COMMS161_Ch1 PDF - Health Communication

Establishing a I PART Context for Health Communication A lot has happened in the last decade. Passage of the Patient There are...

Establishing a I PART Context for Health Communication A lot has happened in the last decade. Passage of the Patient There are Protection and Affordable Care Act opened the way for the decades when United States to become the last industrialized nation to offer health coverage to all citizens. As with any decision of this nothing happens; magnitude, it incited a mixture of controversy, optimism, concern, and there are joy, and renunciation. No matter which of these describes your re- actions, one thing is certain: It is an exciting time to study health weeks when communication. To contribute in meaningful ways, we must be up decades happen. to date, well informed, and aware of the big picture. This section —VLADIMIR ILYICH LENIN lays the groundwork for that. You can read the rest of the book in any order you like, but begin with this section. In Chapters 1 and 2, you will learn about philosophical perspectives and recent events that have led us to the current moment. Understanding that journey makes it easier to envision the future—and ways that you can make a difference in it. 1  CHAPTER 1 Introduction Phil Bretthauer’s doctor was worried. Despite frequent and expensive care, Phil’s health was steadily weakening. He was in and out of the hospital with heart attacks, respiratory problems, and prostate cancer. “It’s a demoralizing position to be in,” said his doctor. Although he was concerned about his patient, he felt powerless to reverse his decline. It is no wonder that Phil himself was discouraged. “If it’s going to happen, it’s going to happen to me,” said the discouraged 70-year-old. As it turned out, a turn- ing point in Phil’s case resulted from improved communication. Phil Bretthauer reviews medications with home health nurse Tammy Bennett. In addition to helping Bretthauer with biomedical concerns, Bennett spends time listening to and talking with him. As a result of their communication, she found volunteer opportunities in the commu- nity for him to lessen his sense of boredom and isolation. 2  CHAPTER 1  Introduction    3 P hil’s story is part of a feature by Jenny Gold the hospital less, which was good for him and for the (2013) for Kaiser Health News and National budget (Gold, 2013). Public Radio. Gold describes a new health care Phil’s case reminds us that health involves medi- delivery model in the United States that encourages cations and procedures, but it also involves being well more two-way communication between patients informed, listening to one another, social interaction, and health professionals and more teamwork be- teamwork, and a great deal more. We are all involved tween care providers. As you will see in a moment, in health communication. Our ideas about health are Phil’s life changed after his physician became part of shaped by personal experiences and our interactions this new model, in the form of an accountable care with professionals, friends, family members, cowork- organization (ACO). An ACO is a network of service ers, and educators. We are also influenced by Internet providers who, together, provide care for a specified content, movies, television shows, public service an- group of Medicare subscribers. The goal is to keep nouncements, and more. At the same time, we influ- these people well, not just to treat them when they ence the people around us with our own actions and become ill. thoughts about health. Based on provisions of the Affordable Care Act In this chapter, we consider what health and passed in 2010, accountable care organizations that health communication are all about. We examine improve the health of their members and save costs philosophical perspectives of health and healing. get a financial bonus. Regardless of what happens Then we focus on how and why people communi- with ACOs, most people agree on the principle un- cate as they do about health. The chapter concludes derlying them—that cost-effective, high-quality with key reasons to study health communication, care will require a greater degree of open commu- including particularly promising career growth. ­ nication, creative thinking, and teamwork than (See Box 1.1 for a list of health-related careers fea- ever before. tured throughout the book.) Phil’s case is an example of multidisciplinary teamwork (which we explore more fully in Chapter 5) and the theory of collaborative medical communi- WHAT DO YOU THINK? cation (Chapter 3), which casts patients and health professionals as peers who talk openly about goals Think beyond the boundaries of conventional and options (Balint & Shelton, 1996; Laine & care to design a team ideally suited to help you Davidoff, 1996). Phil’s physician became part of a stay healthy. multidisciplinary care team when he joined an ac- Who would you want on your team? Perhaps countable care organization. Among other measures, a nurse, a dietician, a physician, a yoga instruc- the team decided to schedule Phil for regular visits tor, a counselor, and/or a massage therapist? by a home nurse. Who else? Phil’s home health nurse, Tammy Bennett, took a By what means would you prefer to communi- collaborative approach. She spent time talking with cate with these people? What would you most Phil about his daily routines and general outlook on like to talk about? life as well as his medical needs. When she realized Do you think your health would be affected if Phil had been taking some of his medication incor- your wishes became reality? If so, how? rectly, Bennett helped him get back on track and avoid the side effects of overdosing. Through their in- teractions, she also learned that Phil was depressed and lonely, just sitting at home all day. Aware that The Philosophy Behind he had once been a NASCAR announcer, she found opportunities for him to be a volunteer announcer This Book at Little League games and a bingo caller at a local It is an exciting and challenging time to be involved rehab center. As he became more socially involved, with health communication. Perhaps more than ever Phil’s health and his outlook improved. He was in before, health care leaders are open to innovative  4   PART I   ESTABLISHING A CONTEXT FOR HEALTH COMMUNICATION BOX 1.1 CAREER OPPORTUNITIES Profiles of More Than 125 Health-Related Jobs Career boxes throughout the book CHAPTER 7 Holistic Medicine Physician marketing coordinator showcase careers related to health Acupuncturist Public relations professional Chiropractor Strategic planning manager and health care. Each box provides Holistic nurse CHAPTER 11 Health Journalism links where you can find more infor- Massage therapist mation and job listings. Here is a list Midwife Health news editor/reporter of jobs profiled in each chapter. Naturopathic physician Health publication editor Nutritionist/dietician Journal or magazine editor CHAPTER 3 Research/Education Reiki practitioner Media relations specialist Yoga instructor Nonprofit organization publicity Consultant manager Professor CHAPTER 8 Mental Health Researcher CHAPTER 12 Public Health Mental health counselor Social worker Business or billing manager CHAPTER 4 Patient Advocacy Psychologist Communication specialist Case manager Emergency management director Social service manager Patient advocate Environmentalist Hospice/palliative care provider Patient care coordinator Epidemiologist Home