Kimberly A. Kaphingst
Direct-to-consumer advertising of prescription drugs (DTCA) is a multibillion-dollar industry in the United States, affecting the health-care landscape. DTCA has been controversial, since a major increase in this type of advertising resulted from re-interpretation of existing regulations in the late 20th century. Health and risk communication research can inform many of the controversial issues, assisting physicians, policymakers, and the public in understanding how consumers respond to DTCA. Prior research addresses four major topics: (1) the content of DTCA in different channels, (2) consumers’ perceptions of and responses to DTCA, (3) individual-level factors that affect how consumers respond to DTCA, and (4) message factors that impact consumers’ responses. Such research shows that the presentation of risk and benefits information is generally not balanced in DTCA, likely affecting consumers’ attitudes toward and comprehension of the risk information. In addition, despite consumers’ generally somewhat negative or neutral perceptions of DTCA, this advertising seems to affect their health information seeking and communication behaviors. Finally, a wide range of individual-level and message factors have been shown to have an impact on how consumers process and respond to DTCA. Consumers’ responses, including how they process the information, request prescription drugs from providers, and share information about prescription drugs, have an important impact on the effects of DTCA. The fields of health and risk communication therefore bring theories and methodologies that are essential to better understanding the impact of this advertising.
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.
The disruption information seeking and processing (DISP) model is a variation on the risk information seeking and processing (RISP) model. While both the DISP and the original RISP models seek to predict how individuals will search for and attend to information in response to a perceived hazard, DISP aims to broaden analysts’ view of the sorts of information individuals may seek in such situations. It does so by expanding the repertoire of social psychology theory on which the model is constructed to include ideas from the literatures on sensemaking and identity maintenance.
A major argument of DISP is that on many occasions the information that people seek in response to a risk will not be directly related to the risk itself. For example, if you hear a news bulletin on an outbreak of food poisoning associated with ground beef, the next thing you look for may not be information on the risks of E. Coli, but a recipe for chicken. While the observation that people seek non-risk-related information in response to risks is a broad one, the DISP concerns itself with one particularly important aspect of this idea.
Specifically, based on research in the sensemaking and identity maintenance traditions, the DISP model proposes that, for information seekers, the self and the various identities in which individuals are personally invested are often as much the objects in need of interpretation as the hazardous environment. The implication of this is that when faced with a risk, individuals are likely to pay attention not just to information on the risk itself (the sort of information prioritized by RISP), but on the identities impacted by the hazard—for example, how a person’s acceptance of or strategy for coping with the risk might affect her self-image as being a good parent, a conscientious employer, etc.
The DISP also proposes that some hazard situations are likely to be more disruptive to individuals’ sense of self than others—namely instances where the individual has a high vested interest in a particular identity that is challenged by the hazard combined with a low sense of self-efficacy with respect to remediating the hazard. A typical example would be a parent who prides herself on keeping her kids safe, who finds out about an environmental risk to children in her neighborhood, but who cannot afford to move.
According to the DISP model, in such a circumstance the individual would likely become more attuned to information about the countervailing positive aspects of the neighborhood, such as good schools or a low crime rate. These sorts of information, which do not pertain to the risk directly, but are nonetheless sought as a consequence of the risk, exemplify the manner in which DISP seeks to expand the focus of the original RISP model. In the parlance of DISP, the model adds a “self-relevant” information dimension to RISP’s original focus on “risk-relevant” information.
Finally, the DISP model proposes the notion of “norm trumping,” suggesting that individuals experiencing disruption in the face of a hazard—who run afoul of the set of social norms associated with an identity in which they are highly invested—are likely to pay particular attention to self-relevant information that emphasizes alternative sets of norms that help to preserve or reconstitute a desired sense of self.
This model has yet to be tested empirically.
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.
Spring Chenoa Cooper and P. Christopher Palmedo
Embarrassment, according to Fischer and Tangney, is an “aversive state of mortification, abashment, and chagrin that follows public social predicaments.” It is usually related to our perceptions of how others perceive us as well as their judgments of us, and it is associated with a loss of self-esteem when we perceive that others have judged us as inadequate or incompetent. However, even mere exposure or attention publicly placed on someone can elicit embarrassment (think of someone pointing at you and laughing).
