PHC 312 SEU Acute Lower Respiratory Tract Infections Discussion


Question: –
Acute lower respiratory tract infections (ALRTIs) account for a critical health problem that affects approximately (15.4%) of the Saudi population. This study focused on previous studies that included children to investigate the epidemiology of LRTIs and respiratory viruses. The detected populations signified that young children are more vulnerable to get ARTIs than adults, as many viruses including human respiratory syncytial virus (HRSV), influenza viruses, and human parainfluenza viruses (HPIVs) were found to be highly infective to infants and children.
Q-Apply effective Health communication Program for mothers of children with Acute lower respiratory tract infections?HEALTH COMMUNICATION
Second Edition
Renata Schiavo
Cover design: JPuda
Cover image : C Pixman/Imagezoo/Getty
Copyright C 2014 by Renata Schiavo. All rights reserved.
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Library of Congress Cataloging-in-Publication Data
Schiavo, Renata, author.
Health communication : from theory to practice / Renata Schiavo.—Second edition.
pages cm.—(Jossey-Bass public health ; 217)
Includes bibliographical references and index.
ISBN 978-1-118-12219-8 (pbk.)—ISBN 978-1-118-41912-0 (pdf)—
ISBN 978-1-118-41639-6 (epub)
1. Communication in medicine—United States. 2. Health promotion—United States. 3. Health
planning—United States. I. Title
R118.S33 2014
610.1 4—dc23
Printed in the United States of America
HB Printing
10 9 8 7 6 5 4 3 2 1
Tables, Figures, Exhibits, and Numbered Boxes • • • • • • • • ix
Preface • • • • • • • • • • • • • • • • • • • • • xv
Acknowledgments • • • • • • • • • • • • • • • • • xvii
The Author • • • • • • • • • • • • • • • • • • • • xxi
Introduction • • • • • • • • • • • • • • • • • • • xxiii
Part One: Introduction to Health Communication
Chapter 1 What Is Health Communication?


In This Chapter • • • • • • • • • • • • • • • • • • • 3
Defining Health Communication • • • • • • • • • • • • • 4
Health Communication in the Twenty-First Century:
Key Characteristics and Defining Features • • • • • • • • • 9
The Health Communication Environment • • • • • • • • • 22
Health Communication in Public Health, Health Care, and
Community Development • • • • • • • • • • • • • • 23
The Role of Health Communication in the Marketing Mix • • • • 25
Overview of Key Communication Areas • • • • • • • • • • 26
The Health Communication Cycle • • • • • • • • • • • • 28
What Health Communication Can and Cannot Do • • • • • • 29
Key Concepts • • • • • • • • • • • • • • • • • • • 31
For Discussion and Practice • • • • • • • • • • • • • • 32
Key Terms • • • • • • • • • • • • • • • • • • • • 32
Chapter 2 Current Health Communication Theories and Issues

In This Chapter • • • • • • • • • • • • • • • • • • 33
Use of Communication Models and Theories: A Premise • • • • 34
Key Theoretical Influences in Health Communication • • • • • 35
Select Models for Strategic Behavior and Social Change
Communication • • • • • • • • • • • • • • • • • • 57
Other Theoretical Influences and Planning Frameworks • • • • 62
Current Issues and Topics in Public Health and Health Care:
Implications for Health Communication • • • • • • • • • 64
Key Concepts • • • • • • • • • • • • • • • • • • • 81
For Discussion and Practice •
Key Terms • • • • • • •

Chapter 3 Culture and Other Influences on Conceptions of
Health and Illness


In This Chapter • • • • • • • • • • • • • • • • • • 83
What Is Culture? • • • • • • • • • • • • • • • • • • 84
Approaches in Defining Health and Illness • • • • • • • • • 85
Understanding Health in Different Contexts: A Comparative
Overview • • • • • • • • • • • • • • • • • • • • 88
Gender Influences on Health Behaviors and Conceptions of
Health and Illness • • • • • • • • • • • • • • • • • 91
Health Beliefs Versus Desires: Implications for Health
Communication • • • • • • • • • • • • • • • • • • 94
Cultural Competence and Implications for Health
Communication • • • • • • • • • • • • • • • • • • 97
Key Concepts • • • • • • • • • • • • • • • • • • • 99
For Discussion and Practice • • • • • • • • • • • • • • 99
Key Terms • • • • • • • • • • • • • • • • • • • • 100
Part Two: Health Communication Approaches and
Action Areas
Chapter 4 Interpersonal Communication


In This Chapter • • • • • • • • • • • • • • • • • • 103
The Dynamics of Interpersonal Behavior • • • • • • • • • 104
Social and Cognitive Processes of Interpersonal Communication • 106
Community Dialogue as an Example of Interpersonal Communication at Scale • • • • • • • • • • • • • • • • 111
The Power of Personal Selling and Counseling • • • • • • • 112
Communication as a Core Clinical Competency • • • • • • • 116
Implications of Interpersonal Communication for TechnologyMediated Communications • • • • • • • • • • • • • 128
Key Concepts • • • • • • • • • • • • • • • • • • • 129
For Discussion and Practice • • • • • • • • • • • • • • 131
Key Terms • • • • • • • • • • • • • • • • • • • • 132
Chapter 5 Mass Media and New Media Communication, and
Public Relations

In This Chapter • • • • • • • • • • • • • • • •
Health Communication in the New Media Age: What Has
Changed and What Should Not Change • • • • • • •



The Media of Mass Communication and Public Relations • • • 138
Public Relations Defined: Theory and Practice • • • • • • • 139
Mass Media, Health-Related Decisions, and Public Health • • • 149
New Media and Health • • • • • • • • • • • • • • • 157
Reaching the Underserved with Integrated New Media
Communication • • • • • • • • • • • • • • • • • 170
Mass Media– and New Media–Specific Evaluation
Parameters • • • • • • • • • • • • • • • • • • • 171
Key Concepts • • • • • • • • • • • • • • • • • • • 174
For Discussion and Practice • • • • • • • • • • • • • • 176
Key Terms • • • • • • • • • • • • • • • • • • • • 177
Chapter 6 Community Mobilization and Citizen Engagement

In This Chapter • • • • • • • • • • • • • • • • • • 179
Community Mobilization and Citizen Engagement: A BottomUp Approach • • • • • • • • • • • • • • • • • • 180
Community Mobilization as a Social Process • • • • • • • • 182
Engaging Citizens in Policy Debates and Political Processes • • • 188
Implications of Different Theoretical and Practical Perspectives for Community Mobilization and Citizen Engagement
Programs • • • • • • • • • • • • • • • • • • • • 190
Impact of Community Mobilization on Health-Related Knowledge and Practices • • • • • • • • • • • • • • • • • 194
Key Steps of Community Mobilization Programs • • • • • • 203
The Case for Community Mobilization and Citizen Engagement in Risk and Emergency Communication • • • • • • • 212
Key Concepts • • • • • • • • • • • • • • • • • • • 216
For Discussion and Practice • • • • • • • • • • • • • • 217
Key Terms • • • • • • • • • • • • • • • • • • • • 218
Chapter 7 Professional Medical Communications

In This Chapter • • • • • • • • • • • • • • • • • • 219
Communicating with Health Care Providers: A Peer-to-Peer
Approach • • • • • • • • • • • • • • • • • • • • 220
Theoretical Assumptions in Professional Medical (Clinical)
Communications • • • • • • • • • • • • • • • • • 224
How to Influence Health Care Provider Behavior: A Theoretical Overview • • • • • • • • • • • • • • • • • 226
Key Elements of Professional Medical Communications
Programs • • • • • • • • • • • • • • • • • • • • 228
Overview of Key Communication Channels and Activities • • • 235
Using IT Innovation to Address Emerging Needs and Global
Health Workforce Gap • • • • • • • • • • • • • •
Prioritizing Health Disparities in Clinical Education to Improve
Care: The Role of Cross-Cultural Health Communication • •
Key Concepts • • • • • • • • • • • • • • • • • •
For Discussion and Practice • • • • • • • • • • • • •
Key Terms • • • • • • • • • • • • • • • • • • •
Chapter 8 Constituency Relations and Strategic Partnerships
in Health Communication

• 240
• 242
• 242


In This Chapter • • • • • • • • • • • • • • • • • • 243
Constituency Relations: A Practice-Based Definition • • • • • 244
Recognizing the Legitimacy of All Constituency Groups • • • • 246
Constituency Relations: A Structured Approach • • • • • • • 247
Strategies to Develop Successful Multisectoral Partnerships • • • 251
Key Concepts • • • • • • • • • • • • • • • • • • • 260
For Discussion and Practice • • • • • • • • • • • • • • 261
Key Terms • • • • • • • • • • • • • • • • • • • • 262
Chapter 9 Policy Communication and Public Advocacy