health aide Patient navigator Fundraiser Senior citizen services providers Social worker Health campaign designer CHAPTER 9 Medical Technology Health department administrator CHAPTER 5 Caregivers Computer and information Health educator Clinical laboratory assistant systems manager Health inspector Dental assistant Health information administrator Health researcher Dental hygienist or technician Media relations professional Dentist Software developer Nonprofit organization director Doctor of osteopathic medicine Nutritionist/dietician Emergency medical technician CHAPTER 10 Health Care Nurse Hospitalist Administration Patient advocate or navigator Licensed practical nurse Chief financial officer Physician Medical records technician Chief operating officer Public policy advisor Medical doctor Departmental director Risk/crisis communication Nurse practitioner Director of human resources specialist Occupational health/safety Health information manager Social worker technician Medical director Occupational therapist CHAPTER 13 Health Promotion and Medical office manager Education Pharmacist Nursing director Pharmacy technician President or CEO Community health educator Physical therapist Strategic planning director Corporate wellness director Physician assistant Fitness instructor Psychiatric technician or aide Health Care Human Resources Health campaign designer/ Psychiatrist Compensation and benefits manager Psychologist manager Health information publication Radiology technologist Customer service representative designer Recreational therapist Human resource manager Hospital-based health educator Registered nurse Recruiter Patient advocate or patient Respiratory therapist Training and development navigator Speech-language therapist specialist School-based health educator Surgeon Health Care Marketing and Public Surgical technologist Relations CHAPTER 14 Health Campaigns Advertising designer Communication director CHAPTER 6 Diversity Community services director Director of nonprofit organization Diversity officer In-house communication director Media relations specialist Health care interpreter Marketing professional Public relations specialist Equal Employment Opportunity Pharmaceutical sales Publication designer (EEO) officer representative Professor/educator  CHAPTER 1  Introduction    5 ideas. They are also facing critical challenges—to shape and promote services that meet control costs, attract clients, and earn employees’ stakeholders’ needs. loyalty. The changes are both destabilizing and excit- A team member uninformed about health care ing. The good news is that disequilibrium, although it administration and current issues misses out on can be stressful, opens the field to new ways of think- leadership opportunities. ing and behaving. People involved with health care Health professionals who do not communicate today have the potential to reshape and improve the effectively with each other confuse patients and system. In Chapter 10, we discuss innovative ways their loved ones with contradictory information. that people in health care organizations are pursuing these goals. Health communication researchers focus only on individual actions rather than recognizing the social and organizational constraints that may limit people’s options. TIPS ON READING THIS BOOK The list goes on. Knowledge gaps are understand- Do not overlook boxes and sidebars. Sometimes able, even among people who have been in health- a feature works best standing on its own. That related careers for some time. The field is changing does not mean it’s less important than the rest. rapidly. Whereas specialization was once encour- Key terms and theories appear in boxes as well aged, now effective health care scholars and practi- as in the main text. tioners are attuned to broader contexts and more Engage in critical thinking. Questions through- diverse ideas. They must be aware of the historical, out the book prompt you to reflect on your cultural, and market pressures that influence health. viewpoints and experiences. Critical think- Success also relies on their ability to encourage feed- ing, the ability to link abstract ideas to actual back, to listen, to analyze, to experiment with new practices, is one of the most useful ways to put communication techniques, and to sell their ideas what you learn to good use. to others. At the same time, we must keep in mind that WHAT DO YOU THINK? health communication is more than business and economics. It involves life and joy and, sometimes, Off the top of your head, define what health heartbreak. Phil’s experiences remind us that physi- means to you. Then keep reading to see how cal regimens are not always enough to make us feel your definition compares to that of the World Health Organization. In Chapter 7, we examine better, and that caring for others involves a mixture of different ways of viewing health in cultures knowledge and compassion. around the world. A central theme of this book is that to be our best (and our best is required), we must understand health communication from a wide range of perspec- tives. Here are some examples of what can go wrong This book is designed to give readers an up-to- when people focus on one area of communication but date look at health communication from many per- neglect others: spectives. After establishing the context for current issues in health communication in Part I, we focus on A patient is well treated, but his or her family interpersonal connections between patients and pro- feels distraught and uninformed. fessional caregivers in Part II, and then broaden the A campaign director unfamiliar with cultural scope in Part III to consider the influence of diversity ideas about health creates messages that are un- and culture. Part IV explores health care resources, appealing or offensive to the target audience. including social support and technology. In Part V, we A marketing/public relations director who consider the ways that people in health care organiza- does not understand the dynamics of patient– tions use communication to lead, inspire, and support caregiver communication is unable to help team members, and to partner with the community.  6   PART I   ESTABLISHING A CONTEXT FOR HEALTH COMMUNICATION The book concludes, in Part VI, with coverage of to good use. Throughout the book, Communication health communication in the media, public health, Skill Builder sections present practical tips for com- and health care campaigns. In this way, we move municating effectively about health. Experts suggest largely from one-on-one communication to macro- strategies for communicating with diverse people, level issues. In real life, of course, we encounter these presenting our concerns as patients, being effective factors simultaneously rather than one by one. Keep leaders, using social media, designing health cam- the interplay between them in mind. paigns, and more. (See Box 1.2 for ideas about how you Perhaps the most rewarding aspect of learning can put your skills to work in a service-learning proj- about health communication is putting what we learn ect or internship.) BOX 1.2 Learn While You Make a Difference Whether it is a service-learning project, an internship, Partner with people in need; honor their or a volunteer effort, there are many ways that you can agenda gain experience and learn about health care while you Identify needed resources and/or policies make a difference in people’s lives. It helps to