Journal of Health Communication: International Perspectives
EDITORIAL
Volume 4, Number 1 Vol. 4, Num. 1: Contents | Editorial | Up Front | Abstracts Editorial: Strategic Health Communication and Social Marketing on
Risk Issues *Editor’s Note: A similar version of this editorial was given as an address at the Institute of Medicine's annual meeting in Washington, DC in October 1998. First, I would like to thank Barry Bloom for the introduction and for inviting me to address this esteemed body. I would like to begin with a little history from the pre-Revolutionary days. Fifty-five years before the American Revolution, there was unique debate around a deadly outbreak of smallpox in Boston. The idea of trying a vaccine -- inoculating blood of a smallpox victim -- was heralded as killing, not curing. Ironically, Cotton Mather, the well-known, strong-willed Puritan minister with venomous views, was outspoken at the time suggesting a need to try the first vaccine for smallpox. All but one of the medical doctors in the community were against his suggestion. James Franklin, owner/editor of the New England Courant joined in the chorus against Mather with vitriolic press attacks for his stand on vaccination. The two men debated for weeks -- Franklin in the paper and Mather from the pulpit, and even had a face to face confrontation. Mather tested the vaccine on his son Samuel, who survived. Years later, James Franklin was replaced by his brother Benjamin Franklin who embraced the cause of freedom and the value of scientific research and knowledge. Jumping to the end of the 20th Century, we hear the prescient prediction by Secretary General of the World Health Organization, Gro Harlem Brundtland, who presaged our current predicament: "As the century closes, the rate of change outstrips the ability of scientific disciplines and our current capabilities to assess and advise. This frustrates the attempts of political and economic institutions, which evolved in a different world, to adapt and cope." In its time, just as society has transformed from an industrial and information age into a communication age, the Academy itself has transformed itself creating an Institute of Medicine. The theme of this year*s Institute of Medicine meeting --RISK-- is a salubrious effort in advancing the IOM definition of public health: “Fulfilling society's interest in assuring conditions in which people are healthy.” Where are we today? In my lifetime alone, we have witnessed change unmatched by any other time in history. The world population has nearly tripled to six billion people, we have walked on the moon, eradicated smallpox and created an international and ubiquitous superhighway -the Internet - whose potential we only recently have tapped into. It is precisely the speed of change, our need to “adapt and cope” that has intrigued me as a physician to focus on how we communicate health and risk issues. I have been intrigued by communication since my undergraduate work in rhetoric. It was the Greek rhetoricians who believed the Homeric ideal to be one of promoting a strong body and strong mind. During my medical training I chose to pursue graduate degrees at Harvard’s Kennedy School of Government in health policy and Emerson College in communication. Today, I “practice” health communication. I prefer the Latin root of doctor -- docere -- a medical teacher. Furthermore, Sir William Osler’s definition of the ideal physician serves as an overarching goal: “The physician’s challenge is the curing of disease, educating people in the laws of health and preventing the spread of plagues and pestilence.” As such, in addition to serving as Editor of the peer-reviewed Journal of Health Communication and on the faculty at Tufts University School of Medicine, my principal practice is at the Academy for Educational Development here in Washington. Our patients are people throughout the world, with audiences in the U.S. and over 80 countries. Our service is not with a scalpel, but the modern day therapeutic intervention --ethical science-based communication. We have built upon the Aristotelian ideal -- all the available means of persuasion -- to use 20th century techniques of social marketing and health communication strategies to advance health. This is the topic of my presentation today. It is my goal that by the end of this presentation, each of us can contribute toward a more health literate public. Today, we are far from the Jeffersonian ideal as “an enlightened society.”