Embarrassment is considered a self-conscious emotion. Self-conscious emotions include those that are evoked by self-reflection and self-evaluation: embarrassment, shame, guilt, and pride. Shame, an intense form of embarrassment, also has structural and larger social contexts, while embarrassment is more individually experienced. Self-conscious emotions play an important role in regulating behavior; they assist us in behaving according to social standards and guide us in responding when those rules are broken. While these emotions provide feedback in social situations, they also provide feedback for anticipated outcomes.
Embarrassment can play an important role in health, both in communication and behavior, and occurs through different forms. Primary embarrassment is the first rush of blood to the face and increased heart rate that usually lasts a few moments. Secondary embarrassment is the after-effect that shapes future behavior. Anticipatory embarrassment is the emotion surrounding the potential for embarrassment in an upcoming situation. Solitary embarrassment is the one that no one actually observes.
Three stigmatized areas of health—mental health, healthcare, and sexual health—may be assessed as case studies through which to understand the literature around embarrassment, as both an affect and an emotion.
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.
Dani Filc and Nadav Davidovitch
The medical encounter is one of the most important channels of communication between the patient and his or her caretaker. Apart from its therapeutic effect, the medical encounter serves to convey information about a symptom or disease; construct a diagnosis and give information about the expected course of a disease (“prognosis”); and discuss treatment plans, including risks and benefits. The centrality of the medical encounter makes ethical considerations fundamental, not only within the clinical context but also within the broader context of health promotion. Furthermore, since the medical encounter is characterized by asymmetry and dependence, it can create problems of abuse of power or subordination. The current dominant liberal bioethical approach tends not to take into account the power relations within the medical encounter, or the social context in which the medical encounter takes place. It is in this sense that a republican egalitarian approach to bioethics can be of use. Instead of traditional bioethics emphasis on the individual and on personal autonomy, a radical egalitarian health rights approach will stress the importance of social structures, and the need for a different institutional framework that works toward making a universal right to health possible. Such an approach also emphasizes the centrality of politics in building adequate institutions and in modifying those social structures that cause inequities in health. These considerations have important consequences on how the medical encounter should be constructed, such as in the case of conveying risk and disclosing medical errors.
The design and dissemination of health and risk messages invariably involves moral and ethical issues. The choice of the topics, the focus on particular recommended practices, the choice of particular groups to be the intended recipients of the messages and their inclusion in or exclusion from the message development process, all raise ethical issues. Further, the persuasive tactics used to influence people to change their attitudes and beliefs and to adopt recommended changes in their lives also raise ethical concerns. For example, persuasive tactics may infringe on people’s privacy when people view images they may find intrusive, offensive, or cause them distress. Tactics that “tug” at people’s emotions may infringe on their unhindered ability to make a conscientious decision. Employing digital media and sophisticated advertising and marketing tactics also elicits ethical challenges both related to their manipulative potential and their differential reach: all of which may contribute to social and health disparities. In addition, the practices recommended in health and risk messages may conflict with values people cherish. For example, people could be urged to change the way they communicate with their spouses on intimate issues, relinquish the consumption of favorite traditional foods—or messages may raise issues that recipients find taboo according to their culture or religious beliefs. Health and risk messages may have unforeseen and unintended adverse effects that could affect people’s emotional and physical aspects by inadvertently contributing to people’s sense of guilt through shaming or stigmatization. Also, on the cultural and social level, such messages may contribute to an idealization of a certain lifestyle or commercialization of products and celebrities associated with the messages.
Philosophical and ethical frameworks typically used in communication ethics, bioethics, communication campaigns, and social marketing literature emphasize the central guiding principles of personal autonomy and privacy with the aim to ensure equity and fairness. The obligation to avoid “doing harm” includes concerns regarding labeling, stigmatizing, and depriving; the obligation to help; the obligation to respect people’s autonomy to make free choices, particularly concerns regarding persuasion tactics and manipulations and the use of threat tactics, provocative appeals, distressing images, framing tactics, cultural sensitivity, and moral relativism; the obligation to obtain consent; the obligation to truthfulness; the obligation to sincerity; the obligation to correctness, certitude, and reliability; the issue of personal responsibility; equity obligations including concerns regarding segmentation and “targeting”; the obligation to comprehensibility; the obligation of inclusion; utility and efficiency considerations; the “harm reduction” approach; and concerns regarding social value priorities and “distortions,” which includes prosocial values as moral appeals.
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.