectives;National Cancer Institute, 2002) by comparing program outcomes,which measure changes in knowledge, attitudes, skills, behavior,and other parameters, with those that were anticipated in the plan-ning phase. However, the ability to draw on multiple disciplinesand theoretical constructs is a definitive advantage of the healthcommunication approach and one of the keys to the success ofwell-planned and well-executed communication programs.

StrategicHealth communication programs need to display a sound strat-egy and plan of action. All activities need to be well planned andrespond to a specific audience-related need. Consider again the



example of Bonnie, the twenty-five-year-old mother who is not sureabout whether to immunize her newborn child. Activities in sup-port of a strategy that focuses on facilitating communication be-tween Bonnie and her health care provider make sense only ifresearch shows all or any of the following points: (1) Bonnie islikely to be influenced primarily, or at least significantly, by herhealth care provider and not by family or other new mothers; (2)there are several gaps in the understanding of patients’ needs thatprevent health care providers from communicating effectively; and(3) providers lack adequate tools to talk about this topic with pa-tients in a time-effective and efficient manner.

Communication strategies (the overall approach that is used toaccomplish the communication objectives) need to be researchbased, and all activities should serve such strategies. Therefore, pro-gram planners should not rely on any workshop, press release,brochure, video, or anything else to provide effective communica-tion without making sure that their content and format reflect theselected approach (the strategy) and is a priority in reaching theaudience’s heart. For this purpose, health communication strate-gies need to respond to an actual need that has been identified bypreliminary research and confirmed by the intended audience.

Process OrientedCommunication is a long-term process. Influencing people and theirbehaviors requires an ongoing commitment to the health issue andits solutions. This is rooted in a deep understanding of target audi-ences and their environments and aims at building consensusamong audience members about the potential plan of action.

Most, if not all, health communication programs change orevolve from what communication experts had originally deviseddue to the input and participation of key opinion leaders, patientgroups, professional associations, policymakers, audience mem-bers, and other key stakeholders.

In health communication, educating target audiences abouthealth issues and ways to address them is only the first step of along-term, audience-centered process. This process often requirestheoretical flexibility to accommodate the needs of interestedgroups and audiences.



While in the midst of many process-oriented projects, manypractitioners may have noticed that health communication isoften misunderstood. Health communication uses multiple chan-nels and approaches, which, despite what some people may think,include but are not limited to the use of the mass media. More-over, health communication aims at improving health outcomesand in the process help advance public health goals or create mar-ket share (depending on whether health communication strate-gies are used for nonprofit or for-profit goals). Finally, healthcommunication cannot focus only on channels, messages, andtools. It also should be process oriented and attempt to persuade,involve, and create consensus and feelings of ownership amongintended audiences.

Exchange, a networking and learning program on health com-munication for development that is based in the United Kingdomand has multiple partners, views health communication as “a pro-cess for partnership and participation that is based on two-waydialogue, where there is an interactive interchange of information,ideas, techniques, and knowledge between senders and receiversof information on an equal footing, leading to improved under-standing, shared knowledge, greater consensus, and identificationof possible effective action” (2005). This definition makes sense inall settings and situations, but it assumes a greater relevance forhealth communication programs that aim to improve health out-comes in developing countries. Communication for developmentoften needs to rely on creative solutions that compensate for thelack of local capabilities and infrastructures. These solutions usu-ally emerge after months of discussion with local community lead-ers and organizations, government officials, and members of targetaudiences. Word of mouth and the ability of the community lead-ers to engage members of their communities is often all that com-municators have at hand.

Consider the case of Maria, a mother of four children who livesin a small village in sub-Saharan Africa together with her seventy-five-year-old father. Her village is almost completely isolated frommajor metropolitan areas, and very few people in town have a radioor know how to read. Maria is unaware that malaria, which is en-demic in that region, poses a higher risk to children than to the el-derly. Since elderly people benefit from a high hierarchical status



in that region, if Maria is able to find money to purchase mosquitonets to protect someone in her family from mosquito bites and theconsequent threat of malaria, she would probably choose that herfather sleep under them, leaving her children unprotected. This isin spite of the high mortality rate from malaria among children inher village. If her village’s community leaders told her to do other-wise, she would likely change her practice and protect her children.