In This Chapter • • • • • • • • • • • • • • • • • • 263
Policy Communication and Public Advocacy as Integrated
Communication Areas • • • • • • • • • • • • • • • 264
Communicating with Policymakers and Other Key Stakeholders • 267
The Media of Public Advocacy and Public Relations • • • • • 271
Influencing Public Policy in the New Media Age • • • • • • • 274
Key Concepts • • • • • • • • • • • • • • • • • • • 277
For Discussion and Practice • • • • • • • • • • • • • • 278
Key Terms • • • • • • • • • • • • • • • • • • • • 278
Part Three: Planning, Implementing, and Evaluating
a Health Communication Intervention
Chapter 10 Overview of the Health Communication
Planning Process


In This Chapter • • • • • • • • • • • • • • • • • • 281
Why Planning Is Important • • • • • • • • • • • • • • 283
Approaches to Health Communication Planning • • • • • • • 285
The Health Communication Cycle and Strategic Planning Process 287
Key Steps of Health Communication Planning • • • • • • • 289
Elements of an Effective Health Communication Program • • • 295
Establishing the Overall Program Goal: A Practical Perspective • • 299
Outcome Objectives: Behavioral, Social, and Organizational •
Key Concepts • • • • • • • • • • • • • • • • •
For Discussion and Practice • • • • • • • • • • • •
Key Terms • • • • • • • • • • • • • • • • • •
Chapter 11 Situation and Audience Analysis

• 300

• 303

• 305

• 306


In This Chapter • • • • • • • • • • • • • • • • • • 307
How to Develop a Comprehensive Situation and Audience
Analysis • • • • • • • • • • • • • • • • • • • • 308
Organizing, Sharing, and Reporting on Research Findings • • • 333
Common Research Methodologies: An Overview • • • • • • 335
Key Concepts • • • • • • • • • • • • • • • • • • • 353
For Discussion and Practice • • • • • • • • • • • • • • 354
Key Terms • • • • • • • • • • • • • • • • • • • • 354
Chapter 12 Identifying Communication Objectives
and Strategies

In This Chapter • • • • • • • • • • • • • • • • • • 355
How to Develop and Validate Communication Objectives • • • 356
Outlining a Communication Strategy • • • • • • • • • • 364
Key Concepts • • • • • • • • • • • • • • • • • • • 372
For Discussion and Practice • • • • • • • • • • • • • • 372
Key Terms • • • • • • • • • • • • • • • • • • • • 373
Chapter 13 Designing and Implementing an Action Plan

In This Chapter • • • • • • • • • • • • • • • • • • 375
Definition of an Action (Tactical) Plan • • • • • • • • • • 376
Key Elements of an Action (Tactical) Plan • • • • • • • • • 379
Integrating Partnership and Action Plans • • • • • • • • • 398
Planning for a Successful Program Implementation • • • • • • 400
Key Concepts • • • • • • • • • • • • • • • • • • • 404
For Discussion and Practice • • • • • • • • • • • • • • 405
Key Terms • • • • • • • • • • • • • • • • • • • • 405
Chapter 14 Evaluating Outcomes of Health Communication

In This Chapter • • • • • • • • • • • • • • • • • • 407
Evaluation as a Key Element of Health Communication Planning • 408
Overview of Key Evaluation Trends and Strategies: Why,
What, and How We Measure • • • • • • • • • • • • • 409
Integrating Evaluation Parameters That Are Inclusive of Vulnerable and Underserved Populations • • • • • • • • • • 425
Evaluating New Media–Based Interventions: Emerging Trends
and Models • • • • • • • • • • • • • • • • • • • 426
Monitoring: An Essential Element of Program Evaluation • • • 430
Linking Outcomes to a Specific Health Communication
Intervention • • • • • • • • • • • • • • • • • • • 432
Evaluation Report • • • • • • • • • • • • • • • • • 434
Key Concepts • • • • • • • • • • • • • • • • • • • 437
For Discussion and Practice • • • • • • • • • • • • • • 439
Key Terms • • • • • • • • • • • • • • • • • • • • 440
Part Four: Case Studies and Lessons from the Field
Chapter 15 Health Communication in the United States:
Case Studies and Lessons from the Field


In This Chapter • • • • • • • • • • • • • • • • • • 443
From Theory to Practice: Select Case Studies from the
United States • • • • • • • • • • • • • • • • • • 444
Emerging Trends and Lessons • • • • • • • • • • • • • 464
Key Concepts • • • • • • • • • • • • • • • • • • • 465
For Discussion and Practice • • • • • • • • • • • • • • 466
Key Term • • • • • • • • • • • • • • • • • • • • 466
Chapter 16 Global Health Communication: Case Studies
and Lessons from the Field

In This Chapter • • • • • • • • • • • • • • • •
From Theory to Practice: Select Case Studies on Global
Health Communication • • • • • • • • • • • • •
Emerging Trends and Lessons • • • • • • • • • • •
Key Concepts • • • • • • • • • • • • • • • • •
For Discussion and Practice • • • • • • • • • • • •
Key Terms • • • • • • • • • • • • • • • • • •
Appendix A Examples of Worksheets and Resources on Health
Communication Planning



