Communication Concepts

According to the National Communication Association (NCA) communication is how messages are understood and interpreted by individuals across contexts (NCA, n.d.). Put simply, communication is the study and practice of transferring information and understanding how people use messages to make meaning. One of the earliest models of communication comes from Harold Lasswell. He created a linear model of communication in the 1940s where he explained communication focuses on “Who (says) what (to) whom (in) what channel (with) what effect?” In the early days of the field, researchers hypothesized that information was transferred to passive audiences via mass media such as radio and television. The early “magic bullet” or “hypodermic needle” theories claimed you could “shoot” or “inject” information into audiences and they would respond accordingly. These early models have been replaced by contemporary theories that recognize that audiences are not passive. People are not simply waiting for information, but rather are active and autonomous agents in integrating and sharing information. This includes how information can be used to make multiple meanings. Today’s theories include participatory communication, which is grounded in the work of Paulo Freire (Freire, 1970), and are based on dialogue and two-way communication (Tufte & Mefalopulos, 2009).

Gary Kreps and Barbara Thornton, two renowned professors of communication, describe health communication as the seeking, processing, and sharing of information that impacts health (Kreps & Thornton, 1992). This concept of health communication as a process applies to how individuals interact with healthcare systems. Consider how patients may seek health information from their medical provider, such as a doctor or nurse, who can engage with them to process and build on their understanding of health-related information. The interaction between two or more people is called interpersonal communication, a two-way exchange of words, ideas, and nonverbal gestures. Interpersonal communication is critical to medical care where both healthcare providers and patients can communicate what is happening and what actions are needed to address a person’s health issue. Shared decision-making is a newer communication term used in healthcare settings that describes the process of patients and providers actively working together to determine treatment plans and decisions (Elwyn et al., 2012). Students in medicine, nursing, and allied health can take communication classes to learn skills for engaging with patients (a process called patient–provider communication). After all, health communication in the context of medical care depends on interpersonal communication between providers and patients who come from diverse backgrounds, cultures, languages, literacy levels, and technologic abilities and requires authentic empathy and respect (van Servellen, 2020).

The ability to work together with people across cultures and backgrounds is referred to as cultural competency (National Center for Cultural Competence, n.d.). Culture is a critical part of health communication. Like an iceberg, often what is visible above the surface are characteristics such as food, language, and manner of dress. Culture that is visible above the surface can include a person’s sex, gender identity, sexual orientation, race, ethnicity, and religion. But a deeper understanding of culture, or the bulk of the iceberg of culture, lies beneath the water and includes more nuanced characteristics such as a person’s history, experiences, attitudes, and knowledge base. These cultural nuances impact how a person understands and prioritizes health topics including illness, disease, and wellness. These audience-centered considerations are critical for health communication creators to understand when designing and implementing any health communication program.

Figure 1.2

The 10 Essential Public Health Services

Source: Centers for Disease Control and Prevention. (2020). 10 Essential Public Health Services. https://www.cdc.gov/publichealthgateway/publichealthservices/essentialhealthservices.html

Public Health Concepts

Unlike the field of medicine that focuses on individual health, public health addresses factors that impact an audience’s health. These include social and economic factors like education and employment and environmental influences such as the exposure to and quality of air, water, and food. Environment and infrastructure both influence health. Infrastructure includes built environments that people spend time in, including housing, transportation, and work environments. Both the natural and built environment impact health behaviors including diet; physical activity; sexual activity; substance use such as tobacco, alcohol, illicit, and prescription drugs; and healthcare use, access, and quality. According to the American Public Health Association (APHA; n.d.-b, public health constitutes both the promotion and protection of community health in different environments. Basically, public health is about assuring the conditions in which people can be healthy (Institute of Medicine, 1988). The U.S. Centers for Disease Control and Prevention (CDC) identifies 10 essential public health services that define its function as follows (Figure 1.2):

The CDC defines health communication as “the study and use of communication strategies to inform and influence decisions and actions to improve health” (CDC, n.d.-b, para. 1). The agency considers several additional aspects in their view of health communication including crisis communication (the process of providing information to the public during an emergency) and risk communication (the process of providing information to the public about the possible outcomes from a specific exposure or behavior). The CDC employs principles of crisis and risk communication throughout emergencies such as outbreaks of disease, foodborne illness, and other health threats by providing information and recommendations to the public about how to stay safe and well at home, schools, workplaces, essential services such as grocery stores and gas stations, and spaces where people participate in activities of leisure and recreation. For example, during the COVID-19 crisis the CDC promoted handwashing and mask wearing to decrease transmission of the virus. The CDC provided accessible guidelines to small businesses to encourage individual customers to mask-up and use hand sanitizer. At the community level, CDC guidelines were translated to reach people across languages and literacy levels. At the organizational level, universities adopted CDC guidelines to provide policies and procedures for their staff and students. Using mass media, the CDC developed COVID-19 vaccination public service announcements (PSAs) for television and the internet. And at the policy level, CDC officials worked alongside federal and state governments to determine when and where mask mandates should be enforced.

