Juliet Iwelunmor and Collins Airhihenbuwa
We provide an overview on the role of culture in addressing the social determinants of health and risk. The fact that everyone is influenced by a set of locally defined forms of behavior means that while not overtly expressed, culture’s effects can be ubiquitous, influencing everything including the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping health and risk messaging. While the dynamic nature of culture is underestimated and often not reflected in most research, efforts to close the gap on social determinants of health and risk will require greater clarity on what culture is and how it impacts culture-sensitive health communication. Thus, the paper begins by reviewing why culture is so vital and relevant to any attempts to improve health and reduce health inequalities. We discuss what is meant by the term “culture” through a narrative synthesis of historical and recent progress in definitions of culture. We conclude by describing three distinct cultural frameworks for health that illustrate how culture can be effectively used as a vehicle through which to address culturally sensitive health communication in local and global contexts. Overall, we believe that culture is indispensable and important for addressing inequalities and inequities in health as well as for facilitating culture-sensitive health communication strategies that will ultimately close the gap on the social determinants of health and risk.
Mohan Jyoti Dutta
This is an advance summary of a forthcoming article in the Oxford Research Encyclopedia of Communication. Please check back later for the full article.
Health and risk are constituted globally amid structures of unequal flow of labor, capital, commodities, and communication, shaped by the material inequalities in the distribution of resources. Globalization—the accelerated flow of goods, people, services, and capital across spaces—has been accompanied by large inequalities in economic access to resources; inequalities in access to health opportunities, health resources, and health care services; and inequalities in health outcomes (reflected in mortality and morbidity rates). Disparities in health outcomes observed within and across nation states are shaped by economic inequalities, noting the structural determinants of health, the inequities in access to health services, as well as the local-national-global policies that constitute health. Drawing upon the foundations in postcolonial and Subaltern Studies theories, the culture-centered approach (CCA) examines the communicative processes by which marginalization takes place in global contexts and the ways in which health risks and vulnerabilities are constituted amid material inequalities in distributions of resources.
With an emphasis on the processes of erasure of diverse voices, the CCA asks the question: What are the processes, strategies, and tactics through which the voices of subaltern communities are erased? The access to communicative spaces, platforms, strategies, and tools is shaped within material structures, thus shaping messages, processes, and discourses within the agendas of powerful political, social, and economic actors with economic access to resources. The disenfranchised, with limited access to the communicative spaces and to the spheres of voicing, are often absent from the discursive spaces where health policies and programs are discussed, the sites where interventions are planned, and the processes where communicative strategies targeting them are carried out. The agency of the subaltern is erased from the sites of recognition and representation where policies are debated, decided upon, implemented, and evaluated.
Connecting communication to materiality, the CCA suggests that erasure of the subaltern sectors of the globe is tied to their material disenfranchisement. Materially disenfranchised communities are missing from the policy platforms that target them through a wide variety of interventions. To understand the unequal distribution of health resources and opportunities, we need to closely examine the inequality in opportunities for having a voice and for participating in decision-making structures and processes. Putting forth the argument that inequalities in health outcomes need to be situated amid economic structures that determine how health resources will be distributed and the ways in which these mechanisms will be discussed and determined, the CCA foregrounds strategies for listening to voices that have hitherto been erased. Through strategies of listening, locally grounded understandings are placed within the discursive spaces of policy formulation and program development. In understanding the health experiences of communities that experience poor health outcomes, the emphasis is on creating spaces for listening that foreground local experiences, interpretations, and understanding. Alternative imaginations of the political economy of health are rooted in the voices of local communities at the margins, foregrounding contextually embedded interpretive frames for organizing health, healing, and curing.
Communication is understood in relationship to materiality, acknowledging the interplays between the symbolic and the material in generating health risks and vulnerabilities, and further suggesting strategies of resistance and participation that seek to invert these inequities by foregrounding subaltern rationalities of health and wellbeing. The presence of subaltern voices brings forth alternative imaginations of health, offering new theoretical frameworks that point toward alternative ways of structuring health, economics, and politics. Attending to differentials in distributions of material and communicative infrastructures, the CCA resists the marginalization of the subaltern sectors through the foregrounding of opportunities for local grassroots participation, in the definition of problem configurations and in the corresponding articulations of locally meaningful solutions. The presence of subaltern voices in discursive spaces offers alternative logics of political and economic organizing that challenge the commoditization of health as private property and suggests ideas of health rooted in community life, sustainable practices, and cooperative economies. Local interpretations of health are foregrounded, situated in relationship to the structures within which these meanings are constituted and fostering openings for imagining new structures of health grounded in local understandings. These local understandings offer entry points of solidarity for re-envisioning global practices that challenge the hegemony of neoliberalism as a universal solution to health and development.