• 468

• 492

• 493

• 493

Appendix B Sample Online Resources on Health Communication

Name Index
Subject Index
Health Communication Definitions
Key Characteristics of Health Communication
What Health Communication Can and Cannot Do
A Comparative Overview of Ideas of Health and Illness
Examples of Disease-Specific Ideas of Illness
Comparing Cultural Norms and Values
Barriers to Effective Provider-Patient Communication:
Patient Factors
Internet and New Media Penetration
Health Communication in the Media Age: What Has
Changed and What Should Not Change
Public Relations Functions in Public Health and Health Care
Characteristics of Psychological Types Relevant to Public
Key Characteristics of Ethical Public Relations Programs
Dos and Don’ts of Media Relations
Mass Media Channels and Related Public Relations Tools
Most Common Uses of the Internet and New Media by
Health Organizations
Sample Factors in Public Perception and Use of New
Media–Specific Tools
Key Audiences of Professional Clinical Communications
Key Obstacles to Clinician Change
Communication Approaches and Tools and Their Effects:
Analysis of Thirty-Six Systematic Reviews
Key Communication Tools and Channels in Professional
Guidelines for Establishing and Preserving Long-Term
Potential Drawbacks of Partnerships
Sample Partnership Success Factors
Key Elements of a Policy Brief
Why Public Advocacy?
Key Elements of an Effective Health Communication Program
Qualitative Versus Quantitative Research Methods
Sample Criteria for a Credibility Assessment of HealthRelated Websites
Examples of Communication Concepts for a Communication Intervention on Childhood Immunization
Key Elements of a Partnership Plan
Drawbacks of Evaluation
Sample Qualitative and Quantitative Methods for the
Assessment of Health Communication Interventions
Sample Tools for the Evaluation of New Media–Based
Examples of Areas of Monitoring with Related Data Collection and Reporting Methods
1.1 The Health Communication Environment
1.2 The Health Communication Cycle
2.1 Health Communication Theory Is Influenced by Different
Fields and Families of Theories
2.2 Attributes of the Audience
2.3 Ideation Theory
2.4 Logic Model and Evaluation Design for a National Program for Infant Mortality Prevention by the Office of
Minority Health, Department of Health and Human Services
3.1 Comparing Culture to an Iceberg
3.2 Health Outcomes as a Complex and Multidimensional
4.1 The Potential Impact of Interpersonal Communication
on Behavior: A Practical Example
6.1 Number of WPV Cases by Year in Nigeria
6.2 Proportion of Actual Noncompliance, High-Risk States,
May 2012
6.3 Preliminary Data, Sokoto VCMs
6.4 Main Reasons for Noncompliance
6.5 Moving from the Pre-During-Post Scenario to the
Preparedness-Readiness Response-Evaluation Constant
Cycle (PRRECC)
9.1 Sample Key Questions for Media Advocacy Planning
10.1 Health Communication Cycle
10.2 Key Steps of Health Communication Planning
Key Steps of Situation Analysis
Changes in Attitudes Toward Polio Virus and Immunization
Social Change and Behavioral Indicators
Integrating New Media and Other Communication Areas
in Approaching Health Communication Planning
and Evaluation
Flu Vaccine Campaign 2009 in Whyville
WhyWellness Virtual World
Egypt: Community Outreach Workers in Action
Cambodia Antenatal Care Campaign Spot
Volunteers Launch the ANC Campaign in Stung Treng,
Cambodia, January 2009
Sample Screenshot from LibGuides
Examples of Outcome Objectives for a Program on Pediatric Asthma
Audience Segmentation Example
SWOT Analysis for the Caribbean Cervical Cancer Prevention and Control Project
Sample Communication Objectives: Understanding the
Connection with Other Program Elements
Numbered Boxes
Diffusion of Innovation Theory: A Practical Example
The Added-Value of Theoretical Models in Evaluating
Mass Media Campaigns
Raising Awareness of Infant Mortality Disparities in San
Personal Selling and Counseling Case Study
The Impact of Effective Provider-Patient Communications on Patient Outcomes: A Pediatric Nurse Practitioner’s Perspective
Impact of Physician Attitudes on Patient Behavior:
A True Story
Johnson & Johnson’s Campaign for Nursing’s Future
Using the Internet as a Key Public Relations Channel: The
Schepens Eye Research Institute
Sports for Health Equity: A Multifaceted National Program
Street Fighters of Public Health: Using Online Tools to
Create Networking Opportunities in Public Health
Tackling Oral Polio Vaccine Refusals Through Volunteer
Community Mobilizer Network in Northern Nigeria
Social Mobilization to Fight Ebola in Yambio,
Southern Sudan
How Bingwa Changed His Ways
Gay Men’s Health Crisis HIV/AIDS Time Line
National Foundation for Infectious Diseases Flu Fight for
Kids: Case Study
How Constituency Relations Can Help Advance an Organization’s Mission: A Practice-Based Perspective
National Cancer Institute Guidelines for Considering
Commercial Partners
Audience Profile: Got a Minute? Give It to Your Kids!
Maintaining Egypt Polio Free: How Communication Made
It Happen!
NCI’s Cancer Research Awareness Initiative: From Message Concepts to Final Message
Community Theater in Benin: Taking the Show on the Road
Using Process Evaluation Data to Refine an EntertainmentEducation Program in Bolivia
WhyWellness: Communicating About Mental Health Within
a Gaming Community
‘‘BodyLove’’—Case Study Summary
Case Study—New Media and the VERB Campaign
Health Equity Exchange: Using an Integrated Multimedia
Communication Approach to Engage US Communities
on Health Equity
Raising Awareness of Sustainable Food Issues and Building
Community via the Integrated Use of New Media with
Other Communication Approaches
What Do Sidewalks Have to Do with Health?
Communication Interventions: Helping Egyptian Families
and Children Stay Safe from Avian Influenza
Preparing for a Nightmare in the Calgary Health Region—
Planning for Pandemic Influenza
Interpersonal Communication: Lessons Learned in India
Case Study—Voices and Images (Tuberculosis)
Applying C4D to Curb Maternal Mortality in Cambodia
The Role of the Health Sciences Librarian in Health
Communication: Continuity in Evidence-Based Public
Health Training for Future Public Health Practitioners
For my wonderful daughters and husband,
Oriana, Talia, and Roger
any colleagues and professionals from a variety of sectors have
approached me since the first edition of Health Communication:
From Theory to Practice was published in 2007. The book has often
provided us with a framework and incentive to share information about
our experiences and discuss many topics as they relate to society, health,
and communication. Of great importance has also been the feedback of
the many faculty members and students (including my own students) who
have used the book as part of their courses in academic programs across the
United States and around the world. I am thankful to all for contributing
to my thinking and professional growth. Their input, suggestions, and our
many conversations are among the main reasons for this second edition.
Other motivating factors for this second edition include health communication’s own evolution, technological advances, and the need to
capture recent experiences and theories that may have been less highlighted in the first edition. This second edition further emphasizes the
importance of a people-centered and participatory approach to health
communication interventions, which should take into account key social
determinants of health and the interconnection among various health
and social fields. While maintaining a strong focus on the importance of
the behavioral, social, and organizational results of health communication
interventions, this book also includes new or updated information, theoretical models, resources, and case studies on health equity, urban health, new
media, emergency and risk communication, strategic partnerships in health
communication, policy communication and public advocacy, cultural competence, health literacy, and the evaluation of health communication
interventions as they relate to various health topics.
Finally, I myself have evolved as I am fortunate to continue to learn
from my work and from the many people I have the pleasure to work
with. My voice has become stronger in favor of health communication
approaches that will encourage participation and community ownership of
the overall communication process, yet will let people decide how much,
when, and how to participate based on their cultural preferences. I also
became increasingly connected to the reason I do this work: to make
a difference in people’s health and lives. My appreciation of the many
challenges of disadvantaged groups has also grown along with my work,
and has influenced my sense of urgency in encouraging people to switch
from a disease-focused mind-set to a health communication approach that
links health with related social, political, and environmental issues, while
keeping a strong commitment to behavioral and social impact.
Put the public back in public health. Think globally, act locally. Tackle
health disparities. These are not just catchy phrases. They are some of the
principles that have been inspiring my work and this book.
s for all projects that are in the making for a long time, this second
edition is inspired by many people and is the fruit of years of thinking
and work for which I am indebted to many colleagues. First and foremost,
my heartfelt thanks go to my editors, Andy Pasternack and Seth Schwartz
of Jossey-Bass, for their invaluable help and expert guidance with the many
questions related to this project, as well as for their great support, cheers,
and much-appreciated commitment to seeing things through. I could not
have made it without them!
Thanks to Joshua Bernstein, Erin Driver, Rachel Gonzales, John Kowalczyk, Doris J. Laird, and C. J. Schumaker for their comments and feedback
on the second edition revision plan and David Anderson, Ellen Bonaguro,
Kathy Miller, and Mario Nacinovich for the invaluable suggestions that
have considerably contributed to the significance of this second edition.
Their helpful feedback was provided via Jossey-Bass’s peer review process. My appreciation also goes to all professional friends and colleagues
who provided suggestions on early drafts of the first and this second
edition, or helped secure relevant case studies and interviews that are
published here. Among them are Doug Arbesfeld, Susan Blake, Joe Casey,
Lenore Cooney, Amanda Crowe, Gustavo Cruz, Chris Elias, Everold Hosein,
Marina Komarecki, Destin Laine, Rafael Obregon, Sherry Michelstein, Elil
Renganathan, and Lisa Weiss. Thank you also to the many authors of the
case studies published in this book for their generosity, time, and willingness
to contribute to this project. I am very grateful to Radhika Ramesh, a graduate of the New York University master’s program in media, culture, and
communication, as well as a former student and a colleague, who worked as
a research and editorial assistant for this second edition, for her dedication
and attention to detail. Also, my thanks go to Ohemaa Boahemaa who
helped with the graphic design of many of the figures included in this book
and managed to fit this in her busy schedule. Thanks to Prarthana Shukla
who was a research assistant for the first edition and to other former public
health students who have contributed feedback, most notably Lawrence
Fung and Ellen Sowala, as well as other students and colleagues who used
the book’s first edition and provided suggestions for changes.
Thank you to colleagues from New York University and the CUNY
School of Public Health at Hunter College, to whom I owe my academic and
teaching experience: Marilyn Auerbach, Jo Ivey Boufford, Jessie Daniels,
Nicholas Freudenberg, Sally Guttmacher, Susan Klitzman, James Macinko,
and Kenneth Olden. Thanks also to the many other colleagues from either
of these two institutions, with whom I have had many conversations on
society, health, and communication or worked closely on different projects.
Most noticeably, May May Leung, for her professionalism, graciousness,
