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Since the evolution of health communication as a theory and practice, the field has integrated many related concepts from other disciplines into its scholarship and professional practice. As such, scholars have described the field as hybrid and multi-disciplinary. This analysis adopts the explorative framework to discuss the interrelationship of health communication and health literacy, therapeutic communication or patient-provider communication, social and behavioural change communication, social marketing and media literacy. The study is a contribution to health communication scholarship in Nigeria to facilitate better understanding, appreciation and application.
Key Words: Health Communication, Media Literacy, Health Literacy, Social Marketing, Social and Behavioural Communication, Therapeutic Communication.
The multi-disciplinary nature of health communication makes scholars in this domain to build their scholarship engagement around relevant and related concepts from other disciplines. In the process, therefore, health communication has adopted a wide range of related concepts from other disciplines and has the potential to adopt many other emerging concepts in the future to enhance and improve health outcomes among members of communities. The nature of human beings, who are described as an enigmatic whole by philosophers (Berdyaev, 1944; Omatseye, 2003; Pessin, 2002), whose nature continues to generate theories and models among scholars; and the complexities that characterise health as a phenomenon are among other justifications for health communication to adopt various concepts from other disciplines in order to achieve its theoretical thrust and practical purposes. This emphasises why health communication is described as a hybrid and interdisciplinary field of inquiry. This is further reflected in its conceptual framework. For instance, health communication is defined asa multifaceted and multidisciplinary approach to reach different audiences and share health- related information with the goal of influencing, engaging and supporting individuals, communities, health professionals, special groups, policymakers and the public to champion, introduce, adopt, or sustain a behaviour, practice, or policy that will ultimately improve health outcomes (Schiavo, 2007). The United States
Department of Health and Human Services (2000) also defines health communication as the field of theory, research, and practice, which studies and uses communication strategies, methods, programs and interventions as means to inform and influence individual and community decisions to enhance health.
Health communication and other related concepts
Health communication as a field of theory and practice involves interpersonal and mass communication programmes aimed at improving the health of individuals, organisations and larger populations through appropriate health information (Ishikawa & Kiuchi, 2010). In understanding and applying information about health issues, there is need for some basic required skills, which are considered critical, because they have considerable impacts on health behaviours and health outcomes of individuals and the general population (Ishikawa & Kiuchi, 2010). These skills according to Ishikawa and Kiuchi (2010) are now regarded as health literacy skills. Scholarship inquiry in health literacy originates from the field of public health and adult education; and dates back to the 1960s with primary attention on written information and materials about health (Centres for Diseases Control and Prevention, 2009). The field has today grown to cover new areas of research, shifting attention away partly from the hospital settings to the larger communities in order to improve people’s understand and use of health information in daily lives (Centres for Diseases Control and Prevention, 2009).
The central thrust of health literacy as noted above largely reflects its interconnection and interrelationship with health communication. This is further reflected in the fact that “improved health literacy may enhance the ability and motivation of individuals to find solutions to both personal and public health problems, and these skills could be used to address various health problems throughout life. The process underpinning health literacy involves empowerment, one of the major goals of health communication.” (Ishikawa & Kiuchi, 2010, p. 1). Nutbeam (2008) also notes that the interrelationship between poor literacy skills and health status of people in general has now gained considerable recognition. This interrelationship has eventuated to the emergence of the concept of health literacy from two different roots - clinical care and public health.
Furthermore, the relationship between health communication and health literacy formed one of the cardinal objectives of Healthy People 2010 project in 2000 in the United States. Health literacy was identified as an effective health communication strategy to improve the health literacy level of people with inadequate or marginal literacy skills in the United States. This is because people with such limited health literacy skills may not be able to adequately understand health information, even in the presence of access to such information and related services (Ishikawa & Kiuchi, 2010).
However, it is instructive to note that health literacy is an extension of the general concept of literacy. Literacy is conceptualised as the ability to read, write, and speak a language in the service of understanding and solving problems with sufficient proficiency to function at work and in society, to achieve goals, and develop knowledge and individual potential (United States Congress, National Literacy Act of 1991, cited in Ishikawa and Kiuchi, 2010). Therefore, health literacy simply denotes the application of literacy skills in health context to enhance healthy living of individuals and general population. Several studies have found significant relationship between low literacy and low health literacy (Hayes et al., 2007; Ishikawa & Kiuchi, 2010; Nutbeam, 2008; Parker, 2000).
Other studies have reported people with a low health literacy level as being prone to various health problems, including longer and more frequent hospitalisations and chronic health conditions (Cuban, 2006; Institute of Medicine, 2004; Nutbeam, 2008; Weiss & Palmer, 2004). Inability to understand physician’s explanations of their conditions (DeWalt, Berkman, Sheridan, Lohr, & Pignone, 2004; Kalichman et al., 2000; Schillingen Bindman, Wang, Stewart, & John, 2004), and non-compliance with prescribed treatment, self-care regimens, making more medication or treatment errors, and lack of the needed skills to navigate the healthcare system (Weiss, 1999) are other manifestations of low health literacy.
