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Health Communication

Theoretical and Critical Perspectives

Ruth Cross, Sam Davis and Ivy O’Neil









polity

Acknowledgements

First and foremost we would like to acknowledge the by-proxy contribution that the students we work with have made to this book. Working with them on the Health Communication module in the post-graduate courses that we teach has led to the creation of this work. We appreciate the challenge and fresh insights that our students bring to our academic work as reflected in the debates within this book.

We deeply appreciate the contribution of the reviewers during the process of writing this book. Their helpful and constructive feedback has led to a better final product.

We would like to acknowledge the significant support that we have received from our editorial team at Polity, particularly Jonathan Skerrett, who has kept us on track!

Last, but not least, we must recognize our ‘silent’ partners in the writing process. Those that have journeyed with us, missed us while we write, listened while we’ve moaned, brought us copious cups of tea and generally been there over the many months it has taken for us to get from start to finish. A big thank you to our families, our friends and our health promotion colleagues. It would have been much harder without you.

Part I
Theoretical Perspectives

1
Introduction to Health Communication: Theoretical and Critical Perspectives

In this introductory chapter we set the scene for Health Communication: Theoretical and Critical Perspectives. We begin by explaining how this book came about and locate health communication within the broader notion of health promotion. We introduce the style of the book and outline the indicative content providing a rationale for the inclusion of the subject matter and emphasizing the global and international outlook of the book. This chapter introduces the three key disciplinary areas which underpin the book’s approach – communication, education and psychology. These disciplinary areas link to later chapters and thread through the discussion and debate therein. We also outline the key themes that run through the book in keeping with the ideological, political and philosophical perspectives that underpin it.

This book came about because we, as lecturers of health communication, noted a dearth of more critical perspectives written for a post-graduate and practitioner audience. There are a number of very good undergraduate and practically focused books on health communication on the market which have made a significant contribution to the field. We were conscious, however, that a more in-depth critique of the issues is relatively lacking. Indeed, we have been unable to find a text which focuses solely on health communication with an in-depth insight into the underpinning disciplines and ideology of health promotion and the more critical, analytical research-informed debates on health communication pertinent to post-graduate level. Spotting this gap in the literature we have set out to produce a text which lays bare some of the more sticky issues in health communication as we see them. We unapologetically dismantle what we view as some problematical underpinning assumptions in the field of health communication and turn to a range of critical perspectives to do this. At the outset, however, it is important that we outline our ideological, political and philosophical position since it is against this background that the book is cast.

We teach health communication on the suite of health promotion and public health masters programmes delivered by Leeds Beckett University. Our main discipline, however, is health promotion and we subscribe to the values and principles of this discipline. As such the ideological, political and philosophical basis of health promotion sets the context to this book. It is via a ‘health promotion’ lens that we will view health communication. We adhere to the position that health promotion is the ‘militant wing’ and ‘critical conscience of public health’ (Green et al., 2015: 48). What we hope to do in this book is explain this position with regard to health communication. As such, while we do offer insights for reflective practice and suggest implications for practice throughout, we have not written a ‘how to do it’ text. As previously stated, there are already plenty of good examples of such texts on the market which we would urge readers to turn to if that is what they are looking for. Instead, we have produced a higher level critical textbook on health communication which challenges many of the ‘taken for granted’, underpinning assumptions of current understanding and practice. We turn to key theoretical and critical perspectives to tease out what we see as the major ideological and political concerns. The book is structured to enable this to take place in a coherent and logical way which, we hope, will aid readers who are relatively new to the debates at hand.

The main purpose of this book is to critically reflect on the assumptions, ideologies and values underpinning well-rehearsed approaches in health communication and, as such, it is aimed at the more advanced reader. This book will appraise health communication and its role in promoting health. Drawing on the evidence base for effectiveness and published international research within the field the book critically considers what works and what does not work in communication for health and health promotion, unpicking common approaches. Moreover, it seeks to scrutinize what we do and why. Crucially the book links theory to practice examining how research relates to real life and what this means for public health and health promotion in our social world.

There is a general assumption that an increase in knowledge directly translates into a change of healthy lifestyle behaviour. The focus of many writers and practitioners is often on why the recipients of health communication efforts do not act on the information and advice given. Increasingly we look to aspects such as message design, health literacy skills, information technologies and social marketing strategies as a means of promoting effectiveness. Recent developments in the use of information communication technology, both software and hardware in health promotion such as internet, social media, mobile devices run through the book and the content is drawn from international research, knowledge and expertise offering a global perspective on the issues raised. In addition we make use of the valuable international health promotion teaching experience we have acquired through working with students on Leeds Beckett courses run in West and sub-Saharan Africa as well as with students who come from all over the world to study on our UK course. We acknowledge the contribution that each of them brings to our growing understanding and appreciation of health communication in a range of contexts.