Hearing loss is common, with approximately 17% of the population reporting some degree of a hearing deficit. Hearing loss has profound impacts on health literacy, health information accessibility, and learning. Much of existing health information is inaccessible. This is largely due to the lack of focus on tailoring the messages to the needs of deaf and hard of hearing (DHH) individuals with hearing loss. DHH individuals struggle with a variety of health knowledge gaps and health disparities. This demonstrates the importance of providing tailored and accessible health information for this population. While hearing loss is heterogeneous, there are still overlapping principles that can benefit everyone. Through adaptation, DHH individuals become visual learners, thus increasing the demand for appropriate visual medical aids. The development of health information and materials suitable for visual learners will likely impact not only DHH individuals, but will also be applicable for the general population. The principles of social justice and universal design behoove health message designers to ensure that their health information is not only accessible, but also equitable. Wise application of technology, health literacy, and information learning principles, along with creative use of social media, peer exchanges, and community health workers, can help mitigate much of the health information gaps that exist among DHH individuals.
Gary L. Kreps
Diffusion is the process through which new ideas, technologies, products, or processes are spread through communication among members of a social system via communication channels over time. Diffusion is a specialized form of communication that focuses on disseminating information about new ideas, products, technologies, services, or regulations. It is an especially important form of communication because it promotes social progress in the evaluation and adoption of important new ideas to address social issues. Diffusion helps to reduce uncertainty about how to address difficult issues and provides direction for achieving social goals.
A large body of research has been conducted from many disciplines on the diffusion of innovations since the original publication of Everett M. Rogers’ seminal book The Diffusion of Innovations in 1962, which is now in its fifth edition (2003). In this book, he introduced the Diffusion of Innovations (DOI) model, which describes a general process of adopting new ideas across multiple populations, cultures, and applications. This research has examined innovations in fields such as agriculture, engineering, sales, education, architecture, technology, public policy, and health care, and has been applied to a range of different issues, such as the adoption of new technologies, consumer purchasing behaviors, and public support for political issues and candidates, but has been especially influential in guiding strategic health promotion. The DOI model has contributed to a greater understanding of health behavior change, including adoption of health promotion recommendations. The model has led to a broad scope of practical applications for promoting public health.
Rebecca Cline and Andrea Meluch
Health consequences and key communication processes that emerge during disasters vary by type of disaster. The types of disasters that researchers have most investigated are rapid-onset natural disasters and slowly-evolving human-caused disasters. Three types of communication processes occur in disasters that have implications for health.
The first set of communication processes involves the social dynamics of affected communities. Communities that experience natural disasters tend to exhibit an emergent altruistic community; community members join together to support each other in the immediate aftermath of the disaster. In contrast, community conflict is the hallmark of slowly-evolving environmental disasters. That conflict triggers a cascade of social dynamics that infests close personal relationships with interpersonal conflict, stigmatization of victims and advocates, and pressures to avoid open communication (i.e., social constraints) regarding the disaster and its traumatic effects. These dynamics contribute to elevated mental health problems.
The second set of communication processes focuses specifically on social support. Supportive communication processes and networks are important resources for coping with ongoing disasters and for mitigating their longer-term mental health effects. Due to differences in community-level social dynamics, patterns of social support evolve differently in natural versus human-caused disasters. Natural disasters are typified by immediate intra-community social support. Community members support each other in the immediate aftermath of the disaster. Ultimately this social support is overwhelmed by the disaster’s needs and deteriorates. As a result, communities are largely dependent on internal and external institutional sources to meet community members’ needs. In contrast, slowly-evolving human-caused disasters tend to exhibit the emergence of corrosive communities. In these communities, those most affected by the disasters (those whose health is harmed or who claim other harmful or potentially harmful effects, and those who function as advocates) tend to experience failed or diminished social support. Whereas the community may previously have been altruistic, mutual help either fails to emerge or is withdrawn in the disaster context. Failed social support contributes to the relatively worse mental health consequences of slowly-evolving human-caused disasters when compared to natural disasters.
