Part One: The Core Modules of the Global Communication Project 2023
The idea for The Global Communication Project, emerged from a discussion between John Elder and Joe Smyser in 2015, with John voicing frustration with how textbooks for health communication were so quickly out-of-date, were prohibitively expensive for most students, and had few visual and no audio or video examples. (And, the examples that were provided were typically of average quality and void of any controversy, limiting the students' opportunity to develop critical skills). Joe suggested the development of this web-based, interactive text with several modules that resemble book chapters of a printed textbook, and we launched an effort to do just that. Joe has since moved on to other endeavors, and Katie Elder has taken over as senior editor of the GCP, but our motives and theme have remained the same.
There are many online and printed textbooks that give extensive and comprehensive introductions to health communication and related approaches to improving public health. Our motivation is not necessarily to improve on these texts, but to tackle the subject through an entirely different format. By using web resources, we can take the learner quickly through more in-depth explorations of topics, including both good and bad examples of health communication. At the same time, we can remain current with the field by providing a dynamic learning experience and illustrating the subject matter far beyond that achieved by reading black print on white pages. However, the availability of examples of and resources for health communication online changes rapidly, just as the field of health communication does in the age of social media and now Artificial Intelligence (AI). Hence, this online text is continually under modification with input from you students, our audience. This text has been used in courses in at least four universities, and the version presented here embodies input from the hundreds of students who have taken these classes.
The modules of the GCP 2022 version comprise the inputs of William J. McGuire’s input/output model  (i.e., the "what," "how," "who," and "to whom" of our health communication efforts) and other specific topics in the fields of health and social communication. There are many theories and models of health communication and social marketing; several of these will be presented below, and again, in the Messages and other modules to which they most pertain. This overall text, however, is structured around the “Communication-Persuasion” (or, as mentioned, "input/output") model. Deriving from social and cognitive psychology and influenced by business and marketing principles, McGuire’s theory is one of the most practical in the field as it serves to structure both a behavior change program (“inputs”) and the evaluation of that program's results (“outputs”). We don't emphasize McGuire's because it is the 'best' theory, but because in general it is the most accessible and applicable to our health communication work.
McGuire’s emphasis among the inputs (as well as ours) is the “message”. The message is the “what” in terms of the basic description of the health, social, or other behaviors we hope the audience performs. It derives directly from Aristotle's concepts of effective communication, beginning with the specific "purpose" or "destination" (telos) of the communication. Messages specifically comprise the content and feel of the health communication. Armed with insightful formative research, effective health communicators and social marketers know how to capture the essence of a health, political, or social issue with words, images, colors, and sounds that best represent their theme. Getting back to Aristotle, the informational content of a message can be thought of as its light (or logos), whereas the colors, sounds, words, and images used to elicit emotion (pathos) can be thought of as its heat. Well-constructed messages are key to achieving a positive public health impact. Poorly constructed ones not only waste resources but may send a totally incorrect message to the audience. Witness, for example, this early (in the COVID-19 pandemic) German effort apparently attempting to encourage people to wear personal protective equipment (PPE), where even the performers are not adequately protected.
The “Audience” (or “to whom”) module sets the stage for any health communication effort. The audience, or “receivers,” comprise the target population we wish to contact (whether they be individuals, neighborhoods, communities, gatekeepers, or politicians). Formative research conducted with actual members of the target audience, or with subject matter experts, is necessary not only during message development, but also for channel selection and audience segmentation. Audience segmentation is crucial to finding the balance between being effective and being efficient: while one size does not fit everyone in our target audience, we cannot afford to tailor messages to each individual in the audience. The process of segmentation determines the strategies required to address types of health or social issues, language or cultural distinctions, age and other demographic variables, and receptivity different subgroups may have to making changes. Conversely, a failure to properly segment an audience can yield negative or even disastrous results, as evidenced by the Bud Light boycott in mid-2023.
As the audience is the receiver of the message, the “Source” is the “who” that is sending the message. The “Source” module presents various options for selecting the best personality, character, or agency to be associated with the origin of the message - whether it be a rock star in the 1950s or in real life. The source of a message determines an audience’s reaction to a message, so particular attention is given to the selection of sources that are most likely to resonate with target audiences.
The channel is the “how,” or the main method or media mix that we use to get the message out. Traditionally, channels have been thought of as print, broadcast (radio or television), or display (e.g., signs, billboards), such as this homage to victims of COVID-19 or these examples of TikTok health influencers. However, with the advent of digital and social media, there has been a revolution in our thinking about health communication. Media mixes (using combinations of the above and other channels) and media delivery systems (for example, print and video presented interpersonally or through the Internet) give us a broader perspective on the effective use of channels. Interpersonal communication, the most enduring and universal form of communication, is now once again at the forefront. Thus, the “Channel” module is supplemented by specialized pieces on “Social Media” and “Patient-Provider Communication.” A separate module specifically on “Entertainment-Education” complements the “Channel” module by delving more deeply into paths to persuasion and the notion of a “communication contract” between source and audience. There are a number of films (such as Spike Lee's BlacKkKlansman) for example, that depict the resilience and courage of the Black community in the United States that strike a balance between entertainment and education.