In today’s world, health communication is all around. Health communication covers social media posts, posters, billboards, PSAs, signs in the workplace, posters at school, printouts and brochures from the doctor’s office or pharmacy, and more. Health communication includes both old media and new media. Old or traditional media are less interactive and more dependent on one-way communication media such as print, TV, film, and radio. New media include technologies that enable multi-way communication such as email, instant messaging, and social media. Social media enable networking, commenting, and direct communication between users on shared platforms and around text, images, photos, memes, and/or videos that are broadly shared.

Along with advances in technology and instant communication, there has also been innovation in health communication approaches and capabilities. Here are a few examples. mHealth, short for mobile health, describes mobile apps and sites used specifically for healthcare. Examples include health monitoring apps or patient portals where users can access information and communicate. eHealth or electronic health more broadly refers to delivering healthcare via electronic means, such as electronic medical records and test results (Motamarri et al., 2014). Transmedia refers to the integrative process of using multiple formats or channels simultaneously. For example, a health communication campaign can share content on billboards, TV ads, and social media.

A quick internet search for the term “health communication” will yield many definitions of health communication. The working definition of health communication that one chooses to use may depend on the context of a study or program or even the background of the person using it. It is good practice to ask yourself which definition appeals to you. Then you can ask yourself why and develop a clear reason for using that definition. Most definitions are essentially similar. What you should know at this point is that health communication lies at the intersection of public health and communication and is a vibrant, multidisciplinary, and constantly evolving field of study and practice that applies principles of communication to support individuals, families, communities, organizations, and policy makers to adopt changes that will improve public health outcomes. In Box 1.2, Scott Damon from the CDC shares his thoughts on health communication. You can listen to an interview with Scott in the podcast episode that accompanies this chapter (Box 1.3).

Socioeconomic Status

Socioeconomic status refers to people’s economic and social circumstances within a hierarchy that could be conceptualized as a ladder from bottom to top. Toward the top of the ladder, wealthier people around the world live longer and healthier lives than people who live in poverty or at the bottom of the ladder. The ladder does not refer to human worth but to access to wealth and power where those on the lower end of the ladder have less than those at the upper end of the ladder. Neighborhoods, the surrounding built environment, housing quality, access to clean water, sanitation infrastructure and services, education quality, and the prevalence of crime and violence all play a part in our health status. Around the world, people who live in wealthier neighborhoods and earn more money are more likely to graduate from high school and enroll in higher education. Those who speak the dominant language in their region or country also experience better health than those who cannot fully participate in the society where they live due to language and literacy barriers. Language and literacy are critical to understanding health information, accessing care, and taking actions related to good health. Health literacy is the degree to which people can obtain and understand health information. This is a growing area of interest in global health communication (Health Resources & Safety Administration, n.d.). Literacy barriers are not as uncommon as one might think. Forty-five million Americans have low literacy, defined as unable to read above a fifth-grade level (National Center for Educational Statistics, 2009).

Stress

Life is full of stressors from study, work, relationships, and more areas. Stress over short periods of time that results in positive outcomes can be healthy. But when it persists, stress can have a negative impact on our health. Prolonged or toxic stress can lead to physical and mental health problems like anxiety, insecurity, low self-esteem, and social isolation, just to name a few. One form of chronic stress is referred to as “weathering.” This describes the cumulative impact of stress due to racism experienced by Black people in the United States over time (Geronimus et al., 2006). This type of stress is measurable in biomarkers that illustrate differences in health by race (an identifier that we construct based on real or perceived physical or biological characteristics) and ethnicity (a socially defined category based on language, history, or other cultural factors; Spector, 2013). Basically, prolonged stress is detrimental to our health and more and more research is demonstrating associations with race, ethnicity, and other factors and how interventions addressed at reducing stress have both direct and indirect positive health outcomes.