and sense of humor; Marcia Thomas and Lorna Thorpe, for our periodic
lunch meetings and their professional friendship; and Jack Caravanos, Paula
Gardner, Judith Gilbride, Barbara Glickstein, Lydia Isaac, Heidi Jones, Diana
Mason, Khursheed Navder, Stacey Plitcha, Lynn Roberts, Diana Romero,
Yumari Ruiz, Arlene Spark, and Christina Zarcadoolas. And a special
thank-you to Sally Guttmacher, who encouraged me to write this book at
the time of its first edition. I also want to acknowledge colleagues from
Columbia University, James Colgrove, Leah Hopper, Lisa Melsch, and
Marita Murrman, for the opportunity to start teaching in fall 2013 at the
Mailman School of Public Health and their support as I get started. I look
forward to our partnership.
There are many people to whom I owe my practical experience in health
communication and related fields. These include the colleagues, partners,
and clients with whom I have had the privilege to work over the years. I spent
endless days (and nights) with many of them brainstorming and learned a
great deal from all of them. The task of naming them all is quite daunting, so
please forgive me if I do not mention someone who greatly contributed to
my work or thinking over the years. A short list of colleagues with whom I
have had the pleasure to work just in the last decade includes Upal Basu Roy,
Ohemaa Bohaemaa, Patricia Buckley, Joe Casey, Paula Claycomb, Lenore
Cooney, Samantha Cranko, Blake Crawford, Amanda Crowe, Gustavo
Cruz, Isabel Estrada-Portales, Rina Gill, Matilde Gonzalez-Flores, Elena
Hoeppner, Everold Hosein, Neha Kapil, Scott Kennedy, John London,
Alka Mansukhani, LaJoy Mosby, Asiya Odugleh-Kolev, Lene Odum Jensen,
Denisse Ormaza, Radhika Ramesh, Akiko Sakaedani Petrovic, Barbara
Shapiro, Glenn Silver, Teresa (Tess) Stuart, Kate Tulenko, Marie-Noelle
Vieu, Beth Waters, Jennifer Weiss, Lisa Weiss, and Sabriya Williams. And
a special thank-you to past colleagues Daniel Berman and Frances Beves
for their friendship of many years, and our many brainstorms.
I also want to acknowledge colleagues from Cases in Public Health
Communication and Marketing, Journal of Communication in Healthcare,
and The Nation’s Health: Lorien Abroms, Samantha Ashton, Susan Blake,
Michelle Late, Craig Lefebvre, Esme Loukota, Ed Maibach, Kimberly Martin, Mario Nacinovich, Mark Simon, and Charlotte Tucker. Thank you
all for the opportunity to help shape the content or direction of these
publications that make such a great contribution to important health
communication topics.
These acknowledgments wouldn’t be complete without recognizing
the role of the American Public Health Association (APHA) Health Communication Working Group (HCWG) of the Public Health Education and
Health Promotion (PHEHP) section in my professional life. Not only has
HCWG provided me with a home within the APHA but it has also given me
the opportunity to enrich my experience and to network with many great
colleagues, including those with whom I have had the pleasure of working
closely on various HCWG activities: Gary Black, Marla Clayman, Rebecca
(Becky) Cline, Carol Girard, Marian Hunman, Julia Kish Doto, Jennifer
Manganello, Judith (Jude) McDivitt, John Ralls, Doug Rupert, J-J Sheu, Julie
Tu Payiatas, Carin Upstill, and Meg Young. Thanks also to PHEHP colleagues Heather Brandt, Michelle Chuck, Regina Galer-Unti, Jeff Hallam,
Stuart Usdan, and Katherine Wilson for their support on various projects in
which I have been involved either with the HCWG or the PHEHP section.
My thanks to all people mentioned here—and to the ones whom I may
have inadvertently omitted or with whom I worked prior to the last ten
years, and I could not mention for space-related reasons—for contributing
to my work and thinking. Also, thank you to all professionals in different
parts of the world who have been championing and helping advance the
field of health communication with their innovative and strategic thinking,
creativity, and commitment.
Finally, many thanks to my husband, Roger Ullman, for his endless
support and lifetime partnership, and to our daughters, Oriana and Talia,
for inspiring my work ethics and life. And to my mother, Amalia Ronchi,
who despite our differences, taught me perhaps the most important lesson
in life: care about others and try to understand them. This lesson is also
important in health communication.
In Memory of Andy Pasternack
“Hello from Jossey-Bass!” This is how I remember my first interaction with Andy. He had learned
from one of Jossey-Bass’ sales representatives that I was thinking to write a book on health
communication and was emailing to talk and learn more about my idea. I didn’t know at the
time how much this was typical of Andy and his entrepreneurial spirit.
Andy was really passionate about providing new resources on what he believed to be
important topics that may help advance people’s work. He was proud of the fact that “authors
preferred to work with Jossey-Bass” and was committed to creating a supportive environment
that would be conducive to that. He cared about “his” authors and wanted to see them succeed
in their professional endeavors. Always kind and cheerful, Andy loved to connect people, talked
very fondly of his family and staff, and knew how to make things happen. His patience and
encouragement were critical to my efforts to write this book . . . and I can’t believe that he
was corresponding with me about the back cover just a few weeks before his departure. Our
professional community owes gratitude to Andy for his vision and professionalism. We will
miss him.
enata Schiavo, PhD, MA, is a health and international communication, public health, and global health specialist with more than
twenty years of experience in a variety of settings, including the United
States and several countries in Europe, Latin America, and Africa. Currently, she is founding president and CEO of Health Equity Initiative, a
nonprofit organization dedicated to building community, capacity, and
strategic communication resources for health equity. Dr. Schiavo is also a
senior lecturer, Columbia University Mailman School of Public Health, and
has held academic appointments at the CUNY School of Public Health at
Hunter College and New York University’s MPH program.
Dr. Schiavo is a member of the board of directors, Public Health
Foundation Enterprise (PHFE); a member of the Cultural Competence
Interest Group of the New York Academy of Medicine (NYAM); and
a member of the Steering Committee of the American Public Health
Association (APHA) PHEPH Health Communication Working Group
(HCWG), for which she also served as 2007–2008 chair. She serves on the
advisory board of The Nation’s Health (the APHA’s official newspaper),
as well as the editorial boards of Cases in Public Health Communication
and Marketing and Journal of Communication in Healthcare. Among
other international affiliations, Dr. Schiavo is a member of the UNICEF
Communication for Development (C4D) Global Web Roster; the World
Health Organization’s Global Technical Network for Communication for
Behavioral Impact (COMBI); and the Italian group Salute-Cura-Societa’
Dr. Schiavo is the author of dozens of publications in the health
communication, public health, and global health fields. She has recognized
international expertise in twenty-plus public health, global health, and
social development areas, and has served on scientific, expert, and review
panels for leading organizations, including the World Health Organization
[WHO], the National Institutes of Health, and the American Public Health
Association. Her work has been supported by the Office of Minority Health
Resource Center, HHS Office of Minority Health; UNICEF; and WHO,
among others.
Dr. Schiavo’s professional interests lie at the intersection of strategic
health communication for behavioral, social, and organizational change;
multisectoral partnerships; health equity; community health; risk communication; and global health. Her recent work has focused on health
equity–health disparities and social determinants of health, maternal and
child health, public health and humanitarian emergencies, pandemic flu,
global hand washing, childhood cancer, and malaria, among others. She
has significant experience on strategy design; research design and implementation; program design, direction, and evaluation; and professional
development, capacity building, and training.
Prior to founding Health Equity Initiative, Dr. Schiavo had the pleasure
of serving as associate professor and director, Community Health/COMHE
at the CUNY School of Public Health at Hunter College; founder and principal, Strategic Communication Resources; executive vice president, Cooney
Waters Group; and head, corporate and marketing communications and
social responsibility programs, Rhodia Farma-Brazil. Her recent consulting
experience includes leading organizations such as the National Association
of Pediatric Nurse Practitioners (NAPNAP); New York University College
of Dentistry; the Office of Minority Health Resource Center, HHS Office of
Minority Health; Solving Kids’ Cancer; UNICEF; the World Bank; and the
World Health Organization.
Renata has significant management experience, because in addition to
current positions, she also served on the boards of directors of Solving
Kids’ Cancer and the Italian American Committee on Education, and was
an elected voting member of the governing council of the American Public
Health Association. Early in her career, Dr. Schiavo was a postdoctoral
research scientist at Columbia University and New York University, where
she worked on numerous molecular and cell biology projects. She holds a
PhD in biological sciences from the University of Naples (Italy) and an MA
in journalism and mass communication from New York University.
For additional information on Renata Schiavo’s background and experience, visit
ealth communication operates within a very complex environment
in which encouraging and supporting people to adopt and sustain
healthy behaviors, or policymakers and professionals to introduce new
policies and practices, or health care professionals to provide adequate
and culturally competent care are never easy tasks. Moreover, most of
these potential changes and behavioral and social results depend on various socially determined factors such as our living, working, and aging
environments; access to health services and information; adequate transportation, nutritious food, parks and recreational facilities; socioeconomic
opportunities; and social and peer support, among many others.
Childhood immunization, for example, is one of the greatest medical
and scientific successes of recent times. Because of immunization, many
diseases that were once a threat to the life and well-being of children have
become rare or have been eradicated in many countries in the world. Yet as
for most other health-related issues and interventions, changing public and
professional minds and enabling parents to immunize their healthy children
have required a worldwide multidisciplinary effort. Health communication
has played a fundamental role in this success story since the introduction
of the first childhood vaccine. Consider the case of Bonnie, the mother of
a newborn child, who is offered a vaccine for her baby at birth or a few
days after.
Bonnie, an American, is the twenty-five-year-old mother of a beautiful
baby girl. She is thrilled about her child but quite fearful because parenting
is new to her. She has read about the benefits of immunization but is
too young to remember any of the diseases against which she should
immunize her child. She does not know anyone who had polio or whooping
cough or Hib (Haemophilus influenzae type B) disease. She has also heard
conflicting information about the potential adverse events or risks that may
be associated with immunization and is unsure about which of the available
information is correct. She is confused and does not know whether she
wants to immunize her child.
Bonnie’s case is a typical example of issues that health communication
interventions can successfully address:

