health communication in practice a case study approach

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In This Article Expand or collapse the "in this article" section Health Communication

Introduction, general overviews, anthologies and edited volumes, datasets and archives, health campaigns research, fear appeal research, health belief model, message tailoring, prospect theory and message framing, psychological reactance theory, risk perception, social cognitive theory, trans-theoretical model of behavior change, health literacy, multicultural approaches, patient/parent/provider communication, media content, interactivity/technology, audience segmentation, contemporary issues, related articles expand or collapse the "related articles" section about, about related articles close popup.

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Health Communication by Glenn Leshner , Elizabeth Gardner LAST REVIEWED: 23 February 2011 LAST MODIFIED: 23 February 2011 DOI: 10.1093/obo/9780199756841-0074

The area of health communication research and theory focuses primarily on the application of communication theory, concepts, and strategies in the service of enhancing public health, and understanding how such processes work. The approaches are numerous and represent significant scholarship across bio-psycho-social levels of analysis. Research can range from how individuals cognitively and emotionally process individual health-related messages to social and cultural contexts that influence how health campaigns are implemented. It can include targeted messaging through mass media or interpersonal communication between patient and health-care provider. Recently, research on issues involving new media and technology has emerged. Overall, research represents efforts from two perspectives: from the field of public health and from the field of communication. Although both areas are interested in improving public health as a general goal, communication scholars emphasize theory and processes, while public health emphasizes outcomes. Recent advances in health communication are integrating these two approaches.

Health communication books primarily revolve around the interactions between health concerns and the health industry with interpersonal, organizational, and mass communication. Authors generally come from either the communication or public health disciplines. The interdisciplinary nature of health communication research is blurring those distinctions, however. Health communication research draws on a large variety of theoretical approaches, especially those from allied fields such as psychology, sociology, and public policy. Research also crosses bio-psycho-social levels of analyses and includes both quantitative and qualitative methodological approaches. Berry 2007 explores the general applications of communication, both verbal and nonverbal, for those whose work involves communicating with patients and relatives, and other careers. Institute of Medicine 2002 focuses on message tailoring. Guttman 2000 discusses values, ethics, and responsibilities of public health campaigns. Schiavo 2007 , Thomas 2006 , and Wright, et al. 2008 comprehensively cover a wide range of health communication topics. Witte, et al. 2001 is an often cited book on theoretically based health message design.

Berry, Dianne. 2007. Health communication: Theory and practice . Maidenhead, UK: Open Univ. Press.

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This book includes chapters on hard-to-reach populations and communication in difficult situations (e.g., genetic counseling). Two chapters are devoted to health information campaigns and skills training. The book would be a useful supplementary text for health psychology or public health students.

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Guttman, Nurit. 2000. Public health communication interventions: Values and ethical dilemmas . Thousand Oaks, CA: SAGE.

In discussing values, ethics, and responsibilities of public health campaigns, Guttman draws on a variety of theoretical frameworks to address the central question of how far interventions should go to change people’s attitudes, beliefs, and behavior. She includes “work sheets” for analyzing and comparing health communication interventions.

Institute of Medicine. 2002. Committee on Communication for Behavior Change in the 21st Century: Improving the health of diverse populations. In Speaking of health: Assessing health communication strategies for diverse populations . Washington, DC: National Academy Press.

This book focuses on message tailoring for reaching target audiences in meaningful ways. It also suggests creative strategies for communicating with diverse audiences. The book is useful for students in health communication and public health, scholars, and practitioners, who are interested in communicating with diverse communities about health issues.

Schiavo, Renata. 2007. Health communication: From theory to practice . San Francisco: Jossey-Bass.

A comprehensive introduction to current issues, theories, and special topics in health communication, combined with a guide to health communication campaigns and program development. The book is designed as an introductory text for students and professionals with no significant field experience, but it also includes advanced topics for health communication practitioners and researchers. It is well indexed, making the book ideal for students who wish to delve deeper into a particular topic.

Thomas, Richard K. 2006. Health communication . New York: Springer.

This book provides a broad background in health communication, with examples of successful applications. It covers basic theory, design strategies for health campaigns, and program evaluation. Includes a discussion on interactive health media in addition to traditional mass media, and covers ways to reach at-risk populations. It can be a useful introductory/supplemental text for novice undergraduate students in communication, public health, and related courses.

Witte, Kim, Gary Meyer, and Dennis Martell. 2001. Effective health risk messages: A step-by-step guide . Thousand Oaks, CA: SAGE.

This book provides instructions for developing theoretically based campaign messages. Introduces theories that inform message development and campaign evaluation. Worksheets are provided at the end of each chapter to provide readers with hands-on, practical experiences in developing effective health risk messages. This book is suitable for practitioners, researchers, and students, and can serve as a supplementary text for public health and health communication classes.

Wright, Kevin B., Lisa Sparks, and H. Dan O’Hair. 2008. Health communication in the 21st century . Malden, MA: Wiley-Blackwell.

This book was written by communication scholars and, as such, has a distinct communication point of view. It is suitable for undergraduate students in an introductory course in health communication, and includes sections on social and cultural contexts, new media, interpersonal communication issues, and emerging challenges. It also can work for students in communication and health-care professions.

Anthologies presented here represent a wide range of research, theory, case studies, and topical essays. Students may notice that some research approaches health communication with an emphasis on health (e.g., Ray 2005 ), while other research emphasizes communication (e.g., Crano and Burgoon 2002 ). Additionally, some research may stress interpersonal and organizational communication (e.g., health-care providers talking with patients, public health policy; Jackson and Duffy 1998 ), while other research emphasizes mass communication (e.g. health information campaigns; Atkin and Wallack 1990 , Hornik 2002 , Kreps 2010 , Maibach and Parrott 1995 , Salmon1989 , Thompson, et al. 2003 ). The volumes presented here touch on all of the perspectives, indicating the interdisciplinary nature of the field. Students will find chapters written by communication scholars, public health researchers, and health and medical professionals.

Atkin, Charles, and Lawrence Wallack, eds. 1990. Mass communication and public health: Complexities and conflicts . Newbury Park, CA: SAGE.

This book examines the challenges practitioners face as they attempt to change health behaviors. It examines why public information campaigns have achieved limited success and what can be done to improve their effectiveness. Although a bit dated, it remains one of the first comprehensive books on mass communication health campaigns.

Crano, William D., and Michael Burgoon, eds. 2002. Mass media and drug prevention: Classic and contemporary theories and research . Mahwah, NJ: Erlbaum.

This book reports the findings of the 17th Claremont Symposium on Applied Social Psychology. It represents work by the National Youth Anti-Drug Media Campaign (funded by the National Institute on Drug Abuse) and focuses largely on a media advocacy approach. Communication scholars dominate, focusing on mass media’s role in reducing drug abuse. The book will appeal to social scientists interested in persuasion and the media, and can be a rich source of literature for health communication and psychology students.

Hornik, Robert C., ed. 2002. Public health communication: Evidence for behavior change . Mahwah, NJ: Erlbaum.

This volume presents case studies that show how public health communication has affected health behavior. It includes sixteen studies of large-scale communication efforts in a variety of health areas, as well as several analytic chapters. It is suitable for scholars, students, practitioners, and policy makers in public health, health communication, and health psychology.

Jackson, Lorraine D., and Bernard K. Duffy, eds. 1998. Health communication research: A guide to developments and direction s. Westport, CT: Greenwood.

Chapters in this book examine the role of communication in a variety of interpersonal contexts (e.g., cultural factors and treatment adherence between health professional/client relationships) and issues of organizational communication and policy. It also contains a chapter on health information campaigns and another on health images in the media. The book is suitable as an introductory resource for health communication and sociology students and for professionals.

Kreps, Gary L., ed. 2010. Health communication . 5 vols. Thousand Oaks, CA: SAGE.

This five-volume set is perhaps the most comprehensive treatment of the research in health communication to date. The volumes focus on health communication in delivering health care, health promotion, risk communication, and new information technologies.

Maibach, Edward, and Roxanne Louiselle Parrott, eds. 1995. Designing health messages: Approaches from communication theory and public health practice . Thousand Oaks, CA: SAGE.

An edited volume with often cited chapters, this book explores the question of message design from both theoretical and practical perspectives. The authors base message design decisions on appropriate theories of human behavior and communication. The book covers theory-driven and audience-centered approaches used in real health information campaigns. This can be a resource for mass communication and public health scholars, students, and professionals.

Ray, Eileen B., ed. 2005. Health communication in practice: A case study approach . Mahwah, NJ: Erlbaum.

This book focuses on the complexities of health communication with in-depth attention to personal, familial, organizational, and cultural contexts through the use of in-depth case studies. The case studies permit students to delve deeply into a given topic and encourage conceptual and analytical reading. This is appropriate for advanced undergraduates and graduate students in a variety of communication and health-allied classes.

Salmon, Charles T., ed. 1989. Information campaigns: Balancing social values and change . Thousand Oaks, CA: SAGE.

Although this edited volume centers on a broader notion of information campaigns than might interest health communication researchers, many of the chapters contextualize their discussions around health communication issues and campaigns. The book’s contributors represent many of the most prolific scholars in communication, including its editor. Excellent background for graduate students in any field interested in social marketing.

Thompson, Teresa L., Alicia Dorsey, Katherine Miller, and Roxanne Parrott, eds. 2003. Handbook of health communication . Mahwah, NJ: Erlbaum.

This handbook was much needed due to the explosion of quality health communication, and represents the expansive, current body of scholarly work in health communication. As with most handbooks, it summarizes work for those both familiar and unfamiliar with the area, and suggests avenues for future research. It is suitable for students, researchers, and practitioners with interests in the various aspects of health communication.

Information about health and health communication research abounds on the Internet. All the organizations listed here are part of, or funded by, a government or non-profit entity. Many non-profit organizations, for example, the American Cancer Society, American Lung Association, and so on, also have websites that contain information which may be useful to a health communication scholar. The National Institutes of Health (NIH) and Centers for Disease Control and Prevention (CDC) websites provide archives of primary research, data, and news. Several datasets are available ( Annenberg National Health Communication Survey (ANHCS) ; CDC WONDER DATA2010 ; Health Information National Trends Survey (HINTS) ) that provide data dealing directly with health communication. PubMed , a service of the National Library of Medicine, is a search engine that accesses an enormous collection of health and health-related research. The Centers for Excellence and Cancer Communication Research (CECCR) sites focus on the cancer communication research conducted at four National Cancer Institute–funded sites.

Annenberg National Health Communication Survey (ANHCS)

ANHCS, a joint project of the two Annenberg schools, is designed to capture national trends relating health behavior and behavioral intentions to media exposure, health knowledge and beliefs, and policy preferences and beliefs. It is one of few surveys emphasizing health communication and its possible outcomes.

CDC WONDER DATA2010: The HealthyPeople Database

This dataset includes a health communication focus area (#11). DATA2010 is an interactive database system developed by staff of the Division of Health Promotion Statistics at the National Center for Health Statistics, and contains the most recent monitoring data for tracking Healthy People 2010. It is updated quarterly.

Centers for Disease Control and Prevention (CDC)

The CDC, part of the Department of Health and Human Services, is the nation’s premier health promotion, prevention, and preparedness agency and a global leader in public health. The CDC is a primary player in public health efforts to prevent and control infectious and chronic diseases, disabilities, and environmental health threats. The website links to news, many health and safety topics, multimedia, data, publications, and so on.

Centers for Excellence and Cancer Communication Research (CECCR)

The centerpiece of the National Cancer Institute’s Extraordinary Opportunity in Cancer Communications. The centers engage in hypothesis-driven research projects and a pilot or developmental research project process, cores, and plan for career development. The CECCR centers are at the University of Michigan, University of Pennsylvania, University of Wisconsin–Madison, and Saint Louis University (recently moved to Washington University). Each center has its own website; thus, content varies to some extent. However, each site does contain full descriptions of the research it conducts.

Health Information National Trends Survey (HINTS)

HINTS was developed by the Health Communication and Informatics Research Branch of the Division of Cancer Control and Population Sciences as an outcome of the National Cancer Institute’s (NCI’s) Extraordinary Opportunity in Cancer Communications. NCI fielded the first HINTS in 2002 and 2003, again in 2007–2008. A special issue of the Journal of Health Communication , devoted to HINTS-related research, was published in May 2006 (Vol. 11, Suppl. 1).

National Institutes of Health (NIH)

NIH is in the Department of Health and Human Services of the federal government. Its mission is to seek fundamental knowledge about the nature and behavior of living systems and the application of that knowledge to enhance health, lengthen life, and reduce the burdens of illness and disability. The expansive NIH website can be used as a portal to the twenty-seven institutes and centers, recent news, grant information, research reports, and so on.

PubMed is an online search engine that contains more than 19 million citations for biomedical literature from MEDLINE, life science journals, and online books. Citations may include links to full-text content from PubMed Central and publisher websites. PubMed is a service of the US National Library of Medicine, an NIH institute.

The explosion of health communication research is reflected in the substantial number of specialty journals devoted to many aspects of the intersection of health concerns and communication processes. Health communication research also appears in general journals as well, such as Communication Research , Human Communication Research , and Media Psychology . The Journal of Communication devoted a special issue to health communication research in 2006. There are a number of specialty journals that publish health communication research. The most prominent are Health Communication , Journal of Health Communication , and Health Education & Behavior . Each publishes a variety of research topics and approaches, although the emphasis tends to be on data-based studies, as does the newer Journal of Health & Mass Communication . Health Promotion Practice and Journal of Communication in Healthcare tend toward professional applications. Several journals are affiliated with health or academic organizations ( Health Psychology and Health Promotion International ). All are refereed.

• Health Communication

A broad journal, encompassing both quantitative and qualitative approaches to health communication. In addition to empirical, data-based articles, other contributions focus on pedagogical, methodological, theoretical, and applied issues. Topics include health campaigns, health information acquisition and processing, and provider–patient interaction.

Health Education & Behavior

Explores social and behavioral change with respect to health issues. Many articles examine all aspects of behavioral health interventions, including how they related to communication processes. It publishes articles across a wide range of research methods, and also contains regular features, including topical essays and programs in health education.