establish Educate the public learning objectives and goals at the beginning and to Meet with policy-makers and community reflect on what you have learned and accomplished leaders when the project is complete. Here are a few ideas. Host strategy sessions Create coalitions and long-term plans Work with a Nonprofit Help with strategic planning Educate People Create a media packet and marketing plan Host a public lecture Publicize an event or program Organize a symposium Provide assistance with training Hold a mini-conference Recruit volunteers Present communication workshops Help with an event already scheduled Write articles and PSAs for the media Conduct surveys Host a health fair booth Raise Money Help develop a crisis management plan Host a fundraising event Stage a mock crisis for practice Collect contributions Plan, Publicize, and Host an Event Recruit sponsors and partners Fundraiser Sell items of value Awards banquet Host a chance drawing Celebration Cleanup or spruce-up activity Health Campaigns Image-building outreach activity Conduct market research Health-enhancing event Create a campaign or assist with one Promote healthy behaviors Advocate Raise awareness of risks Focus on a particular need, risk, or group of people Assess campaign exposure Research the issue Evaluate outcomes  CHAPTER 1  Introduction    7 What Is Health? DEFINING COMMUNICATION It sounds like an easy question. We know when we are Communication is anything but simple. Imagine a healthy and when we are sick. At least that is how it scenario in which a person says to you, “I’m pregnant.” feels most of the time. But sometimes we are not even If we believe that meaning lies only in the words we sure ourselves. There is space in the middle. And de- use, this is a simple two-word parcel of information. pending on our personal and cultural perspectives, As we know, however, communication involves a lot our very idea of being healthy can differ from other more than that. Even in the case of relatively simple people’s definitions. interactions, people negotiate a myriad of potential The World Health Organization (WHO) defines meanings and implications. health as “a state of complete physical, mental and The transactional model of communication social well-being and not merely the absence of dis- proposes that people collaborate to construct mean- ease or infirmity” (WHO, 1948, p. 1). This definition, ing in a process of ongoing, reciprocal influence unchanged for more than 60 years, reminds us that (Barnlund, 1970). If you were asked to comment on healthy is not the opposite of sick. Health often involves the “I’m pregnant” statement, you would probably a sense of harmony and equilibrium between many as- want answers to a number of questions first: Who said pects of life. It may call into play our feelings, physical it? Under what circumstances? Did the speaker look abilities, and relationships with others. Throughout and sound happy, sad, fearful, or some other way? Is the book, we discuss diverse theories about the nature the person who made this statement my wife? My teen- of health and its relation to communication. age daughter? My cashier in the grocery store? The transactional communication model reminds us that communication is a sophisticated process. It does not What Is Health happen within people, but between them, in the midst of many factors that influence how they behave and Communication? what sense they make of the situation and each other. Health communication is shaped by many influences, To clarify, let’s take a closer look at three key aspects including personal goals, skills, cultural values, situ- of transactional communication: collaboration, mul- ational factors, and consideration of other people’s tiple levels of meaning, and the importance of context feelings. The definitions presented in this section em- and culture. phasize the interdependence of these factors. As com- municators, we influence—and are simultaneously Collaborative Sense-Making influenced by—the people and circumstances around A central tenet of transactional communication is that us. We rely on others to help us meet goals and make meaning does not lie in discrete units of information sense of life events. Sometimes the most important or in any one person. Rather, it emerges within experi- thing we do is simply be present for others. ences that are cocreated by the participants. BOX 1.3 PERSPECTIVES True Stories About Health Communication Experiences In Perspectives boxes throughout the book you will managers, and others. They provide insight about read about the real-life experiences of people involved how people of different races, cultures, ages, lan- with health communication. These accounts repre- guages, abilities, sexual orientations, and educational sent the viewpoints of patients, loved ones, caregiv- levels experience health communication. ers, executives, social activists, health campaign 8   PART I   ESTABLISHING A CONTEXT FOR HEALTH COMMUNICATION To return to the previous example, if a friend tells you she is pregnant, you are likely to notice her IN YOUR EXPERIENCE nonverbal cues, do a quick mental inventory of her situation and prior comments, and experience feel- Have you ever felt like the underdog in a health ings of your own. Your reaction to the news may care encounter? show on your face even before the words are com- If so, what contributed to this feeling? Is there pletely out of her mouth. In a study of couples coping anything you or other people might have done with infertility, one woman described feeling happy differently? when a friend announced her pregnancy, but dis- couraged by the comparison to her own situation. Her internal dialogue went something like this: both a content and a relational level (L. E. Rogers “Congratulations. I know that it’s a joyful experience & ­Escudero, 2004; Watzlawick, Beavin, & Jackson, but at the same time, it’s kind of a sick analogy, but 1967). At a content level, meaning is considered to be if someone lost their leg, you don’t go around saying, mostly denotative—that is, subject to literal interpre- ‘Oh, I’ve got two legs, I can run’ ” (Palmer-Wackerly tation. “I’m pregnant” is a simple statement of fact. & Krieger, 2015, p. 618). In such a situation, the At a relational level, participants consider the speaker may pick up on her friend’s dismayed reac- implications of communication in terms of their rela- tion and reframe the announcement and even how tive status and feelings about each other. Relational she feels about it. Ultimately, whether the exchange messages are often conveyed implicitly, as by consid- takes on the key of celebrating, comforting, or any ering how something is said, who says it and when, number of other options depends on how the people and what they do not say. Although relational cues involved coconstruct it. may be subtle, they often convey powerful implica- One implication of transactional communication is tions regarding the expectations, emotions, power, that participants do not take turns being senders or re- and status of the participants. For example, in Chap- ceivers. Instead, they simultaneously send and receive ter 8 we discuss the conundrum that individuals often messages all the time. Even a blank expression is likely over-assist people with physical limitations. Although to be considered feedback, suggesting that the listener their intentions are good, the relational-level implica- is bored, uninterested, or