Engaging Bonnie, her peers, and her community in discussing their
perceptions and opinions about the pros and cons of immunization as
well as any barriers, social norms, or other socially determined factors
that may influence their decisions

Providing Bonnie with research-based and reliable information on

Encouraging participation of Bonnie, her peers, other community
members, and professionals across sectors in developing a communication intervention that would address existing barriers to immunization,
and effectively integrate the opinions, preferences, and needs of parents
and other key groups and stakeholders

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

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

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

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

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

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

Addressing socially determined factors (for example, access to or quality of health services and information, education, living and working
conditions, and others) that may contribute to low immunization rates
in specific segments of the general population
Health communication approaches will work only if they rely on an
in-depth understanding of Bonnie’s and other new mothers’ lifestyles,
concerns, beliefs, attitudes, social norms, barriers to change, and sources of
information about newborns and immunization. It would also be important
to research and understand the cultural, social, and political environment in
which Bonnie lives. What kind of support does she get from family, friends,
and her working environment? Who most influences her decisions on her
child’s well-being and upbringing? What does she fear about immunization?
Is there any existing program in her community that focuses on childhood
immunization? What are the lessons learned? Does she have access to
timely immunization? Does she feel satisfied with the way her health care
provider communicates on immunization (in other words, does she feel that
she can understand and relate to the information her provider discusses)?
These are just some of the many questions that need to be answered
before developing a health communication program intended to promote
behavioral and social change among Bonnie and her peers.
Most important, any kind of health communication intervention needs
to be grounded in communication theory and lessons learned from past
interventions as well as an in-depth understanding of the full potential of the
field of health communication. Communication is considered an important
discipline in the attainment of the Millennium Development Goals (“the
eight MDGs—which range from halving extreme poverty rates to halting
the spread of HIV/AIDS and providing universal primary education, all
by the target date of 2015—form a blueprint agreed to by all the world’s
countries and all the world’s leading development institutions” in 2000;
United Nations, 2013) as well as the post-2015 global agenda. In fact, health
communication can help integrate population, health, and environmentrelated issues to improve public health and social outcomes in different
countries. For example, emerging best practices in health communication
in Rwanda have led to the creation of a Population, Health, and Environment (PHE) Network. This newly established East Africa PHE Network is
designed to “improve communication about PHE issues among policymakers, researchers, and practitioners within Rwanda and throughout eastern
Africa. The PHE Network serves as a forum for information exchange about
cross-cutting PHE issues, community networking, accessing resources” and
also relies on various traditional communication channels (for example,
community-level meetings, participatory planning) and mass and new
media (for example, local radio, newspapers, and Internet).
In the United States, Healthy People 2020, the country’s public health
agenda for one decade, has defined several domains for health communication and health information technology, which are listed in the following.
Goal: Use health communication strategies and health information technology (IT) to improve
population health outcomes and health care quality, and to achieve health equity.
The objectives in this topic area describe many ways health communication and health IT
can have a positive impact on health, health care, and health equity:
• Supporting shared decision making between patients and providers
• Providing personalized self-management tools and resources
• Building social support networks
• Delivering accurate, accessible, and actionable health information that is targeted or
• Facilitating the meaningful use of health IT and exchange of health information among
health care and public health professionals
• Enabling quick and informed action to health risks and public health emergencies
• Increasing health literacy skills
• Providing new opportunities to connect with culturally diverse and hard-to-reach
• Providing sound principles in the design of programs and interventions that result in
healthier behaviors
• Increasing Internet and mobile access
Source: US Department of Health and Human Services. Healthy People 2020. “Health Communication and Health
Information Technology.”
Retrieved July 2012b.
As you may realize yourself after reading this book, in many ways three
of “these areas may encapsulate all others” (Schiavo, 2011b, p. 68): “Building
social support networks . . . providing new opportunities to connect with
culturally diverse and hard-to-reach populations . . . providing sound principles in the design of programs and interventions that result in healthier
behaviors” (Healthy People 2020). These areas speak of innovation; the
integration of different communication areas, strategies, and media, and
health and social issues (after all, there is no magic fix in health communication); the need to include disadvantaged groups and effectively connect
with them as part of the communication process; and the importance
of making sure that communication is grounded in theoretical models,
planning frameworks, and lessons learned from past experiences.
About This Book
Since its first edition in 2007, Health Communication: From Theory to Practice has provided students and professionals from the public health, health
care, global health, community development, nonprofit, and public and private sectors with a comprehensive introduction to health communication
as well as a strategic review of advanced topics and issues that affect the
field’s theory and practice, and a hands-on guide to planning, implementing,
and evaluating health communication interventions. This second edition
further emphasizes the importance of a people-centered and participatory
approach to health communication interventions, which should take into
account key social determinants of health and the interconnection among
various health and social fields.
Although maintaining a strong focus on the importance of the
behavioral, social, and organizational results of health communication
interventions, the second edition also includes new or updated information, theoretical models, resources, and case studies on health equity,
urban health, new media, emergency and risk communication, strategic
partnerships in health communication, policy communication and public
advocacy, cultural competence, health literacy, and the evaluation of health
communication interventions as they relate to various health topics.
Who Should Read This Book
There are many people who I hope will read this book and, if willing, share
their perspectives and feedback with me in the years to come. The following
is only a short list of professionals and health and social change agents for
which this book is designed with the intention to help in everyone’s efforts
to make a difference in people’s health and lives.
Academics: If you are a faculty member in a school or program in
public health, global health, health communication, community health,
communication studies, health education, nursing, environmental health,
nutrition, journalism, design for social innovation, medicine, health and life
sciences, social work, public affairs, international affairs, or psychology, the
multidisciplinary approach to health communication this book proposes
will, I hope, complement other theoretical or practical approaches you may
be using in your work, and provide you with a helpful didactic tool. I also
hope that some of the theoretical concepts, lessons learned, and questions
highlighted in this book will be further explored as part of your teaching
and research efforts together with your colleagues, students, and relevant
communities. The book is designed to fit most course schedules and to meet
the needs of a variety of graduate and advanced undergraduate courses.
Students: Because health communication is an integral part of everyday
life as well as various interventions for health and social change, I hope
that this book will further motivate your interest in this field, and that
some of its key concepts will stay with you throughout your career. The
book is designed to provide you with some of the theoretical resources and
practical skills to address the many challenges of any path you may decide
to pursue. It also reflects my teaching philosophy, which is grounded in
my commitment to help students develop essential strategic and critical
skills, as well as my belief that all courses should be a forum for vibrant
information exchange in which I learn from the students’ perspectives
while they learn from my experience. To this end, this second edition also
incorporates the perspectives and suggestions of many of my students who
used the first edition.
Health and social change agents: Regardless of whether you work in the
public, nonprofit, academic, health care, or private sector, or a multilateral
agency, I hope health communication, as described in this book, will complement your efforts to implement interventions that explore the connection
between health and social issues, or support the creation of a movement for
improved health outcomes and quality of life among different groups and
populations, and ultimately promote behavioral, social, and organizational
change. I hope that this book will help you achieve your vision.
Program managers: Because this book also includes many practical
suggestions and a comprehensive hands-on guide, it is an easy-to-access
resource for the development, implementation, and evaluation of health
communication interventions, as well as for your training efforts of staff
members and relevant partners.
Health care providers: Health communication is an increasingly important competency in provider-patient communication and professional
medical communication settings because it is essential to improving patient
outcomes and promoting widespread application of best clinical practices.
This book covers both communication areas and also includes other relevant topics such as the role of health care providers in public health settings,
using IT innovation to address emerging needs and global health workforce
gaps, and prioritizing disparities in clinical education via increased training in cross-cultural health communication. These topics are designed to
appeal to educators and health care providers in light of the expanded role
of clinicians in patient, public health, and global health outcomes.
Community leaders: Although community leaders are by definition
health and social change agents, I felt the need to include this specific
category given the role communities in the United States and in international settings play or should play in the health communication process. I
hope that community leaders from a variety of sectors read this and find
it helpful in designing and implementing community-based interventions
and forums to raise the influence of community voices on how we communicate about health and illness and the kinds of behavioral, social, and
organizational results we seek to achieve.
Finally, one of the book’s fundamental premises is the role good health
(or lack thereof) plays either positively or negatively in influencing community development and people’s ability to connect with socioeconomic
opportunities. Because health communication can play a key role in raising
awareness of the strong interconnection among these fields, or in advocating for policy and social change, and in promoting healthy behaviors, I