Involving Maria’s community leaders in the communicationprocess that would lead to a change in her habits requires a long-term commitment. Such effort demands the involvement of localorganizations and authorities who are respected and trusted bycommunity leaders, as well as an open mind in listening to sug-gestions and seeking solutions with the help of all key stakehold-ers. Because of the lack of local capabilities and widespread accessto adequate communication channels, this process is likely to takelonger than any similar initiative in the developed world. There-fore, communicators should view this as an ongoing process andapplaud every small step forward.

Cost-EffectiveCost-effectiveness is a concept that health communication borrowsfrom commercial and social marketing. It is particularly importantin the competitive working environment of nonprofit organiza-tions, where the lack of sufficient funds or adequate economicplanning can often undermine important initiatives. It implies theneed to seek solutions that allow communicators to advance theirgoals with minimal use of human and economic resources. Never-theless, concerns related to cost-effectiveness should never prompta significant reduction of the program’s objectives unless resourcesare not adequate to support all of them. Communicators shoulduse their funds as long as they are well spent and advance theirresearch-based strategy. They should also seek creative solutionsthat minimize the use of internal funds and human resources byseeking partnerships, using existing materials or programs as astarting point, and maximizing synergies with the work of other de-partments in their organization or external groups and stake-holders in the same field.



Creative in Support of StrategyCreativity is a significant attribute of communicators since it allowsthem to consider multiple options, formats, and channels to reachtarget audiences. It also helps them devise solutions that preservethe sustainability and cost-effectiveness of specific health commu-nication interventions. However, even the greatest ideas or the best-designed and best-executed communication tools may fail toachieve behavioral or social change goals if they do not respond toa strategic need identified by marketing and audience-specific re-search and endorsed by key stakeholders from target groups. Toooften communication programs and resources fail to make an im-pact because of this common mistake.

For example, providing a brochure to a target audience on howto use insecticide-treated nets (ITNs) makes sense only if the audi-ence is already aware of the cycle of malaria transmission, as well asthe need for protection from mosquito bites. If this is not the caseand members of target communities still believe that malaria is con-tracted by bathing in the river or is a complication of some otherfevers (Pinto,1998; Schiavo, 1998, 2000), the first strategic impera-tive is disease awareness, with a specific focus on the cycle of trans-mission and subsequent protective measures. All communicationmaterials and activities need to address this basic information be-fore talking about the use of ITNs and potential reasons to usethem instead of other protection measures. The communicator’screativity should come into play by devising the most suitable andculturally friendly tools to engage intended groups in the processof changing their behaviors, beliefs, and attitudes toward the dis-ease and its prevention. However, creativity should never be usedto develop and implement great, sensational, or innovative ideasthat do not respond to actual needs and strategic priorities.

Audience and Media SpecificThe importance of audience-specific messages and channels be-came one of the most important lessons learned after the anthrax-by-mail bioterrorist attacks that rocked the United States inOctober 2001.



At the time, several letters containing the lethal agent Bacillusanthracis were mailed to senators and representatives of the media(Jernigan and others, 2002; Blanchard and others, 2005). The at-tack also exposed government staff workers, including U.S. postalworkers in the U.S. Postal Service facility in Washington, D.C., andother parts of the country, to anthrax. Two workers in the Wash-ington facility died as a result of inhalation anthrax (Blanchardand others, 2005).

Communication during this emergency was perceived by sev-eral members of the medical, patient, and worker communities aswell as public figures and the media to be often inconsistent anddisorganized (Blanchard and others, 2005; Vanderford, 2003).Equally important, postal workers and U.S. Senate staff have re-ported erosion of their trust in public health agencies (Blanchardand others, 2005). Several analyses point to the possibility that theone message–one behavior approach to communication (UCLA,2002)—in other words, using the same message and strategic ap-proach for all audiences—led to feelings of being left out amongpostal workers, who in the Brentwood facility in Washington, D.C.,were primarily African Americans or individuals with a severe hear-ing impairment (Blanchard and others, 2005). They also point tothe need for public health officials to develop the relationshipsthat are needed to communicate with groups of different racialand socioeconomic backgrounds, as well as “those with physicallimitations that could hinder communication, such as those withhearing impairments” (Blanchard and others, 2005, p. 494;McEwen and Anton-Culver, 1988).