McGuire’s paradigm also includes “outputs,” namely, the cognitive-behavioral changes that the audience proceeds through to arrive at the desired behavior change, whether the change be the purchase of a commercial product, reducing an unhealthy or increasing a healthier practice, or participation in a social cause. These outputs comprise a “hierarchy of effects” model, as they are predicated on a logical sequence of cognitive-affective-behavioral change, from being exposed and paying attention to a message, all the way to permanent behavior change and even reaching out to others to do the same. Although research has shown that individuals do not necessarily proceed lock-step through this output hierarchy, its logical formulation is central to the design of the evaluation of our health communication efforts, even though our primary task is to design and implement the “inputs”. In other words, we need to know why we’re going about this effort in the first place, or the “destination” or overall purpose of our campaign.
Now we'll turn to predominant theories in health and social communication. The learner should be familiar with the half dozen or so lead theories in the field, and especially understand where they overlap or diverge.
Part Two: A Brief Overview of Theories
"What has been will be again,
What has been done will be done again;
There is nothing new under the sun.”
This verse from ancient Hebrew scripture can be applied to much of the evolution of health behavior and communication theories and models over the past century. Writers from diverse academic backgrounds - from experimental, clinical and social psychology; to anthropology, to marketing and economics - have made many contributions to the field of health communication. These contributions build on, overlap with, and even borrow from the works of others - all the way back to the aforementioned Greek terms (telos, pathos, logos) conceptualized as part of the art of persuasion more than 2,300 years ago.
In The Global Communication Project 2023, we are relying on McGuire‘s input-output model to structure the course, as this model presents a very pragmatic approach to designing health communication and (to a lesser extent perhaps) evaluating health communication efforts. Nevertheless, it would be short-sighted not to take readers through the other important theories that contribute to the field. For example, McGuire writes about his “outputs” in terms of the cognitive-affective-behavioral change that audiences would be expected to go through to benefit from the health communication effort. His outputs manifest a hierarchy of effects; in other words, it is at least implied that an individual would have to go through awareness, liking, and other previous steps to eventually get to the ultimate behavior change and maintenance of the change that we could expect. This model has a long history of application to the broad field of marketing to consumers (see example from Lavidge and Steiner’s work over 60 years ago).
McGuire, however, is not the only writer who has addressed the issue of hierarchy of effects leading to behavior change. For instance, Prochaska, DiClemente, and others discuss the “stages of change,” which in many ways directly parallel McGuire’s hierarchy even though their model has its roots in clinical rather than social psychology.
Even a field as diverse as anthropology has produced parallel concepts. Everett Rogers is perhaps the best known of these individuals who discuss outputs in terms of “Diffusion of Innovations”. From Rogers’ perspective, individuals may be classified as innovators, early adopters, late adopters, and resistors. A successful health communication campaign therefore moves people from “right to left;” in other words, from not adopting an innovative health behavior to be more willing to act in a way consistent with influential early adopters. Journalist Malcolm Gladwell’s (2000) The Tipping Point provides more detail on how a group of early adopters eventually grow into a majority.
Behavioral psychology also has a unique contribution to communication, as much of our communication is not only directed at personal health behavior, but also health-related policies that reinforce some behaviors and put barriers into place for other behaviors. The work of B.F. Skinner, an experimental psychologist, initiated the “experimental analysis of behavior” that eventually became dominant in the broader applied discipline of behavior modification. Skinner’s contributions to public health behavior change derive especially from his concept of “contingencies of reinforcement.” Essentially, this concept holds that individuals are more likely to re-engage in a behavior if that behavior meets with a “pleasant” consequence (a contingency labeled “positive reinforcement”). Much of what is done in marketing attempts to show individuals what the beneficial aspects of behavior change are, and conversely, the unpleasant consequences of engaging in unhealthy behavior. Richard Thaler’s (2017) “Nudge Theory” uses Skinner’s principles to show how entire populations are eventually shaped by microeconomic forces.
Behavior modification, therefore, aligns closely with a broader field of economics and business, especially as presented in its most practical form by Philip Kotler. Kotler’s “5 P’s” center around the concept of “price.” The price point in consumerism means that a product will be purchased if it is seen as sufficiently beneficial and at the same time is sufficiently inexpensive for the consumer to feel comfortable buying it. Therefore, the price concept parallels Skinner’s notion of contingencies of reinforcement.
This brings us back full circle to social psychology. For instance, Albert Bandura has noted that people do not need to be directly reinforced or face consequences for their behavior if they simply can observe what happens to others in similar situations. Again, we see a direct relationship here to Rogers’ Diffusion of Innovations, whereby innovators or early adopters or individuals are being observed by the rest of the community to see whether innovations are meeting with pleasant consequences (or, conversely, whether the aversive consequences for these actions supersede any benefit derived from them).