The ideological, political and philosophical position of health communication: theoretical and critical perspectives

As we briefly outlined earlier, the foundations of this book are located within our ideological, political and philosophical position which mirrors health promotion’s disciplinary perspective. Health promotion adheres to a specific set of values and principles which distinguishes it from the broader field of public health. These include empowerment, equity, tackling health inequalities, addressing the social determinants of health, privileging a social model of health, advocacy, ethical practice, participation, collaboration and upstream approaches. As defined by Dixey et al. (2013: 1) we understand health promotion to be ‘a social movement with the central aim of tackling the social determinants of health and so bringing about greater social and health justice’. At the outset it is also important to define what we understand by health education as opposed to health promotion. We see health education as an integral part of health promotion but health promotion does not stop there; it goes much further. While health education focuses on the behavioural determinants of health and seeks to address these through preventive and educational efforts aimed largely at the individual, health promotion addresses structural, social and environmental determinants of health as well (Green et al., 2015). So, where does health communication sit within this? We would argue that contemporary health communication practice is more akin to health education than health promotion with its attendant focus on the individual and behaviour change. We aim, in this book, to explain this in some detail. What we would advocate, then, is that health communication adopts approaches which are more ideologically, politically and philosophically akin to health promotion. For example, we privilege the concept of empowerment recognizing the centrality of power in health in all domains. Health communication efforts should, in our opinion, challenge uneven power distribution and advocate for those who are relatively disempowered the challenging of structures, policies and practices which result in subordination and oppression. Therefore the ideological basis of this book is in keeping with the more radical roots of health promotion and this is reflected in the key themes within it that we return to throughout. We will now outline these key themes.

Key themes within health communication: theoretical and critical perspectives

Several important central concepts thread through this book and we will return to them again and again with regard to the different debates. Empowerment is a key concept in health promotion. While open to some debate around definition, conceptualization and measurement empowerment is absolutely central to health promotion (Woodall et al., 2012; Christens, 2013). We advocate empowering approaches in health communication. Linked to this we reject, and are critical of, victim-blaming approaches. Too often health communication efforts result in pointing the finger of blame at individuals or groups who ‘fail’ to take up advice and change their behaviour without taking into consideration the wider, complex contexts of everyday life. Health promotion takes into account the social, political and environmental factors that influence behavioural choices and practices acknowledging the fundamental importance of these in determining health outcomes. In this book we therefore explore the wider social determinants of health and the influence of these on health communication.

Health promotion is not about telling people what to do or doing things to people, it is about working with people. Key to this is true participation. Our position is that health communication efforts should involve the people for whom they are intended. Individuals and communities should be meaningfully engaged in interventions designed to address their concerns. We are therefore critical of top-down, paternalistic and tokenistic means of health communication. Equity is a key principle of health promotion (Green et al., 2015). Equity is linked to equality. Health promotion is concerned with tackling health inequalities and addressing the gap between the least well-off and most well-off in society. We return to issues of equity and equality throughout the book. Health promotion is predicated on a social model of health which privileges lay perspectives. Health communication efforts often fail because there is a significant disconnect between what the ‘experts’ say and how this is received and understood by people in the context of their experience (Dutta, 2008). This disconnect can occur for a number of reasons. Often a reductionist, deficit model is used to explain this, the assumption being that people do not understand, misunderstand, cannot make sense of information or are simply irrational (Tulloch and Lupton, 2003; Wilkinson, 2001; Willig, 2008). We consider this to be highly problematic and we are critical of cognition as equated with higher order function. We therefore adopt a non-deficit, non-deviant approach characterized more by an ‘assets’ model (Morgan and Ziglio, 2007). Rather than focusing on what is problematic, deficient or ‘missing’ in people asset-based approaches seek to explore, utilize and build upon existing resources, capacities and talents.

We are highly critical of the neoliberal agenda which we see as driving much contemporary health communication practice. Neoliberal discourse creates and emphasizes individual responsibility for health minimizing the role of the state. Neoliberalism is a specific political and economic ideology based on an individualization thesis which emphasizes personal freedom, control and choice which are constructed as freely available to the neoliberal subject (Stuart and Donaghue, 2012). It positions people as autonomous agents directing their own destiny (Rose et al., 2006) and possessing the freedom to transform and reinvent themselves (McRobbie, 2009). Neoliberal ideology has become firmly embedded within so-called ‘Western’ contexts within the past two decades and now permeates all areas of human experience. The gradual withdrawal of state welfare provision has redirected responsibility to the individual subject (Gill and Scharff, 2011) within the private domain (Bell et al., 2011). In relation to health communication, processes of individualization are reinforced by Western political ideologies which emphasize responsibility and self-determination. The creation of the post-modern, neoliberal subject is reductionist and brings about a problematic lack of attention to the wider determinants of health undermining a progressive agenda. The neoliberal critique is therefore a key theme in this book.