Early Life

The first few years of life, especially until age 3, are critically important in human development (Britto et al., 2017). This is when the foundations of health are established and continue to influence health through adulthood. Early education on good eating habits and lifestyles that promote health and well-being result in better health outcomes later in life. In fact, what happens even before birth is also important. Negative pregnancy experiences can lead to less-than-optimal fetal development. For example, poor nutrition, maternal stress, smoking, and misuse of drugs and alcohol can all impact the health of the fetus. The first 1,000 days refers to the days from conception to a child’s second birthday and are considered extremely important in determining health outcomes. For example, interventions that promote nutrition during these first 1,000 days can help prevent childhood obesity in later years by establishing healthy habits early (Woo Baidal et al., 2016). Experience and exposure to health promoting resources and activities versus exposure to circumstances and environments that threaten health during early childhood development are part of what determines a person’s health throughout their life.

Social Exclusion

Social exclusion is somewhat self-explanatory as the conditions that result in being excluded from social benefits. Levitas and colleagues (2007, p. 9) define social exclusion as “a complex and multi- dimensional process. It involves the lack or denial of resources, rights, goods and services, and the inability to participate in the normal relationships and activities, available to the majority of people in a society, whether in economic, social, cultural or political arenas. It affects both the quality of life of individuals and the equity and cohesion of society as a whole.” A person’s social health refers to a person’s ability to form and maintain healthy relationships with others. Social exclusion results from racism, discrimination, xenophobia, and stigmatization and has a major impact on health by preventing people from having access to services and participating in activities. The roots of social exclusion are based on a person’s social identity that includes but is not limited to gender, age, area of residence, occupation, race, ethnicity, religion, citizenship status, disability, sexual orientation, and gender identity.

Work

Meaningful and well-paid work versus unemployment has large impacts on determining health. Being employed provides income which is critical for meeting basic needs—such as food, shelter, clothing, and access to healthcare. However, income is not the only work-related predictor of health. A healthy workplace that promotes health, well-being, and safety throughout all aspects of the work environment is equally important. Have you ever worked in a place that was toxic? Perhaps you’ve had an unreasonably demanding or inconsiderate boss, struggled with work–life balance, and simply stayed at a job just because of income and other benefits. All of these stressors have short- and long-term health impacts. For most people, work is where they spend most of their time throughout their life. This entails chronic influences on health, for better or worse.

Unemployment

Unemployment can mean being laid off from a job and/or being unable to find and maintain steady work despite wanting to work. In the United States, the national unemployment rate is reported weekly by the Bureau of Labor Statistics. Being unemployed is linked to adverse effects. Unemployment is associated with mental health impacts such as anxiety and depression, whereas job security increases health, well-being, and job satisfaction. Social programs such as unemployment compensation, workers compensation insurance to cover injuries on the job, disability insurance, and continuing health coverage after job loss (a program abbreviated as COBRA) can help provide a stopgap for people. Optimal public health occurs when unemployment is low and people are consistently employed at good jobs making fair wages and receiving benefits such as healthcare and paid time off.

Social Support

Constructive social relationships and interactions contribute to a person’s health. Social interaction allows people to develop support networks. In public health, when we talk about social networks, we are talking about how people and groups operate within a person’s personal network, that is, a theory called social network theory (Valente & Pitts, 2017). This is different than the term social network which is used to describe a social media platform, such as Facebook and the 2010 movie The Social Network, although the idea is similar. Real human interactions have the capacity to make people feel loved and valued and provide people with the emotional and physical support they need for healthier behavior patterns. At the same time, a person’s social network can have negative influences on a range of health behaviors. Teenagers are more likely to smoke cigarettes if their parents also smoke (Kandel et al., 2015) and less likely to wear a seatbelt in a car if their friends or parents are also not wearing a seatbelt (Williams et al., 2003).

Addiction

It is well known that alcohol, drugs, and tobacco contribute to poor health outcomes. People turn to these substances and others as coping or relaxation mechanisms often to tolerate or distract themselves from pain or stress. The danger is that these substances are often highly addictive. This can make other problems, such as mental health, unemployment, or homelessness, worse. In recent years, the United States has experienced an epidemic of opioid use. Serious and debilitating addictions often begin when a person takes legal and prescribed opioids such as those designed for pain management. Becoming dependent on these chemicals in order to feel good, those who are addicted often use them for longer than intended or without a prescription, and when prescribed medication is no longer an option, they turn to illegal opioids such as heroin, methamphetamine, and fentanyl. Thousands of people die each year from drug overdoses and many of these deaths are preventable. Harm reduction is a set of evidence-based strategies for reducing drug-related consequences (National Harm Reduction Coalition, n.d.). Public health has long supported harm reduction strategies such as needle exchanges that first started in the 1980s to reduce the spread of HIV among people who use drugs and, more recently, training community members to administer naloxone (brand name Narcan) to counteract an opioid overdose. Many members of the public first learned about naloxone when Demi Lovato overdosed in 2018, and naloxone saved her life.

