El Sistema de Eliminación

To detail the story of health communication we need to outline the two mainstreams of inquiry guiding research and application in the field. The predominant consensus among health communication scholars is that the field is located at the meeting point between health care and mass communication (Basil, 2014a; P. Crawford & Brown, 2011; DuPré, 2014; Dutta & Basu, 2011;

R. Thomas, 2006; Wright et al., 2012). Nowadays, communication in health care tends to be delivered on a number of fronts including by health care deliverers to consumers, by health professionals, health teams, during patients’

decision-making processes or in the form of therapeutic communication¹(Ibid).

The public communication of health focuses on the use of communication strategies to promote healthy lifestyles and choices and prevent risks (Basil, 2014a; P. Crawford & Brown, 2011; DuPré, 2014; Dutta & Basu, 2011; Leshner, 2014; R. Thomas, 2006; Wright et al., 2012). Both of the inquiries are interdependent and function in a parallel manner in order to achieve health objectives.

The dominant research paradigm in the field embraces two steps to conduct health communication research and intervention; audience-based and message-based (Dutta & Zoller, 2008; Dutta, 2008; Leshner, 2014). In audience-based research, appropriate target groups are identified and effective ways to reach them are drawn up (Ibid). In message-based research, the focus is on the use of strategies to design effective health messages. This approach also encompasses the continuous development of the design of the campaign and also of the evaluation process to accomplish the aims of the campaign or intervention (Ibid).

The dynamism and rapid development of the field have generated a wide diversity of field studies. This has taken place in two stages. At first, as the practice of health communication developed scholarly interest was piqued and an association established. In the second phase, a range of theories and approaches have emerged. As a consequence, the development of health

1 This term refers to the communication aspects of the therapy delivery. As Tamparo and Lindh argued

“therapeutic professional communication takes place between a person who has specific need and a person who is skilled in techniques that can alleviate or diminish that problem” (2008, p.6).

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communication is inseparable from the development of public health and epidemiology and both need to be considered in tandem.

The issue of maintaining health is rooted deeply in the history of humankind, and health behaviours such as sex, diet, and seeking cures have been significant since ancient times (Basil, 2014a). Through history, behaviour-oriented health risks have run in parallel with the most risky aspect of health, the infectious disease (Basil, 2014a; CDC, 2014b; Kar, Alcalay, & Alex, 2001a;

Kar et al., 2001b; Roberto, 2014; WHO, 2015b). In fact, viral disease is largely responsible for the emergence of both epidemiology and for notions of public health (Ibid). In the past, primitive health systems were not able to cope with infectious diseases. That lead to millions of deaths such as in the “Black Death”

of 14th Century Europe and the cholera epidemic of the 1800s (Basil, 2014a;

Bukoski, 1991a; Bukoski, 1991b; R. Eckersley, 2006; Schumacher & Milby, 1999). A glimmer of hope emerged in 1854 when John Snow successfully identified the source of cholera and isolated it (Ibid). A few decades later, the germ theory was developed by Louis Pasteur and public health scholarship and epidemiology had begun (Ibid).

The 19th and 20th centuries witnessed the advance of the modern health paradigm (western paradigm) which set out to contain many of the deadliest infectious diseases in the developed and developing worlds, and partially in the Third World (Basil, 2014a; Kar et al., 2001b; Roberto, 2014). Undoubtedly, communication contributed to this success through educating the public about public health measures such as drinking clean water and support for vaccination programmes (Ibid). Just as technology advancement was an implicit part of the 20th Century, so mass communication offered a new set of means to accomplish success (Ibid). This stage in public health scholarship is known as the infectious disease (communicable disease) phase (Ibid).

In the latter half of the 20th Century, public health faced a new range of disease challenges, namely behaviour-oriented, non-communicable diseases.

These diseases are driven by two causes; modifiable behaviours and physiological features. Non-communicable diseases cause, nowadays, more death than infectious disease (Basil, 2014a; Kar et al., 2001b; Roberto, 2014;

WHO, 2015b). Poor diet, lack of physical activity, smoking cigarettes and using drugs are major contributors to premature death (Ibid). It is true that the

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developed world has largely succeeded in tackling communicable diseases, but the change in the lifestyles, driven by prosperity, in the West has put new pressure on health care (Ibid). On the other hand, the Third World still is facing infectious disease challenges due to health system incapacity and the rising threat of non-communicable disease (Ibid). It is this combination of elements that has led to the current stage in public health.