Broadly speaking, the concept of health literacy has been variously defined by different scholars. Though most of these definitions are varied in scope, they reflect the general concept of literacy as the foundation springboard. However, it is argued that there is yet to be a universally acceptable definition of health literacy, various attempts by different scholars and health agencies have enhanced the understanding and application of the concept beyond the hospital environments (Chinn, 2011; Ishikawa & Kiuchi, 2010). According to the United States Department of Health and Human Services (2000), health literacy refers to the degree of individuals’ capability to obtain, process, and understand basic health information and services needed to make appropriate health decisions. In a broader perspective, the World Health Organisation (2008) defines health literacy as the cognitive and social skills, which determine the motivation and ability of individuals, to gain access, understand, and use information in ways, which promote and maintain good health. Also, the United Kindgom Department of Health (2004) conceptualises health literacy as the capacity of an individual to obtain, interpret and understand basic health information and services in ways that are health-enhancing (Cited in Sihota & Lennard, 2004). The concept is also espoused as our ability to obtain, interpret and understand basic health information and services, as well as our competence and motivation to use such information and services in ways that enhance our health (Kilker, 2000).
From these definitions, certain postulations are advanced, which further justify the interrelationship between health communication and health literacy. Firstly, health literacy theoretically and practically goes beyond focusing on patients and health care consumers in healthcare settings and their understanding of medical information alone. It involves individuals outside the clinical settings and the promotion of health and preventive behaviours in larger communities (Ishikawa and Kiuchi, 2010). Secondly, these definitions indicate that health literacy involves some degree of knowledge, personal skills, and confidence that may bring about changes in personal lifestyle and living conditions to improve personal and community health (Ishikawa and Kiuchi, 2010).
Thirdly, these definitions show that health literacy is important and has the potential to stimulate a more sophisticated understanding of the concept and process of health communication within clinical and community settings. This is because health literacy as variously defined above highlight factors that enhance the effectiveness of a health communication process. These factors include more personal forms of communication and community based educational outreach (Nutbeam, 2008). Finally, it is inferred from these definitions that health literacy also focuses attention on the cognitive elements of comprehending, analysing, and applying health information and messages to make decisions on health matters (Ishikawa and Kiuchi, 2010).
In summary, health literacy is a component and an outcome of the whole process of health communication. This is because health literacy is regarded as an asset to be built and to be achieved through health communication and health education (Nutbeam, 2008). Consequently, a greater empowerment in health decision making process for individuals and populations is achieved (ibid). It is also argued that the effects of poor health literacy can be mitigated by improving the quality of health communications and greater sensitivity among health professionals, individuals and the general population. This can be achieved through the application of health communication strategies and health education methods in print, broadcast and electronic communication, as well as improved interpersonal communication between the public and health care providers (Coulter & Ellins, 2007; Pignone, DeWalt, Sheridan, Berkman, & Lohr, 2005).
In the domains of health communication and health literacy scholarship, researchers continue to advocate the advancement and application of health literacy skills through an intensive health communication process. This advocacy is widely advanced because health literacy is a means through which individuals are empowered to enable them control their health and the range of personal, social and environmental determinants of health (Nutbeam, 2008). Low level of health literacy skills among members of societies across the world, including the developed countries like the United States, and its consequences on the health behaviours of people and nations’ economy is another strong justification for advancing the course of health literacy (DeWalt et al., 2004; Nutbeam, 2008). Nutbeam (2008) puts this into a clear perspective that “data from many developed nations show a relationship between low health literacy level and declining use of available health information and services” (p. 2073). This is reflected in low responsiveness to health education, poor use of disease prevention services and poor selfmanagement of disease (DeWalt, Berkman, Sheridan, Lohr, & Pignone, 2004).
Institute of Medicine (2004) also argues for the advancement of health literacy in its popular national study conducted in the Unites States on health literacy. The study indicates that almost 50 percent of all United States adults or approximately 90 million people have difficulties in understanding and acting on health information (Cited in Bendycki, 2008,). Bendycki (2008) further observes that:
These 90 million persons are not simply those persons for whom English is not their first language, but also includes the following subsets: people who only achieve an 8th to 10th grade education; persons who are learning disabled; some of the elderly; a subset of the disabled; and educated persons who are not conversant in “medspeak,” that is the language of the hospital, physician’s office, or the pharmacy. Clearly, the problem of health literacy is not limited to the poor, the medically disenfranchised, the uneducated, or the undereducated. The problem of health literacy is all around us. (p. 32)
This has therefore resulted into a huge financial loss, which also accounts for the concern generated among scholars, to advance the practice of health literacy among members of health profession and members of the public. In the United States, for instance, it is found that low functional literacy was responsible for a huge additional sum of $32 billion to $58 billion dollars in healthcare expenditures in 2001 (Friedland, 2002). Further, low health literacy level costs such a magnitude economic loss of $3.4billion to $7.6billion in Wisconsin State, United States (Vernon, 2009) and the annual cost of low health literacy in the entire United States ranges from $106 billion (lower bound) to $238 billion (upperbound) (Vernon, Trujillo, Rosenbaum, & DeBuono, 2007).
Consequently, for the past few years, health literacy has become a major area of research in health care delivery among health professionals and scholars in health communication. This is because health literacy contributes to health outcomes among people (Mackert, Ball, & Lopez, 2011). Kripalani and Weiss (2006) emphasise the need for physicians to also undergo continuous seminars, workshops on the concept and practice of health literacy. In the process, physicians and other health care professionals will leam and appreciate the need for sharing testimonials from low health literate patients, the need for explaining the link between health literacy and outcomes, discussion on techniques for clear communication, and role-playing exercises to practice clear communication.