The third set of communication processes relate to institutional responses in disasters. In natural disasters, institutional communication is driven largely by widely disseminated and applied models that are intended to prevent harm and to provide resources to address harm and to reduce further negative consequences to health and well-being. Institutions and their agencies provide resources immediately following the disaster to meet basic human needs and, thereafter, to restore normalcy to the community and thereby protect community members’ physical and mental health. These efforts assume that natural disasters unfold in predictable stages (i.e., preparedness, warning, post-disaster, recovery) and that institutions’ responses should vary according to the stage of the disaster. In contrast, no such response models exist for slowly-evolving human-caused disasters. Moreover, community members experiencing such disasters often encounter what they perceive as institutional failures by both community-based and external responding institutions. Often community institutions (e.g., business, government) are perceived as causing the disaster and/or minimizing it, if not denying its existence or covering it up. As a result, communities experiencing this class of disasters tend to develop substantial distrust for local and responding institutions.
Gary L. Kreps
Ehealth, also known as E-health, is a relatively new area of health communication inquiry that examines the development, implementation, and application of a broad range of evolving health information technologies (HITs) in modern society to disseminate health information, deliver health care, and promote public health. Ehealth applications include (a) the widespread development of specialized health information websites (often hosted by government agencies, health care systems, corporations, professional societies, health advocacy organizations, and other for-profit and nonprofit organizations); (b) the widespread use of electronic health record (EHR) systems designed to preserve and disseminate health information for health care providers, administrators, and consumers; (c) an array of mobile health education and support applications that have often been developed for use with smartphones; (d) mobile health behavior monitoring, tracking, and alerting equipment (such as wearable devices and systems imbedded in vehicles, clothing, and sporting equipment); (e) interactive telemedicine systems for collecting health data and delivering health care services remotely; (f) interactive adaptive tailored health information systems to support health education, motivate health behaviors, and to inform health decision making; (g) online social support groups for health care consumers, caregivers, and providers; (h) health promotion focused digital games to engage consumers in health education and train both providers and consumers about health promoting procedures; (i) dedicated computer portals that can deliver a variety of digital health information tools and functions to consumers, caregivers, and providers; and (j) interactive and adaptive virtual human agent systems that can gather and provide relevant health information, virtual reality programs that can simulate health environments for training and therapeutic purposes, and an ever-increasing number of digital applications (apps) for addressing a range of health conditions and activities. As information technology evolves, new ehealth applications and programs are being developed and introduced to provide a wide range of powerful ehealth systems to assist with health care and health promotion.
Ehealth technologies have been found by many researchers, practitioners, and consumers to hold tremendous promise for enhancing the delivery of health care and promotion of health, ultimately improving health outcomes. Many popularly adopted ehealth applications (such as health websites, health care portals, decision support systems, and wearable health information devices) are transforming the modern health care system by supplementing and extending traditional channels for health communication. The use of new ehealth applications enables the broad dissemination of relevant health information that can be personalized to the unique communication orientations, backgrounds, and information needs of individuals. New ehealth communication channels can provide health care consumers and providers with the relevant health information that they need to make informed health care decisions. These ehealth communication channels can provide this information to people exactly when and where they need it, which is especially important for addressing fast-moving and dangerous health threats. Yet, with all the promise of ehealth communication, there is still a tremendous amount of work to be done to make the wide array of new ehealth applications as useful as possible for promoting health with different audiences. This article describes the current state of knowledge about the development and use of HITs, as well as about strategies for improving ehealth communication applications to enhance the delivery of health care and the promotion of public health.
Maureen P. Keeley
End of life communication includes both verbal and nonverbal messages that transpire following a diagnosis of a terminal illness and death. The circumstances that occur at the end of life create opportunities for unique and important communication. Specifically, communication at the end of life is impacted by numerous and complicated factors: First, cultural views on death and dying often determine what is talked about, when it can be talked about, and who is included in the conversations. Second, the fears, desires, and needs of the terminally ill must be taken into account at the end of life as it is their personal end of life journey. Third, the nature of the relationships between the terminally ill and their family and friends have tremendous influence on the nature and topics of conversations that will be shared. Fourth, interactions with healthcare professionals (preferably with palliative care specialists) tend to be more task focused, emphasizing end of life decision making and comfort care for the terminally ill. Fifth, as people are tending to live longer with terminal illness and often doing so far from their family, professional caregivers and hospice volunteers are also engaging in meaningful and significant communication with the terminally ill.
Communication at the end of life often determines whether or not the dying are allowed to die with dignity, with some control over their final wishes, and whether they are ultimately able to obtain some peaceful closure. Within close relationships communication at the end of life has the potential for authentic conversations that bring people closer, heal old wounds, and allow the terminally ill and close others to create some final memories and to say goodbye to one another. Communication at the end of life with health professionals has the potential for both the terminally ill and their family members to have greater satisfaction with end of life decisions and control of pain for the terminally ill, as well as better outcomes regarding grief and bereavement following the death for family members. For hospice volunteers and professional caregivers, communication at the end of life teaches the necessity and complexities of interactions at the end of life for the larger society.