Food

Consuming healthy food is vital for developing and maintaining good physical and mental health. Many people worldwide do not have access to proper food, resulting in malnutrition, stunted growth, and poor health outcomes. The term food insecurity describes a lack of consistent access to adequate food (U.S. Department of Agriculture [USDA], 2022). People who experience food insecurity may worry they will run out of food and not have enough money to buy more, may not be able to afford balanced meals, and may skip meals or eat less food to stretch between paychecks or other income. The Supplemental Nutrition Assistance Program (SNAP, previously known as “food stamps”) is a U.S. federal program for people with low incomes to buy healthy food at grocery stores and farmers markets. WIC (which stands for Women, Infants, and Children) is another federal food program that provides food for women and children in the United States. Approximately half of all infants born in the United States benefit from WIC (USDA, n.d.).

At the same time, the overconsumption of unhealthy food contributes to overweight and obesity, which are associated with comorbid conditions such as type 2 diabetes and high blood pressure. Childhood obesity is a serious problem in the United States. In recent years, nearly 20% of children have been classified as obese, with higher rates—or disparities—among Black and Hispanic children (CDC, n.d.-a). Childhood obesity has serious short- and long-term consequences. A landmark study in 2005 found that children born at the time who develop childhood obesity may have a shorter life expectancy than their parents (Olshanky et al., 2005).

Transportation

Access to safe and reliable transportation is a fundamental SDOH. Reliable, safe, and affordable transportation is needed for people to maintain access to and participation in school, work, recreation, and medical care or other SDOH. For people living in a rural or remote area and needing emergency medical care, the nearest hospital may be dozens of miles away. Thus, transportation involves access to safe roads and vehicles, including both personal vehicles and mass transit, such as trains and buses. Every year, over one million people die in road-related incidents, which are the leading cause of death for children and adolescents in the United States (Global Road Safety Partnership, n.d.). Preventing road-related deaths and injuries is an important public health issue and includes ensuring access to seatbelts, helmets, and car seats as well as education about the risks of and ultimate regulation of driving under the influence, at dangerous speeds, or the use of distracting electronic devices while driving. In the U.S. context, cycling and walking are often underrecognized forms of transportation that can promote good health by exercising, reducing air pollution, and increasing social contact. Cyclists, scooter riders, and pedestrians all require safe pathways that are unobstructed, free from litter and debris, are clearly lit, and have safe zones where they merge with or intersect vehicle traffic.

The WHO provides a useful framework for understanding the SDOH in which there are two broad types of health determinants that influence health and can lead to health inequities: structural determinants and intermediary determinants. Structural determinants refer to the socioeconomic and political context in which a person is born into and lives in. These include governance; how society organizes itself to make and implement decisions; economic, social, and public policies; and the social and cultural values that communities place on health. An individual’s socioeconomic position is further determined by a number of factors, such as education, occupation, income, gender, race or ethnicity, and social class. What is more, structural determinants of health also affect the intermediary determinants of health. These include material circumstances that people have access to, such as the quality of housing and how much one can earn, that provide the financial means to buy food, clothing, or other requirements for healthy living. Intermediary determinants include the work environment, psychosocial circumstances like how constructive versus destructive a persons’ relationships are, behaviors, and personal circumstances such as health status. Structural and intermediary determinants of health are bridged by factors such as social cohesion and social capital. These dynamics and exchanges describe the willingness of people living in a community to make sacrifices and to cooperate with each other for a wider benefit.

The SDOH impact people’s health around the entire globe. Let’s look at an example. In 2015, the life expectancy of a child born in Sierra Leone was 50 years whereas in Australia it was 83 years—a difference of 33 years! These differences exist even within countries. For example, in Australia the life expectancy of people is 7.8 years lower for Indigenous females and 8.6 years lower for Indigenous males, compared to non-Indigenous Australians (Australian Institute of Health and Welfare, 2023). It’s also important to keep in mind that the links between these different factors are not always linear but are complex and can go in both directions. For example, poor income and education can impact health and poor health can limit opportunities for people to participate in the workforce or receive education. Also, if a population is affected by a lot of disease, it can have a broader impact on the socioeconomic and political context.