However, despite the impacts of health literacy in achieving health outcomes, it is argued that it cannot achieve enhanced health outcomes among members of the public in isolation of society at large. This is because the structural formation and management of society are also important in achieving and enhancing health outcomes of individual members of society (Nutbeam, 2000; Wang, 2000; World Health Organisation, 2008). Therefore, authors like Nubeam (2000) and Wang (2000) have theorised what they called the social determinants framework within which health literacy should be broadly examined. The social determinants framework holds that health literacy should be understood beyond individual health behaviours to investigate how structural factors such as income, education, social exclusion, and social organisation impact health (Nutbeam, 2000; Wang, 2000). This also finds resonance in the fact that the scope of understanding health literacy should be critically expanded to include the ability to access, understand, evaluate, and communicate information on the social determinants of health (World Health Organisation, 2008).
Several studies conducted on public perception of social determinants framework on perceived reasons for poor health and health inequalities indicate that respondents generally acknowledge the impact of structural and material factors on their health. These factors include unemployment, education and environmental pollution on health. However, the study shows that respondents are more convinced that individual behaviours have a greater impact on their health attitudes and behaviours than structural and material factors (see Blaxter, 1997; P. A. Collins, Abelson, & Eyles, 2007; Davidson, Kitzinger, & Hunt, 2006; Eyles et al., 2001; McIntyre, McKay, & Ellaway, 2005; Popay et al., 2003; Reutter, Neufeld, & Harrison, 1999). Therefore, the means through which individuals can attain the required capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions is the role being played by health literacy.
Mayer and Connell (2003) suggest some important points in using health communication to effectively achieve health literacy by health professionals. These include: (1) Admit that health literacy is a problem and that clear communication is critical to successful healthcare, (2) Major points should be limited to things the patient needs to know versus what is nice to know. Summaries provide repetition and emphasis of message, (3) Move from formal to friendly. Adopt a user-friendly tone, using a conversational style and vivid nouns, verbs, and pronouns. Keep technical jargon to a minimum. Write short, declarative sentences and use bullet points for lists, (4) Give priority to patient action and motivation, (5) Avoid jargon, unnecessary background information, and statistics, (6) Long sentences should be simple in structure, (7) Use active rather than passive voice when communicating, (8) Think about your target audience and remember that you are writing for these individuals (Cited in Bendycki, 2008, p. 35).
The media explosion of the 21st century as a result of the emergence of information communication technologies has largely re-defined many aspects of human endeavours - education/academia, business and economy, politics, sports, environments, arts and cultures, health and so forth. This has consequently, led to the pursuance and acquisition of certain general and specialised knowledge and skills. These skills empower people with the required capacities, competencies and capabilities to cope effectively in this century. One of these competencies is media literacy. The media saturated and information explosive world that we currently live, necessitates the need for media literacy, especially people of young age. This will enable them with the competencies required to deconstruct media contents for better use. People of this age, especially young people, have demonstrated a media-driven lifestyle over time. This is the reason why Prensky (2001) describes young people as the N- or net generation, D- or digital generation, the millennial generation, or “digital natives.
Therefore, media literacy, which is regarded as a relatively new approach, has been developed by scholars in the field of media studies as a means of empowering young people, in particular, to be critical in their media viewing habit. Media literacy enables media audiences to critique media messages in order to make good and informed decisions about their health and other issues affecting their lives (J. A. Brown, 1998). People in general, especially the adolescents, are immersed in the popular media - television, newspaper, movies, music, teen magazines, books, the Internet (J. A. Brown, 1998) and are media-driven in their social quests, tastes, choices, automobiles, relationships and general life pattern (Bello, Adejola, & Adebimpe, 2013). It has now been realised that media literacy is as important as the classics in teaching cultural norms and expectations (J. A. Brown, 1998). This is because the skill of coping with mass media messages is of utmost importance, and it is not necessarily a simple one to master. It is much more than booting up the computer, turning on the television set, or flipping the pages of magazines and newspapers (Baran, 2009). Rather, “it is indeed, a leamable skill, one that can be practised; this skill is media literacy, the ability to effectively and efficiently comprehend and use any form of mediated communication.” (Baran, 2009, p. 29).
Several studies have identified mass media as a super peer for general populations, including young people, glamorising them with a heap of information to enhance desirable health behaviours and health outcomes (J. D. Brown, Halpem, & L’Engle, 2005; Selkie, Benson, & Moreno, 2011). Prensky (2001) further contends that through mass media, people of young age in the contemporary times are undergoing another dimension of socialisation process that is significantly different from that of older generations. This makes mass media to be ranked topmost among the most important socialisation agents, which exert a greater influence on the health behaviours of young people (Strasburger & Wilson, 2002).
On the contrary, many authors have also found that the media increasingly enhance the aggression level of young people, their sexual behaviour, body satisfaction and eating disorders, as well as alcohol use and cigarette smoking (J. D. Brown & Cantor, 2000; Lenhart, Purcell, Smith, & Zickuhr, 2010). In other words, it is argued that the media also do more harm to young people, considering the explosive amount of general and health information available in the media and the inability of young people to choose relevant information from appropriate sources (Gray, Klein, Noyce, Sesselberg, & Cantrill, 2005). This is because they lack the required skills and cognitive requirements needed to critically evaluate and interpret the usefulness of the mixed messages about health received from the media on one hand (Bergsma, 2011; Gray et al., 2005), and the lack of emotional maturity to consult appropriate authorities - family, teachers, friends, or medical experts for proper guidance once they have accessed health information, on the other hand (Ettel, Nathanson, Ettel, Wilson, & Meóla, 2012).