so on. Thus, the transactional tions may be that “you are needy and incapable” and model highlights the importance, not only of words, but of ever-present nonverbal cues. As you will see in Chapter 3, many people criticize the traditional model of pa- tient–caregiver communication in which patients are mostly silent and health pro- fessionals do most of the talking. This is likely to result in misunderstandings and in a power differential that limits patients’ opportunities to help shape their own care. From a transactional perspective, the blame does not lie solely with health profession- als, however (Kreps 1990; T. L. Thompson, 1984). Patients are often observed to be quiet and submissive. Whether they realize it or not, they may contribute to the very dy- namic they dislike. At a relational level, people may use touch, eye contact, space, silence, Multiple Levels of Meaning and other cues to suggest who they are to each other and what they are Transactional communication is consis- accomplishing in terms of communication. What do the nonverbal cues tent with a relational approach, which in this photo suggest to you about the nature of the relationship and the proposes that meaning is interpreted at type of communication involved?  CHAPTER 1  Introduction    9 “you are different from me and from other people.” In word of mouth, that they target messages to African reality, people with physical challenges often say they American men specifically, and that they focus on the prefer to be treated just like anyone else (e.g., Nemeth, idea that fitness helps men feel better, live longer, and 2000). In a similar way, a person may feel gratified by be there for their families (D. B. Friedman, Hooker, a health professional who treats him as an equal but Wilcox, Burroughs, & Rheaume, 2012). put off by one who insinuates that he is ignorant or ir- As we will discuss throughout the book, people responsible about his health. (Bear in the mind that, who do not understand and respect cultural differ- as a collaborator in the process, the person’s response ences often do harm even when they are trying to help will help to shape the ultimate meaning and tone of (Dutta & de Souza, 2008). See Chapters 6, 7, 13, and that encounter.) 14 for more on this. In summary, the transactional perspective re- Context and Culture minds us that communication episodes are collabora- The anthropologist Clifford Geertz (1973) famously tive and unique accomplishments. The people involved observed that people are suspended in “webs of signif- interactively shape the meanings that emerge at both icance” (p. 5). In other words, none of us exists in iso- a content and relational level, and they do so within lation. We are influenced by larger environments and many layers of context. Awareness of this perspective contexts—such as our past experiences, the neighbor- may help you appreciate the sophisticated nature of hoods in which we live, the cultures with which we health communication phenomena you read about in identify, and so on. Each of these is likely to influence this book and avoid drawing simplistic conclusions what we consider acceptable and how we interpret about them. That being said, do not expect every com- what happens around us. munication study that is described to be transactional In Chapter 2, we consider how health care has in nature. Researchers sometimes single out or isolate evolved over time and the effects of recent reform ef- particular aspects of health communication for study, forts. On the surface, these happenings may seem and rightfully so. With an understanding of trans- irrelevant to the way we communicate about health actional communication, perhaps you can appreci- as individuals. However, they probably influence us ate these as components of a larger process as you more than most people realize. For example, a health continue to learn and put the pieces together. professional might wish to spend an hour with each patient but be prohibited from doing so by organiza- tional rules and structures. Patients who criticize the PERSPECTIVES professional for being “hurried and inattentive” may miss the reality that the system is more to blame than “When I first began working at a continuing care the individual. retirement community I would speak loudly, lean From a transactional perspective, cultural mores close to people, and draw out my words. Finally, are woven into the sense-making endeavors of every- a resident gave me a little advice: ‘Just relax, we day communication. Cultural expectations influence can hear you fine. You’re the one that may need how we behave as patients (Chapter 4), how society to listen better.’ I began to listen to their stories, regards health concerns such as mental illness and exchange jokes, and ask them for advice. I quickly obesity (Chapters 6 and 7), and so on. You might know realized I was surrounded by people with wisdom someone who does not seek care for depression be- and history that far exceed mine.” cause, in the culture in which she was raised, mental —Chris illness is considered shameful. One way of honoring diverse contexts is to avoid imposing one’s worldview on others as much as pos- DEFINING HEALTH COMMUNICATION sible. For example, before designing a campaign to promote physical activity among African American Gary Kreps and Barbara Thornton (1992) define men, researchers interviewed members of the target health communication as “the way we seek, process, audience to learn more about their preferences and at- and share health information” (p. 2). We search out titudes. The men interviewed suggested that the health and pass along messages and mingle what we hear and promoters use a combination of media messages and see with our own ideas and experiences. In this way,  10   PART I   ESTABLISHING A CONTEXT FOR HEALTH COMMUNICATION BOX 1.4 THEORETICAL FOUNDATIONS The Basis for Health Communication He who loves practice without theory is like the What behaviors enhance and compromise coping sailor who boards the ship without a rudder and efforts? compass and never knows where he may cast. How do interpersonal relationships influence —LEONARDO DA VINCI health? How does multiculturalism influence health and health care? As we explore the field of health communication, theo- ries connect the dots, just as constellations reveal pat- How can health care organizations stimulate teamwork and innovation? terns in the stars. Good theories make sense of diverse In what ways do media messages influence our information and help us to get our bearings. They help health? us know, in advance, where we are headed and what How do people respond to public health paths are available to us. Theoretical Foundations seg- campaigns? ments (sometimes in the text, sometimes in boxes of What factors influence people to become more their own) showcase theories relevant to health com- knowledgeable and proactive about their own munication. These theories address such issues as: health? What is health? How do we make sense of health crises? we are actively involved in health communication, not is wrong and what could be better. This involves indi- just passive recipients of information. A great deal of vidual health as well as organizational structures and health communication involves professional caregiv- public policy. ers, such as doctors, nurses, pharmacists, aides, thera- Health communication scholars have also brought pists, counselors, and technicians. But we