Health Promotion International

The official journal of the International Union for Health Promotion and Education is published in association with the World Health Organization. It publishes original articles, reviews, and debates on major themes from various health organizations. It includes theoretical and empirical pieces, policy research, and research on health campaigns.

Health Promotion Practice

Publishes articles devoted to the practical application of health promotion and education. The journal is geared toward professionals engaged in the practice of developing, implementing, and evaluating health promotion and disease prevention programs. It also focuses on applications of public health education programs and best practice strategies in various settings.

Health Psychology

A scholarly journal of the American Psychological Association, Division 38 (Health Psychology). It contains largely scientific research articles that examine the intersection of psychology and health, although it occasionally carries case studies, commentaries, and letters to the editor.

Journal of Communication in Healthcare

A British journal featuring articles on how to improve communication in all aspects of health-care delivery, health promotion, and the health-care business. It publishes in-depth articles, qualitative research, and real case studies on how to communicate with patients, the public, staff, and media.

Journal of Health Communication: International Perspectives

A bimonthly scholarly journal focusing on current developments in the field of health communication. It publishes both quantitative and qualitative studies, ethical essays, and book reviews, as well as a special section designed to provide information to practitioners and academics. It occasionally dedicates an issue to a special topic, such as Health Information National Trends Survey (HINTS) research (March 2006 supplement, Vol. 11) or polio (March 2010 supplement, Vol. 15). Journal of Health & Mass Communication . A nascent journal that publishes primarily theoretical and empirical papers, and essays and book reviews that focus on mass media effects or processes with respect to health-related issues or topics. Articles can have a psychological, social, historical, or cultural orientation but must focus on mass communication and health.

Research into the effectiveness of health communication campaigns can take several forms, and depends in large part on the strategies and tactics of the campaigns themselves. Three common approaches include diffusion of innovation (DOI), social marketing, and media advocacy. DOI focuses on factors that impact how “innovations” (e.g., health information and behaviors) spread through a community or society. Rogers 2003 is the key resource on DOI theory. David, et al. 2006 provides an example of DOI research, while Hornik 2004 describes Everett Rogers’s central role in DOI development. Social marketing is modeled on principals from marketing, essentially the selling of behaviors and attitudes. Media advocacy focuses on enacting change at the policy or social level by garnering media coverage of health issues that demonstrates an environmental rather than individual orientation to public health. Rice and Atkin 2001 contains chapters on social marketing and media advocacy research. Kreps 2009 is an example of theoretical integration that can inform both research and practice. Also provided are works representing the media channel framework (Stanford Communication Model), research integral to several fields, including communication and epidemiology, represented by Flora and her colleagues ( Flora, et al. 1997 , Schooler, et al. 1998 , Stephens, et al. 2004 ).

David, Clarissa, Joseph N. Cappella, and Martin Fishbein. 2006. The social diffusion of influence among adolescents: Group interaction in a chat room environment about antidrug advertisements. Communication Theory 16:118–140.

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The goal of this study was to test the effects of online group interaction among adolescents about antimarijuana advertisements on relevant attitudes and behaviors. The authors conducted an experiment that manipulated chatting and argument strength in antidrug ads. They found a boomerang effect, where those who chatted reported more pro-marijuana attitudes and beliefs than those who just viewed the ads.

Flora, June A., Melissa N. Saphir, Caroline Schooler, and Rajiv N. Rimal. 1997. Toward a framework for intervention channels: Reach, involvement, and impact. Annals of Epidemiology 7:S104–S112.

Flora and her colleagues propose the media channel framework, a guide for planners of mass media interventions to predict which media channels will have the greatest impact with their intended audience. Demonstrated with survey data from the Stanford Five-City Project, this framework orders media channels along two dimensions: reach/specificity and arousing/involving.

Hornik, Robert. 2004. Some reflections on diffusion theory and the role of Everett Rogers. Journal of Health Communication 9:143–148.

DOI: 10.1080/1081070490271610 Save Citation » Export Citation » Share Citation »

Hornik’s thoughtful essay focuses on the adoption process. In particular, he examines this particular portion of the DOI theoretical framework, which is important for scholars who are interested in the role of public health information campaigns and how such campaigns can influence behavior.

Kreps, Gary L. 2009. Applying Weick’s model of organizing to health care and health promotion: Highlighting the central role of health communication. Patient Education & Counseling 74:347–355.

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This article describes Weick’s model of organizing as a useful theory that can help increase understanding of the communication demands of health care and health promotion. It identifies relevant applications from the model for health communication research and practice.

Rice, Ronald E., and Charles K. Atkin. 2001. Public communication campaigns . 3d ed. Thousand Oaks, CA: SAGE.

This is the third edition of the classic book by Rice and Atkin. In addition to including current theory and research, it contains chapters on more recent and controversial campaigns, including examples from both AIDS and antidrug campaigns. The final section introduces a variety of recent campaign dimensions, including community-oriented campaigns, entertainment-education campaigns, and Internet/Web-based campaigns. A valuable resource for students, both undergraduate and graduate, and researchers in the fields of communication, mass media, and public health programs.

Rogers, Everett. 2003. Diffusion of innovations . 5th ed. New York: Free Press.

This is the fifth edition of the classic book on diffusion of innovations. Although not specifically about health communication, this theory has guided many public health campaigns and subsequent research. This book would be helpful for any student of health communication.

Schooler, Caroline, Steven H. Chaffee, June A. Flora, and Connie Roser. 1998. Health campaign channels: Tradeoffs among reach, specificity, and impact. Human Communication Research 24:410–432.

DOI: 10.1111/j.1468-2958.1998.tb00423.x Save Citation » Export Citation » Share Citation »

In an effort to chart the effectiveness of different health campaign media channels, Schooler and colleagues apply the media channel framework to impact data from the Stanford Five-City Multifactor Risk Reduction Project (FCP). The authors frame the channel framework as a way for planners to maximize resources such as time and money for the greatest potential impact.

Stephens, Keri K., Rajiv N. Rimal, and June A. Flora. 2004. Expanding the reach of health campaigns: Community organizations as meta-channels for the dissemination of health information. Journal of Health Communication 9:97–111.

DOI: 10.1080/10810730490271557 Save Citation » Export Citation » Share Citation »

Analyzing data from the Stanford Five-City Project, these scholars examine the relationships between membership in community organizations and health outcomes, above and beyond general media use, demographics, and health-specific media use.

Research on the processing and effects of fear appeal messages has been ongoing for more than fifty years. Fear appeals are generally defined as messages that include a threat to one’s health if an unhealthy behavior is engaged in (or if a healthy behavior is not). The following works include the article most often cited as the first experimental study on fear appeals. The classic Janis and Feshback 1953 is one of the earliest examinations of fear appeal effects. It was followed by a progression of fear appeal theories, which developed over time, as each theory built on its predecessors. The parallel processing model in Levanthal 1971 introduces the idea that fear messages can deflect a person’s response into fear or danger control. The protection motivation theory (PMT) in Rogers 1975 and Rogers 1983 improves on the parallel processing model by introducing antecedent variables, such as perceived severity and susceptibility. Witte 1992 and Witte 1994 build on PMT, and their extended parallel process model (EPPM) has received wide acceptance as a useful way of modeling how fear appeals are processed. Dillard and Anderson 2004 , and Witte and Allen 2000 are important pieces that reflect on the knowledge developed through fear appeal research.

Dillard, James P., and Jason W. Anderson. 2004. The role of fear in persuasion. Psychology & Marketing 21:909–926.

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Previous research on fear/threat appeals has correlated fear intensity with persuasion. The authors propose that fear might influence persuasion in at least four conceptually distinct ways: (1) the proclivity to experience fear, (2) the rise from baseline to peak, (3) peak intensity, and (4) the decline from peak to postmessage fear. The authors find positive relationships between traitlike activation of the behavioral-inhibition system (BIS) and various indices of fear arousal.

Janis, Irving L., and Seymour Feshback. 1953. Effects of fear-arousing communications. The Journal of Abnormal and Social Psychology 48:78–92.

DOI: 10.1037/h0060732 Save Citation » Export Citation » Share Citation »

This is the classic study on the effects of fear appeal messages, which showed that tooth-decay messages moderate or strong in fear were less effective than messages minimal in fear. Students should be familiar with this study because it serves as the foundation for later conceptual and theoretical work in the area.

Leventhal, Howard. 1971. Fear appeals and persuasion: The differentiation of a motivational construct. American Journal of Public Health 61:1208–1224.

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This theoretical article contrasts two models of how individuals react to threatening messages: the drive model and the parallel processing model. Leventhal details the parallel processing model, which provides the theoretical foundation for much subsequent fear appeal research, and how it relates to preventive health behavior. He defines the two key elements, fear control and danger control, and relates how an individual’s appraisal of the message impacts each.

Rogers, Ronald W. 1975. A protection motivation theory of fear appeals and attitude change. Journal of Psychology 91:93–114.

DOI: 10.1080/00223980.1975.9915803 Save Citation » Export Citation » Share Citation »

Rogers introduces protection motivation theory. In the model, components of fear appeal messages (severity, susceptibility, and efficacy of recommended response) initiate cognitive mediating processes (appraised severity, expectancy of exposure, and belief in efficacy of response, respectively), which arouse protection motivation. This motivational state is proposed as a predictor of response acceptance.

Rogers, Ronald W. 1983. Cognitive and physiological processes in fear appeals and attitude change: A revised theory of protection motivation. In Social psychophysiology . Edited by John Cacioppo and Richard Petty, 153–176. New York: Guilford.

Rogers reviews empirical tests of protection motivation theory (PMT) and presents an updated version of the model. The main revisions to PMT include (1) expanding antecedent conditions to include both environmental and intrapersonal sources of information, (2) distinguishing threat appraisals from coping appraisals, and (3) adding self-efficacy to the model as a separate construct from response efficacy.

Witte, Kim. 1992. Putting the fear back into fear appeals: The extended parallel process model. Communication Monographs 59:329–349.

DOI: 10.1080/03637759209376276 Save Citation » Export Citation » Share Citation »

This conceptual article synthesizes decades of fear appeal research and presents Witte’s dual-process model, which distinguishes thoughtful, adaptive responses to threatening messages from fear-driven, maladaptive responses. The extended parallel process model (EPPM) details how fear appeal processing during exposure to a threatening persuasive message leads to either acceptance of the message’s recommendation (adaptive, danger control) or rejection (maladaptive, fear control).

Witte, Kim. 1994. Fear control and danger control: A test of the extended parallel process model (EPPM). Communication Monographs 61:113–134.

DOI: 10.1080/03637759409376328 Save Citation » Export Citation » Share Citation »

This article details a comprehensive empirical test of the EPPM. The investigation provides general support for the model and confirms the parallel cognitive (adaptive danger control) and emotional (maladaptive fear control) processes. Specifically, fear directly predicts fear control but not danger control processes, efficacy appraisals predict danger control but have no association with fear control, and threat perception partially mediates the path from fear to behavior under conditions of high perceived efficacy.

Witte, Kim, and Mike Allen. 2000. A meta-analysis of fear appeals: Implications for effective public health campaigns. Health Education & Behavior 27:591–615.

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This meta-analysis of decades of fear appeal research suggests that strong fear appeals produced high levels of perceived severity and susceptibility, and were more persuasive than low or weak fear appeals. The authors found that high-efficacy fear messages produced the greatest behavior change. This study can provide students with a broad view of fear appeal research.

Message Information and Processing Theories

How individuals process media messages has always been of interest to health communication scholars. The theories and concepts presented here focus on message processing perspectives that are either specific to health communication or were developed in other disciplines and often employed in health communication research. Admittedly, there are many other message processing theories that are also used in health communication, including those are also heavily utilized in other information processing and persuasion research (e.g., ELM, TRA/TPB, LC4MP). The health belief model has influenced much succeeding research. Prospect theory serves as the basis for much of the framing research in health communication, particularly how individuals process gain- and loss-framed messages. Psychological reactance theory spurned research that explores why individuals resist messages designed to enhance their health. How risk is perceived has been shown to impact many attitudes and behaviors, including information seeking. The risk perception attitude framework is offered as a potentially useful way of examining this phenomenon. Social cognitive theory explains how people can acquire attitudes and behaviors through social modeling. The concept of self-efficacy is central to much health communication research, including research on fear appeals. The stages of change theory and message tailoring paradigm emphasize creating messages designed to target particular characteristics of individuals, including the stage where an individual is in the addiction recovery process.

The health belief model (HBM), first proposed by Rosenstock 1974 , sought to link perceptions to health behavioral change. It emphasizes several important perceptual concepts, such as perceived severity, susceptibility, and barriers. Janz and Becker 1984 reviews much of the HBM literature a decade after Rosenstock’s piece.

Janz, Nancy K., and Marshall H. Becker. 1984. The health belief model: A decade later. Health Education Quarterly 11:1–47.

The authors review forty-six empirical tests of health belief model (HBM) constructs’ influence on various preventive (e.g., vaccination) and sick-role (e.g., medication compliance) health behaviors. Across studies, perceived barriers were the most influential dimension on health behavior change. Perceived severity was least influential for preventive actions, but second-most influential for sick-role behaviors.

Rosenstock, Irwin M. 1974. The health belief model and preventive health behavior. Health Education Monographs 2:354–386.

This monograph outlines the health belief model, which holds that perceptions of susceptibility to and severity of disease interact with cues about benefits and barriers to action, to guide motivated health behavior change. The article discusses evidence in support of (and in contrast to) the model and explores the influence of demographic variables.

The idea of tailoring message content to particular audience segments was made possible on a large scale by new communication technologies. Message tailoring has been a focal point of one of the Centers for Excellent in Cancer Communication Research (CECCR), and is represented by Hawkins, et al. 2008 . Tailoring can be based on a number of individual difference variables, such as demographic and cultural factors. Kreuter has been one of the foremost researchers on tailoring messages for enhanced health outcomes (see Kreuter and Haughton 2006 , and Hawkins, et al. 2008 ).

Hawkins, Robert P., Matthew Kreuter, Kenneth Resnicow, Martin Fishbein, and Arie Dijkstra. 2008. Understanding tailoring in communicating about health. Health Education Research 23:454–466.