Given this situation, media literacy training has been identified as an effective catalyst for self-efficacy and agency among digital natives and the general population in order to understand the inner workings of health messages in the media (Jackson & Barnes, 2013). Media literacy is conceptualised as a systematic process that empowers citizens and transforms their passive relationship with media into an active, critical engagement capable of challenging the traditions and structures of a privatised, commercial media culture, and finding new avenues of citizen speech and discourse(Bowen, 1996, cited in Bello, Adejola & Adebimpe, 2013). Further, Tallim (1993) defines media literacy as the process through which media audiences are empowered with the ability to sift through and analyse the media messages ranging from music to video and web environments to product placements in films and virtual displays through critical thinking skills. “It is about asking pertinent questions about what is there, and noticing what lies behind media production- the movies, the money, the values and the ownership- and to be aware of how these factors influence contents” (Tallim, 1993, citedin Belloetal.,2013, p. 118).
Furthermore, media literacy is conceptualised as the ability to access, analyse, evaluate and communicate information in a variety of formats, including print and nonprint, which transforms audience from merely recognising and comprehending information from the media to the higher order of critical thinking skills implicit in questioning, analysing and evaluating that information (Considine, 1995). Therefore, media literacy is principally concerned with empowering media audiences to develop an informed and critical understanding of the nature of the media, their techniques and the overall impact of these techniques (Ontario Ministry of Education Canada, 1989). Media literacy, an outcome of media education, is regarded as an extended information and communication skill responsive to the changing nature of information in our society. It further emphasises the skills students need to be taught in school; the competencies citizens must have as they consume information in their various homes and living rooms, and the ability workers must have as they move on in the 21st century and the challenges of a global economy (Considine, 1995)
Centre for Media Literacy (n.d) postulates that the heart of media literacy is an informed inquiry, which is premised on a four- step inquiry process of awareness, analysis, reflection, action, through which young people can be empowered with media navigating skills. This informed inquiry process makes media literacy an alternative to censoring, boycotting or blaming the media. Media literacy is deeply committed to freedom of expression, and its strength lies in its ability to inspire independent thinking and foster critical analysis among media audiences in order to make wise choices (Centre for Media Literacy, n. d). Thoman (1995) further notes that media literacy involves three different stages of a continuum leading to media empowerment. The first stage is the consciousness and awareness of individuals to appreciate the importance of managing their media diet - that is, making choices and reducing the time spent with television, videos, electronic games, films and various print media and all forms of media in general.
The author states that the second stage is learning specific skills of critical viewing. In other words, it is learning to view media contents with critical mind, analysing and questioning what is in the frame, how it is constructed and what may have been left out. These skills according to Thoman (1995) are best learned through inquiry-based classes or face to face interactive group engagements as well as from creating and producing one’s own media messages. Media audiences need to move above what lies in the frame to deeply explore issues among which are: who produces the media that we experience- and for what purpose? Who profits? Who loses? And who decides? This is what Thoman (1995) postulates as the third stage of media literacy. This stage takes a more critical approach as it involves social, political and economic dimensions and analysis on how media audiences make constructive meanings from their media experiences, and how the mass media drive the global consumer economy. This inquiry can sometimes set the stage for various media advocacy efforts to challenge or redress public policies or corporate policies (Thoman, 1995).
In the domain of health communication, media literacy is being applied as a means of empowering and helping media audiences, especially young people, to see that the media are in the business of selling them products and behaviours that often are not good for them. This view makes media audiences to be more critical of what they read and watch so that they are less likely to engage in unhealthy behaviours promoted in the media (J. D.Brown, 2006). This framework has increased the volume of studies that advocate the application of media literacy in health communication process and campaigns, as well as the intersection of media literacy and health communication (Jackson & Barnes, 2013). It is further contended that it is better to concentrate on the media consumers rather than the source of the message (the media) because affecting or changing media contents is a difficult proposition given the commercially-driven and liberalised media landscape that operates across the world (J. D. Brown, 2006).
Though health care advocates, health communication practitioners and governments have succeeded in the past in changing media contents. An example is cigarette advertising, which was banned on radio and television, in the past years through regulatory mechanisms. However, while efforts are on to persuade the media to provide healthier contents for media audiences, the most effective and prudent approach is to use media literacy to reduce the potentially harmful effects of the media on adolescents’ health (J. D. Brown, 2006). Therefore, there have been several bodies of literature examining how media literacy (critical-thinking) skills have been used for preventing unhealthy behaviours, reduction of health risks among adolescents and wise use of media contents (see Austin & Johnson, 1997; Bergsma, 2004; Bergsma & Ingram, 2001; Wade, Davidson, & O’Dea, 2003). Further, “the constructs of empowerment education in media literacy and health promotion interventions deal with building individual resistance to unhealthy messages by inculcating critical-thinking skills (inquiry).” (Bergsma, 2004, p. 153). Similarly, “many of the studies on the effectiveness of health-promoting media literacy education conclude that media literacy education has a significant potential to promote healthy knowledge, attitudes, and merits further study”(Bergsma, 2011, p. 27).