The lessons learned from the anthrax scare support some ofthe fundamental principles of good health communication prac-tices. Messages need to be audience specific and tailored to chan-nels allowing the most effective reach to target audiences. Since itis very likely that communication efforts always aim at producingmultiple audience-appropriate behaviors, the one message–one be-havior approach should be avoided (UCLA, 2002) even when timeand resources are lacking. As highlighted by the anthrax case study,in developing audience-specific messages and activities, the con-tribution of local advocates and community representatives is fun-damental to increase the likelihood that messages will be heard,understood, and trusted by target audiences.



Relationship BuildingCommunication is a relationship business. Establishing and pre-serving good relationships is critical to the success of health com-munication interventions, and, among other things, can help buildlong-term and successful partnerships and coalitions, secure cred-ible stakeholder endorsement of the health issue, and expand thepool of ambassadors on behalf of the health cause.

Most important, good relationships help create the environ-ment of “shared meanings and understanding” (Pearson and Nel-son, 1991, p. 6) that is central to seeking social or behavioralchange at the individual and community levels. Good relationshipsshould be established with key stakeholders and representatives oftarget audiences, health organizations, governments, and manyother critical members of the extended health communicationteam. (A detailed discussion of the dos and don’ts of successfulpartnerships and relationship building efforts is included in Chap-ters Eight and Twelve.)

Aimed at Behavioral and Social ChangeToday we are in the “era of strategic behavior communications”(Piotrow and others, 2003, p. 2). Although the ultimate goal ofhealth communication has always been influencing behaviors andsocial norms, there is a renewed emphasis on the importance ofestablishing behavioral and social objectives early in the design ofhealth communication interventions.

“What do you want people to do?” is the first question thatshould be asked in communication planning meetings. Do youwant them to immunize their children before age two? Becomeaware of their risk for heart disease and behave accordingly to pre-vent it? Ask their dentists about oral cancer screening? Want locallegislators to support a stricter law on the use of infant car seats?Create an environment of peer-to-peer support designed to dis-courage adolescents from initiating smoking? Answering thesekinds of questions is the first step in identifying suitable andresearch-based objectives of a communication program.

Although different theories (see Chapter Two) support theimportance of behavioral or social change as key indicators for



success, these two parameters are actually interconnected. In fact,social change typically takes place as the result of a series of be-havioral changes at the individual, group, or community level.

The Role of Health Communicationin the Marketing MixHealth communication strategies are extensively used in the com-mercial and nonprofit sectors to support and motivate behavioralchange, product adoption, or the endorsement of a health issueor cause. In the private sector, health communication strategies areprimarily used in a marketing context. Still, many of the other be-havioral and social constructs of health communication—and def-initely all of these models and tools that position the audience atthe center of any intervention—are considered and used at leastat an empirical level. As in other settings (for example, publichealth), health communication functions tend to be similar tothose described in the “What Health Communication Can andCannot Do” section of this chapter.

Many in the private sector regard health communication as acritical component of the marketing mix, which is traditionally de-fined by the key four Ps of social marketing (see Chapter Two for amore detailed description): product, price, place, and promotion—in other words, “developing, delivering, and promoting a superioroffer” (Maibach, 2003).

When looking at the health communication environmentwhere change should occur and be sustained (Figure 1.1), it be-comes clear that effective communication can be a powerful toolin seeking to influence all of the factors that are highlighted in thefigure. It is also clear that regardless of whether these factors arerelated to the audience, health behavior, product, service, social,or political environment, all of them are interconnected and canmutually affect each other. At the same time, health communica-tion interventions can tip the existing balance among these factorsand change the weight they may have in defining a specific healthissue and its solutions.

Figure 1.1 also reflects some of the key principles of marketingmodels as well as the socioecological model (Morris, 1975) and



other theoretical models (VanLeeuwen, Waltner-Toews, Abernathy,and Smit, 1999) that are used in public health to show the con-nection and influence of different factors (individual, interper-sonal, community, organizational, and public policy) on individual,group, and community behavior as well as to understand theprocess that may lead to behavioral and social change.

Health Communicationin Public HealthPrior to the recent call to action by many federal and multilateralorganizations, which encouraged a strategic and more frequentuse of communication, health communication has been used onlymarginally in public health. It has been perceived more as a skillthan a discipline and confined to the mere dissemination of sci-entific and medical findings by public health professionals (Bern-hardt, 2004).