DOI: 10.1093/her/cyn004 Save Citation » Export Citation » Share Citation »

A panel of scholars from National Cancer Institute–funded CECCR programs explicates the concept of tailoring as linked processes of audience segmentation and message customization. The article outlines two primary goals/mechanisms of tailoring (enhance processing, acceptance) and three classes of message strategies (personalization, feedback, content matching), and compares the relative efficacy of strategies across different goals.

Kreuter, Matthew W., and Lorna T. Haughton. 2006. Integrating culture into health information for African American women. American Behavioral Scientist 49:794–811.

DOI: 10.1177/0002764205283801 Save Citation » Export Citation » Share Citation »

This article examines culturally appropriate tailoring strategies for health communication. A cancer prevention campaign exposed 1,227 African American women to magazines tailored with behavioral (e.g., knowledge, self-efficacy), cultural (e.g., collectivism, religiosity), or combined content. All conditions elicited similar short-term effects, yet only the combined treatment produced long-term change, suggesting that group- and individual-based tailoring strategies are most effective when intertwined.

Framing theory, first proposed by Kahneman and Tversky 1984 as a subjective choice model, has been applied to a variety of social science fields, including health communication. The idea of framing health behaviors as something to gain or to lose has generated a substantial amount of research. Salovey and his colleagues have been at the forefront of this effort. Rothman, et al. 2006 provides a summary about how this theory can help promote healthy behaviors.

Kahneman, Daniel, and Amos Tversky. 1984. Choices, values, and frames. American Psychologist 39:341–350.

DOI: 10.1037/0003-066X.39.4.341 Save Citation » Export Citation » Share Citation »

This article details prospect theory, which contends that the framing of decisions interacts with the subjectivity of human choice. In contrast to rational decision-making models, prospect theory holds that framing outcomes as gains prompts risk aversion (i.e., people prefer a “sure gain”), whereas losses prompt risk seeking (i.e., rejection of a “sure loss”). Additional theoretical tenets, such as subjective weighting of probabilities, are also discussed.

Rothman, Alexander J., Roger D. Bartels, Jhon Wlaschin, and Peter Salovey. 2006. The strategic use of gain- and loss-framed messages to promote healthy behavior: How theory can inform practice. Journal of Communication 56:S202–S220.

This article reviews research on two primary frames in health communication: appeals that emphasize the benefits of adopting a recommendation (gain frames) or those that emphasize the costs of nonadoption (loss frames). Based on findings from cancer communication literature, the authors conclude that gain-framed messages are most effective for prevention behaviors, while loss-framed messages are most effective for detection behaviors.

Brehm and Brehm 1981 introduces psychological reactance theory, which attempts to explain why individuals sometimes do not adopt information that is beneficial for them. Its application to health communication is especially valuable because it helps to identify key barriers to health message acceptance. Dillard and Shen 2005 attempts to focus reactance as a combination of cognitions and affects.

Brehm, Sharon S., and Jack W. Brehm. 1981. Psychological reactance: A theory of freedom and control . San Diego, CA: Academic Press.

This book compiles fifteen years of research on psychological reactance, providing an empirical grounding for the conceptual tenets of reactance theory. Early chapters integrate research on components, determinants, and effects of reactance, followed by a longer series of psychology-focused topical chapters, such as reactance and individual differences, and clinical applications.

Dillard, James P., and Lijiang Shen. 2005. On the nature of reactance and its role in persuasive health communication. Communication Monographs 72:144–168.

DOI: 10.1080/03637750500111815 Save Citation » Export Citation » Share Citation »

This article demonstrates that state reactance can be operationalized as an amalgam of self-reported anger and negative thoughts, by comparing four conceptual models across twin experiments (flossing, alcohol). The study also illustrates the negative influence of controlling language in persuasive health communication on message outcomes, as mediated by state reactance.

How risk is perceived has been shown to impact many attitudes and behaviors, including information seeking. Slövic 1987 proposes a risk perception model that has been applied to health risks. Turner, et al. 2006 tests Rimal’s risk perception attitude framework across two health risks. This model has the potential to yield fruitful research.

Slövic, Paul. 1987. Perception of risk. Science 236:280–285.

DOI: 10.1126/science.3563507 Save Citation » Export Citation » Share Citation »

Slövic proposes a psychometric model to predict acceptance or rejection of hazards such as nuclear power or nanotechnology. The typology is anchored by axes classifying how new and catastrophic the risk is perceived to be. According to the model, risk communicators should emphasize the familiar aspects and potential benefits of hazards to allay concerns.

Turner, Monique M., Rajiv N. Rimal, Daniel Morrison, and Hyojin Kim. 2006. The role of anxiety in seeking and retaining risk information: Testing the risk perception attitude framework in two studies. Human Communication Research 32:130–156.

DOI: 10.1111/j.1468-2958.2006.00006.x Save Citation » Export Citation » Share Citation »

A pair of between-subjects experiments (skin cancer, diabetes) tested the risk perception attitude framework, which argues that efficacy beliefs moderate the influence of risk perception on information-seeking behaviors. High risk, particularly when coupled with low efficacy, induced anxiety, which bolstered information-seeking intentions and, indirectly, behaviors, but also hindered retention.

Social cognitive theory (SCT) developed out of social learning theory, and attempts to explain how people learn through observing the reward and punishment of others’ behaviors. SCT has been a central theory to health message effectiveness, especially in regard to the important factors of social modeling. Self-efficacy, as Bandura 1977 argues, is a central appraisal process in SCT. Bandura 2001 is a comprehensive review of SCT, and a good primer for students unfamiliar with the key tenets of the theory.

Bandura, Albert. 1977. Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review 84:191–215.

DOI: 10.1037/0033-295X.84.2.191 Save Citation » Export Citation » Share Citation »

This article outlines a cognitive processing model of behavior change centered on self-efficacy, an appraisal mechanism proposed to mediate the influence of treatment interventions on behavior change. The author presents an experiment that demonstrates the effectiveness of an efficacy-building approach to elicit positive behavior change among adult snake phobics.

Bandura, Albert. 2001. Social cognitive theory of mass communication. Media Psychology 3:265–298.

DOI: 10.1207/S1532785XMEP0303_03 Save Citation » Export Citation » Share Citation »

In this article, Bandura expands his concept of self-efficacy to a model where personal experiences, behavioral patterns, and environmental factors converge to determine behavior change. Reviewed studies indicate that media interventions can effectively convey coping strategies/tactics to audiences and link together people for higher-order learning and persuasion effects.

The trans-theoretical model of behavior change, also called stages of change theory, emphasizes messages that target the stage when an individual is in the addiction recovery process. Prochaska and Velicer 1997 details the model and how it can inform message design. Jones, et al. 2003 applies the stages of change model to diabetes.

Jones, Helen, Lynn Edwards, T. Michael Vallis, Laurie Ruggiero, Susan R. Rossi, Joseph S. Rossi, Geoffrey Greene, James O. Prochaska, and Bernard Zinman. 2003. Changes in diabetes self-care behaviors make a difference in glycemic control: The Diabetes Stages of Change (DiSC) study. Diabetes Care 26:732–737.

DOI: 10.2337/diacare.26.3.732 Save Citation » Export Citation » Share Citation »

This article reviews a stage-matched intervention promoting diabetes self-care. Diabetics in the stage-matched condition, compared to a control group receiving traditional diabetes treatment, reported better blood glucose self-monitoring, healthier eating, and greater likelihood to stop smoking. Increased self-monitoring of blood glucose interacted with the treatment to predict weight loss and lower blood glucose levels.

Prochaska, James O., and Wayne F. Velicer. 1997. Behavior change: The transtheoretical model of health behavior change. American Journal of Health Promotion 12:38–48.

This article details an integrative model of behavior change that matches outreach strategies to six “stages” on a temporal continuum from addiction to recovery (precontemplation, contemplation, preparation, action, maintenance, termination). Messages targeted at different stages should use different strategies, such as fear appeals for preaction stages and counterconditioning exercises for post-action stages.

Health literacy is an important concept because research has linked it to health knowledge, health behaviors, and health outcomes. Currently, there is not one commonly accepted definition of health literacy. Conceptually, health literacy has been defined from a clinical perspective, where it is considered a property of an individual to be assessed in order to mitigate the negative health impact of an individual’s poor literacy. The most commonly used measures in the early 21st century reflect that approach. American Medical Association 1999 defines health literacy in this way. This definition captures key elements of health care, but ignores important factors external to the health-care sector ( Institute of Medicine 2004 ). Health literacy is also being studied from a public health perspective, where it is viewed more as an attribute of an individual that can be improved. This approach tends to view health literacy as an outcome variable, rather than a diagnostic. The Institute of Medicine definition aligns with such a perspective. Both perspectives recognize the importance of individuals’ motivations and abilities to obtain , understand , and use information to make informed health decisions and interact successfully with the health-care system, rather than simply possessing a set of literacy skills. According to Nutbeam 2008 , the definition adopted by the World Health Organization sees health literacy more as a process that can empower individuals to take control of their health (see Schapira, et al. 2008 ; Quick Guide to Health Literacy ).

American Medical Association. 1999. Health literacy: Report of the Council on Scientific Affairs. Ad hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical Association. Journal of the American Medical Association 281:552–557.

A dozen AMA experts in health literacy compiled this report, which synthesizes academic literature (1966–1996) on definitions of health literacy, outcomes of low health literacy, and communication strategies for physicians. The report discusses areas for future research, such as screening techniques, and the adoption of health literacy as a policy issue.

Institute of Medicine. 2004. Health literacy: A prescription to end confusion . Washington, DC: National Academies Press.

This report contends that nearly half of the American population faces difficulty utilizing health information. Emphasizing systemic as well as individual responsibility for health literacy, recommends action steps to improve low health literacy based on comprehensive assessments of health information delivery across a variety of contexts.

Nutbeam, Don. 2008. The evolving concept of health literacy. Social Science & Medicine 67:2072–2078.

DOI: 10.1016/j.socscimed.2008.09.050 Save Citation » Export Citation » Share Citation »

This article contrasts conceptualizations of health literacy as a risk factor for poor health status (clinical approach) and as an asset for improved health control (public health approach). Nutbeam concludes that both perspectives inform a nuanced understanding of health information use and calls for integration of the camps to address inadequacies in current measurement tools.

Schapira, Marilyn M., Kathlyn E. Fletcher, Mary Ann Gilligan, Toni K. King, Purushottam W. Laud, B. Alexandra Matthews, Joan M. Neuner, and Elisabeth Hayes. 2008. A framework for health numeracy: How patients use quantitative skills in health care. Journal of Health Communication 13:501–517.

DOI: 10.1080/10810730802202169 Save Citation » Export Citation » Share Citation »

Based on focus groups with primary-care patients, this article proposes a conceptual framework for health numeracy, the quantitative complement to health literacy, comprising three skills domains: primary (e.g., counting, arithmetic), applied (e.g., following a prescription regimen, paying medical bills), and interpretive (e.g., understanding the ability of statistics to represent future possibilities).

US Department of Health and Human Services. Quick Guide to Health Literacy Washington, DC: Office of Disease Prevention and Health Promotion.

This user-friendly guide for health professionals and educators includes fact-filled overviews of health literacy concepts and practical strategies to improve the usability of health information and services, and build patient knowledge. Information is in plain language and richly supplemented with best practices and examples, such as talking points for a patient/provider exchange.

Cultural factors, including race and ethnicity, are important factors in health communication research. Much of the research efforts that take cultural factors into account are driven by data that show persistent health disparities among cultural subgroups. Such factors can impact how individuals are best reached in health promotion campaigns ( Flora, et al. 1977 , Hecht, et al. 2006 , Hornik and Ramirez 2006 ), how individuals differentially interpret messages ( Kar and Alcalay 2001 , Kreuter and McClure 2004 , Viswanath and Emmons 2006 ), how individuals interact (or don’t) with the health-care systems, etc. Understanding how cultural factors, across individual and societal levels, impact health outcomes is crucial to understanding how to reduce health disparities ( Ball-Rokeach and Wilkin 2009 ). The works cited here provide an indication of how researchers think about the value of incorporating cultural factors into their research.

Ball-Rokeach, Sandra, and Holley A. Wilkin. 2009. Ethnic differences in health information-seeking behavior: Methodological and applied issues. Communication Research Reports 26:22–29.

DOI: 10.1080/08824090802636983 Save Citation » Export Citation » Share Citation »

This article presents the results of a field experiment on how survey methodologies (Internet vs. telephone) affect researchers’ recommendations about the best communication channels that practitioners should employ to reach ethnic populations. Findings for Hispanics and Anglos from two different surveys were compared. The authors found that responses varied as a function of the methodology employed.

Flora, June A., Caroline Schooler, and Rosalind M. Pierson. 1997. Effective health promotion among communities of color: The potential of social marketing. In Social marketing: Theoretical and practical perspectives . Edited by Marvin E. Goldberg, Martin Fishbein, and Susan E. Middlestadt, 353–374. Mahwah, NJ: Erlbaum.

This book chapter, written by scholars affiliated with the Stanford Five-City Project, shows how social marketing can provide a useful theoretical framework for effect health promotion among communities of color. Specifically, it illustrates how to incorporate culturally appropriate and culturally relevant material to three social marketing principles: audience orientation, message tailoring, and exchange theory.

Hecht, Michael L., John W. Graham, and Elvira Elek. 2006. The drug resistance strategies intervention: Program effects on substance use. Health Communication 20:267–276.

DOI: 10.1207/s15327027hc2003_6 Save Citation » Export Citation » Share Citation »

This study evaluates the Drug Resistance Strategies (DRS) Project, a culturally grounded, communication-based substance use prevention program implemented in middle schools in Phoenix, Arizona. When compared to a control group, the DRS intervention appeared to significantly limit the increase in the number of students reporting recent substance use, especially alcohol and marijuana use.

Hornik, Robert C., and A. Susana Ramirez. 2006. Racial/ethnic disparities and segmentation in communication campaigns. American Behavioral Scientist 49:868–884.