One of the major themes in public health campaigns, which also remains a core issue in health communication inquiry and practice, is the health behaviour of members of society. Several studies have underscored the significance of health behaviours in public health issues and the need for individuals to maintain good health behaviours. This is considered important for individual members of society in order to achieve healthy living rather than attributing health problems to environmental factors alone (see Blaxter, 1997; P. A. Collins et al., 2007; Davidson et al., 2006; Eyles et al., 2001; McIntyre et al., 2005; Popay et al., 2003; Reutter et al., 1999). Therefore, “many of the significant challenges we face in public health require that individuals change their behaviours as part of the solutions. Barriers to behaviour change, whether known or unidentified, compound these challenges even more. Robust social marketing practice offers significant promise to overcome these impediments to improving the public’s health” (Daniel, Bernhardt, & Eroglu, 2009, p. 2120).
Social marketing, which developed in the realm of marketing research and scholarship (Andreasen, 1994), specifically focuses attention on the development and integration of marketing concepts and principles to influence or change behaviours that benefit individuals and communities for greater social goods (ibid). It is observed that the rapidly changing landscape in the field of health communication in the last few decades has evolved from one unidirectional approach of relying on public service announcements to better sophisticated approaches. One of these better sophisticated approaches is social marketing, an extension of commercial marketing (Weinreich, 2010). Rather than disseminating information in a top-down approach, public health professionals now focus their concern on the needs and desires of the target audience or consumers. This is facilitated through an in-depth research before embarking on health campaigns. This approach defines the very essence of social marketing (Weinreich, 2010).
Furthermore, Andreasen (1994) strongly contends that for better appreciation and application of social marketing in relevant domains, it is fundamental to share a clear understanding of the concept through adequate and scholarly definitions. The author conceptualises social marketing as the adaptation of commercial marketing technologies to programmes designed to influence the voluntary behaviours of target audiences to improve their personal welfare and that of society of which they are a part. The first and formal conceptualisation of social marketing was attempted by Kotier and Zaltman (1971). According to the authors, “social marketing is the design, implementation and control of programs calculated to influence the acceptability of social ideas and involving considerations of product planning, pricing, communication, distribution, and marketing research.” (p. 5). Kotier and Roberto (1989) further postulate that social marketing is "an organised effort conducted by one group (the change agent), which intends to persuade others (the target adopters), to accept, modify, or abandon certain ideas, attitudes, practices, and behaviours" (p. 6).
In summary, the ultimate goal of social marketing is "social good" for the benefits of members of society, while in "commercial marketing," the aim is primarily "financial." Social good in this context are framed to include: health, welfare and environmental sustainability (Aiden, 2010). Hence, social marketing has been identified as an applied approach built on the principles and perspectives of commercial marketing to achieve social goods. Social marketing is used by health advocates to understand and unravel complex public health issues by focusing on how consumers (members of the public) relate with services as well as products that enhance public health. The central thrust of social marketing is the notion of voluntary exchange, whereby individuals willingly adopt products, ideas and behaviours that can enhance their health (Daniel, Bernhardt & Erog“ lu, 2009). The application of social marketing approach in health communication campaigns has been identified as resulting into a stronger and more permanent behaviour changes (French & Blair-Stevens, 2007). In the recent past, other exponents of social marketing have advocated its application beyond the operational or traditional level, which focuses on achieving behavioural change. In other words, they have also called for strategic application of social marketing to inform and affect policy formulation for strategic development to enhance social goods (Lefebvre, 2013).
Historically, the evolution of social marketing dates back to the 1950s, though without the term “social marketing.” (Wiebe, 1951-1952) proposed a rhetorical question similar to the approach of social marketing, which underpins the intersection of marketing and society. Wiebe (1951-1952) asked, "why can’t you sell brotherhood and rational thinking like you can sell soap?” The author identified some challenges in selling social good as if it were a commodity. Over a decade later, the work of Simon (1968) followed and expanded the effort of Wiebe on social marketing. Simon (1968) approached family planning campaigns through marketing approach, yet without the term “social marketing” (Cited in Andreasen, 1994). The supreme scholarly engagement on the evolution of social marketing as a field of study was marked with the publication of the classic article of Kotier and Zaltman in 1971, where the term social marketing was coined and made its debut in the literature. The article was titled “Social Marketing: An Approach to Planned Social Change” and published in the Journal of Marketing in 1971.
Kotier & Ziltman (1971) conceptualise social marketing “as the design, implementation and control of programs calculated to influence the acceptability of social ideas and involving considerations of product planning, pricing, communication, distribution, and marketing research.” (p. 5). The authors conclude that social marketing is an applied field that represents a bridging mechanism, which links the behaviours scientist's knowledge of human behaviour, with the socially useful implementation of what that knowledge allows. (B. Brown, 1986) however, underpins major factors that contribute to the emergence of social marketing. He argues that it (social marketing) is a natural outgrowth of several developments in and out of marketing, including the following: (1) Increased needs of non-business organisations for marketing services (2) Attacks on marketing's negative impact on society (3) The emergence of exchange theory (4) The coalescence of social marketing oriented theory, and (5) The decline of consensus-oriented perceptions of social reality.
Lefebvre (2013) notes that since the 1980s, there have been effective and wide applications of social marketing to address myriad of social issues, including, improving the quality of health care, disaster preparedness and response, ecosystem and species conservation, patient-centred health care, active living communities and environmental issues. Other areas social marketing application are global threats of antibiotic resistance, sanitation demand, reducing health disparities, government corruption, injury prevention, landowner education, marine conservation and ocean sustainability, sustainable consumption, transportation demand management, water treatment systems and youth gambling problems (ibid).