serve as attention to social factors. It is common to think about caregivers for friends and loved ones as well. Chapter 8 health in terms of personal choices—a good diet, an demonstrates the value of social support when we are active lifestyle, regular checkups, and good informa- ill, healthy, and even (perhaps especially) when we tion. But the evidence is clear (see Chapters 6 and 14) cope with death and dying. that these options are not available to everyone in the same measure. Improving the health of a community requires that we also consider social equity, commu- THE HISTORY OF HEALTH nity resources, access to care, and the environment. COMMUNICATION Health communication is often persuasive in Health communication emerged as a defined area of nature. Communication—be it through news stories, study in the late 1960s. Interest was spurred most no- PSAs, entertainment programming, or conversations tably by researchers and practitioners in psychology, with health professionals or loved ones—has an impact medicine, sociology, and persuasion who recognized on whether we smoke, exercise, drink and drive, get that communication is central to the process of health enough sleep, take part in health screenings, and so and healing (Kreps, Query, & Bonaguro, 2008, p. 5). on. Persuasive communication is a powerful tool. How, Health communication has also flourished as a com- and under what circumstances, should we use it to in- ponent of communication, business, nursing, public fluence people’s behavior? What persuasive appeals are health, and allied health programs, to name just a few. most effective? Which are unethical? We examine an- One lesson that has emerged is that communica- swers to these questions and others in Part VI. tion is not separate from health care, but is therapeu- Today, health communication research is a thriv- tic in itself. It is also the vehicle through which people ing field. Notable publications include the journal learn about health and reach agreement about what Health Communication, first published in 1989 and  CHAPTER 1  Introduction    11 still led by founding editor Teresa Thompson at the practitioners and scholars and covers a gamut of University of Dayton, as well as Qualitative Health issues ranging from interpersonal communication, to Research, the Journal of Health Communication, culture, media, public health, education, and more. It Communication & Medicine, The Routledge Hand- involves the work of scholars around the world—from book of Health Communication (T. L. Thompson, Europe to Australia and New Zealand, Asia, Canada, Parrott, & Nussbaum, 2011), and many others. (See the United Kingdom, and the Americas (Thompson Box 1.5 for a list of relevant organizations, and see et al., 2011). Chapter 3 for a more comprehensive list of journals.) The following section introduces three approaches As you probably realize by now, health commu- to health care that are fundamental to how and why nication is quite diverse. It unites interdisciplinary people communicate as they do. BOX 1.5 RESOURCES Health Communication Organizations and Resources This book is designed to give you a rich and current Eastern Communication Association: overview of health communication. We will visit a www.ecasite.org number of locations (social settings, doctors’ offices, European Association for Communication in board rooms, movie theatres, and more) and look at Healthcare: www.each.eu health through different people’s eyes. My hope is European Public Health Association: www.eupha.org that, as you explore each perspective, your apprecia- tion of the nuances that influence health and health Health Care Public Relations Association: https://www.hcpra.org communication will increase. Along the way you will International Communication Association probably want to know more than can be fit into one (Health Communication Division): book, so Resources boxes provide information about www.icahdq.org relevant websites, organizations, publications, International Union for Health Promotion and and more. Education: www.iuhpe.org To get you started, here is a list of organizations National Cancer Institute: http://www.cancer.gov and websites you might wish to investigate for more National Center for Health Marketing: information about health communication: www.cdc.gov/healthmarketing National Communication Association (Health American College of Health Care Administrators: Communication Division): www.natcom.org http://www.achca.org National Institute of Health: www.nih.gov American College of Health Care Executives: http://www.healthmanagementcareers.org National Prevention Information Network: https://npin.cdc.gov American Communication Association: www.americancomm.org Public Relations Society of America, Health Academy: healthacademy.prsa.org/index.html American Public Health Association: www.apha.org South Asian Public Health Forum: www.saphf.org American Society for Healthcare Human Re- Southern States Communication Association: source Administration: http://www.ashhra.org www.ssca.net Association for Education in Journalism & Mass U.S. Department of Human Services Health Communication: www.aejmc.org Communication Activities: www.health.gov/ communication Centers for Disease Control and Prevention: http://www.cdc.gov Western States Communication Association: www.westcomm.org Central States Communication Association: www.csca-net.org World Federation of Public Health Associations: www.wfpha.org Coalition for Healthcare Communication: www.cohealthcom.org World Health Organization: www.who.int/en 12   PART I   ESTABLISHING A CONTEXT FOR HEALTH COMMUNICATION Health Care Models try to isolate key variables by bracketing out extrane- ous information. A medical interview may sound a lot What causes ill health? If your answer is germs, you like this: When did the symptoms start?... Does it have probably been influenced by the biomedical hurt when I do this?... On a scale of 1 to 10, how model, which is not surprising, considering that it bad is the pain?... Have you had a fever? Health has been the primary basis of conventional Western communication influenced by the biomedical model medicine for the last 100 years. But if you believe that is typically focused and specific. Health profession- illness is caused by a variety of factors—such as peo- als’ questions require only brief answers, such as two ple’s frame of mind, their values, and the communities weeks ago and yes. in which they live—your views more closely reflect a Biomedical talk tends to have its own vocabulary, biopsychosocial or sociocultural model. Following is which can be puzzling and intimidating to patients. A a description of each model and its impact on health mother summoned to the hospital after her son had communication. been injured remembers: BIOMEDICAL When I walked into the trauma center, they told me Justin had suffered severe trauma The biomedical model is based on the premise that to his brain, a subarachnoid hemorrhage ill health is a physical phenomenon that can be ex- in the sylvian fissure and right posterior plained, identified, and treated through physical fossa, frontal lobe contusions, diffuse axonal means. Biomedicine is well suited to a culture fa- shearing injuries, and a non-displaced miliar with engines and computers. “Repairing a vertical fracture of the C6 vertebra. What I body, in this view, is analogous to fixing a machine,” heard was “brain damage, broken neck.” writes Charles Longino (1997, p. 14). Physicians are like scientists or mechanics. They collect informa- Although her son’s condition was critical, he eventu- tion about a problem, try to identify the source of it, ally recovered. His mother says she feels lucky about and fix it. the outcome, but she will never forget the terror of The focus is often reductionist. That is, in accor- being confronted with medical jargon that frightened dance with the scientific method, health professionals and confused her, rather than helping her understand what was really wrong. At its best, the biomedical approach is efficient and definitive. Medical tests and observations may yield evidence that can be logically analyzed and treated with well-established methods. One criticism of the model, however, is that it marginalizes patients’ feelings and social experiences, sometimes to the extent of treating people as impersonal collections of parts or symp- toms. People are often dissatisfied when caregivers do not listen to their concerns surrounding an illness, and they may mis- trust diagnoses if they feel that caregivers do not fully understand their problems. BIOPSYCHOSOCIAL Experts agree that the future of health care must involve greater collab- The biopsychosocial perspective takes into oration between diverse care providers, health care leaders, and others. account people’s physical conditions (biol- The challenge is to develop the communication skills necessary to make ogy), their thoughts and beliefs (psychology), the most of multidisciplinary teamwork and problem solving. and their social expectations. From this  CHAPTER 1  Introduction    13 perspective, health experiences are not solely physi- the recipient’s preferences and psychological needs cal phenomena but are also influenced by people’s (Wittenberg-Lyles, Washington, Demiris, Oliver, & feelings, their ideas about health, and the events of Shaunfield, 2014). their lives. There is evidence to support the biopsychosocial The biopsychosocial perspective emphasizes that premise that people’s thoughts and emotions have no one approach works well with everyone. For exam- an influence on their overall health and coping abil- ple, some family caregivers welcome loved ones’ help, ity. Researchers have long known that emotional whereas others find it disruptive. A caregiver inter- stress tends to elevate people’s heart rates and blood viewed by Elaine Wittenberg-Lyles and colleagues put pressure. They are now finding that excessive stress it this way: “After not having anybody for a while and reduces the body’s resistance to disease (e.g., Lovell, then having somebody here all the time kind of makes Moss, & Wetherell, 2011). On the bright side, health me—adds to my stress” (p. 906). The researchers ob- is sometimes enhanced by good humor, a positive at- serve that more social support is not always better. titude, and social support (e.g., Gallagher, Phillips, A more important consideration is how well it meets Ferraro, Drayson, & Carroll, 2008). BOX 1.6 PERSPECTIVES A Memorable Hospital Experience In my short 27 years I have visited hospitals in four not part of her technical duties. The nurses at St. Jude states, and only one stands out in my memory: St. stepped out of their textbook roles to accommodate Jude Children’s Research Hospital in Memphis, Ten- the needs of their patients. nessee. My family spent nearly two years of our lives Members of the housekeeping and dietary staff walking in and out of the doors of St. Jude while my were always helpful, too. When my sister thought sister was being treated for leukemia. she had an appetite for a hamburger or macaroni and Walking into the administrative office the first cheese, they always did their best to get some up to her day we arrived was like being in Grandma’s house before she realized she did not want anything at all. seated by a warm, open fireplace. During those first The last person I recall from the support staff was hours of our shock and fear over my sister’s diagnosis, Mrs. Fran, our social worker. She was a dream, not the hospital staff worked quickly on her paperwork just a friend you could talk to but one you could count without making us feel the least bit rushed. The on to take care of the little things you naturally forget warmth and tone of their voices was like that of a in situations such as ours. When my sister died, family member. We were assured we could always Mrs. Fran was there for my family and made all the reach them—if not at work, at home! They were our arrangements to get us back home to Louisiana. new family. There were many difficulties in dealing with the The doctors at St. Jude stopped and spoke with death of a loved one, and my sister was only 15. How- families and patients and answered any questions ever, my parents and I feel an incredible debt to they were asked. The doctors were not the only gems St. Jude. We have founded a fundraising chapter for in the hospital, though. I remember two very special St. Jude in Baton Rouge and I hope to pursue a career nurses, Jackie and Mary. One night my parents and I to help caregivers, families, and the public under- went to eat and were late getting back (it was shrimp stand the importance of interpersonal communica- night!). We found Mary, who had gotten off work 1½ tion skills in hospitals and other health care centers. hours earlier, reading to my sister. Jackie assisted my —GWYNNÉ WILLIAMS sister with manicuring her nails, even though it was 14   PART I   ESTABLISHING A CONTEXT FOR HEALTH COMMUNICATION SOCIOCULTURAL IN YOUR EXPERIENCE From a sociocultural perspective, health reflects a complex array of factors involving personal choice, Have your health care experiences social dynamics, and culture. Social variables include been characterized more by the biomedi- wealth, poverty, prejudice, access to health services, cal, the biopsychosocial, or the sociocultural and living conditions, to name a few. Culture is em- model? How? bodied in shared values, traditions, and rituals. Which do you prefer and why? The sociocultural perspective rejects the notion, on the one hand, that health is purely personal, and on the other hand, that people are simply products of their environment. Instead, it recognizes that these factors are mutually reflexive. Therefore, focusing on The Importance of Health only one factor is typically counterproductive. As an example, the popular Drug Abuse Resis- Communication tance Education (DARE) program has been largely Health communication is important to individu- ineffective at changing schoolchildren’s long-term als, organizations, and society overall. It is crucial attitudes and behavior concerning illegal drugs to meeting medical goals, enhancing personal well- (Birkeland, Murphy-Graham, & Weiss, 2005). After being, saving time and money, and making the most of studying the data, Nicole Stephens and colleagues health information. Following are six reasons to study concluded that DARE’s impact is limited because it health communication. Each of these is addressed has focused almost exclusively on drug use as a matter more fully in the chapters that follow. of personal choice. The larger reality, they found, is First, communication is crucial to the success of that some young people live in environments in which health care encounters. Without it, caregivers cannot drug use is prevalent, highly encouraged by their hear patients’ concerns, make diagnoses, share their peers, and considered normal. Those