DOI: 10.1177/0002764205283806 Save Citation » Export Citation » Share Citation »

This article describes what communication campaigns do to address racial health disparities and looks for evidence that segmented campaigns reduce disparities. The authors note several arguments that segmentation can risk negative effects yet find no evidence about whether racial/ethnic segmentation reduces disparities, although they argue that some approaches to segmentation are justified.

Kar, Snehendu B., and Rina Alcalay, eds. 2001. Health communication: A multicultural perspective . Thousand Oaks, CA: SAGE.

This book is based on a review of available literature and intervention experiences selected from modern and traditional societies. It focuses on a particular project designed to develop health promotion interventions from a multicultural perspective, and is suitable for students and practitioners interested in a multicultural perspective.

Kreuter, Matthew W., and Stephanie M. McClure. 2004. The role of culture in health communication. Annual Review of Public Health 25:439–455.

DOI: 10.1146/annurev.publhealth.25.101802.123000 Save Citation » Export Citation » Share Citation »

This is a theoretical paper that examines the role of culture as a factor in enhancing the effectiveness of health communication. The authors describe how culture may be applied in audience segmentation and introduce a model of health communication planning, based on McGuire’s communication/persuasion model.

Viswanath, K., and Karen M. Emmons. 2006. Message effects and social determinants of health: Its application to cancer disparities. Journal of Communication 56:S238–S264.

In an attempt to inform health disparities among various cultural subgroups in the United States, this article reviews message effects research, particularly framing and narrative, and links those phenomena to sociostructural factors, such as socioeconomic status, social organizations, social networks, community environment, and public policies. The authors show how individual-level mechanisms can be linked to social variables to help explain message effects on health behavior.

A substantial amount of research is conducted that examines patient/provider communication. The ultimate goal of this research is to improve that communication in order to enhance patients’ health knowledge, attitudes, and behaviors. Cameron 2009 and Rimal 2001 examine theoretical and methodological issues, respectively. Epstein and Street 2007 reports on critical processes that influence the effectiveness of clinicians’ communication with patients. Northouse and Northouse 1998 is perhaps the most comprehensive look at patient/provider communication. Williams, et al. 2002 links health literacy and its impact on patient/provider communication. Albrecht, et al. 2009 provides a useful model for clinical communication.

Albrecht, Terrance L., Louis A. Penner, and Rebecca J. W. Cline. 2009. Studying the process of clinical communication: Issues of context, concepts, and research directions. Journal of Health Communication 14:47–56.

DOI: 10.1080/10810730902806794 Save Citation » Export Citation » Share Citation »

Albrecht and her colleagues present a model pertinent for clinical communication. Of particular interest is the description of their ongoing oncology research program where the authors videorecord interactions between physicians, patients, and family/companions during the discussion of a clinical trial. They also describe their coding procedures.

Cameron, Kenzie A. 2009. A practitioner’s guide to persuasion: An overview of 15 selected persuasion theories, models and frameworks. Patient Education and Counseling 74:309–317.

DOI: 10.1016/j.pec.2008.12.003 Save Citation » Export Citation » Share Citation »

This article summarizes fifteen theories that apply to health communication. Several (e.g. consistency theories, cognitive processing models) are not specific to health communication, while others are (e.g., fear appeal theories). Cameron presents a nice range of theories and summaries, which can inform both researchers and practitioners.

Epstein, Ronald M., and Richard L. Street Jr. 2007. Patient-centered communication in cancer care: Promoting healing and reducing suffering NIH Publication No. 07-6225. Bethesda, MD: National Cancer Institute.

This National Cancer Institute (NCI) monograph identifies the main patient/provider communication issues that research has shown impact health outcomes. It examines the emotional and cognitive processes that a cancer patient may be undergoing and provides information for clinicians on how to best communicate with their patients.

Northouse, Laurel L., and Peter G. Northouse. 1998. Health communication: Strategies for health professions . 3d ed. Stamford, CT: Appleton & Lange.

This text helps nurses and other health care professionals improve their personal communication style for more effective provider/patient communication. New models of communication have been added in this edition, as well as a new chapter on multicultural issues and one on communicating across the lifespan. Good for nursing and allied health profession students.

Rimal, Rajiv N. 2001. Analyzing the physician-patient interaction: An overview of six methods and future research directions. Health Communication 13:89–99.

DOI: 10.1207/S15327027HC1301_08 Save Citation » Export Citation » Share Citation »

Rimal presents a study on coding schemes across six varied studies that documented physician-patient interaction in Texas. He categorizes the way the different studies defined communication, distinguishing between the transmission and ritualistic views. The author also distinguishes the studies based on who exerts the control in their communication, patients or physicians. He offers benefits of improved communication on the part of physicians.

Williams, Mark V., Terry Davis, Ruth M. Parker, and Barry D. Weiss. 2002. The role of health literacy in patient–physician communication. Family Medicine Journal 34:383–389.

This article reports on a literature review conducted on health literacy. The authors found that overall, health literacy is poor in the general population, and that those with poor health literacy tend to have worse health status. They call for the education of medical students and physicians in improved patient-doctor communication skills.

There are numerous approaches to examining mediated content in health communication. The studies listed here examine health content in news and advertising, strategies for persuasive message content, and how individuals look for health information in media. Slater, et al. 2008 and Slater, et al. 2009 examine how cancer is covered in US newspapers. Basil, et al. 2000 and Kelly, et al. 2000 track cigarette advertising in magazines. Hinyard and Kreuter 2007 shows how narratives can be used in persuasive communication. Dillard, et al. 2007 links the perceived effectiveness of persuasive messages to formative campaign research. Rideout 2008 measures the impact of an episode of Grey’s Anatomy on the public’s learning about a health issue.

Basil, Michael D., Debra Z. Basil, and Caroline Schooler. 2000. Cigarette advertising to counter New Year’s resolutions. Journal of Health Communication 5:161–174.

DOI: 10.1080/108107300406875 Save Citation » Export Citation » Share Citation »

Content analyses of popular magazines (1964–1995) show that tobacco advertising, both inside magazines and on their back covers, is more frequent in the months following New Year’s Eve than during other months of the year. The authors conclude that cigarette marketers capitalize on periods when recent quitters are most vulnerable.

Dillard, James P., Kirsten M. Weber, and Renata G. Vail. 2007. The relationship between the perceived and actual effectiveness of persuasive messages: A meta-analysis with implications for formative campaign research. Journal of Communication 57:613–631.

DOI: 10.1111/j.1460-2466.2007.00360.x Save Citation » Export Citation » Share Citation »

This meta-analysis introduces empirical support for the conceptual link between perceived and actual message effectiveness variables. The authors found a moderate correlation between the two, indicating the usefulness of perceived efficacy variables in formative campaign research. The moderating roles of novelty, focus (promotion/prevention), and type of measure (impact, attribute) are also discussed.

Hinyard, Leslie J., and Matthew W. Kreuter. 2007. Using narrative communication as a tool for health behavior change: A conceptual, theoretical, and empirical overview. Health Education & Behavior 34:777–792.

DOI: 10.1177/1090198106291963 Save Citation » Export Citation » Share Citation »

This article is a good primer for the use of narrative in health messages. It defines narrative communication and describes the rationale for using it in health-promotion programs, reviews theoretical and empirical explanations of narrative effects in persuasion, and outlines future research needs in narrative health communication.

Kelly, Kathleen J., Michael D. Slater, David Karan, and Liza Hunn. 2000. The use of human models and cartoon characters in magazine advertisements for cigarettes, beer, and nonalcoholic beverages. Journal of Public Policy & Marketing 19:189–200.

DOI: 10.1509/jppm.19.2.189.17135 Save Citation » Export Citation » Share Citation »

This article tracks the use of human and cartoon models in advertisements for cigarettes, beer, and nonalcoholic beverages over one year (1996–1997) from twelve popular magazines. Cigarette ads featured more lifestyle content and cartoon characters than either beverage category. Moreover, cartoon-based cigarette ads were disproportionately more common in younger-audience magazines.

Rideout, Victoria. 2008. Television as a health educator: A case study of Grey’s Anatomy Menlo Park, CA: Henry J. Kaiser Family Foundation.

This study measures the impact of a medical story line in an episode of the television program Grey’s Anatomy . This is a unique case study in that the researchers worked with program writers and producers to include a medical issue in the plot. Three cross-section surveys measured the episode impact on viewers. Learning about the likelihood of HIV transmission from mother to child increased upon viewing the program.

Slater, Michael D., Marilee Long, Erwin P. Bettinghaus, and Jason B. Reineke. 2008. News coverage of cancer in the United States: A national sample of newspapers, television, and magazines. Journal of Health Communication 13:523–537.

DOI: 10.1080/10810730802279571 Save Citation » Export Citation » Share Citation »

This piece focuses on the content rather than outcomes of cancer news, aggregating articles from 2002–2003. For all cancer types examined, proportion of coverage did not match proportion of incidence, most notably for breast (overrepresented) and lung (underrepresented) cancers. Coverage also concentrated on treatment, rather than prevention or detection practices.

Slater, Michael D., Andrew F. Hayes, Jason B. Reineke, Marilee Long, and Erwin P. Bettinghaus. 2009. Newspaper coverage of cancer prevention: Multilevel evidence for knowledge-gap effects. Journal of Communication 59:514–533.

DOI: 10.1111/j.1460-2466.2009.01433.x Save Citation » Export Citation » Share Citation »

This article finds that regional/market-size differences in news coverage and education are linked to knowledge disparities about cancer prevention at the regional level. The influence of news consumption on knowledge was contingent on nonlinear moderation by education level. Macro-level factors such as regional news availability also predicted knowledge gaps.

Advances in new communication technologies have empowered health consumers with unique opportunities to obtain information about health issues in new ways. These technologies also afford health providers with interesting ways to communicate with health consumers and scholars with new research opportunities to explore the processes involved in how people obtain health information. These technologies can also provide systems of information, social, and emotional support to patients and other health information seekers. The range of research is nearly as broad as the range of new communication technologies; thus, the work listed here reflects that variability. Parker and Thorson 2009 , Rice and Katz 2001 , and Whitten and Cook 2004 provide broad and encompassing approaches to health communication technologies. Kreuter, et al. 1999 focuses on using computer technology for message tailoring.

Kreuter, Matthew, David Farrell, Laura Olevitch, and Laura Brennan. 1999. Tailoring health messages: Customizing communication with computer technology . Mahwah, NJ: Erlbaum.

Through the use of new technologies, researchers and practitioners in health education and health communication can provide health information and behavior change strategies that are customized to the unique needs, interests, and concerns of different individuals. These tailored health messages can be effective in assisting individuals in understanding and responding to health concerns.

Parker, Jerry C., and Esther Thorson, eds. 2009. Health communication in the new media landscape . New York: Springer.

This book aggregates contributions from scholars in communication, journalism, health informatics, public health, and from medical and health professionals. It is a wide-ranging text that will be of interest to students in a variety of health communication fields as well as health professionals who wish to engage patients in new and effective ways.

Rice, Ronald E., and James E. Katz, eds. 2001. The Internet and health communication: Experiences and expectations . Thousand Oaks, CA: SAGE.

This book provides an in-depth analysis of the changes in human communication and health care resulting from the Internet revolution. The contributors, representing a wide range of expertise, provide an extensive variety of examples from the micro to the macro, including information about HMO websites, Internet pharmacies, and Web-enabled hospitals.

Whitten, Pamela, and David Cook, eds. 2004. Understanding health communication technologies . San Francisco: Jossey-Bass.

This text provides a hands-on guide for students and professionals for effective deployment of management of communication technologies in health settings. It provides an overview of the distribution and use of communication technologies within the health field and includes information about current and emerging health care communications technologies.

Audience segmentation research has received significant attention. The idea is to determine how and which consumers seek health information and how they use that information. Segmentation is particularly useful in helping health program planners reach and effectively support consumers with the most appropriate health information. Traditionally, segmentation has been conducted using demographic variables, but this has resulted in limited effects (e.g., Kazbare, et al. 2010 , Slater 1996 ). More recently, psycho-behavioral segmentation ( Dutta-Bergman 2005 , Wolf, et al. et al. 2010 ) using a combination of cognitive, behavioral, and other individual difference variables has been used to segment audiences with regard to a variety of important health issues. Donohew, et al. 1994 and Stephenson 2002 represent the Kentucky school, which applies the individual difference variable of sensation seeking to various health communication problems. The works presented here represent a mix of segmentation research in order to show a range of ways by which audiences have been segmented and the relationships segmentation has with a variety of outcome variables.

Donohew, Lewis, Philip Palmgreen, and Elizabeth P. Lorch. 1994. Attention, need for sensation, and health communication campaigns. American Behavioral Scientist 38:310–322.

DOI: 10.1177/0002764294038002011 Save Citation » Export Citation » Share Citation »

This article represents the Kentucky school of health communication, dominant in the field of sensation-seeking research. The study details the formation and implementation of a televised antidrug public service announcement campaign targeting high sensation seekers (SS). Messages high in attention value (AV) resonated most strongly with high-SS, and low-AV messages with low-SS. message characteristics to appeal to high-SS individuals (e.g., emotionality, ambiguity) and lab and field tests of campaign content are also discussed.

Dutta-Bergman, Mohan J. 2005. The relation between health-orientation, provider-patient communication, and satisfaction: An individual-difference approach. Health Communication 18:291–303.

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Health orientation is an individual-difference concept defined as an individual’s motivation to engage in healthy attitudes, beliefs, and behaviors. Dutta-Bergman finds that patients who were actively oriented toward their health sought out health information, held strong health beliefs, and were also more likely to actively participate in the doctor-patient relationship.

Kazbare, Laura, Hanx C. M. van Trijp, and Jacob Kjær Eskildsen. 2010. A-priori and post-hoc segmentation in the design of healthy eating campaigns. Journal of Marketing Communications 16:21–45.

DOI: 10.1080/13527260903342712 Save Citation » Export Citation » Share Citation »

A nutrition-oriented public health program for 13- to 15-year-olds was administered to compare the impact of four segmentation models: single-segment; a priori grouping based on demographics or, alternatively, behavioral variables; and post-hoc segmentation. Results favor the post-hoc model for a healthy diet campaign, and imply that audience segmentation should extend past demographic variables.

