Part One: The Core Modules of the Global Communication Project 2024

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Elder and Joe Smyser in 2015, with John voicing frustration with how textbooks for health communication were so quickly out-of-date, were prohibitively expensive for most students, and had few visual and no audio or video examples.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 or even low quality and void of any controversial topics, limiting the students' opportunity to develop critical skills. After several years of teaching the required MPH Health Communication course at San Diego State, Dr. Smyser suggested the development of this web-based, interactive text with several modules resembling book chapters of a printed textbook, and we launched an effort to do just that. Joe has since moved on to other endeavors, and Dr. Katie Elder, Assistant Teaching Professor of Communication at UC Santa Barbara, has taken over as senior editor of the GCP. Note however that the application of our philosophy remains the same: A) providing high quality material of B) little or no cost that C) allows students to critically point out strengths and weaknesses of existing health communication campaigns. Ultimately, this will lead to D) students being able to develop their own high quality communication pieces and overall campaigns.

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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 five universities, and the version presented here embodies input from the hundreds of students who have taken these classes.

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The modules of the GCP 2024 version comprise the inputs of William J. McGuire’s input/output model [1] (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 do not endorse McGuire's because his is the 'best' theory, but because in general it is the most accessible and applicable to our health communication work.

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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 and communicate 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) Alberta (Canada) attempt to discourage family and friendship gatherings in order to limit the spread of COVID, without really mentioning alternative protection.

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, it is not (yet) feasible to tailor messages to each individual in the audience. The process of segmentation determines the potential receptivity to strategies required to address types of health or social issues depending on language or cultural distinctions, age and other demographic variables, and other subgroup distinctions. Conversely, a failure to properly segment an audience can yield negative or even disastrous results, as evidenced by the consumer audience-initiated 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 GCP 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 Georgia public school teachers 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 media (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 American Fiction) for example, that depict the irrational need to stereotype diverse Americans and strike a balance between entertainment and education.

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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 formulate 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.

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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.

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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.”

 

Ecclesiastes 1:9

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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 – all have made contributions to the fields of health communication and social marketing. 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 Aristotle’s art of persuasion more than 2,300 years ago.

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In The Global Communication Project 2024, 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).

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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.

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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 across the spectrum; 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.

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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, introduced 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.

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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.

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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 from the perspective of anthropology innovators or early adopters are being observed by the rest of the community to see whether their innovations are meeting with pleasant consequences (or, conversely, whether the aversive consequences for these actions supersede any benefit derived from them).

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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 Extended 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.

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These and other theories and models will be revisited in modules derived from 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 as Ecclesiastes advises us are any completely novel.