Social marketing effectively became an integral part of public health communication campaigns since the 1980s, (Roccella & Ward, 1984). For instance, the National High Blood Pressure Education Program and the Community Heart Disease Prevention Studies in Pawtucket, Rhode Island at Stanford University in the United States confirmed the effectiveness of social marketing approach in addressing population-based risk factors and behaviour change (Lefebvre & Craig, 1988). Furthermore, early adoption and application of social marketing into health communication of public health issues took place in the State of Victoria in Australia in 1988. The Victoria Cancer Council developed its anti-tobacco campaign "Quit" and "SunSmart"; and "Slip! Slop! Slap!" campaign against skin cancer. These campaigns were launched in 1988 with landmark results (Victorian Health Promotion Foundation, n.d.). Another example of the application of social marketing in a public health communication campaign is the "Choosing Health," which was launched in the United Kingdom in 2004 (United Kindgom Department of Health, 2004).
Generally, the application of social marketing approach into public health communication campaigns has witnessed rapid growth and expansion, covering a wide range of health issues such as HIV/AIDS prevention, provision of basic health services, point-of-use water sanitation methods, control of childhood diarrhoea (through the use of oral re-hydration therapies) and malaria control and treatment (Lefebvre, 2011). Social marketing practice in public health campaigns is now progressing in many countries of the world. Some of these countries include: Australia, Canada, the United States of America, New Zealand and the United Kingdom (United Kingdom Department of Health, 2004).
Social marketing has been widely applied in the area of community public health since its introduction in the late 1980s (Lefebvre & Flora, 1988). Lefebvre and Flora (1988) postulate that to achieve a large scale and broad-based approach in behavioural change for an improved public health system; social marketing is central. The scholars, therefore, espoused eight important components of social marketing, which have become popular in public health campaigns across the world. These components are highlighted below.
(i) A consumer orientation to realise or achieve social goals.
(ii) ii. An emphasis on the voluntary exchanges of goods and services between providers and consumers.
(iii) Research in audience analysis and segmentation strategies.
(iv) The use of formative research in product and message design and the pretesting of these materials.
(v) An analysis of distribution (or communication) channels.
(vi) The use of marketing mix- using and blending product, price, place and promotion characteristics in intervention planning and implementation.
(vii) A process tracking system with both integrative and control functions.
(viii) A management process that involves problem analysis, planning, implementation and feedback functions.
Considering the social psychological dimensions of human behaviours and the need to improve these behaviours to achieve good health outcomes, a branch of social marketing has emerged. This is called community-based social marketing (CBSM). This branch of social marketing was propounded by a Canadian environmental psychologist, Doug McKenzie-Mohr, who postulates that community-based social marketing is inevitable as a systematic way to foster more sustainable behaviours among community members in achieving good health outcomes (McKenzie-Mohr, 2000). Community-based social marketing emerged in order to change or improve the behaviours of communities for the purpose of reducing their impacts on the environment (McKenzie-Mohr, 2000). McKenzie-Mohr (2000) further states that:
Community-based social marketing has been shown to be quite effective at fostering sustainable behaviours. Its effectiveness is due to its pragmatic approach, which involves the following steps: carefully selecting an activity to be promoted, identifying barriers to the activity, designing a strategy to overcome these barriers, when possible, piloting the strategy with a small segment of a community, and finally, evaluating the impact of the program once it has been implemented across a community, (p. 532)
Essential tools for community-based social marketing according to McKenzie-Mohr (2000) include: piloting and evaluation, focus group, survey and case studies. Other proponents of social marketing have averred that the tools of community-based social marketing have provided useful insights to health advocates, who employ these tools, to foster sustainable behaviours in many areas such as energy conservation (Schultz, Nolan, Cialdini, Goldstein, & Griskevicius, 2007), environmental regulation (Kennedy, 2010), and recycling (Haldeman & Turner, 2009).
One of the essential values of social marketing in general is that, it offers a dynamic model with interconnected activities, which if properly designed, would ensure an effective response to public health problems. These activities are called the marketing mix, which centrally define the whole engagement of a marketing plan (Daniel et al., 2009). The authors state further that:
These elements are called the 4 P’s: product (including services, behaviours, and policy changes), price (what the consumer must “give up” to change), place (environmental and societal context in which health decisions and behaviours occur), and promotion (the provision of information and the appeal to the consumer emotion that makes them want to engage in healthy behaviours), (p. 2120)
In social marketing, the four P’s model has been expanded to include other P’s like policies, partners, packaging, purse strings (Weinreich 2010). This is because “the focus on audience is a basic principle of social marketing given the differences in attitudes, preferences and behaviours, each of the P’s should be designed with the target audience in mind.” (p. 2121). Audience perspective approach has been widely used particularly in addressing HIV/AIDS problem and many other public health issues (Daniel et al., 2009). Social marketing uses effective communication strategies, which rely on formative research. In this case, target audiences are made to understand the context, the issue from their perspective, and factors that influence improved practices. Hence in social marketing, “communication goes beyond the delivery of a simple message or slogan to encompass the full range of ways in which people individually and collectively convey meaning.” (Health Communication Capacity Collaborative, 2009, p. 2). Health Communication Capacity Collaborative (2009) further identifies interpersonal communication system, mass communication, community-based activities and the use of information communication technologies as powerful tools in achieving the goal of social marketing.