Slater, Michael D. 1996. Theory and method in health audience segmentation. Journal of Health Communication 1:267–284.

DOI: 10.1080/108107396128059 Save Citation » Export Citation » Share Citation »

This article aims to reinforce the theoretical foundation of health audience segmentation practices by reviewing the segmentation literature and critically examining common methods. It argues that health communication research and practice should move toward hierarchical multivariate segmentation techniques and outlines how these clustering strategies can be implemented.

Stephenson, Michael T. 2002. Sensation seeking as a moderator of the processing of anti-heroin PSAs. Communication Studies 53:358–380.

An experiment examined young adults’ ( N = 200) processing of antidrug video public service announcements, concentrating on the roles of sensation seeking (SS) and perceived message sensation value (PMSV). PMSV facilitated cognitive and affective processing, especially for high-SS individuals. It also predicted stronger antiheroin attitudes for this group indirectly through enhanced narrative and sensory processing.

Wolff, Lisa S., Holly A. Massett, Edward W. Maibach, Deanne Weber, Susan Hassmiller, and Robin E. Mockenhaupt. 2010. Validating a health consumer segmentation model: Behavioral and attitudinal differences in disease prevention-related practices. Journal of Health Communication 15:167–188.

DOI: 10.1080/10810730903528041 Save Citation » Export Citation » Share Citation »

A national mail panel survey ( N = 1,650) confirmed the validity of a psycho-behavioral model of health audience segmentation based on health information-seeking behaviors and its corresponding ten-item screening instrument. The segments (formed by a 2 × 2 matrix of doctor-dependence/independence and active/passive health orientation) are linked to patterns of prevention-related attitudes and behaviors.

A number of scholars think and write about issues in health communication that are not easily categorized in the usual manner. The following articles include some pieces written about health communication in a reflective manner that cut across traditional domains and concerns, each of which could develop into its own subfield. Fishbein and Cappella 2006 provides a theoretical framework for developing effective health communication. Witte and Meyer 1996 proposes an ecological theory in order to help organize years of studies. Kreps and Maibach 2008 explores important issues at the intersection of communication and public health. Kreps, et al. 2002 discusses what the authors call “big science” as an opportunity to enhance federally funded research.

Fishbein, Martin, and Joseph N. Cappella. 2006. The role of theory in developing effective health communications. Journal of Communication 56:S1–S17.

The authors argue for the centrality of communication theory and how theory can be applied to developing messages designed to promote healthy behavior. They propose an integrative model of behavioral prediction, which integrates a number of behavioral theories. They use data from a study on smokers’ intentions to continue smoking and to quit, and show how the model helps identify the critical beliefs underlying these intentions.

Kreps, Gary L., and Edward W. Maibach. 2008. Transdisciplinary science: The nexus between communication and public health. Journal of Communication 58:732–748.

DOI: 10.1111/j.1460-2466.2008.00411.x Save Citation » Export Citation » Share Citation »

This article examines the major theoretical and practical intersections between health communication and public health disciplines. It identifies theoretical, methodological, and societal contributions from health communication and suggests directions for future collaborations. It also examines ways that collaboration between health communication and public health has begun to generate important scientific outcomes.

Kreps, Gary L., K. Viswanath, and Linda M. Harris. 2002. Advancing communication as a science: Research opportunities from the federal sector. Journal of Applied Communication Research 30:369–381.

The authors argue that communication science can be advanced by pursuing what they call a “big science” strategy, where the goal is to apply research findings to significant social issues and problems. By “big science,” the authors mean research programs that employ large samples and longitudinal designs. These types of research programs are expensive, and the authors review major funding programs in various government agencies.

Witte, Kim, and Gary Meyer. 1996. Bringing order to chaos: Communication and health. Communication Studies 47:229–242.

Witte and Meyer discuss an ecological theory of health communication that addresses how it influences health and health-related behaviors. They use chaos theory concepts to support a synergistic model of health communication, showing how many health communication variables can work together to help influence health behaviors. The authors propose this model in contrast to reductionist health communication research.

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Health Communication: A Social Practice Approach

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• Cite this living reference work entry

• Olaf Werder 3 &
• Kate Holland 4  

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Health behavior ; Health campaigns ; Health discourses ; Health narratives ; Health promotion ; Health representations ; Participation ; Social action

The study and practice of communication processes and strategies that play a crucial role for community dialogue and active participation in mutual health maintenance or improvement.

Introduction: Health Communication

Health communication is generally defined as the study and practice of communication processes and strategies that serve to improve health outcomes via information sharing and education (CDC, 2011 ; Schiavo, 2007 ). Since communication can take many forms, health communication is in principle open to a host of theories, models, and strategies to examine phenomena but also debates and critiques about best approaches and precise objectives to achieve better health.

By and large, the field of communication explores, on the one side, symbols and channels of communication processes and, on the other, the reception and...

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Department of Media and Communications, University of Sydney, Sydney, NSW, Australia

Olaf Werder

University of Canberra, Canberra, ACT, Australia

Kate Holland

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School of Health Sciences, The University of Nottingham, Nottingham, UK

Paul Crawford

Queen Margaret University, Edinburgh, UK

Paul Kadetz

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Graduate School of Nursing Science, St. Luke's International University, Tokyo, Japan

Jeffrey Huffman

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Werder, O., Holland, K. (2024). Health Communication: A Social Practice Approach. In: Crawford, P., Kadetz, P. (eds) Palgrave Encyclopedia of the Health Humanities. Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-030-26825-1_143-1

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DOI : https://doi.org/10.1007/978-3-030-26825-1_143-1

Received : 21 August 2020

Accepted : 28 January 2023

Published : 09 November 2023

Publisher Name : Palgrave Macmillan, Cham

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Health communication in primary health care -A case study of ICT development for health promotion

Amina jama mahmud.

1 School of Health Sciences, Blekinge Institute of Technology, Karlskrona, Sweden

Ewy Olander

Sara eriksén.

2 School of Computing, Blekinge Institute of Technology, Karlskrona, Sweden

Bo JA Haglund

3 Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden

Developing Information and Communication Technology (ICT) supported health communication in PHC could contribute to increased health literacy and empowerment, which are foundations for enabling people to increase control over their health, as a way to reduce increasing lifestyle related ill health. However, to increase the likelihood of success of implementing ICT supported health communication, it is essential to conduct a detailed analysis of the setting and context prior to the intervention. The aim of this study was to gain a better understanding of health communication for health promotion in PHC with emphasis on the implications for a planned ICT supported interactive health channel.

A qualitative case study, with a multi-methods approach was applied. Field notes, document study and focus groups were used for data collection. Data was then analyzed using qualitative content analysis.

Health communication is an integral part of health promotion practice in PHC in this case study. However, there was a lack of consensus among health professionals on what a health promotion approach was, causing discrepancy in approaches and practices of health communication. Two themes emerged from the data analysis: Communicating health and environment for health communication. The themes represented individual and organizational factors that affected health communication practice in PHC and thus need to be taken into consideration in the development of the planned health channel.

Conclusions

Health communication practiced in PHC is individual based, preventive and reactive in nature, as opposed to population based, promotive and proactive in line with a health promotion approach. The most significant challenge in developing an ICT supported health communication channel for health promotion identified in this study, is profiling a health promotion approach in PHC. Addressing health promotion values and principles in the design of ICT supported health communication channel could facilitate health communication for promoting health, i.e. ‘health promoting communication’.

Primary Health Care (PHC) has been singled out as the most suitable health care setting to meet the increasing need for health promotion interventions and to curb the rising number of chronic diseases [ 1 - 3 ]. A majority of people depend on health care services for health information, yet PHC is poorly equipped to provide this service [ 4 ]. Developing Information Communication Technology (ICT) supported health communication in PHC could contribute to increased health literacy and empowerment, which are foundations of health promotion and the notion of enabling people to increase control over their health and its determinants, and thereby improve their health [ 5 , 6 ]. It is however essential to conduct a detailed analysis of the setting and context prior to implementing an intervention in order to “avoid murky water and increase the likelihood of success” [ 7 ] (pg 506). The aim of this study was to gain a better understanding of health communication for health promotion and factors affecting such communication in a PHC setting, as a first phase in the development of an ICT supported health channel.

Health communication

The development of health communication for promoting health has mainly taken place outside the health care services [ 1 ]. When health communication does occur within the health care services, it lacks a broad socio-ecological health promotion approach, needed to tackle lifestyle related ill health and health inequalities [ 8 , 9 ]. An ecological health promotion approach addresses socioeconomic and cultural factors that determine health as well as providing information and life skills to make appropriate health decisions. Such an approach includes both promoting health and preventing diseases [ 10 ], and is referred to as a health promotion approach in this paper.

Consistent with this health promotion approach, health communication in this article is defined as ‘the art and technique of informing, influencing and motivating individuals, institutional and public audiences about important health issues’ [ 11 ]. The communication adopts a participatory approach whose main aim is empowerment through dialogue and mutual learning; the process is as important as the outcome [ 12 ].

Participatory communication could facilitate collaborative learning for both provider and receiver of health communication [ 13 ]. Health communication providers can learn about receiver’s needs and preference for health communication through collaboration process; an insight that could enable them to construct health communication resources that is relevant and accessible to intended receivers. Likewise, receivers may gain more knowledge on health and health management as well as relationship between health and lifestyle through the same dialogue process. Raising health literacy of both parties is important for sustainable health care services [ 14 ].

Improving health literacy is critical to empowerment [ 15 ]. As a concept, health literacy encompasses more than transmitting health information and developing skills. It entails improving people’s access to health information and support capacity to use it effectively; in order for them to make informed choices, reduce health risks and increase quality of life [ 14 , 16 ]. In this light, health literacy is an important public health goal to reduce inequity [ 6 ]. The Ottawa Charter identified creation of supportive environment, developing of personal skills and reorienting health services as important action areas [ 17 ]. These action areas are incorporated in the Swedish Public Health policy [ 18 ], whose overarching goal is ‘to create societal conditions to ensure good health, on equal terms, for the entire population’. To achieve this, eleven goal areas have been identified, two of which are; to enable citizen participation in social and health care services; and to re-orient health care services into a more health promoting health services [ 18 ].

ICT- mediated health communication

ICT mediated health communication media, with internet at the forefront, are increasingly becoming an accepted strategy for communicating health. Internet’s flexibility and accessibility through different channels makes it an ideal platform for communicating health [ 19 , 20 ]. Health channel in this paper is defined as a mode of transmission that enables messages to be exchanged between “senders” and “receivers.” In the context of internet, senders of the communication may have to contend with participants who engage, contest, reframe and deepen the messages in the communication process. This may take place either in an on-going dialogue in real-time or via other feedback avenue [ 21 ]. Implementation of ICT for health communication or aspects of ICT in health communication, as in eHealth applications, is essential to meet growing demands for cost-effective, appropriate and individually tailored health care as well as to increase accessibility to health services [ 22 ], improve population health outcomes and to achieve health equity [ 19 ]. Yet the implementation of ICT supported health communication for health promotion within health care services has been slow in uptake [ 8 , 19 ]. Criticism has been leveled at the existing ICT mediated health communication in health care as it is perceived to be predominantly individual based and pro-medicine in its approach [ 4 , 23 ], lacking a holistic approach and ability to address determinants of health [ 22 ]. Thus there is a need to rethink health promotion in planning for ICT mediated health communication [ 8 , 22 ] for a holistic approach in conceptualization and design of ICT systems in health care [ 24 ]. Innovative ways to design ICT systems in health care can contribute to individual wellbeing and quality of life, and achieve improved public health and sustainable e-services in general [ 25 ].

In the light of the challenges facing PHCs and opportunities presented by ICT in health care services outlined in the background, there is need to conduct a feasibility study prior to implementation of a new ICT supported health communication tool; in order to situate practice in its context and increase the likelihood of success [ 7 ]. Implementation of ICT is expensive, time consuming and often quickly outdated [ 8 , 26 ]. In order to develop sustainable ICT systems that fulfill health promotion goals in PHC, there is a need for both the system developers and health personnel to understand what functions the system is supposed to fulfill and the contexts in which it is to function [ 27 ]. This need informs the aim of this study which is to gain a better understanding of health communication for health promotion and factors affecting such communication in a PHC setting. This study has the potential to guide researchers and PHC managers in future feasibility studies and/or the implementation of ICT systems.

Study setting

The study was conducted within a county council owned PHC and its health promotion center ‘ Hälsotorg ’ in the southeast of Sweden which provides health services to approximately 10,500 inhabitants. The PHC center houses several units: General Practitioner (GP) and District Nurse (DN) consultations services, Child Health Services (CHS), Hälsotorg, Pharmacy, Dental and Psychiatric Clinic.

The Hälsotorg was partly owned and managed by the PHC. Hälsotorg emerged in several county councils in the 1990’s as a collaboration between the then, state owned, pharmaceutical company and PHC in a bid to increase health promotion within the PHC services [ 28 ]. According to local evaluation reports, the concept and ambitions of Hälsotorg were appreciated by health personnel as well as visitors [ 29 ]. As it contributed to the alliance building with other actors working in the field of health, opened up PHC to the non patient segment of the society and thereby increasing citizens’ accessibility to and participation in health care as stipulated by the national public health policy [ 18 ]. This makes PHC a natural entry point for reorientation of health care towards a more health-promoting health services as proposed by the World Health Organization (WHO) [ 17 , 30 ] and the Swedish National Public Health Policy [ 18 ].

To improve accessibility to health promotion initiatives for the local community, a research and development project entitled ‘Virtual Hälsotorg ’ (VHT) was initiated to make Hälsotorg activities more accessible to the local community through an internet supported interactive health channel. The main objective of the VHT project was to develop an interactive digital health channel for health promotion, a virtual “meeting place” for health issues between community members and health care personnel in PHC. According to the project goals, VHT channel was to be specifically adapted to the socio-cultural context of PHC and the local community. The VHT project was part of an EU funded research and development project exploring how ICT can be used to increase citizens’ accessibility to and participation in health care, and development of health care services.