youth “may find recommendations, or follow up on treatment out- it harder to resist drug use by simply ‘saying no,’” the comes. “Health communication is the singularly most researchers assert. “Instead, a different set of inter- important tool health professionals have to provide vention strategies—for example, decreasing students’ health care to their clients,” write Kreps and Thornton exposure to situations where drug use is likely—may (1992, p. 2). Patients who take an active role in medi- be more useful or effective” (Stephens, Markus, & cal encounters are more likely than others to be satis- Fryberg, 2012, p. 729). fied with their care (Ashraf et al., 2013). Ultimately, no medical model is comprehensive Interpersonal communication is crucial, con- enough to cover all facets of health. The best option sidering that about 32 million people in the United may be awareness that health can be approached in States (roughly 1 in 7 adults) are unable to read more different ways and the versatility to use dimensions of than a simple children’s storybook (U.S. Depart- these models appropriately. The biopsychosocial and ment of Education, 2015). Added to that figure are sociocultural models are appealing for their thorough- people who, although they can read, have language ness and personal concern (see Boxes 1.6 and 1.8). differences and physical challenges that make it dif- However, implementing a holistic approach is no easy ficult to understand and use health information. All task, and sometimes a biomedical solution is enough. of these fall within the category of health literacy. In Chapters 3 through 5, we explore patterns and tech- People with health literacy challenges are usually niques of patient–caregiver communication. In Chapters less knowledgeable about health issues than others, 6 and 7, we investigate the link between health and so- and they may miss appointments, avoid medical care ciocultural factors such as social status, race, gender, because they are embarrassed or frustrated, prepare age, and ability. Then we return to the idea in Chapter incorrectly for surgery and other procedures, misin- 14, where we consider how a critical-cultural perspec- terpret the instructions for medications, and more. tive can help health promoters give voice to marginal- Experts estimate that health literacy challenges ized groups and allow them to challenge and perhaps result in avoidable medical costs totaling more than transform inequitable social structures. $106 billion a year in the United States (Vernon,  CHAPTER 1  Introduction    15 BOX 1.7 ETHICAL CONSIDERATIONS An Essential Component of Health Communication Our customers routinely bare their bodies, as An Ethical Considerations box in each chapter pres- well as their souls, within our organizations. I ents an ethical dilemma and a list of discussion can think of no other enterprise in our society questions and additional resources. I encourage where so much is placed in the hands of others. you to discuss and debate these issues, eliciting di- —LARRY SANDERS, CHAIR OF THE AMERICAN COLLEGE verse views. Do not be afraid to change your mind OF HEALTH CARE EXECUTIVES or to argue both sides of an issue. It is usually easier to behave ethically if you have thought the issues Sanders (2003) advises those who provide and study through before you find yourself in a real-life dilemma. health care, “One of the most significant ways we can Following are some questions you might ask yourself demonstrate how much we care about those we serve as you consider your options concerning ethical chal- is to visibly display our personal commitment to oper- lenges posed in this book and elsewhere. ating with extraordinary integrity, ethics and moral- Is this option legal? ity each and every day” (p. 46). Is it honest? Is deception or omission of the truth It is imperative that people involved with health involved? care understand the ethical implications of their ac- Who will be hurt? Who will be helped? tions and conduct themselves with honor and integrity. Will the decision benefit me personally but hurt They must also be aware of the perceptions of others. others? If people perceive—rightly or wrongly—that health- Are the results worth the hardship involved? related professionals are unethical, they may experi- Is it culturally acceptable? ence stress, avoid medical care, lie to health care Will my decision compromise people’s privacy or providers, or withhold information to protect trust? themselves. Will my decision be demeaning or degrading to Many of the ethical dilemmas that people in anyone? health care face are essentially matters of communi- Is it fair? Will my action unfairly discriminate cation. They involve honesty, privacy, power, conflicts against anyone? of interest, social stigmas, media images, advertising, Is the action appropriate for the situation? and persuasive messages about health. In most cases, Have I considered all the options? there is more than one option, but no simple solution. How would I wish to be treated in the same What seems right in one situation may be wrong in situation? another. Personal preference and culture, among other How would I feel if my decision or action were factors, shape what people want and expect. Even so, published in tomorrow’s newspaper? there is value in thinking through the implications and exploring diverse reactions with others. Trujillo, Rosenbaum, & DeBuono, 2007), and the loss to be well informed about health issues and to take in productivity and quality of life is immeasurable. an active role in maintaining their own health (Koch- Effective communication can offset the tragic and Weser, Bradshaw, Gualtieri, & Gallagher, 2010; Rains, costly consequences of low literacy (Chapter 6). 2008a). However, the media is also filled with glam- Second, wise use of mass media and social media orous images of people engaging in unhealthy behav- can help people learn about health and minimize the iors, making media literacy especially important. In influence of unhealthy and unrealistic media por- Chapter 9, we survey innovative ways that health pro- trayals. Media consumers—especially those who rely moters are making use of online and mobile commu- on newspapers, magazines, and computers—are likely nication. In Chapters 11, 13, and 14 we explore health  16   PART I   ESTABLISHING A CONTEXT FOR HEALTH COMMUNICATION BOX 1.8 PERSPECTIVES Down, But Not Out As a high school baseball pitcher, it was devastat- in during office hours, so they sacrificed their own ing to hurt my shoulder just three weeks from the time to come in early and stay late for me. Not once playoffs. My doctor helped to lighten the mood a bit did they complain. They always had smiles on their by saying, “You’re a great kid and I like you, but I hate faces and always seemed positive and excited to be seeing you here in my office. That means something’s helping me. wrong.” I always felt comfortable with him because After two weeks of the well-conditioned rehab he knew how to connect with me and assure me that they put me through, I felt completely pain free and whatever the problem was, he would get it fixed and ready to pitch again. “Now if you ever need to come get me back out on the field. in again for any therapy or some shoulder exercises, As it turned out, I didn’t need surgery, but I did you just come on in. Don’t hesitate. We’ll be here,” the need physical therapy five days a week. The thera- head physical