Figure 1.1. Health Communication Environment

AudienceHealth beliefs, attitudes, and behavior

Cultural, age, and gender-related factorsLiteracy levels

Risk factorsLifestyle issues

Socioeconomic factors

Political EnvironmentPolicies, laws

Political willingnessand commitment

Level of priority inpolitical agenda

Social EnvironmentStakeholders’ beliefs, attitudes, and practicesSocial normsSocial structureExisting initiatives and programs

Recommended Health Behavior,Service, or ProductBenefitsRisksDisadvantagesPrice or lifestyle trade-offAvailability and access

HEALTHCOMMUNICATION


Fortunately, most public health organizations and leaders(Freimuth, Cole, and Kirby, 2000; U.S. Department of Health andHuman Services, 2005; Institute of Medicine, 2003; Bernhardt,2004; National Cancer Institute and National Institutes of Health,2002; Piotrow and others, 1997) now recognize the role that healthcommunication can play in advancing health outcomes and thegeneral health status of interested populations and special groups.Most important, there is a new awareness of the reach of healthcommunication, as well as its many strategic action areas (for ex-ample, interpersonal communications, professional medical com-munications, and public relations).

As defined by Healthy People 2010 (U.S. Department of Healthand Human Services, 2005), the U.S. public health agenda, thescope of health communication in public health “includes diseaseprevention, health promotion, health care policy, and the businessof health care as well as enhancement of the quality of life andhealth of individuals within the community” (p. 11–20; Ratzan,1994). Health communication “links the domains of communica-tion and health” (p. 11–3) and is increasingly regarded as a science(Freimuth and others, 2000), of great importance in public health,especially in the era of emerging infectious diseases, global threats,bioterrorism, and a new emphasis on a preventive and patient-centered approach to health.

Overview of Key Communication AreasGlobal health communication is a term increasingly used to includedifferent communication approaches and action areas, such as in-terpersonal communications, social and community mobilization,and advocacy (Haider, 2005; Waisbord and Larson, 2005). Well-planned health communication programs rely on an integratedblend of different action areas that should be selected in consid-eration of expected behavioral and social outcomes (World HealthOrganization, 2003; O’Sullivan, Yonkler, Morgan, and Merritt,2003; Health Communication Partnership, 2005e). Long-term re-sults can be achieved only through a participatory process that in-volves all interested audiences and uses all culturally appropriateaction areas and communication channels. Remember that thereis no magic bullet in health communication.



Message repetitiveness and frequency are also important fac-tors in health communication. Often the resonance effect, whichcan be defined as the ability to create a snowball effect for messagedelivery by using multiple vehicles, sources, and messengers, canhelp motivate people to change by reminding them of the desiredbehavior (for example, complying with childhood immunizationrequirements, using mosquito nets for protection against malaria,attempting to quit smoking) and its benefits. To this end, severalaction areas are normally used in health communication and aredescribed in detail in the topic-specific chapters in Part Two:

• Interpersonal communications, which uses interpersonal chan-nels (for example, one-on-one or group meetings) and is based onactive listening, social and behavioral theories, and the ability torelate to and identify with the audience’s needs and cultural pref-erences and efficiently addressing them. This includes “personalselling and counseling” (World Health Organization, 2003, p. 2),which takes place during one-on-one encounters with members ofinterested audiences and other key stakeholders, as well as duringgroup events and in locations where materials and services areavailable. It also includes provider-patient communications, whichhas been identified as one of the most important areas of healthcommunication (U.S. Department of Health and Human Services,2005) and should aim at improving health outcomes by optimiz-ing the relationships between providers and their patients.

• Public relations, public advocacy, and government relations, whichrelies on the skillful use of culturally competent and audience-appropriate mass media, as well as other communication channelsto place a health issue on the public agenda, advocate for its solu-tions, or highlight the importance that the government and otherkey stakeholders take action.

• Community mobilization, a bottom-up and participatory pro-cess. By using multiple communication channels, community mo-bilization seeks to involve community leaders and the communityat large in addressing a health issue, becoming part of the key stepsto behavioral or social change, or practicing a desired behavior.