Once again, we can see the mutual influence of these various theories, arguably none of which is complete in and of itself, but all of which can contribute to our understanding of effective health communication. More recently, for example, Kim Witte and her colleagues define the Expanded Parallel Processing Model (EPPM), which explains how cognitive processes may determine whether people act to lower their risk of a negative health condition, or whether this action is seen as too difficult or would be insufficient improve health. The EPPM thereby provides a cognitive perspective on how Skinner’s contingencies, Kotler’s price, and Rogers’ diffusion may be effective.
These and other theories and models will be revisited in modules most relevant to their specific contributions. A health campaign designer needs a fairly broad understanding of the contributions that diverse schools of thought make to a full health and social communication effort. None is complete by itself, nor are any completely novel.
Analysis Activity 1.1
Audience research informs us by what label the audience - and whatever causes it embraces - wants to be called. Witness, for example, the use of "pro-choice" vs. "abortion rights" among the millions protesting the controversial June 2022 Supreme Court overturning Roe v. Wade. What are the pros and cons of each of the terms? Are they interchangeable?
Part Three: Additional Modules
“Entertainment-Education” is a hybrid of message and channel inputs, showing how different balances between the heat and light of communication may be appropriate for different themes and goals. The “Public Speaking” module looks not only at this traditional form of communication, but also discusses how best to support public presentations with slide shows and other resources. “Patient-Provider” communication reminds us of our health focus and the fact that a great deal of medical knowledge the public learns is through primary and secondary care providers. "Artificial Intelligence" promises to revolutionize how audiences receive and process health and social information, with both promising and scary prospects (see July 2023 article by Leana Wen). "Geographic Information Systems" technology gives us powerful tools for everything from understanding audiences to evaluating the impact of disease and public health efforts. We will wrap up with a “Program Evaluation” module that puts McGuire’s Outputs and Glasgow’s ‘RE-AIM’ frameworks that not only show us how to assess our program’s impact, but also how to look at it in the broader context of multiple levels of impact. We will use as a vehicle an evaluation model that reaches across the seemingly unrelated illnesses of mosquito-borne diseases and childhood obesity. Finally, our “Ethics and the Future” module looks at recent scandals and ethical violations that have been committed by or at least through social media, and what vulnerabilities we have and protections we should develop in and beyond our field, balancing the fact that public health is a cause we all share, while personal health is among the most private aspects of our lives.
Part Four: In Summary
We hope that you, our audience, enjoy and benefit from your exploration of The Global Communication Project 2023. We would greatly appreciate your suggestions on how to improve the modules: what topics should we add? What updated links would you suggest from YouTube, TedTalks, publicly available publications, etc. would improve the text? Which of these should be central to the GCP2023 and which would be better in optional modules? Would you be willing to write some content? Your thoughts are appreciated!
About Your Editors
Katherine ("Katie") Elder, Ph.D., M.P.Aff., is Assistant Professor of Health Communication at California State University, Channel Islands. Prior to joining CI, she worked as a postdoctoral fellow at the University of Texas Health Science Center on a grant-funded project designed to tailor health-related messaging to the needs and beliefs of legislators. She studies translation and implementation science, focusing specifically on how to bridge the gap between public health research and health policy. Her research interests are motivated by her work in the public sector. Prior to her doctoral studies, she worked for two years as a program analyst in the Obama administration at the U.S. Department of Health and Human Services' Recovery Act Office, where she was responsible for stimulus-created jobs data posted on Recovery.gov. She has also worked on projects for the U.S. Agency for Healthcare Research and Quality, the U.S. Department of State, and the Centers for Disease Control and Prevention. Katie received her Ph.D. in Health Communication from the University of Southern California and her Masters of Public Affairs from the Lyndon B. Johnson School at the University of Texas at Austin.
John Elder, Ph.D, MPH, is Distinguished Professor of Public Health (Emeritus) at San Diego State University, and recipient of the “Distinguished Professor” designation for both his research and his teaching. John received his Ph.D. in Clinical Psychology from West Virginia University and his MPH in International Health from Boston University. He has worked on some of history’s largest health communication projects in the USA and abroad, such as the Pawtucket (Rhode Island) Heart Health Program (USDHHS/NIH), the 21-nation HealthComm Child Survival Project (USAID), the PEPFAR HIV/AIDS project (USDOD) and the COMBI dengue and subsequently tuberculosis projects (PAHO/WHO). He teaches the MPH health communication class at SDSU and has recently helped to start a community garden in a lower income, urban neighborhood in San Diego.
Analysis Activity 1.2
Describe yourself in terms of your general characteristics, personal history, important lifetime experiences, or other ways you deem important and are willing to share in order for your instructor and classmates to get to know you better. Then, write a bit about your background in public health and/or communication, and what you would like to get out of this course.
Analysis Activity 1.3
Share a favorite photo that you have taken. What is it about the photo that you appreciate?
 McGuire, W.J. (1985) Attitudes and Attitude Change. In: Lindzey, G. and Aronson, E., Eds., Handbook of Social Psychology, 3rd Edition, Vol. 2, Random House, New York, 233-346.