therapist told me. “Yes ma’am, I appre- pists were really great. They were very strict when it ciate everything you all have done for me,” I replied. came to my rehab and throwing program. “Absolutely I am thankful to have had those professionals who no throwing if you feel any pain whatsoever. You got gave me their best effort and went to the absolute it?” one therapist said to me. They treated me like roy- maximum to ensure that I was taken care of and alty, even though I wasn’t, and made sure I was doing treated properly. I can never repay them for what they the right things to get healthy again. With the ur- did for me. gency to get back in the game quickly, they placed me —DREW on a fast-paced, demanding rehabilitation regimen. They made sure I received the appropriate amount of Drew went on to earn titles as Pitcher of the Year work every day, and they repeatedly asked me how in Alabama, All-County Pitcher of the Year, and my shoulder was coming along. Most Valuable Pitcher of the Year, in addition to I can’t say enough about how helpful and flex- pitching for his college team. ible they were with me. It was tough for me to come images in the media, media literacy, and how to create their caregivers have the best chance of having their effective health campaigns. concerns immediately addressed, which is likely to Third, communication is an important source improve their health and save time and money. of personal confidence and coping ability. Health Fifth, communication helps health care organi- professionals are less likely to experience burnout zations operate effectively. Communication skills are and less likely to leave the profession if they are sat- useful in recruiting employees, establishing innova- isfied (Dyrbye et al., 2013). Likewise, patients cope tive teams, creating efficient systems, and sustaining best when they feel comfortable talking about deli- service excellence (Chapter 10). Studies show that su- cate subjects such as pain and death. And people in- pervisors’ communication skills are one of the most volved in support groups often cope better and even important determinants of employees’ satisfaction live longer than similar persons who are not members and their intention to stay on the job. Organizational (Chapter 8). In short, good communication is condu- leaders can also use communication to assess market cive to good health. needs and respond to patient preferences. Fourth, effective communication saves time and Sixth, health communication may be important money. Caregivers who listen attentively and com- to you because of career opportunities. The health in- municate a sense of caring and warmth are less likely dustry already employees about 15.6 million people than others to be sued for malpractice (Dym, 2008). in the United States, and that number is expected to Likewise, patients who communicate clearly with skyrocket to more than 20 million within a few years.  CHAPTER 1  Introduction    17 Job Growth in Health Care of empowering people and addressing their health (in millions) needs, ideally before they become ill or injured. From a transactional perspective, meanings and 21.3 relationships are mutually and continually cocon- structed by the people involved, who are themselves influenced by contexts, culture, and past experiences. Content-level meanings are explicit, but relational messages are typically implicit reflections on the power and status of people involved in communica- 14.3 tion transactions. Three of the most popular ways of looking at health care are the biomedical, biopsychosocial, and 10 sociocultural models. The biomedical model assumes that disease is best understood and treated in physi- cal terms. The biopsychosocial model treats health 7 as a broad concept that includes social, personal, and physical factors. The sociocultural model proposes 1989 1999 2009 2020 that health-related behaviors reflect both personal FIGURE 1.1 The job outlook in health care is better than in choices and the larger dynamics in which people live. any other segment of the economy. Health communication is important for several reasons. It allows patients and caregivers to share con- Sources: Hatch & Clinton, 2000; U.S. BLS, 2013 cerns and establish trust. It helps people cope and build self-confidence. Communicating well saves time and money and helps organizations solicit, organize, and Experts predict that nearly one-third of the U.S. jobs implement new ideas. Finally, media messages have created between 2012 and 2022 will be in health care the potential to improve or discourage healthy habits. (U.S. BLS, 2013). This includes jobs in clinical care, If health communication is good or bad, we have public relations, marketing, health care administra- a host of people to thank or to blame. Almost always tion, human resources, education, community out- we are among those people. We influence the process reach, crisis management, patient advocacy, and throughout our lives. We all have something to gain by more. (See Figure 1.1.) understanding the process and, hopefully, something Reasons for the notable job growth are threefold: to contribute as well. (1) Baby boomers are retiring, which diminishes the current pool of professionals in health care; (2) health needs are simultaneously escalating as the average Key Terms and Theories age of the population increases; and (3) health care accountable care organization (ACO) reform has the potential to add 20 to 30 million health Americans to health insurance rosters, qualifying transactional model of communication them to receive medical care. Labor analysts predict relational approach a particularly high demand for nurses, allied health health communication professionals, health educators, public health special- biomedical ists, and health care administrators. Communication biopsychosocial skills are a valuable asset in these and every other sociocultural aspect of the health industry. Summary Discussion Questions Health communication is accomplished within a com- 1. Imagine that you have been given responsibility plex array of influences. Teamwork skills, listening, for your family members’ health. You can hire any and intercultural competence are central to the goals collection of professionals you like, but you should 18   PART I   ESTABLISHING A CONTEXT FOR HEALTH COMMUNICATION not limit your thinking to traditional aspects of communication during this encounter? Why or health care. What factors would you consider in why not? terms of each person’s health? Who would you 3. What do you think of the case studies about involve in making sure that your healthy family St. Jude Hospital (Box 1.6) and the baseball members stay healthy? player’s physical rehabilitation (Box 1.8)? Have 2. Spend a few minutes writing about a health care your experiences been mostly similar to these or encounter you have experienced as a patient, different? How? loved one, or health professional. Identify at least 4. Divide a sheet of paper into three columns. Label three content-level and three relational-level them “biomedical,” “biopsychosocial,” and “socio- messages in the encounter. How were the cultural.” Under each heading, list aspects of your relational-level messages conveyed? What role health well described by that perspective. Reflect did culture and prior experiences play in the on how these factors influence the way you think encounter? Were you mostly satisfied with about and communicate about your health.