The Economist recently blamed this on how the public gets information
from the news media -- “a dumbing down that panders to inanity, prurience
and prejudice.” • The mouse is a little man... One of our most pressing dilemmas is how do we overcome such misconceptions and communicate health and risk to the divergent populations and cultures? The answer lies beyond simple recommendations at these meetings at the IOM, UN or WHO. While I have been fortunate enough to develop and present Maxims for Effective Communication on Health and Risk Issues that were adopted at the World Health Organization earlier this year, without application and action by people such as ourselves here today, they are mere printed images. Regardless, this is not an easy task. Lewis Thomas reminded us of the challenge in On Magic in Medicine, “It is much more difficult to be convincing about ignorance concerning disease mechanisms than it is to make claims for full comprehension.” How Do We Do This? The remedy begins with each of us to move beyond the current pre-millennium
malaise to effective and ethical leadership that matches our scientific
prowess. However, we cannot continue with a vaccine mentality. There
is no single intervention that can establish trusted health leadership
to advance understanding of risk. Tobacco abuse continues despite the evidence. It is backed by a multi-billion dollar industry that develops new markets and marketing schemes that condone cigarette smoking. In the past twenty years, worldwide consumption of tobacco has increased by 75%. (Bill Novelli is one of the pioneers and experts in the field who has re-framed tobacco as a children’s health issue) We know the harm is not just cigarette use and lung cancer. One quarter of American children are exposed to second hand smoke in their homes each day. Certain risks are consistently supported with evidence that children and infants exposed to environmental tobacco smoke at home have significantly elevated rates of respiratory symptoms and respiratory tract infections, middle ear infection, severity of asthma and sudden infant death syndrome. In 1994 alone, 250,000 children got lung and bronchial infections and 11,000 were hospitalized in the U.S. due to second hand smoke. The tobacco struggle is a modern-day David and Goliath in a “socially-toxic” world. Another example is the subject of my recent book, The Mad Cow Crisis: Health and the Public Good . It is an example of how NOT to deal with risk. Misunderstanding, mismanagement, and failed policy-making caused a Mad Cow Crisis. The BSE Crisis, due to bovine spongiform encephalopathy, has cost over $10 Billion worldwide and an immeasurable amount of misdirected energy. This saga began as a result of a British scientific panel release of inconclusive data of the infinitesimal, hypothetical chance of contracting a disease by eating beef. No one would take leadership regarding the science or the health risk. So, the media and others quickly hypothesized that the same mechanism of cattle getting BSE was the mechanism for the twenty human cases of nvCJD (Creutzfeldt-Jakob Disease). Two and half years later with now over two dozen cases, there is no solution, cure or definitive diagnostic test, nor identification of the vector. If we recall an editorial by the editors of the New England Journal of Medicine in 1994 where they stated “the problem is not in the research but in the way it is interpreted for the public,” we could easily blame the messenger. However, we should move beyond and open new avenues with effective health communication. What to Do? Four predominant areas have emerged within this field called health communication. Each addresses an overall goal of health communication as the ethical employment of persuasive means for health decision-making. In short, it means getting the right message to the right people, at the right time, with the intended effect. The strategies are public relations, advocacy, negotiation and social marketing. Public relations was coined in the early 20th century, and is a technique
for changing the culture or the environment for individual decision making.
We could use public relations strategies to advance discussion of the
need for a health literacy. A health literacy that could provide
a necessary basis for making informed Advocacy may be considered as old as the ancient Greeks writings on politics. It targets a change in the regulatory environment, including the workplace or legislative arena. Advocacy utilizes media, policy and social mechanisms in the effort to elicit change. Advocacy activates the ever-increasing channels of communication, targeting niche groups, opinion leaders and champions - with specific appeals to achieve the desired result. The days of broadcasting messages are gone: we must narrowcast our message to specific targeted audiences. Today, social and media advocacy strive to influence the political agenda to enact policy change at a variety of levels. The emphasis on research on certain diseases and treatment regimens -- such as HIV and breast cancer were due to advocates’ efforts. Negotiation was popularized with French diplomacy training in 1700. Today negotiation’s aim is to change the nature of the involvement of people. In the health setting , such as the program at Dartmouth Medical School, it is termed Shared Decision Making, involving the patient in the treatment process. In other cases it can be influencing the decision maker responsible for delivering health messages. When it involves the entertainment media, we call it an entertainment-education strategy. A recent study indicated that 32% of regular viewers of NBC’s ER indicated that information they receive on the show helps them make choices about their family’s health care, an one in eight said they have contacted their physician because of something they saw on the show. Other studies indicate that discussion of immunizations on soap operas actually increased the number of mothers seeking vaccinations for their children. The desired result of negotiation is that people more effectively participate in decisions -- working with community groups, public-private partnerships and other interested parties. The roots of social marketing in the middle of this century were not
in marketing per se but in social psychology and mass communication.
Social Marketing is often thought today of employing the tools of the
commercial marketing world; modifying the 4Ps of marketing -- product,
price, place and promotion -- to change target audience behavior.