• Professional medical communications, a peer-to-peer approachtargeting health care professionals that, among others, aims to (1)promote the adoption of best medical and health practices; (2)



establish new concepts and standards of care; (3) publicize recentmedical discoveries, beliefs, parameters, and policies; (4) changeor establish new medical priorities; and (5) advance health policychanges.

• Constituency relations, a critical component of all other areasof health communication as well as a communication area of its own.Constituency relations refer to the process of (1) creating consen-sus among key stakeholders about health issues and their poten-tial solutions, (2) expanding program reach by involving keyconstituencies, (3) developing alliances, (4) managing and antic-ipating criticisms and opponents, and (5) maintaining key rela-tionships with other health organizations or stakeholders.

What Health CommunicationCan and Cannot DoHealth communication cannot work in a vacuum and is normally acritical component of larger public health interventions or corpo-rate efforts. Because of the complexity of health issues, it may “notbe equally effective in addressing all issues or relaying all messages”(National Cancer Institute and National Institutes of Health, 2002,p. 3), at least in a given time frame.

Health communication cannot replace the lack of local infra-structure (such as the absence of appropriate health services orhospitals) or capability (such as an inadequate number of healthcare providers in relation to the size of the population being at-tended). It cannot compensate for inadequate medical solutionsto treat, diagnose, or prevent any disease. But it can help advocatefor change and create a receptive environment to support the de-velopment of new health services or the allocation of additionalfunds for medical and scientific discovery, access to existing treat-ments or services, or the recruitment of health care professionalsin new medical fields or underserved geographical areas. In doingso, it helps secure political commitment, stakeholder endorsement,and community involvement to encourage change and improvehealth outcomes.

Because of the evolving role of health communication, otherauthors and organizations have been defining the potential con-tribution of health communication to the health care and publichealth fields. For example, the U.S. National Cancer Institute



(2002) has a homonymous section, which partly inspired the needfor this section, in one of its publications on the topic.

Understanding the role and the potential impact of health com-munication on different aspects of public health, and health carein general, is important to take full advantage of the contributionof this emerging field to health outcomes as well as to set realisticexpectations on what can be accomplished among team members,program partners, intended audiences, and other key stakehold-ers. Table 1.3 lists what health communication can and cannot do.


Table 1.3. What Health Communication Can and Cannot Do

Health Communication Can Help. . .Raise awareness of health issues todrive policy or practice changes.Secure stakeholder endorsement ofhealth issues.“Influence perceptions, beliefs andattitudes that may change socialnorms” (NCI, 2002, p. 3).Promote data and emerging issues toestablish new standards of care.“Increase demand for health services”(NCI, 2002, p. 3) and products.Show benefits of behavior change.“Demonstrate healthy skills” (NCI,2002, p. 3).Provoke public discussion to drivedisease diagnosis, treatment, orprevention.Suggest and “prompt action” (NCI,2002, p. 3).Build constituencies to support healthpractice changes.Support the need for additional fundsfor medical and scientific discovery.Advocate for equal access to existinghealth products and services.Create a climate of receptivity for newhealth services or products.Strengthen third-party relationships.Improve provider-patientrelationships, and ultimately, patientcompliance and outcomes.

Health Communication Cannot. . .Work in a vacuum, independent fromother larger public health ormarketing interventions.Replace the lack of localinfrastructure or capability.Compensate for the absence ofadequate treatment or diagnostic orpreventative options.“Be equally effective in addressing allissues or relaying all messages”, atleast in the same time frame(NCI, 2002, p. 3).



Key Concepts• Health communication is a multifaceted and multidisciplinary

approach to reach different audiences and share health-relatedinformation with the goal of influencing, engaging, and sup-porting individuals, communities, health professionals, specialgroups, policymakers, and the public to champion, introduce,adopt, or sustain a behavior, practice, or policy that will ulti-mately improve health outcomes.

• Health communication is an increasingly prominent field inpublic health, as well as in the private sector (both nonprofitand commercial).

• One of the key characteristics of health communication is itsmultidisciplinary nature, which allows the theoretical flexibil-ity that is needed to consider each situation and audience fortheir unique characteristics and needs and select the best ap-proach and planning framework to reach out to people andinvolve them in the health issue and its solutions.

• Health communication is an evolving discipline that shouldalways incorporate lessons learned and practical experiences.Practitioners should have a key role in defining theories a

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