Addressing the SDOH is not easy. It involves identifying the structural and intermediary determinants of health and taking appropriate actions to improve them. To do this requires actions across all sectors of society and at all levels, including local, national, and international. The actions will depend on the existing socioeconomic and political context, as well as available and dedicated resources.

Why Use Theories, Models, and Frameworks?

There are several reasons to use theories, models, and frameworks in health communication planning and evaluation. By linking to previous scientific studies and evidence, they provide justification and direction for program activities and serve as the basis for the processes that are incorporated into public health practice. Theories can provide answers to questions such as: Why don’t people engage in health-conducive behaviors? How do we go about changing behaviors? And what are the factors that we need to look at when we want to evaluate a program? Another reason to use theories, models, and frameworks is that the field of health communication is based on a body of scientific evidence. An evidence base is built by making sure that an intervention is grounded in a plausible and testable theory of change, with specific outputs and results (short, medium, and long term). These outputs and results are identified by referring to existing theories. By addressing known factors that influence a specific health topic, health communicators can plan, implement, and evaluate programs that are more likely to achieve the intended positive results in behavior and social change.

How to Use Theories, Models, and Frameworks

Theories, models, and frameworks are part of the very first steps of researching and designing a program. Once a public health problem is identified, theories, models, and frameworks are what are used to design the program or address the problem. Then, when a program is implemented, theories, models, and frameworks can help guide the program and keep it on track so that it is implemented as it was designed or in ways that effectively adapt to changes along the way. Finally, programs themselves are researched and evaluated using the same theories, models, and frameworks to determine if the program “worked” or not. Research can include quantitative or qualitative ways of measuring a program. For example, the program impact may be measured both in numbers of people reached and by how meaningfully it reached them. Both quantitative and qualitative program evaluation can and should, where possible, include participatory research that engages members of the community a program is trying to reach.

Health communicators can select from many different theories and are not limited to choosing just one. Later chapters will discuss specific theories in more detail. Many of the theories you’ll learn in this book have common elements but may use different ways to describe them. High-quality health communication is based on mixing and matching constructs from theories that link best to the problem and can be used together to achieve expected results. Asking whether or not one should use this theory or that theory is a flawed or ineffective way of looking at public health topics. A better way is to determine what factors or constructs predict a desired change. These will depend on the behavior you are trying to change or the social change that you’re trying to accomplish. Researching the problem and previous programs that have addressed it will lead you to a theory or theories to include in your model or framework.

The Social Ecological Model

The SEM (Figure1.4) is a way of understanding an individual as part of their social environment. This ecological approach is a popular model in public health and is considered a best practice to engage. You will come across the SEM countless times in public health communication. The idea is that public health happens in the world, not a lab. So, it is important to understand what surrounds the people we aim to help, the problem we want to solve, and the work that we need to do. Remember models are bigger than theories and contain one or more theories. The SEM emphasizes that health communication is not only about influencing individual behavior change, but also about engaging people and resources at different levels of an individual’s surroundings. The SEM places an individual at the center of this model. Then, like a bullseye or target, each larger level, or circle of the model, represents people and factors that help to shape and influence an individual’s behavior. The SEM can be tailored or designed to a project to emphasize intervention at different levels, depending on the health topic. For example, while the focus of a health communication program may be to promote a healthy diet and physical activity among school children, social support, access to safe places to exercise, availability of fresh fruits and vegetables, and policy (e.g., free and reduced cost school lunch programs) might all play a role and require intervention at higher levels or the outside circles of the bullseye.

Some example factors at the individual (or intrapersonal) level include individual characteristics such as age, sex, race, education, health literacy, knowledge, attitudes, self-efficacy, and skills that influence an individual’s behavior. At the interpersonal level, people and relationships can influence a person’s health. Factors at this level can include social networks and social support from family members, friends, peers, and neighbors who provide social identity, support, and role definition. Community-level factors include environmental considerations for a person’s health, such as access to parks, safe places to exercise, transportation, and availability of healthy food options. Factors at the organizational level (sometimes called institutional level) include formal organizations such as schools and workplaces and informal organizations, such as clubs, that can influence health via rules, regulations, policies, and informal structures, which may constrain or promote behaviors. And policy-level factors include laws implemented at the local, state, or federal level that regulate and support healthy actions and practices and are critical to support health communication programs. For example, a health communication program wishing to reduce texting and driving will want to consider local laws on the topic. Successful health communication programs must consider each level of the social ecological model and work with partners to create an enabling environment to support topics covered in health communication programs. In other words, it is not enough to raise awareness about a topic in a health communication program; one must also consider wider effects and impact across the model.

Figure 1.4

The Social Ecological Model