This stage is marked by a combination of chronic and acute diseases either transmissible or non-transmissible in nature (Kar et al., 2001b; Roberto, 2014). The prevalence of disease is determined by different variables but the extent of economic development and the availability of public health services are both key factors (Ibid). Communication theories and practice have played a central role in efforts to confront public health epidemics and other challenges.

So where and when did health communication begin? In fact, communication about healing, diseases, and protection cannot be limited to modernity nor even to the known communication literature. Since prehistory, people have painted or carved signs in caves containing messages about threats to life, including health (Basil, 2014a). However, this chapter will engage with only the known story of health communication in the literature

The first appearance of health communication was in the 1960s when doctors found the purely-scientific medical approach inadequate (Basil, 2014a;

Dutta, 2008; Harrington, 2014; Kreps, 2014; Northouse & Northouse, 1998; R.

Thomas, 2006). Although the bio-medical paradigm had achieved advancements in treatment and diagnosis, the healthcare deliver-receiver relationship had not advanced to a similar level (Ibid). In the 1960s, the receiver of health services was seen as a passive player in the health care context while the doctor was considered the authority (Hoving et al., 2010). In practice, the one-sided (top-down) relationship has continued to be popular among health professionals (Ibid). However, scholars were working on finding a solution to what was often a blockage in the delivery of health care. Health communication as a practice and a discipline was born.

At the time, sociologists and psychologists were simultaneously testing the communication variable in the health context. Their work and findings started to filter through to medical and communication professionals, who were also pondering the importance of communication in health care (Kreps, 2014;

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Thompson, 2003; Wolff, 2007). New insights into the study of therapeutic communication were discerned by psychologists who examined the role of interpersonal communications especially within the family. Watzlawick’s influential work, The Pragmatics of Human Communication (1967), brought yet more attention on to communication roles in the health setting (Ibid).

One of the early studies about the communication interaction between the physician and the patient was conducted by paediatricians trying to understand the influence of verbal communications on patient welfare and follow-up care (Korsch et al., 1968). The study concluded that communication was an important way to limit the lack of warmth in the doctor-patient relationship and was a positive factor in patients’ accepting medical advice (Ibid). Social, economic and cultural backgrounds were also considered by Barbara Korsch to be influential in the interaction between the physician and patient (Ibid). By contrast, since the 1960s and 70s, there have not been any significant shifts in perceptions about the patient’s passive role (Hoving et al., 2010).

Furthermore, health communication has expanded to include other areas. Since the 1970s, health institutions have faced difficulties in covering the cost of services provided to patients, leading to a change in the way hospitals work (DuPré, 2014; R. Thomas, 2006). In particular, the rise of consumerism in the health sector has seen a shift in patient identity from a beneficiary of government services to a consumer with the right to choose (Hoving et al., 2010). As a result, the need to communicate with consumers to assure customer satisfaction has added greater emphasis to communications in the health sector (Ibid). The rise of consumerism has also been arguably responsible for the growth of marketing in the health care sector, especially in the United States (Andreasen, 1994; Hastings & Domegan, 2013; Kotler &

Roberto, 1989). In recent decades, the evolution of marketing has offered new possibilities for health promotion, such as through social marketing² (Ibid).

In the same manner, the emergence of prevention as a strategy to minimise the risks imposed to public health have drawn the attention of communication scholars and practitioners. Communication is now considered

2 More discussion about social marketing and communication strategies will appear in the following section.

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essential to the prevention of diseases, both infectious and chronic (Bukoski, 1991a; Bukoski, 1991b; Fields, 1995; Freimuth, 2014; Roberto, 2014;

Schumacher & Milby, 1999; Wilson & Kolander, 2003). It was soon recognised that there were communication needs at all levels of prevention; primary, secondary and tertiary (Ibid). In primary care, doctors focus on educating patients’ about how to take care of themselves and prevent potential risks (Ibid).

Similarly, health professionals at the other two levels use communication such as a therapeutic tool at the tertiary level to achieve the same objective (Ibid).