What this book adds to the health communication literature

This book brings communication, education and psychological theories together within one key text. It specifically sets out to challenge assumptions and practice in health communication rather than reiterating well-rehearsed ideas and concepts. It examines the theoretical underpinning of these three disciplines in empowering and motivating change through health communication. This book has greater analytical and critical depth more appropriate to a post-graduate and a critically reflective continuing professional development audience. It is designed to encourage critical thinking, application of theory, critical reflection and analysis. The arguments in the book are grounded in the evidence base and current research is drawn upon to support these bringing the debates to life. Case study examples are peppered through the text to illustrate the issues under discussion and a global perspective is threaded throughout the book. Contemporary perspectives are considered throughout including changing technology and the use of social media in health communication.

Who should read it?

The primary audience for Health Communication: Theoretical and Critical Perspectives is a post-graduate audience and students in their final year of undergraduate programmes related to health, health promotion and public health. The book is also highly suitable for a variety of post-registration health and healthcare practitioners and any practitioner who has a role in health improvement. This will include post-graduate students in health promotion, public health, nursing including community nursing, health psychology and other health professionals. It may also include those studying, or working in, community development.

Overview of the book

The first part of the book outlines what we see as the three main disciplines contributing to health communication. In Part 1: Theoretical Perspectives, we critically explore relevant theory drawing on the three key disciplinary perspectives that are crucial for communicating health promotion and public health, namely education, communication and psychology. In this part of the book a range of theories are described, discussed, applied and critiqued with reference to the international research literature in health communication. The second section of the book Part 2: Key Topics is organized chapter by chapter around some contemporary topic areas in health communication. It looks at three key areas in turn: methods and media, social marketing and health literacy. The final section of the book Part 3: Issues and Challenges focuses on some of the broader challenges in health communication and in changing behaviour. There are three chapters in this part of the book. The first considers challenges in health communication and behaviour change. The second critically debates the politics of health communication and behaviour change. The final chapter in the book looks to the future in anticipation of what changes in society, technology and communication may have on how health is promoted through communication efforts. Each of the book’s chapters is now briefly outlined in turn.

Chapter 2 – Communication Theory

Chapter 2 provides a critical overview of communication theories relating to health communication. Effective communication is central to any human encounter and is crucial in effecting changes in health promotion. The chapter provides a critical discussion of communication models underpinning health promotion practice. It explores one-way, top-down information transfer and two-way communication of health messages. It discusses the dialogical importance of communication that leads to empowerment and change in society. It then discusses the personal and interpersonal nature of health communication and the importance of knowledge and skills in communicating health messages, considering the different elements within the communication loop in a critical manner. The chapter takes a critical view of the health promoter as an effective communicator and an expert witness in health, challenging received assumptions and debating some ethical dilemmas in the context of environmental, social and cultural societal norms. Running through this chapter (and, indeed, the book as a whole) is a more complex discussion about power and empowerment, the scope for, and availability of, choice and control. As such Power Analysis is discussed as a way of considering the meaning of empowerment.

Chapter 3 – Educational Theory

This chapter provides the reader with an overview of the relationship between progressive educational theory and health promotion, highlighting what it is and why it may be of value to the professional practitioner. In defining progressive educational theory, it becomes clear that it is vital to health promotion – both in theory and in practice – and is indeed key to achieving the social justice agenda that is championed in health promotion. Central to this is Freire’s much maligned theory of empowerment and so, in a timely reappraisal, we evaluate his ideas to see if they are still relevant to professional practitioners today. Following a critical discussion which looks at the implications of Freire’s empowerment theory, we introduce the progressive educational ideas of John Dewey and Martin Buber who provide alternative but complementary theories to empowerment that are worthy of consideration.

Chapter 4 – Psychological Theory

This chapter draws on theories of behaviour change from the discipline of psychology. It outlines the key theoretical approaches to understanding the process of behaviour change and considers what the evidence is to support these. It draws on international research to examine the complexities of human behaviour and describe the key approaches which are taken. Key theories are briefly outlined, and then critiqued. These include the ‘classic’ major theories in this field such as the Health Belief Model, the Theory of Reasoned Action and the Theory of Planned Behaviour, the Trans-Theoretical Model and Protection Motivation Theory. The chapter then moves on to introduce and critique other innovations in behaviour change theory such as social psychological theory concerned with the influence of others, the notion of self-esteem and perceptions of control and two further specific theories – the Behavioural Ecological Model and the Theory of Triadic Influence. Throughout this chapter relevant research findings are drawn upon to illustrate key points and enhance the discussion, bringing theoretical features to life.