Study design

The Virtual Hälsotorg (VHT) research project adopted a Participatory Action Research (PAR) approach [ 31 ]. A model, entitled Spiral Technology Action Research (STAR) [ 27 ], was used to guide the design process. The STAR model combines health promotion and social theories, PAR approach, critical pedagogy and ICT systems design approaches using rapid cycle of change strategies [ 27 ]. The iterative nature of the STAR model allowed continuous feedback and dialogue between partners in the research project which resulted in action/improvement of the product thereby making it a tangible method for realize the PAR approach of the project. The STAR model consists of five developmental cycles entitled; Listen, Plan, Do, Study and Act . For the VHT project, these cycles were combined to form three developmental phases; phase 1; Listen, phase 2; Plan and Do, phase 3; Study and Act. This article covers the first phase Listen ; which entails ‘scanning the setting’. This article had a dual purpose. First, to familiarize with the setting for the intervention. Second, to assess health communication needs and identify subject’s interaction with technology. The goal of this phase in the VHT project was to ensure that the development of the system was guided by the users, both health professionals and the local population, needs as expressed by them [ 27 ].

A qualitative exploratory case study [ 32 ] methodology with multiple data collection methods; field study with participatory observations, document studies and focus groups were applied in the study to facilitate a holistic view of health communication practiced at Hälsotorg and PHC (Table ​ (Table1). 1 ). PAR approach, provided possibilities to understand individual and organizational factors as well as the relationships between these factors [ 32 , 33 ]. Since the boundary between Hälsotorg and its context (PHC) were not clearly evident, the whole context was treated as a single case study [ 32 ]. The case and unit of analysis was the phenomenon ‘health communication’ in the context of PHC in general and Hälsotorg in particular. According to Yin, use of multiple sources of evidence allows the investigator to address a broader range of issues comprehensively thereby contributing to convincing and accurate findings or conclusions [ 32 ] hence increasing credibility and trustworthiness of the results [ 33 ].

Summary of data description, sources and methods used for data collection

Case description

Hälsotorg in this study was managed by health professionals from the PHC and the Pharmacy. It offered a range of health promotion activities including health information in print and electronic media, individual health counseling on life style related health problems like stress, physical inactivity, overweight and chronic diseases such as hypertension and diabetes. It also offered group activities such as: open public lectures, ‘power walking’ and aerobics for people with physical disabilities. A customer computer placed at the Hälsotorg; provided access to free, trustworthy internet-based health information sites and self-administered lifestyle tests. All activities were open to all citizens free of charge.

The term ‘visitor’ was used to describe all who visited Hälsotorg, regardless of how or why they came, in contrast to ‘patients’ in other PHC units. Hälsotorg personnel did not have an obligation to document visitors in the electronic patient record, thus all visitors had the right to be anonymous. Hälsotorg had two types of clientele; visitors, who visited of their own accord and visitors who came on referral from GP, DN or CHS.

The case was expanded to include experiences of personnel from the other three Hälsotorg in the region to get a broader perspective of health promotion services offered and to solicit input on the content and development of a VHT model usable in all county council owned PHC in the region. The GP and DN consultations services, CHS and Hälsotorg belong to the same organization and will henceforth be referred to collectively as ‘PHC’ in this paper, likewise, personnel from respective units will be referred to as ‘health personnel’, unless the need to separate them arises.

Fields study

To familiarize with the setting for the intervention, find and assess needs, and identify how subjects interacted with technology, a field study was conducted under a period of three months, twice a week, in 2008–2009. AJM took part in Hälsotorg activities and staff meetings in the PHC, collecting data using participatory observations [ 33 ]. A total of 251 people visited the Hälsotorg during the period of the field study, some of whom took part in the informal interviews which formed part of the field notes.

Participatory observation as a method contributed to a better understanding of the context, its actors and their interrelations. Thereby a nuanced understanding of the context as a basis for understanding data collected through other methods such as focus groups and document studies [ 33 ]. Furthermore, findings from the participatory observations were used to identify key actors (study sample) and to design questions for the focus group. Participatory observation was useful as expression of needs, especially for technology based resources, is often tacit and hard to deduce for the majority of the people [ 31 , 34 ].

A field study manual covering; activities conducted at Hälsotorg , participants and reason for participation. The manual also focused on how health communication was framed and communicated as well as tools and strategies used to communicate health. The interaction between health personnel and between health personnel and Hälsotorg visitors were also covered. The manual observations notes, impromptu conversations and personal reflections were recorded in field notes. The notes were then expanded when the situation allowed or at the end of the day to identify assumptions, make sense of the data, and record personal insights that might have affected the data [ 34 ] and discussed with the DN at Hälsotorg .

When Hälsotorg visitors allowed it, AJM actively participated in the activities which gave the opportunity to closely observe the activity and ask questions in an unobtrusive way [ 34 , 35 ]. Similarly, AJM, helped in the planning of two public lectures during the field study, thus giving insights on how health communication via mass-media was articulated and executed. Field notes were read repeatedly to make sense of the collected data and get a sense of whole. The data was later coded and categorized using qualitative data analysis [ 34 ].

Document studies

Purposive sampling was used to identify documents, printed materials and records [ 34 ] that were of importance to health communication and health promotion in PHC. A total of 13 documents and other printed materials used at Hälsotorg were identified as crucial to understand how health promotion in PHC was articulated in text and how it is interpreted in praxis as basis to understand the what, how and why of health communication for health promotion practiced in PHC and factors influencing it (Table ​ (Table1 1 ).

The national documents; the public health policy 2007/8:110 and pharmacy (Apoteket AB) Action plan 2002, were identified through an earlier study of Hälsotorg implementation analysis [ 28 ]. The county council documents were identified during field studies data collection period and obtained through internet searches on the county council website. The rest of the documents included; an evaluation report of Hälsotorg in the region, meeting protocols, monthly reports (mainly activities offered and statistics of visitors) kept by all Hälsotorg during the field study. All the documents related to the development, visions and goals for health promotion in PHC. Qualitative content analyses were conducted whereby phrases describing health promotion, health communication in PHC as well as PHC’s missions, role and responsibility in health promotion were highlighted and coded [ 34 ].

Focus groups

To explore the knowledge and experiences [ 34 , 36 , 37 ] of the different actors in the PHC, focus groups were conducted with actors involved in health promotion in PHC (Table ​ (Table1). 1 ). Purposive sampling was used to identify potential information rich sources and main actors [ 37 ] among health care personnel in PHC and local community members. To gain a better understanding of health communication for health promotion in PHC and capture perspectives and experiences of the different actors who affect or are affected by it, effort was made to include providers, receivers and decision makers of health communication in PHC.

Focus group participants were recruited using snowball methods [ 38 ] where PHC manager and DN in Hälsotorg played a key role in identifying and recruiting of informants. A letter containing project information and a request for participation was sent out to prospective informants in PHC and to a Swedish language class for immigrants. Respondents to the letter, were later contacted to decide on dates and places for focus groups. Five focus group interviews were conducted. Group 1 and 2 consisted of DNs in PHC (n=9). Group 3, was Hälsotorg’s network (n=10) consisting of PHC managers, a pharmacy manager, dental clinic manager, psychiatric clinic manager, Hälsotorgs personnel across the region, and a public health strategist. Group 4 consisted of immigrants from a Swedish language school while group 5 was made up of Hälsotorgs’ personnel in the PHC of this case study. The total number participants in focus groups was 30 (Table ​ (Table1 1 ).

The immigrant group was a strategic choice as Hälsotorg personnel recounted that from their experience, immigrant groups had low health literacy and were hard to reach. During the period of this study, Hälsotorg had contact with immigrants in the Swedish language instruction school (SFI). The immigrants were informed about the study and requested to participate.

Data was collected using semi-structured, open ended interview guide [ 34 , 39 ] divided in two parts. The first part pertained informants’ personal experiences of designing, delivering / receiving health information/ health communication in or from PHC. The second part concerned informants’ knowledge and experience of ICT supported tools for health information and suggestions for improvements of health communications for health promotion. The interview guide was modified to adapt to the different groups of informants in order to capture the varying perspectives, experiences, roles and needs. Focus groups with health personnel were conducted in private rooms within the PHC, while focus group with the immigrant group was conducted in their classroom which was a familiar environment [ 31 ]. AJM functioned as the principle moderator in all the focus groups assisted by EO who took notes. A post meeting analysis of the session was held by the researchers at the end of every session to compare notes and identify new ideas (if any) that needed to be explored in the next focus group [ 37 ]. Focus groups discussions were audio taped and transcribed per verbatim [ 34 ]. Data was read repeatedly to achieve immersion and obtain a sense of whole, then coded and categorized using inductive qualitative content analysis [ 34 ].

Data analysis

Data from focus groups, participatory observations and document analysis were analyzed, coded and categorized separately using inductive qualitative content analysis [ 34 ]. Emerging categories from the different data sets were constantly compared to each other and integrated into themes (Table ​ (Table2) 2 ) to form a rich description of the case [ 32 ]. Coding was initially done by AJM and thereafter negotiated and checked for comprehension with the other co-authors. The derived results were then presented to the DN in Hälsotorg for validation. Two main themes emerged from the data analysis namely; communicating health and environment for health communication.

Analysis process and resulting themes

Ethical considerations

The informants were informed on the nature of the study, in accordance with the Swedish Ethical Review Act (SFS 2008:192) and informed consent was obtained from participants. Permission to a conduct field study was granted by the PHC manager. One of the main aims of PAR is to create equality between the researcher and research subjects [ 31 ] as well as making explicit the researcher’s assumptions, values and motives [ 40 ]. To achieve this kind of transparency, AJM kept the participants informed of the project through; talking to the personnel, taking part in workplace meetings and holding debriefing sessions with the other research members to ensure that personal values and motives did not affect the outcome of the study. Debriefing sessions provided useful arena to discuss difficulties caused by AJM’s dual role of a researcher and health worker when actively taking part in the activities in Hälsotorg . However, since the participatory element of enquiry was limited to participatory observation, few problems were encountered as the researcher was sensitive to the participants’ wishes [ 31 ]. AJM would always seek their permission prior to engaging in any activity. The study was approved by ‘The regional ethical committee for Lund/Malmö region’, at Lund University in Sweden. Diary number 2009/120.

The overall analysis shows that health communication is an integral part of health promotion practice in Hälsotorg and PHC but there was a dearth of consensus among health professionals on what a health promotion approach is, causing discordance in approaches and practices of health communication. Two main themes emerged from the analyzed data: Communicating health and Environment for health communication (Table ​ (Table2). 2 ). The results are presented in these themes with their categories and sub-categories. Quotations are included to illustrate how the interpretation is grounded in the data.

Communicating health

Communicating health was identified as a major function for PHC by all informants. This theme captures how health was communicated, understood and practiced. Health personnel identified a number of strategies and tools used for health communication as well as types of health communication carried out in PHC.

Strategies for health communication

This category mirrored two different approaches used by health personnel to accomplish objectives for health communication; empowerment and behavior change strategies . Empowerment was indicated in the policy documents, and acknowledged by health personnel, as the ultimate goal for health communication in PHC. Field studies and focus groups indicated however that the empowerment strategy was more evident in Hälsotorg and in CHS compared to the rest of the PHC units.

In the empowerment strategy, health personnel assumed the role of a dialogue partner and facilitator for the learning process of patients and visitors. Decision were made based on the receiver's understanding of the information. This approach was commonly referred to by DNs as ‘m eeting the clients where they are, in order to guide them to where they want to go in terms of better health ’. In most Hälsotorg this empowerment strategy mostly focused on building capacity and providing tools for visitors to make informed decisions or creating solutions to health problems or lifestyle changes through a dialogue, while in CHS, it focused on facilitating empowerment of parents and creating a supportive environment for families. As one Hälsotorg visitor expressed:

“ Here (in Hälsotorg ) I can discuss different things at the same time, I was referred here by my Doctor because of my high cholesterol but then, I ended up discussing my sleep patterns that is more disturbing to me really more than high cholesterol (laughter)…You can’t do that at the PHC ” ( Hälsotorg visitor 1)."

Or as another informant expressed;

"“That’s how we work all the time, promoting health and preventing ill health in the home now we focus a lot on unhealthy drinking and we routinely ask both mothers and fathers about their drinking habit not just mothers. It is important that children are safe and parents who need help, feel they can get it” (FG 1)."

In contrast to the empowerment strategy, the behavior change strategy focused on disease and risk prevention. Health personnel were more or less authoritative and ‘instructed’ the patient/visitor, assuming the role of expert, who ultimately informed the patient /visitor, what was best for them. One of the (health) personnel explained the health communication process as follows:

"“We normally go through their (patients’) eating habits and daily exercises together if any and then I show them what they are doing wrong. Then I “teach them” the right diet and tell them that they have to exercise at least half an hour per day. Some do not follow our advice but that’s their own responsibility” (FG 2)."

Comparison of data from interviews and field studies showed that the different strategies could be traced to health personnel’s understanding of the health promotion concept and the exhibited discrepancy between their intentions to promote health and the existing praxis for health communication in their respective units.

Tools for health communication

This category included tools as channels, tools as methods, and tools as competencies.

Tools as channels for health communication included telephones, printed and electronic materials, and Internet-based resources. These were used for health communication with patients/clients/visitors separately or in combination, depending on the nature or purpose of the activity and the desired outcome. According to informants and observations, telephone, printed and electronic materials were common channels for health personnel’s communication with patients and visitors. Health personnel used Internet mostly to search for health information for the purpose of updating their knowledge or to retrieve health information materials for their clients/visitors. Patients and visitors used telephones mostly for health communication with health personnel, while Internet was used to seek knowledge in an area of interest or concern;-mainly chronic diseases and self care.

Tools as methods included questionnaires, brochures, and electronic or printed health tests . Almost all individual counseling sessions were initiated using a printed or electronic health questionnaire followed by a dialogue. Health personnel were positive towards these tools, as they gave structure to health communication activities. However, according to health personnel and visitors these methods could potentially encourage an expert-laymen driven approach, reducing health communication to filling of questionnaires instead of having a dialogue between partners. Health personnel acknowledged the shortcomings of the questionnaires as an effective tool for promoting health as follows:

"“…yaaa (hesitating) …we don’t produce them (questionnaires) ourselves…they are standardized and most people have more than one health concern, there is a risk that you focus too much on the questionnaire instead of listening to the patient” (FG 2)."