certainly hope that colleagues from the community and social development
fields will consider this book to be a useful resource on how to communicate
about key social determinants of health as well as the influence health issues
can have on their work and community and social outcomes.
Overview of the Contents
Two of the fundamental premises of this book are (1) the multidisciplinary
and multifaceted nature of health communication and (2) the interdependence of the individual, social, political, and disease-related factors that
influence health communication interventions, and, more in general, health
and social outcomes. With these premises in mind, the division of topics in
parts and chapters is only instrumental to the text’s readability and clarity.
Readers should always consider the connection among various theoretical
and practical aspects of health communication as well as all external factors (political, social, cultural, economic, market, environment, and other
influences that shape or contribute to a specific situation or health problem
as well as affect key groups and stakeholders) that influence this field.
This introduction is an essential part of the book and is instrumental to
maximize use and understanding of the text.
This book is divided in four parts. Part One focuses on defining
health communication—its theoretical basis as well as its contexts and
key action areas. Part One also establishes the importance of considering
cultural, geographical, socioeconomic, ethnic, age, and gender influences
on people’s concepts of health and illness, as well as their approach to health
problems and their solutions. Finally, this part addresses the role of health
communication in public health, health care, community development, as
well as in the marketing or private sector contexts.
Part Two focuses on the different areas of health communication
defined in Part One: interpersonal communication, mass media and new
media communication; community mobilization and citizen engagement;
professional medical communications; constituency relations and strategic
partnership in health communication; policy communication, and public
In all chapters in Part Two, key health communication issues are raised
in the form of a question or brought to life in a case study. This is followed
by a discussion of a specific communication approach or area. All chapters
discuss specific communication areas in the context of the multidisciplinary
nature of health communication and the need for an integrated approach.
Special emphasis is placed on the importance of selecting and adapting
health communication strategies, activities, materials, media, and channels
to a fast-changing social, political, market, and public health environment.
Case studies and testimonials from experts and practitioners in the field
are included in many of the chapters in Part Two.
Part Three provides a step-by-step guide to the development, implementation, and evaluation of a health communication intervention. Each
chapter covers specific steps of the health communication planning process
or implementation and evaluation phases. Case studies, practical tips, and
specific examples aim to facilitate readers’ understanding of the planning
process, as well as to build technical skills in health communication planning. Recent methodologies and trends in measuring and evaluating results
of health communication programs are explored here, and so are specific
strategies and tools to evaluate new media–based interventions.
Part Four examines select health communication case studies and
related lessons. This last section of the book includes two chapters,
respectively featuring case studies from the United States and global
health communication. Yet, as discussed in Chapter Sixteen, and in light
of the existing comprehensive definition of global health, key themes,
emerging trends, and potential lessons that emerged from case studies in
both chapters for the most part apply across geographical boundaries and
health issues.
Appendix A contains resources and worksheets on health communication planning. Online resources listed in Appendix B point to job listings,
conferences, journals, organizations, centers, and programs in the health
communication field. The Glossary of key health communication planning
terms at the end of the text should be used as a reference while reading this
book, as well as a way to recap key definitions in health communication
planning. Some of the key terms from the Glossary are highlighted in bold
type and briefly defined the first time they are mentioned in the text so that
readers can become familiar with them before approaching the chapters in
Part Three that more specifically cover these topics. Other topic-specific
definitions are included in all relevant chapters.
Many chapters start with a practical example or case study. This is often
used to establish the need for communication approaches that should be
based on an in-depth understanding of intended audiences’ perceptions,
beliefs, attitudes, behavior, and barriers to change, as well as the cultural,
social, and ethnic context in which they live. Although referring to current
theories and models, the book also reinforces the importance of the experience of health communication practitioners in developing theories, models,
and approaches that should guide and inform health communication planning and management.
Each chapter ends with discussion questions for readers to reflect on,
practice, and implement key concepts. Finally, all chapters are interconnected but are also designed to stand alone and provide a comprehensive
overview on the topic they cover. An instructor’s training supplement
is available at Additional materials
such as videos, podcasts, and readings can be found at www.josseybass Comments about this book are invited and can
be sent to, or via the contact form at
Author’s Note
As someone who has been spending a lot of time teaching, practicing, and
thinking about health communication, I fully understand the complexity of
communicating about health, behavior, and related social issues. Changing
human and social behavior to attain better health outcomes and positively
affect people’s quality of life is often a lifetime endeavor, which is also
intertwined with our own professional changes. We change, and our work
and beliefs may change or evolve over time. In a way, I hope that we never
stop questioning ourselves, and learning from professional and personal
experiences, because this is the only way to stay true to what we should
value the most: making a difference in people’s health and lives.
My heartfelt appreciation and admiration go to all professionals, students, patients, policymakers, and ordinary people who every day dedicate
their time to make a difference to their own health outcomes or those of
their families, communities, special groups, or populations. These include
all professionals and researchers in the public health, health care, community development, and urban planning fields; the students or young
practitioners who have committed themselves to a rewarding but demanding career; the patients who strive to keep themselves informed and make
the right health decisions; the health care providers who dedicate their
lives to alleviate and manage human suffering; the urban planners and
environmentalists who work to leave to our communities and children
the kind of natural and built environments they need to stay healthy; the
mass media, new media gurus, government officers, associations, advocacy
groups, global health organizations from the public and private sectors, and
everyone else who may have an impact on health and social change.
I believe that being aware of current health communication theories and
experiences may ease the process of affecting health and social outcomes
and make the task more approachable for all of these groups and individuals.
I hope this book will help and will give you a glance into my world.
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As readers approach Part One, I cannot help but wonder what they may
already think or know about health communication. I wish this book had
eyes and ears to listen to all of your discussions so I could learn about
each one of you. I would love to know how health communication may
help advance your professional goals and what you find helpful in achieving
the kinds of behavioral, social, and organizational results that may support
improved health outcomes in your neighborhoods, communities, and countries. After all, one of the main mantras of health communication is to get to
know the groups we seek to engage and care about. This is why I hope that
as for the first edition, many of you will write and share your experience with
this book.
Part One is the backbone of the book. It focuses on defining health
communication—its theoretical basis as well as its contexts and key action
areas. It also establishes the importance of cultural, geographical, socioeconomic, ethnic, age, and gender influences on people’s concepts of health
and illness, as well as their approach to health problems and their solutions.
Finally, this part addresses the role of health communication in public
health, health care, community development, as well as in the marketing or
private sector contexts.
This section is divided into three chapters, which are strictly interconnected in their scope and aim to provide a balanced theoretical and
practical introduction to the field. Chapter One introduces readers to health
communication, its key contexts and action areas, as well as its cyclical
nature and the planning framework that we will discuss in detail in Part
Three. Chapter Two provides an overview of key theoretical influences in
health communication as well as contemporary health-related and public
issues that influence or may influence its theory and practice. The chapter
also includes a brief discussion of select planning frameworks and models
used for the development of health communication interventions by a
variety of US and international organizations. Chapter Three discusses the
importance of cultural, ethnic, geographical, gender, age, and other factors
in communicating about health and illness with a variety of groups and
p01.tex V2 – 09/11/2013
how communication is influenced by and influences all of these factors.
It also provides examples of different concepts of health and illness and
establishes cultural competence as a core competency for effective health
Once again, welcome to my world!
9:03am Page 2
Health communication is an evolving and increasingly
prominent field in public health, health care, and the nonprofit and private sectors. Therefore, many authors and
organizations have been attempting to define or redefine it over time. Because of the multidisciplinary nature
of health communication, many of the definitions may
appear somewhat different from each other. Nevertheless,
when they are analyzed, most point to the role that health
communication can play in influencing, supporting, and
empowering individuals, communities, health care professionals, policymakers, or special groups to adopt and
sustain a behavior or a social, organizational, and policy
change that will ultimately improve individual, community, and public health outcomes.
Understanding the true meaning of health communication and establishing the right context for its implementation may help communication managers and other
public health, community development, and health care
professionals identify early on the training needs of staff,
the communities they serve, and others who are involved
in the communication process. It will also help create the
right organizational mind-set and capacity that should
lead to a successful use of communication approaches
to reach group-, stakeholder-, and community-specific
• Defining Health
• Health Communication in the
Twenty-First Century: Key
Characteristics and Defining
• The Health Communication
• Health Communication in
Public Health, Health Care,
and Community
• The Role of Health
Communication in the
Marketing Mix
• Overview of Key
Communication Areas
• The Health Communication
• What Health Communication
Can and Cannot Do
• Key Concepts
• For Discussion and Practice
• Key Terms
This chapter sets the stage to discuss current health communication contexts. It also positions