Suruchi Sood, Amy Henderson Riley, and Kristine Cecile Alarcon
Entertainment-education (EE) began as a communication approach that uses both entertainment and education to engender individual and social change, but is emerging as a distinct theoretical, practice, and evidence-based communication subdiscipline. EE has roots in oral and performing arts traditions spanning thousands of years, such as morality tales, religious storytelling, and the spoken word. Modern-day EE, meanwhile, is produced in both fiction and nonfiction designs that include many formats: local street theater, music, puppetry, games, radio, television, and social media. A classic successful example of EE is the children’s television program Sesame Street, which is broadcast in over 120 countries. EE, however, is a strategy that has been successfully planned, implemented, and evaluated in countries around the world for children and adults alike. EE scholarship has traditionally focused on asking, “Does it work?” but more recent theorizing and research is moving toward understanding how EE works, drawing from multidisciplinary theories. From a research standpoint, such scholarship has increasingly showcased a wide range of methodologies. The result of these transformations is that EE is becoming an area of study, or subdiscipline, backed by an entire body of theory, practice, and evidence. The theoretical underpinnings, practice components, and evidence base from EE may be surveyed via the peer-reviewed literature published over the past 10 years. However, extensive work in social change from EE projects around the world has not all made it into the published literature. EE historically began as a communication approach, one tool in the communication toolbox. Over time, the nascent approach became its own full-fledged strategy focused on individual change. Backed by emerging technologies, innovative examples from around the globe, and new variations in implementation, it becomes clear that the field of EE is emerging into a discrete theoretical, practice, and evidence-based subdiscipline within communication that increasingly recognizes the inherent role of individuals, families, communities, organizations, and policies on improving the conditions needed for lasting social change.
Health promotion communication interventions invariably raise ethical issues because they aim to influence people’s views and lifestyles, and they are often initiated, funded, and influenced by government agencies or powerful public or private organizations. With the increasing use of commercial advertising tactics in health promotion communication interventions, ethical issues regarding advertising can be raised in health promotion communication when it applies techniques such as highly emotional appeals, exaggerations, omissions, provocative tactics, or the use of children. Key ethical concerns relate to infringing on people’s privacy, interfering with their right to freedom of choice and autonomy, and issues of equity (such as by widening social gaps, where mainly those who are better off benefit from the interventions). Interventions using digital media raise ethical issues regarding the digital divide and privacy. The interventions may have unintended adverse effects on the psychological well-being of individuals or groups (e.g., by inadvertently stigmatizing or labeling people portrayed as negative models). They can also have an effect on cultural aspects of society (e.g., by idealizing particular lifestyles or turning health into a value) and raise concerns regarding democratic processes and citizens’ consent to the interventions.
Interventions can have repercussions in multicultural settings since members of diverse populations may hold beliefs or engage in practices considered by health promoters as “unhealthy,” but which have important cultural significance. There are also ethical concerns regarding collaborations between health promoters and for-profit organizations. Identifying and considering ethical issues in the intervention is important for both moral and practical reasons. Several ethical conceptual frameworks are briefly presented that elucidate central ethical principles or concerns, followed by ethical issues associated with specific contexts or aspects of communication interventions.
Patric R. Spence, David Westerman, and Robert G. Rice
Humans often prefer representations that are cognitively easier to store, and such representations are easier to retrieve later to make judgments about the social world. Exemplification theory draws on physiological memory mechanisms and argues that simple, iconic, concrete, and emotionally arousing depictions of events (exemplars) are favored and thus more likely to be stored and used than are abstract, inconsequential depictions or representations. Inconsequential information or representations are forgotten because they are not processed as being essential for survival. Exemplified events vary on a continuum of how accurately they represent a larger occurrence of events. Through specific uses of pictures, quotes and other depictive strategies, concrete, iconic, and emotionally arousing information is often added to a story. Research has documented the strength of specific exemplars in creating inaccurate estimations of events and perceptions of severity and susceptibility. Moreover, in the presence of a risk, portrayals with exemplars have been shown to motivate individuals to intend to change behavior. Exemplification is a strong theory that is understudied and underutilized. The theory has strong explanatory, predictive, and organizing power, and it has application to phenomena in contexts such as media effects, persuasion, crisis and risk communication, health communication and public relations.