Chapter 5 – Methods and Media

This chapter discusses the methods and media used in communicating health messages. It will specifically look at mass media and related theory such as Diffusion of Innovation theory. Mass media can be a powerful agent for bringing about social change. However, it tends to be a one-way, top-down communication strategy which is often persuasive (even manipulative) and paternalistic. This chapter will critique popular methods of communication within health promotion such as TV and radio, art and drama, and emotional appeals as well as participatory approaches such as peer education. The evidence base and the effectiveness of these methods will be explored. It considers the use of media advocacy and narrowcasting as a way to influence policy change. The development of information communication technology has been rapid and profound over the past two decades. The use of electronic communications such as mobile phone technology, internet and social media as a channel for communicating health messages is increasingly popular. This chapter will therefore also critically analyse the development of electronic media as a communication method. It ends by considering some limitations of, and challenges in, health communication.

Chapter 6 – Social Marketing

This chapter provides an overview of social marketing, outlines what social marketing is and highlights how social marketing can be applied to health communication and health promotion. It reviews the literature on social marketing examining the relevance of it to health communication and establishing the strengths and weaknesses of social marketing as a strategy for health promotion. Taking a critical stance, this chapter explores the efficacy of social marketing and looks at how social marketing has been utilized in a variety of international contexts. It also examines the confusing/competing relationship of social marketing as a strategy to promote health linking to critical commentary elsewhere in this book about the use of mass media as a method for communicating health messages.

Chapter 7 – Health Literacy

In Chapter 7 we look at the increasingly important concept of health literacy in the field of health promotion and take a critical look at this evolving concept and its implications for effective health communication. We trace the historical origins and development of health literacy to reveal competing and divergent definitions, focusing in particular on the functional definition of health literacy which, arguably, since the millennium has come to dominate English-speaking nations. We evaluate the contribution of functional health literacy and note the limitations of an approach which, despite the rapid developments in global digital technology, still centres on basic competence in traditional literacies. Dependent upon organized systems of healthcare and tied to the power of the written word, we will show functional health literacy to be a peculiarly Western project ideally suited to positivist health frameworks which claim to evidence effectiveness in health promotion interventions. In response to calls for a more inclusive and critical form of health literacy, we explore other possibilities for a radical reconceptualization of health literacy: one that is grounded in informal adult education theories which empower communities to question, participate and act to deliver a critical experiential form of health literacy.

Chapter 8 – Challenges in Health Communication and Behaviour Change

This chapter takes a more critical approach to the concept of behaviour change and the issues and challenges that health promoters face in communicating health messages to a diverse population. It will outline the key challenges that exist adopting a more analytical approach to the notion of behaviour. It draws on the wider literature to consider what challenges are faced and how these might be overcome to promote better health outcomes. We therefore consider alternative ways of thinking about behaviour and behaviour change discussing ideas about ‘health behaviours’ in contrast with notions of ‘social practices’. We critically examine communication issues relating to factors such as culture, gender and age, focusing on challenges arising from communicating with different groups of people in different contexts. The chapter critically considers process and structural barriers in communicating health messages. Finally it includes an appraisal of ethical issues in health communication such as those associated with dilemmas in persuasive and coercive communication, and the challenges that such methods pose to concerns within empowerment.

Chapter 9 – The politics of Health Communication and Behaviour Change

This chapter brings together a critical overview of the content covered thus far and highlights what we believe are some of the key political debates in health communication, debates that are central to health promotion considered as a more radical, social endeavour.

Taking a social constructionist perspective this chapter unpicks the notion of health communication as the route to behaviour change and challenges linear assumptions that this is the primary solution for improving health outcomes. Drawing on debates around individualism, agency and structure which are linked to concepts of citizenship and governmentality, it appraises the politics of health communication and behaviour change within the contemporary context of an increasingly neoliberal public health agenda.

Chapter 10 – Looking to the Future

This final chapter in the book begins by returning to the main themes of the book. It then discusses the mechanisms of global health communication followed by a consideration of changing technologies and the potential, but uncertain, futures these bring as well as the implications for health communication. A new paradigm is presented which reconstructs health behaviour as ‘social theories of practice’ and we argue for the use of critical perspectives and techniques in health communication. Finally, we put forward a challenge to competency frameworks.

Pedagogical features in health communication: theoretical and critical perspectives

In Chapters 2 to 9, there are four opportunities for reflection within each chapter provided at key stages in the discussion. At these points the reader is invited to engage in a task related to the content of the chapter. Each chapter also has suggestions for further reading with a short annotation about the nature of the text so that the reader can follow things up accordingly. The book contains case studies and international examples which aim to bring the issues under consideration to life. In addition, there are key insights provided which are labelled ‘Implication for Practice’ where it is intended that learning can be taken forward by the reader.