Tools as competencies for health communication encompassed knowledge, abilities and pedagogical skills for health communication, which were perceived as necessary tools for imparting or working with health promotion. Knowledge and abilities refer to skills necessary for health personnel to impart health related knowledge that influences individual health choices and self-care. Pedagogical skills refer to health personnel’s ability to apply those skills appropriately and in a way that fosters empowerment in their clients/patients. DNs, in particular, expressed a desire for internal courses to improve their pedagogical skills and capacity to act as health promotion agents. As expressed in one of the focus groups:

"“…of course we can be better at communicating when it comes to health promotion and disease prevention…but it is not always easy. For instance, when you get a patient with hypertension who is a bit fat, you can talk about diet…but to apply it generally in the day to day activities is hard..that needs a different kind of structure, skills and knowledge …pedagogical skills that unfortunately are not there in us…” (FG 1)."

Types of health communication

Three types of health communication were identified from the data: interpersonal, group and ICT mediated health communication. Interpersonal communication was the most common type of communication used in PHC and at Hälsotorg as the majority of activities/services targeted individuals. Motivation Interview (MI) was the recommended method for individual health counseling in the county council policy document and also acknowledged and used by the DN’s. Face-face verbal communication between patients/visitors and health personnel in either planned individual counseling or during ‘drop in’ sessions. The patient/visitor’s needs and abilities were the main focus of interpersonal communications. According to health personnel, it is important to identify patient’s source of motivation as opposed to health personnel’s. As exemplified in the following quotation by health personnel:

"“… it is hard for people to change their habits…but we try to help them identify things that would make them want to change, for example if a visitor is diabetic and overweight…to us it is natural to say diabetes is the problem, but maybe the person wants to lose weight because they want to look beautiful…(all informants nod in agreement)…then beauty is that person’s motivation but in the end the results (of losing weight) would be good for their diabetes too” (FG5)."

Group communication was mostly used at Hälsotorgs during group activities such as physical training and open lectures on different lifestyle related ill health. Different kinds of physical training sessions were offered for example; aerobics for physically challenged persons (including wheelchair- bound persons) and power walking. Open lectures also varied in content, from stress to cardiovascular diseases. These activities paved way for group communication and facilitated dialogue on varied health issues between health personnel and community members.

Findings show that group activities were appreciated by both Hälsotorg personnel and visitors. Hälsotorg personnel saw these sessions with group discussions, as opportunities to communicate health to a larger population, something that is not always easy to accomplish in the day to day work. For visitors, these sessions were more than just an opportunity to exercise or get health information; they presented an opportunity for collaborative learning and opportunity to act on the knowledge acquired for health gains. This would not have been possible if Hälsotorg had not created supportive and inclusive environment for all citizens, regardless of health condition. As expressed by a Hälsotorg visitor:

"“ Hälsotorg has saved my life…I come every Tuesday and walk with this group…it is nice…I made some friends…and the DN can see when somebody is having difficulties…I have a bad heart and I would never dare go on long walks like this if I didn’t know there was somebody to help me if I collapse…she sometimes tells me and the whole group to reduce our pace…because she “sees” when I am struggling…” ( Hälsotorg visitor 6)."

ICT mediated health communication , especially the Internet, was regarded as an important media for health communication by all informants. Younger Hälsotorg visitors and immigrant informants were more positive to the use of internet as a source of health communication; they reported using Internet for health information needs more extensively than health personnel and older Hälsotorg visitors. Younger Hälsotorg visitors and immigrants reported using internet to search information on lifestyle related ill health. Mainly information on weight loss, diet, smoking cessation and stress as well as cardio-vascular diseases. Information on how to contact the local PHC clinics and hospitals was also reported. Immigrant informants used both Internet and digital television, as these channels offered health information in their native languages. Hälsotorg personnel frequently used web based-lifestyle questionnaire on the Pharmacy’s website apoteket.se to tests the visitors’ diet, sleep, exercise, smoking and drinking habits.

Results from the web based-lifestyle questionnaire was used as a basis for individual counseling sessions regardless of what health problem the visitors came in for. A clear irritation was noted among some of the visitors who did not see the connection in for example the hypertension control they came in for and answering the long questionnaire while others appreciated the questionnaire, noting that it has helped them realize that they need to eat better balanced diet or stop smoking for example.

A common phenomenon noted during the field studies was the number of Hälsotorg visitors coming in with health information acquired from the Internet, wanting to discuss the content and validity with the personnel. A DN expressed criticism of the Internet as a source for health information as follows:

"“…patients come with all kinds of information, sometimes wrong information and it’s hard to counter that kind of misinformation…the new health channel would be good because we will be able to give them access to health information that we know is correct” (FG 3)."

Environment for health communication

The environment for health communication was seen as both a facilitator and barrier to health promoting communication efforts in PHC. Two important factors affecting the environment of health communication were identified: Strategic positioning and Collaborating for health communication . Positioning of Hälsotorg within a PHC center affected health communication at the PHC units and Hälsotorg , as well as the collaboration efforts between the different actors.

Strategic positioning

According to the analyzed policy documents, Hälsotorg were strategically placed both organizational and physically within the PHC context to provide local citizens with health promotion and disease prevention services; and to help them navigate the health care system using health information and health communication as strategies. Provision of these services was aimed at increasing health literacy and capacity for self-care among the population, which was supposed to reduce pressure on the PHC medical services.

Organizational and physical positioning were identified as important factors shaping health communication practice in PHC. Organizational positioning referred to the placement of Hälsotorg within the PHCadministrative organization. According to the National Pharmacy Action plan, placing Hälsotorg within the PHC and the pharmacy organizations was a strategy to profile health promotion and disease prevention services in order to involve local citizens in a health dialogue, help people manage their health problems and stay healthy. The Pharmacy, which already had counseling services and a large flow of mainly healthy customers, could play an important role in promoting health at population level in collaboration with PHC. The county council plans also highlighted the importance of adopting a health promotion approach and the creation of a supportive environment for health within the health care services. Hälsotorg was pinpointed as an important setting for realization of these esteemed goals in the first plan (2007–2009) but was not mentioned in the second plan (2008–2010).

PHC was associated with being sick in most people’s minds, according to DNs. ‘Healthy people’ rarely visited PHC, a statement that was echoed by immigrant informants and Hälsotorg visitors. They only contacted or visited PHC when they were ill, prior to their knowledge of Hälsotorg’s existence. The most frequent visitor was a middle-aged woman or an elderly male pensioner with multi-health problems. Some of the health personnel perceived the clientele as being the ‘wrong type’ for health promotion interventions. They expressed a wish to relocate Hälsotorg in order to attract a ‘younger’ and healthier clientele. As expressed below

"“ It is perhaps about the kind of people who walk through our walls (referring to the PHC building)… am I being mean? It is the wrong target group. I feel like…maybe we ought to go to schools, year 7, 8 9, those are the ones we should be aiming at” (FG 2)."

However, not all health personnel held the same view. Some regarded the placement of Hälsotorg within PHC context as perfect as related by other health personnel

"“ …we cannot only target the healthy, we have an obligation to help those who already experience ill health like those with diabetes, they really consume a lot of resources and the best place to “capture” them is in PHC where they come for regular controls. If we can help them prevent further health deterioration like kidney failure, then it is worth the effort” (FG2)."

In ambition to reach out to a larger and ‘different’ audience with health communication, Hälsotorg personnel conducted ‘ Hälsotorg on wheels week’ where they set up camps in the town centre and offered their services to the general public, a move that was much appreciated by both the personnel and the public, according to Hälsotorg personnel’s own documentation. The DNs’ opinion about the positioning of Hälsotorg was not shared by informants in FG 3, who regarded Hälsotorg’s positioning to be the best location to intercept people suffering from minor health problems with services geared towards primary and tertiary disease prevention.

DNs in the focus groups (FG1 and 2), indicated that the organization leadership promoted the image of PHC as a setting for ‘sick care’ through policies on the physical environment of the clinics. An example given by informants was a policy where no posters or information leaflets with health information were allowed in the GP waiting rooms while it was allowed in the CHS and Hälsotorg. This differentiation caused frustration among the personnel, as one of them expressed:

"“Sometimes, I feel like we could be more proactive and put up information pamphlets and posters on HEALTH! But no, we are not allowed, no reasons or discussions! ”(FG2)."

Another informant suggested that the PHC management thwarted their efforts to use health communication proactively, expressing disappointment as follows:

"“.we don’t have notice boards here, I tried to put up some notices on health promotion activities but was summoned and told that I cannot do that by the management!…I don’t understand how they reason” (FG 5)."

Physical positioning refers to the placement of Hälsotorg in the entrance hall of a PHC and/or a Pharmacy or a hospital. Field study observations revealed that Hälsotorg’s physical position made it easy for people to stop by and discuss health concerns, obtain help to navigate the health system e.g. to find the appropriate health clinic at which to seek help. On arrival at the Hälsotorg , curious passersby and referral patients from PHC were introduced to a variety of free services offered. These included universal health information, individual health counseling and access to trustworthy Internet-based health information sites for health promotion .

For visitors with a high risk for lifestyle-related diseases like diabetes and cardiovascular diseases, disease prevention services such as hypertension control, lifestyle tests and group physical activities were offered. The most popular group activity was aerobics for people with physical disabilities.

A disadvantage of the openness of Hälsotorg , was the surrounding noise and lack of privacy during consultations and individual counseling. This was observed during field studies and later acknowledged by the informants. The noise often led to irritation and disgruntlement, thereby affecting the quality and outcome of the sessions. Hälsotorg personnel expressed that the planned Hälsotorg channel would partly solve this problem:

"“This virtual Hälsotorg channel can be good for us; it presents a totally new way of planning individual counseling we can offer a quieter, individual based counseling in the comfort of their homes” (FG 3)."

Adding that the privacy presented by the VHT would enable them to increase the range of services offered to their clients as follows:

"“We can even put up programs (in VHT) where clients can work at their own pace and convenience, without stress or worrying about being disturbed” (FG 3)."

Collaborating for health communication

Collaboration within and outside the health care services such as NGO’s, churches, local communities and municipalities was highlighted as very important for promoting health and providing a supportive environment for health (County Council plan 2007–2009). Hälsotorg was specifically pointed out as a significant converging arena for the different actors to collaborate in creating a supportive environment to achieve health services’ health promotion goals, a setting for communicating health with both patients and local citizens (ibid).

Locating Hälsotorg within the organizational and physical boundaries of health care services resulted in successful collaboration between different professionals and health care organizations for many years, according to the informants and document analysis. Informants acknowledged that making use of the available resources within the different sections of the PHC organization would benefit patients/visitors especially, in health services where lack of resources and time constraints was the norm. However, different structural and organizational factors served as facilitators or obstacles to collaboration efforts. Three categories; interests , resources and trust were identified as factors affecting collaboration efforts and thereby health communication for health promotion purposes.

Collaboration between organizations/professions depended on shared common interest in terms of either the same target group and / or similar organizational demands. PHC organization in this study was made up of specialized units; CHS, GP and DN consultation. Each unit was allocated resources to work with specific or prioritized target groups. Hälsotorg personnel expressed a feeling of marginalization, which they attributed to the fact that they targeted ‘healthy clients’ as opposed to sick/ill patients targeted by the other PHC units. During the field study it was noted that Hälsotorg personnel unsuccessfully tried to enlist the help of DNs with special competencies such as diabetes or incontinence, to give a public lecture at Hälsotorg . Promoting health was conceived as ‘non-urgent’ and was not prioritized, which explained the difficulty of establishing collaboration with Hälsotorg .

Organizational demands of “need-based” prioritization resulted in prioritization of curative and risk-disease prevention in most PHC units. External organizational demands such as national directives and policies were also cited by health personnel as factors affecting interests and, thereby collaboration. For example prioritization of child and geriatric health in the policy years 2008–2010, led to PHC units prioritizing collaboration around these two target groups. Since Hälsotorg did not have a specified ‘target group,’ it experienced difficulties finding collaborating partners in PHC. In an effort to bridge the gap between Hälsotorg and the other PHC units, all the hypertension controls were relocated to Hälsotorg . This was a decision that was not popular among Hälsotorg personnel as it was seen as ‘medicalization’, of their services, as expressed below:

"“…it undermines the whole purpose of my work…I don’t mind them coming but I have to document in their medical journal…I have to talk about their medical history, diseases…that becomes the focus!…Hälsotorg becomes the extended arm of their medical clinic..” (FG5)."

Availability of resources was identified as pre-requisite for communicating health to the public. However, resources were scarce in PHC according to the health personnel. Thus lack of or poor collaboration between different professions and organizations was attributed by the DNs to the scarce resources. Two types of resources were identified from the data: time and economy. Lack of time was attributed to a high workload and little time allocated to each patient, often ageing and multi-morbid patients. However, some DNs suggested that unwillingness to think ‘outside the box’ and negative attitudes towards collaboration more than workload contributed to poor collaboration. Lack of economic resources was also cited by health personnel as a hindrance towards engaging in activities outside the prioritized areas. Health personnel pointed out that they operated on a tight budget, with constant cutbacks which forced them to focus on ‘their’ areas of responsibility.

Trust was identified as an important collaboration factor in and for health communication between health personnel and visitors; and between health personnel in different PHC units. Hälsotorg visitors related that they came to Hälsotorg and took part in the activities because they had confidence in the professionals who worked there. The information they received was perceived as trustworthy, correct and evidence based as it came from a health care authority. DNs in other PHC units also expressed that it was easier to collaborate with Hälsotorg when it was managed by ‘one of them’, meaning a DN

"“…We try to refer our patients to Hälsotorg they are not used to it but we explain that it is one of our own that will help them and the only difference is that there are no medical records. Once they hear they’ll meet a District Nurse, they go willingly…” (DN 8)."

The planned VHT was regarded as an opportunity to overcome some of the collaboration obstacles faced by health personnel. According to health personnel, VHT could be a converging “virtual space” where PHC units could work together but at the same time profile their specific services and communicate with respective target groups.