Social and behavioural change communication
In health communication discipline, both as a field of inquiry and practice, health behaviour is a central theme. This makes scholars in health communication to focus more on the health behaviours of individual members of society. This approach enables health communication practitioners to understand the attitudes and the dynamics of health behaviours of individuals and communities. In other words, research efforts in health communication over the years have examined the effects of communications and mass media messages on the health behaviours of members of the public. Health communication practitioners, health advocates and health care professionals concentrate efforts on the use of interpersonal communication, mass communication and other forms of communication as viable means to influence, improve and change the health behaviours of individuals and the general population. This is because research has shown that much of health status is dependent on health behaviours rather than medical treatment, prevention and cure (Homik, 2002).
The central nature of health behaviours and the need for an improvement or outright change depending on the context, has led health communication researchers to focus much attention on understanding why people exhibit different health behaviours and how to elicit desirable health behaviours among them. This has resulted into the development of models of health behaviour, which now provide a practical framework for health communication practitioners in addressing many public health issues among members of society (ibid). In addressing the health behaviours of people in general, Homik (2002) identifies three models, which have proven effective in many public health campaigns. According to Honik (2002),
There are three complementary models of behaviour change implicit in many public health communication campaigns. The individual effects model focuses on individuals as they improve their knowledge and attitudes and assumes that individual exposure to messages affects individual behaviour. The social diffusion model focuses on the process of change in public norms, which leads to behaviour change among social groups. The institutional diffusion model focuses on the change in elite opinion, which is translated into institutional behaviour, including policy changes, which in turn affect individual behaviour, (p. 54)
Social and behavioural change communication, which involves these three models of behaviour, has been identified as one of the practical approaches in addressing the health behaviours of people in general (Honik, 2002). Originally known as behavioural communication change, social and behavioural change communication is widely used by health communication practitioners, health advocates and health care professionals in addressing the behaviour change of members of society. This is to allow members of the public increase and control their health habits. Enhanced health outcomes at individuals’ levels and communities are achieved through the interplay of biology and social determinants such as knowledge, attitudes, norms and cultural practices, which are captured by the framework of social and behavioural change communication (Health Communication Capacity Collaborative, 2009). The fact that behavioural change is central in achieving enhanced health outcomes, has made many health promotion efforts to focus attention largely on health behaviours with the use of the most powerful and fundamental human interaction- communications that positively influence these social dimensions of health and well-being. This is what is now referred to as social and behavioural change communication (Health Communication Capacity Collaborative, 2009).
Through social and behavioural change communication, tens of millions of people change their health habits and other lifestyle aspects every year (Jenkins, 2003). This is because health communication and health promotion campaigns focus attention on “both individual and family behaviours as well as healthy public policies in the community that protect a person against numerous health threats and elicit a general sense of personal responsibility for maximizing one’s safety, host resistance, vitality, and effective functioning.” (Jenkins, 2002, p. 6). Homik (2002) also notes that there has been a consistent behavioural change in the health lifestyle of many people in the contemporary world, and this is largely attributed to public health communication that integrates social and behavioural change communication and normal media coverage of health issues.
Behavioural change communication, now known as social and behavioural change communication (Leclerc-Madlala, 2011) is defined as a research-based consultative process of addressing knowledge, attitudes and practices through identifying, analysing and segmenting audiences and participants in programmes by providing them with relevant information and motivation through well-defined strategies, using an audienceappropriate mix of interpersonal, group and mass-media channels, including participatory methods (United Nations Children’s Education Fund, 2013). The locus of social and behavioural change communication is how to affect the health behaviours of individual members of society. This is what Singhal (2003) likens to a metaphorical tree (individual members of society) in the entire forest (society at large). The author contends that individuals’ attitudes and behaviours are largely essential in achieving good health outcomes in society,rather than harmful cultural values, societal norms and structural inequalities. This view is also supported by other scholars who state that:
The explicit emphasis on behaviour change as an outcome helped to highlight the need for a thorough understanding of the full range of determinants, both internal and external factors, to understand why people do what they do and how to facilitate healthy options, decisions and support. These determinants could include knowledge and attitudes as well as many other factors elucidated in theories such as access to services, emotions, real and perceived consequences, social support (Glanz, Rimer & Viswanath, 2008, 23)
According to Glanz, Rimer, and Viswanath (2008), behavioural change communication is an evidence- and research-based process of using communication to promote behaviours that lead to improvements in health outcomes. Behavioural change communication intends to foster necessary actions in homes, communities, health facility or society at large. This is to improve health outcomes, promote healthy lifestyles and to prevent the impact of health problems using an appropriate mix of interpersonal, group and massmedia channels (Glanz, Rimer & Viswanath, 2008).
The fact that human behaviours cannot be isolated from the socio-ecological system within which we live and interact has made scholars to later advance the nuances on behavioural communication change to what they now term social and behavioural communication change. As rightly observed, behavioural change communication efforts have concentrated much on individual behaviour change given that the commonly applied models emphasise individuals as subjects of concern (Storey & Figueroa, 2012). However, Leclerc-Madlala, (2011) notes that human behaviours are sometimes products of subcultures and reflection of a particular socio-ecological context. This submission makes a change to require support from multiple levels of influence, resulted in an expansion of the approach to become social and behaviour change communication (SBCC) (Leclerc-Madlala, 2011).