the importance of health communication in public health, health care, and community
development as well as the nonprofit and private sectors. Finally, it describes key elements,
action areas, and limitations of health communication, and introduces readers to “the role
societal, organizational, and individual factors” play in influencing and being influenced
by public health communication (Association of Schools of Public Health, 2007, p. 5) and
communication interventions in clinical (Hospitals and Health Networks, 2012) and other
health-related settings.
Defining Health Communication
There are several definitions of health communication, which for the most
part share common meanings and attributes. This section analyzes and aims
to consolidate different definitions for health communication. This analysis
starts from the literal and historical meaning of the word communication.
What Is Communication?
intended audiences or
key groups
All groups the health
intervention is seeking to
engage in the
communication process
An understanding of health communication theory and practice requires
reflection on the literal meaning of the word communication. Communication is defined in this way: “1. Exchange of information, between individuals,
for example, by means of speaking, writing, or using a common system of
signs and behaviors; 2. Message—a spoken or written message; 3. Act of
communicating; 4. Rapport—a sense of mutual understanding and sympathy; 5. Access—a means of access or communication, for example, a
connecting door” (Encarta Dictionary, January 2007).
In fact, all of these meanings can help define the modalities of welldesigned health communication interventions. As with other forms of
communication, health communication should be based on a two-way
exchange of information that uses a “common system of signs and behaviors.” It should be accessible and create “mutual feelings of understanding
and sympathy” among members of the communication team and intended
audiences or key groups (all groups the health communication program is
seeking to engage in the communication process.) In this book, the terms
intended audience and key group are used interchangeably. Yet, the term
key group may be better suited to acknowledge the participatory nature of
well-designed health communication interventions in which communities
and other key groups are the lead architects of the change process communication can bring about. For those who always have worked within a
participatory model of health communication interventions, this distinction
is concerned primarily with terminology-related preferences in different
models and organizational cultures. Yet, as audience may have a more
passive connotation, using the term key group may indicate the importance
of creating key groups’ ownership of the communication process, and of
truly understanding priorities, needs, and preferences as a key premise to
all communication interventions.
Finally, going back to the literal meaning of the word communication
as defined at the beginning of this section, channels or communication
channels (the means or path, such as mass media or new media, used
to reach out to and connect with key groups via health communication
messages and materials) and messages are the “connecting doors” that allow
health communication interventions to reach and engage intended groups.
Communication has its roots in people’s need to share meanings
and ideas. A review of the origin and interpretation of early forms of
communication, such as writing, shows that many of the reasons for which
people may have started developing graphic notations and other early forms
of writing are similar to those we can list for health communication.
One of the most important questions about the origins of writing is,
“Why did writing begin and for what specific reasons?” (Houston, 2004,
p. 234). Although the answer is still being debated, many established
theories suggest that writing developed because of state and ceremonial
needs (Houston, 2004). More specifically, in ancient Mesoamerica, early
forms of writing may have been introduced to help local rulers “control
the underlings and impress rivals by means of propaganda” (Houston,
2004, p. 234; Marcus, 1992) or “capture the dominant and dominating
message within self-interested declarations” (Houston, 2004, p. 234) with
the intention of “advertising” (p. 235) such views. In other words, it is
possible to speculate that the desire and need to influence and connect
with others are among the most important reasons for the emergence
of early forms of writing. This need is also evident in many other forms
of communication that seek to create feelings of approval, recognition,
empowerment, or friendliness, among others.
Health Communication Defined
One of the key objectives of health communication is to engage, empower,
and influence individuals and communities. The goal is admirable because
health communication aims to improve health outcomes by sharing
The path selected by
program planners to
reach the intended
audience with health
communication messages
and materials
health communication
A multifaceted and
multidisciplinary field of
research, theory, and
practice concerned with
reaching different
populations and groups to
exchange health-related
information, ideas, and
methods in order to
influence, engage,
empower, and support
individuals, communities,
health care professionals,
patients, policymakers,
organizations, special
groups, and the public so
that they will champion,
introduce, adopt, or
sustain a health or social
behavior, practice, or
policy that will ultimately
improve individual,
community, and public
health outcomes
Includes groups who have
a higher risk for poor
physical, psychological, or
social health in the
absence of adequate
conditions that are
supportive of positive
Includes geographical,
ethnic, social, or
groups who do not have
adequate access to health
or community services
and infrastructure or
adequate information
health equity
Providing every person
with the same
opportunity to stay
healthy or to effectively
cope with disease and
crisis, regardless of race,
gender, age, economic
conditions, social status,
environment, and other
socially determined
health-related information. In fact, the Centers for Disease Control and
Prevention (CDC) define health communication as “the study and use of
communication strategies to inform and influence individual and community decisions that enhance health” (CDC, 2001; US Department of
Health and Human Services, 2012a). The word influence is also included
in the Healthy People 2010 definition of health communication as “the
art and technique of informing, influencing, and motivating individual,
institutional, and public audiences about important health issues” (US
Department of Health and Human Services, 2005, pp. 11–12).
Yet, the broader mandate of health communication is intrinsically
related to its potential impact on vulnerable and underserved populations.
Vulnerable populations include groups who have a higher risk for poor
physical, psychological, or social health in the absence of adequate conditions that are supportive of positive outcomes (for example, children,
the elderly, people living with disability, migrant populations, and special groups affected by stigma and social discrimination). Underserved
populations include geographical, ethnic, social, or community-specific
groups who do not have adequate access to health or community services
and infrastructure or information. “Use health communication strategies
. . . to improve population health outcomes and health care quality, and
to achieve health equity,” reads Healthy People 2020 (US Department of
Health and Human Services, 2012b). Health equity is providing every
person with the same opportunity to stay healthy or to effectively cope with
disease and crisis, regardless of race, gender, age, economic conditions,
social status, environment, and other socially determined factors. This can
be achieved only by creating a receptive and favorable environment in
which information can be adequately shared, understood, absorbed, and
discussed by different communities and sectors in a way that is inclusive
and representative of vulnerable and underserved groups. This requires
an in-depth understanding of the needs, beliefs, taboos, attitudes, lifestyle,
socioeconomics, environment, and social norms of all key groups and
sectors that are involved—or should be involved—in the communication
process. It also demands that communication is based on messages that
are easily understood. This is well characterized in the definition of communication by Pearson and Nelson (1991), who view it as “the process of
understanding and sharing meanings” (p. 6).
A practical example that illustrates this definition is the difference
between making an innocent joke about a friend’s personality trait and
doing the same about a colleague or recent acquaintance. The friend
would likely laugh at the joke, whereas the colleague or recent acquaintance might be offended. In communication, understanding the context
of the communication effort is interdependent with becoming familiar
with intended audiences. This increases the likelihood that all meanings
are shared and understood in the way communicators intended them.
Therefore, communication, especially about life-and-death matters such
as in public health and health care, is a long-term strategic process. It
requires a true understanding of the key groups and communities we seek
to engage as well as our willingness and ability to adapt and redefine the
goals, strategies, and activities of communication interventions on the basis
of audience participation and feedback.
Health communication interventions have been successfully used for
many years by public health and nonprofit organizations, the commercial
sector, and others to advance public, corporate, clinical, or product-related
goals in relation to health. As many authors have noted, health communication draws from numerous disciplines and theoretical fields, including
health education, social and behavioral sciences, community development,
mass and speech communication, marketing, social marketing, psychology, anthropology, and sociology (Bernhardt, 2004; Kreps, Query, and
Bonaguro, 2007; Institute of Medicine, 2003b; World Health Organization [WHO], 2003). It relies on different communication activities or
action areas, including interpersonal communication, mass media and
new media communication, strategic policy communication and public
advocacy, community mobilization and citizen engagement, professional
medical communications, and constituency relations and strategic partnerships (Bernhardt, 2004; Schiavo, 2008, 2011b; WHO, 2003).
Table 1.1 provides some of the most recent definitions of health
communication and is organized by key words most commonly used to
characterize health communication and its role. It is evident that “sharing meanings or information,” “influencing individuals or communities,”
“informing,” “motivating individuals and key groups,” “exchanging information,” “changing behaviors,” “engaging,” “empowering,” and “achieving
behavioral and social results” are among the most common attributes of
health communication.
Another important attribute of health communication should be “to
support and sustain change.” In fact, key elements of successful health communication interventions always include long-term program sustainability
as well as the development of communication tools and steps that make it
easy for individuals, communities, and other key groups to adopt or sustain
a recommended behavior, practice, or policy change. If we integrate this
practice-based perspective with many of the definitions in Table 1.1, the
new definition on page 9 emerges.
Table 1.1 Health Communication Definitions
Key Words
To inform and influence (individual and community) decisions
“Health communication is a key strategy to inform [emphasis added throughout table] the public about
health concerns and to maintain important health issues on the public agenda” (New South Wales
Department of Health, Australia, 2006).
“The study or use of communication strategies to inform and influence individual and community
decisions that enhance health” (CDC, 2001; US Department of Health and Human Services, 2005).
Health communication is a “means to disease prevention through behavior modification” (Freimuth,