In social marketing the focus is on the determinants of the behaviors
of our intended “patients.” By merging the science of marketing,
polling, public opinion and communication, social marketers A recent example of social marketing is with the use of drive-through flu shots in Atlanta. Here, the health provider has made the ease of access -- modifying the place of delivery -- to increase the immunization rate amongst target audiences. They have reduced the barriers to health seeking behavior. Such social marketing strategies could offer great strides in vaccination. Consider that only 15 to 30% of the targeted populations --- the elderly, immuno-compromised individuals and individuals with pulmonary or cardiac conditions -- are vaccinated against pneumococcus. While we know it is the most common cause of bacterial pneumonia and middle ear infections in the United States -- ultimate compliance is not be achieved. A strategic social marketing diagnosis and treatment plan could translate into results. While all of the aforementioned interventions -- Public relations, advocacy, negotiation and social marketing -- have unlimited promise and potential, they will not a priori develop a healthier world. There Are New Opportunities Coupled with credible and deliberative leadership, the new communication technologies can advance understanding of health within the public. Soon, the Internet will not be associated with a computer as it will be ubiquitous -- accessed from television, land-linked and cellular phones, satellites, radio, kiosks and other new venues. The new technologies give us great opportunity for recreating the current state of health “as we know it” to health as it “ought to be.” Recommendations As I mentioned earlier, I have recommendations all of us here at the IOM today could embody. Shall we say to build upon the Hippocratic ideal of “do no harm” to a proactive Oslerian ideal to “educate people in the laws of health and prevent the spread of disease.” Today’s physician can not rely on the practice environment to treat ills but also must reach out to patients throughout their daily activities. Clinicians New and traditional media continue to educate the public with or without
physician’s involvement. The 21st Century physician should advance
his/her healthy influence with active involvement in accurate health and
medical content. The individual MD can also use the practice environment
for teachable moments on the rationale behind compliance with antibiotic
regimens or other treatments. With negotiation and shared decision
making, we may be able to increase compliance beyond the dismal 35% as
reported in the literature. Community Citizen While many hide behind a smokescreen and blame the system for the “socially toxic environment,” few of us actively participate in advocacy or public relations strategies. The new 21st Century MD should become the spokesperson for the health of the community. Strategically, this means advocating for health and medical “education” beyond the health setting. While health moves from hospital to home and certain decision making by MBAs rather than MDs, the physician should work with medical and community organizations in a multi-disciplinary fashion to influence health related decisions made by non-physicians. Understanding of risks-- from sexually transmitted diseases, alcohol, tobacco and other drug abuse, and anti-microbial resistance to name a few, cannot be addressed only with an annual conference or printed report. (Any involvement advances our role as health citizens and creates a more health literate public.) Policy Maker While the Institute of Medicine is known as the source for accurate expert information amongst all of us, it does not adequately diffuse to the public psyche. Perhaps we ought to consider an expanded approach. Each of us could help broaden the audience of IOM activities. If our target is influencing policymakers as the intermediaries in influencing public health that is only one approach. Yet, while policy is slow and the public continues to gather their principal health information from the mass media and ever-growing new media, we might consider some of the aforementioned communication strategies for the IOM in the 21st century. Researcher Of course, there is a great role for scientific discovery in advancing health. Molecular and evolutionary biology along with biotechnology offer a glimpse in to the future. However, the translation of progress to the public is limited. In the 21st Century, we must not only strive for new medical discovery, but also to translate such knowledge into a healthier society. I suggest each researcher consider developing a “public abstract” or health “legend” of their study results. This should be simple so that it could be easily explained to their mother or twelve year old child. Oftentimes, we are so close to what we do that we cannot communicate it to the most important publics. Leadership Finally, the MD must advance a leadership position not only in the hospital and health care facility but in creating “health.” This is where the IOM and our professional societies and organizations could be most powerful. MDs can influence the debate on quality, “care management,” and the overarching goal of educating patients to be more health literate with appropriate demand for services and realistic expectations. The MD can also create virtual leadership with the advancement and ability to narrowcast new technologies. I do not think all MDs want to be leaders, but we can start with those here in the room and diffuse strategies to re-position medicine as the healing art and science with health for all. In conclusion, I spoke earlier about the cure for smallpox. Dr. Edward Jenner’s paper proclaiming a treatment was not obvious at the time, as the leading peer-reviewed journal of the day would not publish his work. He had to pay to publish a book and also use communication strategies to have a newspaper print his account in the Columbia Centinel. Today, there continues to be articles that were initially rejected by a journal and later served as a basis for a Nobel Prize or other significant developments. Such examples include the hepatitis B virus and the radio-immunoassay technique....Galileo’s words from centuries ago are often frighteningly true today: “in questions of science, the authority of thousands is not worth the humble reasoning of a single individual.” Finally, as a physician my primary concerns are prevention of disease and promotion of healthy, quality lives for all people. My hope is that as we can all be doctors and communicators and contribute to quality, healthy lives. My hope is that each of us, from a multitude of approaches, contribute to a healthier world by delivering anethical component of health each day. ____________ |