In other words, the addition of ‘social’ to behavioural change communication is considered as an advancement on BCC in order to make public health communication approach systematic and socio-ecological within communication initiatives (Leclerc- Madlaha,2011). This is because individuals and their immediate social dynamics are dependent on the larger structural and environmental systems, which require social change approaches that can focus on both the individuals and the community as the unit of change (United Nations Children’s Education Fund, 2013). Hence, it is postulated that:
Social and behavioural change communication for health is a research- based, consultative process that uses communication to promote and facilitate behaviour change and support the requisite social change for the purpose of improving health outcomes. To achieve social and behaviour change, SBCC is driven by epidemiological evidence and client perspectives and needs. SBCC is guided by a comprehensive ecological theory that incorporates both individual level change and change at broader environmental and structural levels. Thus, it works at one or more levels: the behaviour or action of individual, collective actions taken by groups, social and cultural structures, and the enabling environment. (The Manoff Group, 2013, p. 4).
It is therefore contended that evidence-based communication approach like social and behavioural communication has the required potential to increase knowledge, shift attitudes and cultural norms to produce changes in a wide variety of behaviours (United Nations Children's Fund, 2005). Over the years, health practitioners, health advocates and health care professionals have effectively used social and behavioural communication to achieve enhanced health outcomes among members of the public in many areas of public health. Some of these public health issues, where social and behavioural change communication has proven effective, include reducing the spread of malaria, the use of family planning methods, prevention of HIV/AIDSA AND improving new-born and maternal health (United Nations Children’s Fund, 2005).
In core practice, social and behavioural change communication encompasses three underlying assumptions. (1) It is an effective communication approach systematically planned to satisfy audience needs, aspirations and preferences, (2) It is a dynamic behaviour change model that underpins psychological framework to initiate specific health actions easier, feasible and closer to the ideal in order to protect and improve health outcomes, (3) It is a social-oriented model that initiates changes in the social system to achieve shifts in the perception of issues, people’s participation and engagement, policies, gender and norms and relations (The Manoff Group, 2013).
Therapeutic communication or patient-provider communication
The dynamics and ubiquitous nature of communication in the existence of humanity and the sustenance of the universe renders communication as practically inevitable in all human endeavours. In health care delivery, health management and public health campaigns, the use of communication is central. In the recent past, one of the major areas of concern in health communication research was the communication process and the relationship patterns that exist between health care providers and patients. This led to the emergence of the concept of therapeutic communication or what is also called patientprovider communication (Miller, 2010). The need to build relationships and initiate a heart-to-heart communication system is central to health care delivery and disease management. It is important for health care providers to acquire communication skills to improve upon and be able to avoid jargon-laden communication with patients. In this case, communication should be considered as a form of therapy (S. Collins, 2009).
Therapeutic communication is defined as the face-to-face process interaction that focuses on advancing the physical and emotional well-being of a patient. Nurses use therapeutic communication techniques to provide support and information to patients Laffan (2011). “It may be necessary to use a variety of techniques to accomplish nursing goals in communicating with a patient. Correctional nurses must attend to the therapeutic nature of the interactions taking place with patients. Caring, the essence of a nursepatient relationship must be the forefront in determining communication and action.” (Laffan, 2011p. 1).
From this definition, it can be deduced that communication can be administered in form of a therapy the same way drugs are administered to patients for prevention, assessment and management of a disease. One may propose further that communication therapy has three components, namely: engagement or information gathering level, to determine the nature of disease or illness; assessment and re-orientation level, to provide health education; and the effect or consequential level, to modify or change health behaviour. S. Collins (2009) states that the nature and manner of health care delivery largely shape or influence patients’ experience in general. Through effective therapeutic communication, patients can have firm belief and reassurance, can be better motivated to comply to a medication instruction, can comprehensively understand their illness, can freely express their desires and can feel protected and empowered (S. Collins, 2009). S. Collins (2009) emphasises the essence of communication in health delivery system further:
Communication is therapeutic. Building relationships is the cornerstone of nursing work, particularly with patients with learning disabilities; communication is a prerequisite to that process. It can also be lifesaving. If a patient is informed about what symptoms to mention, a cancer is more likely to be diagnosed and treated in time. Nurses have the most contact with patients, doing ‘connecting work’ that complements doctors’ consultations. Nurses provide the ‘glue’ - escorting a patient into the consulting room; identifying with challenges in adhering to lifestyle changes by reporting their own experience; allowing patients to disclose concerns not shared with doctors; being chatty; sharing a joke; and providing explanations where doctors’ communication has failed, (p. 1.)
This analysis has shown that there is a convergence between health communication, health literacy, therapeutic communication, media literacy, social marketing and social and behavioural change communication, which can lead to behavioural and attitudinal change among members of society to achieve good health outcomes. In view of this, the following concluding statements are made.
Health communication should necessarily be viewed and addressed as an interdisciplinary field of enquiry by both researchers and professionals. This will facilitate better understanding, appreciation and application of the field.
Health communication should be practised by health communication professionals and advocates as an interdisciplinary profession. This necessitates an integrated approach, which connects health communication with other related concepts from other disciplines in order to achieve desirable health goals among members of the public.
Attitudinal and behavioural change in the health lifestyle of individuals, communities and the general populations can be effectively achieved through an integrated approach to health communication campaigns.
Health communication as a field of enquiry and professional practice has the potential to integrate many other related new concepts into its theory and practice in the future so long as it deals with human beings, human society couple with the complex nature of human health.
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First published in: Journal of Communication andMediaResearch Voi. 6 No. 2, October 2014 as "Interrelationship of health communication and other related concepts" by Semiu Bello
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