The aim of this study was to gain a better understanding of health communication for health promotion and factors affecting such communication in a PHC setting, as a first phase for developing the ‘Virtual Hälsotorg’ (VHT), an interactive health channel. According to Kreps [ 8 ], understanding the context is central to planning of health communication interventions, especially within the health care services, where a myriad of individual, organizational and societal factors influence health related decisions and practice. Findings from this study highlight the interrelation between individual and organizational factors, tools and strategies that affect framing of health communication and, how health communication is communicated, received and understood. These factors need to be addressed by researchers and PHC actors in the planning and designing an ICT mediated health channel for health promotion [ 8 , 24 ], to achieve its goal of improving health literacy [ 4 , 14 ], and to realize the national public health goal of re-orienting health care services into a more health promoting services [ 18 ].

PHC in this study is expected to act as a single organization; working towards the same goal of preventing diseases and promoting health for individuals and the community, according to the health policy documents. However, analyses show that the studied PHC faces challenges of catering for a clientele of different ages and health status, as well as serving both individuals and the community as a group. Furthermore, the PHC units were assigned different target groups and adopted different strategies for health communication, making it difficult to achieve the cohesive organization and stated goals. This study therefore highlights a discrepancy between what is stated in policy documents and expressed intentions by health personnel, from the health communication in practice at the PHC.

Collaboration between different actors within and outside the health care settings is an important principle in health promotion. to increase effectiveness and validity of programs [ 41 ]. Division of the PHC into specialized units, each with a given target group, ear marked resources for the target group and prioritization were important factors in contributing to the poor adaptation of a health promotion approach in PHC. This demarcation affected content of, and approaches to health communication as well as collaboration between the different PHC units and other partners. Similar results were reported in Johansson et al. [ 42 ], where health personnel exhibited both the will and skills for promoting health but lacked the chance to implement them due to perceived lack of opportunity or support from the organization. Thus, organizational structures play an important role in creating a supportive environment to enable integration of health promotion [ 43 ]. Health promotion in the PHC studied was regarded as a non-urgent service and as such was not prioritized, which confirms findings from earlier studies showing that health promotion in PHC is sidelined from the rest of PHC activities [ 42 - 44 ].

Health personnel in PHC possess competencies of working with a range of strategies, tools and types of health communication; competencies that could contribute to better ICT based health communication channels such as the planned VHT. DNs in this study have experience of, and skill for working with individual counseling, knowledge and experience that can be used to inform the design of interactive services of the VHT channel; such as tailoring of health information to better suit the intended end users. Tailoring of health information is believed to be one of the most effective strategies for health promotion and lifestyle-changing interventions [ 23 , 45 , 46 ].

The results also revealed a need for skills development in health promotion approach among health personnel in this study. Majority of informants equated health promotion to primary prevention, disease prevention and/or prevention of risk for diseases. Prevention was the dominant approach in health communication strategies and health professionals’ repertoire. This despite policy documents clearly stated the need for a health promotion approach in PHC and Hälsotorg even when working with primary, secondary and tertiary disease prevention. Similarly, health promotion was understood as activities to promote health as opposed to an approach to health promotion . According to Irvine [ 47 ], health professionals in primary care settings, including nurses, lack adequate knowledge to integrate health promotion in their daily work in an effective and planned manner. Thus there is a need to prioritize education and training of health personnel in health promotion knowledge and skills. By involving them directly in the development process of the planned health communication channel, collaborative learning could be facilitated through dialogue between different professionals and lay people.

Allocating Hälsotorg within the PHC context resulted in a symbiotic relationship between Hälsotorg and PHC. Hälsotorg contributed to a more health promoting PHC services through its health promotion activities while PHC’s narrow and “reactive” prevention approach were forced upon Hälsotorg despite protests from Hälsotorg personnel , like the hypertension controls. However, results also show that Hälsotorg and PHC collaborated in the planning and hosting of theme weeks and public lectures despite their differences. Establishment of VHT could benefit from this existing mutual relationship as it aims to promote health by providing accessible and empowering health communication, and creating a supportive environment for health for individuals and the community. VHT could be a potential and ideal converging point for PHC and Hälsotorgs’ health promotion and prevention approaches. This collaboration could further strengthen the PHC’s health promotion ambitions as stated in the policy documents.

DN’s in this study blamed the poor adaptation of health promotion approach in PHC to the lack of support and interest from the management. Similar results were displayed in Johansson et al. study [ 42 ], where health personnel had both the will and skills but lacked the chance to show them due to perceived lack of opportunity or of support from the organization. In this study however, there seems to be contradictions, as participatory observations and meetings with the PHC leadership revealed a willingness among PHC leaders to create infrastructures to improve health communication for the purpose of promoting health. These different perceptions could be the result of the lack of dialogue between PHC leadership and DNs.

According to previous studies [ 19 , 45 , 48 ], trust can be a defining factor for health information seekers ’ use or rejection of the content of health information on the internet. Trust in content and professions were also cited as two most important factors for choosing health communication resources by local citizens in this study. Pilemalm et al. [ 45 ] suggest that involving end users in the design process increases trust among them and thereby probability of their using the system. There is therefore a need to involve all the actors; from PHC managers to DNs in a dialogue during the process of developing VHT; in order to create trust between PHC actors, facilitate sense of shared ownership and sustainability [ 45 , 49 ].

Communicating health is given as an important function in PHC however; results show that there was a lack of synthesis in approaches, strategies and tools to achieve this common goal of promoting health and preventing diseases at individual and community levels. Similarly, empowerment was stated as the ultimate goal of health communication initiatives in PHC but results show that behavior change was the most common approach. Earlier studies have shown that health communication for the purpose of promoting health within health care services, lack a broad socio-ecological health promotion approach [ 8 ]. An approach that is necessary to increase individual and population health literacy in order to tackle the determinants of health and the growing burden of chronic diseases [ 4 , 6 , 8 ]. In order to identify a common health promoting approach and strategies based on health promotion values and principles, a participatory design involving both end users and providers throughout the design process will be used. Participatory design is attributed to contribute to capacity building as participants learn with and from each other while working towards the same goal, making it an appropriate method for development of VHT [ 24 , 45 ].

Data analysis revealed that PHC personnel face a growing challenge of addressing health queries from informed patients and visitors who are more versed with internet use than themselves. In order to meet this, and other future health communication challenges, health personnel need to improve their capacity for using internet-based information [ 19 , 50 ]. Lack of health information in other languages, besides Swedish, is another aspect that needs to be taken into consideration as studies indicate that immigrants generally experience poorer health than native Swedes [ 43 ]. According to the Swedish board of statistics, immigrant communities in Sweden increased from 95750 in 2006, to 96467 in 2011. Prognoses indicate that this trend will continue [ 51 ]. An accessible Internet-based health communication could be a strong motivation for immigrants to seek health information frequently and manage their own health. One of the major challenges to introducing a new technology in PHC is the need to increase the capacity of health personnel’s ability to use ICT resources effectively while paying attention to the eminent risk for contributing to communication inequalities and digital divide [ 19 ]. Equity and inclusion of the needs of non- Swedish speakers will need to be considered by enabling participation of these groups in the design process of health promoting services.

Study strengths and limitations

Use of triangulation of methods and involving other researchers and informants in the data analysis process provided a rich description of the case and context. Furthermore, this study revealed that a multi-method approach unearths more details that are difficult to identify using a single method, for instance, the discrepancy between policy and what is practiced. This provides readers with information to make their own judgments on the study’s applicability in similar contexts, thereby increasing the study’s transferability [ 52 ].

Prolonged participatory observation of three months increased the study’s credibility [ 53 ] and enabled the researcher to study not only what was present but also what was ‘missing’. Two important observations made were; the lack of communication between PHC and Hälsotorg personnel and absence of pharmacy personnel at Hälsotorg [ 34 ]. Participatory observations also gave a detailed documentation of the methodology used for health communication and transparency of decisions, which increases the dependability of this study [ 52 ].

By familiarizing with the target groups, the researcher also gained ‘access’ to the field as well as an opportunity to recruit participants for the continued VHT project. According to Smith et al. [ 40 ], the success of a PAR research project, like the VHT, depends upon the establishment of an environment for trust between the researcher and the subjects of the study. Furthermore, this phase resonated well with the ‘listen’ phase of the STAR model [ 27 ] which entails interacting with the target groups, familiarizing with the context, identifying how target groups interact with technology and carrying out a needs assessment.

A limitation of the study is that it is built on one Hälsotorg and one PHC, and as such, based on a small number of informants. This may have had an impact on the results, as the experiences of the other Hälsotorg have not been explored fully.

Confining the field study to only one Hälsotorg may have narrowed the results as a previous study [ 28 ] showed that Hälsotor g offer different services and some had existed longer than others. However, expanding the case to include workers from the other Hälsotorg , was an effort made in order to compensate for the above mentioned limitations.

Exclusion of GP’s and other health professionals, like dieticians and physiotherapists, from the study is a shortcoming as they could have contributed with valuable information to the study. However DNs, included in this study, was the professional group in PHC who were responsible for health promotion services. Including GP’s was considered, but was not feasible as a majority of the GP’s working at the PHC, at the time of the study, were hired on temporary assignment basis.

This study identified challenges facing the development of health communication for health promotion in PHC. Understanding the opportunities and obstacles for health promotion and health communication in PHC makes it possible to start a dialogue with the different actors identified in the study i.e. health care personnel, PHC managers and local citizens. Engaging the actors in a dialogue could facilitate a consensus on common strategies to overcome the hindering factors and capitalize on the opportunities.

The most significant challenge in developing an ICT supported health communication channel for health promotion identified in this study is profiling a health promotion approach in PHC. To achieve VHT’s health promotion intentions, the development of VHT channel will have to be based on health promotion values and principles of empowerment, participation, holistic and intersectoral approach, equity, sustainability and multi-strategy. There is a need for a shift of focus from individual to a more population- based orientation, placing emphasis not only on people at risk but also directed at health determinants [ 22 , 23 , 25 ]. Furthermore, there is a need for a combination of different strategies, aiming at effective participation of all stakeholders on equal terms, and on professionals taking an enabling role instead of an expert role when communicating with patients/PHC visitors [ 8 , 23 , 45 ]. Finally equity issues need to be addressed through the creation of accessible health communication to improve health literacy [ 14 ], even for non- Swedish speakers as well as those with low literacy [ 53 ]. By addressing these factors in the design of e-Health services, health communication via an ICT supported channel could be health communication for promoting health, i.e. ‘health promoting communication’.

Although this study provides valuable insights to factors that need to be taken into consideration prior to development of an ICT supported health channel, there is a need for further research to better understand the needs for health communication among non-Swedish speakers and to further explore the relationship between the different organizational and social factors affecting health communication.

Abbreviation

ICT: Information Communication Technology; PHC: Primary Health Care; VHT: Virtuellt Hälsotorg’ (Virtual Health Channel); WHO: World Health Organization; STAR: Spiral Technology Action Research; PAR: Participatory Action Research; GP: General Practitioner; DN: District Nurse; CHS: Children Health Services.

Competing interests

Authors declare no competing interests.

Authors’ contributions

AJM, EO and BH contributed to the conceptualization and design of the study. AJM conducted data collection, analysis and drafting of the manuscript. AJM, EO, SE and BH contributed to interpretation of the results and critical revision of the manuscript. All authors have read and approved the final manuscript.

Pre-publication history

The pre-publication history for this paper can be accessed here:

http://www.biomedcentral.com/1472-6947/13/17/prepub

Acknowledgements

This study was part of the ‘Syster Gudrun Fullskalelabb I Blekinge för IT i vård och omsorg’ research and development project (Nurse Gudrun’s full-scale lab in Blekinge for IT in nursing and caring). We would like to thank all the participants who have contributed to this study. We would also like to thank the Blekinge Research Board for generously funding the VHT project. Last but not least, we thank the School of Health Sciences, Blekinge Institute of Technology, for the support and opportunity to work in research.

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Health communication in primary health care -a case study of ICT development for health promotion

Affiliation.

• 1 School of Health Sciences, Blekinge Institute of Technology, Karlskrona, Sweden. [email protected]
• PMID: 23363566
• PMCID: PMC3568410
• DOI: 10.1186/1472-6947-13-17

Background: Developing Information and Communication Technology (ICT) supported health communication in PHC could contribute to increased health literacy and empowerment, which are foundations for enabling people to increase control over their health, as a way to reduce increasing lifestyle related ill health. However, to increase the likelihood of success of implementing ICT supported health communication, it is essential to conduct a detailed analysis of the setting and context prior to the intervention. The aim of this study was to gain a better understanding of health communication for health promotion in PHC with emphasis on the implications for a planned ICT supported interactive health channel.

Methods: A qualitative case study, with a multi-methods approach was applied. Field notes, document study and focus groups were used for data collection. Data was then analyzed using qualitative content analysis.

Results: Health communication is an integral part of health promotion practice in PHC in this case study. However, there was a lack of consensus among health professionals on what a health promotion approach was, causing discrepancy in approaches and practices of health communication. Two themes emerged from the data analysis: Communicating health and environment for health communication. The themes represented individual and organizational factors that affected health communication practice in PHC and thus need to be taken into consideration in the development of the planned health channel.

Conclusions: Health communication practiced in PHC is individual based, preventive and reactive in nature, as opposed to population based, promotive and proactive in line with a health promotion approach. The most significant challenge in developing an ICT supported health communication channel for health promotion identified in this study, is profiling a health promotion approach in PHC. Addressing health promotion values and principles in the design of ICT supported health communication channel could facilitate health communication for promoting health, i.e. 'health promoting communication'.

Publication types

• Research Support, Non-U.S. Gov't
• Community-Based Participatory Research
• Cultural Competency
• Decision Making, Organizational
• Delivery of Health Care, Integrated / organization & administration*
• Electronic Health Records
• Emigrants and Immigrants
• Focus Groups
• Health Communication / methods*
• Health Knowledge, Attitudes, Practice
• Health Promotion / methods*
• Health Services Accessibility / standards
• National Health Programs
• Organizational Case Studies
• Planning Techniques
• Primary Health Care* / methods
• Primary Health Care* / standards
• Professional-Patient Relations
• Program Evaluation
• Social Marketing