Linnan, and Potter, 2000, p. 337). It has been defined as “the study and use of methods to inform and
influence individual and community decisions that enhance health” (Freimuth, Linnan, and Potter, 2000,
p. 338; Freimuth, Cole, and Kirby, 2000, p. 475).
“Health communication is a process for the development and diffusion of messages to specific
audiences in order to influence their knowledge, attitudes and beliefs in favor of healthy behavioral
choices” (Exchange, 2006; Smith and Hornik, 1999).
“Health communication is the use of communication techniques and technologies to (positively)
human and environmental health” (Maibach and Holtgrave, 1995, pp. 219–220; Health Communication
Unit, 2006). “It may include diverse activities such as clinician-patient interactions, classes, self-help
groups, mailings, hot lines, mass media campaigns, and events” (Health Communication Unit, 2006).
Motivating individuals and key “The art and technique of informing, influencing and motivating individual, institutional, and public
audiences about important health issues. Its scope includes disease prevention, health promotion, health
care policy, and business, as well as enhancement of the quality of life and health of individuals within
the community” (Ratzan and others, 1994, p. 361).
“Effective health communication is the art and technique of informing, influencing, and motivating
individuals, institutions, and large public audiences about important health issues based on sound
scientific and ethical considerations” (Tufts University Student Services, 2006).
Change behavior, achieve social “Health communication, like health education, is an approach which attempts to changeasetofbehaviors
and behavioral results
in a large-scale target audience regarding a specific problem in a predefined period of time” (Clift and
Freimuth, 1995, p. 68).
“There is good evidence that public health communication has affected health behavior . . . In
addition, . . . many public agencies assume that public health communication is a powerful tool for
behavior change” (Hornik, 2008a, pp. xi–xv).
“. . . behavior change is credibly associated with public health communication . . . ” (Hornik,
2008b, p. 1).
“. . . health communication strategies that are collaboratively and strategically designed, implemented, and evaluated can help to improve health in a significant and lasting way. Positive results are
achieved by empowering people to change their behavior and by facilitating social change” (Krenn and
Limaye, 2009).
Health communication and other disciplines “may have some differences, but they share a common
goal: creating social change by changing people’s attitudes, external structures, and/or modify or
eliminate certain behaviors” (CDC, 2011a).
Increase knowledge and under- “The goal of health communication is to increase knowledge and understanding of health-related issues
standing of health-related issues and to improve the health status of the intended audience” (Muturi, 2005, p. 78).
“Communication means a process of creating understanding as the basis for development. It places
emphasis on people interaction” (Agunga, 1997, p. 225).
Table 1.1 Health Communication Definitions (continued)
Key Words
Empowers people
“Communication empowers people by providing them with knowledge and understanding about specific
health problems and interventions” (Muturi, 2005, p. 81).
“. . . transformative communication . . . seek[s] not only to educate people about health risks, but
also to facilitate the types of social relationships most likely to empower them to resist the impacts of
unhealthy social influences” (Campbell and Scott, 2012, pp. 179–180).
“Communication processes are central to broader empowerment practices through which people are
able to arrive at their own understanding of issues, to consider and discuss ideas, to negotiate, and to
engage in public debates at community and national levels” (Food and Agriculture Organization of the
United Nations and others, 2011, p. 1).
Exchange,interchangeofinforma- “A process for partnership and participation that is based on two-way dialogue, where there is an
tion, two-way dialogue
interactive interchange of information, ideas, techniques and knowledge between senders and receivers
of information on an equal footing, leading to improved understanding, shared knowledge, greater
consensus, and identification of possible effective action” (Exchange, 2005).
“Health communication is the scientific development, strategic dissemination, and critical evaluation
of relevant, accurate, accessible, and understandable health information communicated to and from
intended audiences to advance the health of the public” (Bernhardt, 2004, p. 2051).
“One of the most important, and largely unrecognized, dimensions of effective health communication
relates to how engaging the communication is” (Kreps, 2012a, p. 253).
“To compete successfully for audience attention, health-related communications have to be polished
and engaging” (Cassell, Jackson, and Cheuvront, 1998, p. 76).
Health communication is a multifaceted and multidisciplinary field
of research, theory, and practice. It is concerned with reaching different populations and groups to exchange health-related information,
ideas, and methods in order to influence, engage, empower, and
support individuals, communities, health care professionals, patients,
policymakers, organizations, special groups and the public, so that
they will champion, introduce, adopt, or sustain a health or social
behavior, practice, or policy that will ultimately improve individual,
community, and public health outcomes.
Health Communication in the Twenty-First Century:
Key Characteristics and Defining Features
Health communication is about improving health outcomes by encouraging
behavior modification and social change. It is increasingly considered an
integral part of most public health interventions (US Department of Health
and Human Services, 2012a; Bernhardt, 2004). It is a comprehensive
approach that relies on the full understanding and participation of its
intended audiences.
A category that includes
materials, events,
activities, or other tools
for delivering a message
using communication
Health communication theory draws on a number of additional disciplines and models. In fact, both the health communication field and its
theoretical basis have evolved and changed in the past fifty years (Piotrow,
Kincaid, Rimon, and Rinehart, 1997; Piotrow, Rimon, Payne Merritt, and
Saffitz, 2003; Bernhardt, 2004). With increasing frequency, it is considered
“the avant-garde in suggesting and integrating new theoretical approaches
and practices” (Drum Beat, 2005).
Most important, communicators are no longer viewed as those who
write press releases and other media-related communications, but as
fundamental members of the public health, health care, nonprofit, or health
industry teams. Communication is no longer considered a skill (Bernhardt,
2004) but a science-based discipline that requires training and passion, and
relies on the use of different communication vehicles (materials, activities,
events, and other tools used to deliver a message through communication
channels; Health Communication Unit, 2003b) and channels. According to
Saba (2006):
In the past, and this is probably the most prevalent trend even
today, health communication practitioners were trained “on-the-job.”
People from different fields (sociology, demography, public health,
psychology, communication with all its different specialties, such as
filmmaking, journalism and advertising) entered or were brought into
health communication programs to meet the need for professional
human resources in this field. By performing their job and working in
teams, they learned how to adapt their skills to the new field and were
taught by other practitioners about the common practices and basic
“lingo” of health communication. In the mid-90s, and in response
to the increasing demand for health communication professionals,
several schools in the United States started their own curricular
programs and/or “concentrations” in Health Communication. This
helped bring more attention from the academic world to this emerging
field. The number of peer-reviewed articles and several other types of
health communication publications increased. The field moved from
in-service training to pre-service education.
As a result, there is an increasing understanding that “the level of technical competence of communication practitioners can affect outcomes.”
A structured approach to health communications planning, a spotless
program execution, and a rigorous evaluation process are the result of adequate competencies and relevant training, which are supported by leading
organizations and agendas in different fields (Association of Schools of
Public Health, 2007; US Department of Health and Human Services, 2012b;
American Medical Association, 2006; Hospitals and Health Network, 2012;
National Board of Public Health Examiners, 2011). “In health communication, the learning process is a lifetime endeavor and should be facilitated by
the continuous development of new training initiatives and tools” (Schiavo,
2006). Training may start in the academic setting but should always be
influenced and complemented by practical experience and observations,
and other learning opportunities, including in-service training, continuing
professional education, and ongoing mentoring.
Health communication can reach its highest potential when it is
discussed and applied within a team-oriented context that includes public
health, health care, community development, and other professionals from
different sectors and disciplines. Teamwork and mutual agreement, on
both the intervention’s ultimate objectives and expected results, are key to
the successful design, implementation, and impact of any program.
Finally, it is important to remember that there is no magic fix that can
address health issues. Health communication is an evolving discipline and
should always incorporate lessons learned as well as use a multidisciplinary
approach to all interventions. This is in line with one of the fundamental
premises of this book that recognizes the experience of practitioners as
a key factor in developing theories, models, and approaches that should
guide and inform health communication planning, implementation, and
Table 1.2 lists the key elements of health communication, which are
further analyzed in the following sections.
Table 1.2 Key Characteristics of Health Communication
• People-centered
• Evidence-based
• Multidisciplinary
• Strategic
• Process-oriented
• Cost-effective
• Creative in support of strategy
• Audience- and media-specific
• Relationship building
• Aimed at behavioral and social results
• Inclusive of vulnerable and underserved groups
Health communication is a long-term process that begins and ends with
people’s needs and preferences. In health communication, intended audiences should not be merely a target (even if this terminology is used by
many practitioners from around the world primarily to indicate that a
communication intervention will focus on, benefit, and engage a specific
group of people that shares similar characteristics—such as age, socioeconomics, and ethnicity. It does not necessarily imply lack of audience
participation) but an active participant in the process of analyzing and prioritizing the health issue, finding culturally appropriate and cost-effective
solutions, and becoming effectively engaged as the lead change designer
in the planning, implementation, and assessment of all interventions. This
is why the term key group may better represent the role communities,
teachers, parents, health care professionals, religious and community leaders, women, and many other key groups and stakeholders from a variety
of segments of society and professional sectors should assume in the
communication process. Yet, different organizations may have different
cultural preferences for specific terminology even within the context of
their participatory models and planning frameworks.
In implementing a people-centered approach to communication,
researching communities and other key groups is a necessary but often not
sufficient step because the effectiveness and sustainability of most interventions is often linked to the level of engagement of their key beneficiaries
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