Public health specialists acknowledge, therefore, that communication is an important way of achieving their goals (Abroms & Maibach, 2008a; Alcalay, 1983; Beato & Telfer, 2010; Hornik, 2002; Noar et al., 2010; Simons-Morton et al., 1997). In fact, public health interests in communication have led to the emergence of more roles for the mass media and for mass communication in promoting health to maximise the achievements of public health programmes (Ibid). Communication’s capacity to reach a wider audience through mass media and through technological channels has fuelled the growth of mass media campaigns in health communication (Atkin & Rice, 2013; Atkin & Rice, 2014; Salmon & Atkin, 2003; Silk, Atkin, & Salmon, 2011).

The study of communication in health care has progressed rapidly in the years following the first study. In addition to the research, there have been contextual and structural changes that have backed up the need for more research about communication in health. Most significant, health systems and institutions struggling with costs has led to a change not only in understanding the patient is a consumer, but also on an organisational level through the merging of hospitals and medical facilities into larger, holding entities (DuPré, 2014; Schiavo, 2014). Such a development, especially in the US, introduced a new set of challenges such as the communication between management and shareholders as well as between consumers and healthcare deliverers (Ibid).

Moreover, the 1980s-90s witnessed considerable shifts in the position of the patient in the context of healthcare. For example, in the 1980s, under pressure from self-care and self-help groups, several countries introduced regulations regarding patients’ right to be informed about their condition and the potential treatments (Hoving et al., 2010; R. Thomas, 2006). Consequently, communication with patients shifted from being a matter that was the personal

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preference of the professionals to a more regulated exchange (Ibid). Patients advanced from a passive to an active role in the healthcare process. In the following years the situation has developed further still and patient-health education and patient involvement in making healthy choices are common positions (Ibid).

Above all, health communication has not been immunised from changes in the surrounding context. Cultural diversity and technological advancements have raised more concerns and questions about health and communication (Dutta, 2008; Schiavo, 2014; Wright et al., 2012). Technological improvements in the late 20th Century have certainly been perceived as a great opportunity to improve health, especially as the notion of e-health³ has evolved (DuPré, 2014;

Kreps & Neuhauser, 2010; Lupton, 2015; Neuhauser & Kreps, 2003; Noar &

Harrington, 2012; Sundar et al., 2011; Wright et al., 2012). However, the dilemma of multiculturalism in healthcare delivery systems has emerged as an imperative challenge to the dominance of culture in health and healing (Dutta, 2007; Dutta, 2008; Kar et al., 2001a; Kar et al., 2001c). The cultural shifts caused by demographic changes in the West have encouraged scholars to investigate communication’s role in understanding diversity, inequality and discrimination in healthcare delivery (Ibid). Multiculturalism, cultural diversity and demography are, indeed, largely responsible for the growth of the critical/cultural perspective in the study and application of culture in health communication⁴.

Having said that health communication was born and developed within the environment of healthcare, some scholars argue that the emergence of the mass media has been a critical factor. Studies investigating the role of the mass media in health interventions and campaigns began in earnest at the beginning of the 20th Century (Dutta & Souza, 2008; Wakefield, Loken, & Hornik, 2010b;

Wartella & Stout, 2002). At the core of most of these studies was the attempt to both predict and change behaviour around health.

3 E-health refers to the use of communication technologies such as the internet, wireless, e-applications, satellite positioning in the delivery of health care and health promotion to the public (DuPré, 2014;

Kreps & Neuhauser, 2010; Noar & Harrington, 2012; Sundar, Rice, Kim, & Sciamanna, 2011; Wright et al., 2012).

4 The third section of the chapter is dedicated to this issue, which is the framework of this thesis.

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One of the earliest health campaigns was conducted by Lashley and Watson in 1922. It was a film campaign about sexual diseases. The results of the study concluded that the film had an effect on the audience’s knowledge about sexual diseases, but not on their attitudes (Wartella & Stout, 2002).

Another study in 1933, by Peterson and Thurstone, focused on the use of mass media to change the attitudes of children and adolescents (Ibid).

Children and adolescents were exposed to pictures and films on various topics.

The attitudes of the participants were then measured by means of a paper-pencil test in the classrooms (Ibid). The findings supported the greater effect of mass media campaigns on younger people compared to adults, especially if the children had not received any information about the potential topics prior to exposure (Ibid).

Further, after these initial beginnings in communicating health, the momentum in researching and applying communication in health-related issues has reached new levels in terms of communication levels and practice. Beyond the doctor-patient interaction, health communication has achieved more progress in other areas (Ratzan et al., 2004). Public health communication, in other words, has gone through three different eras (Ibid).

First was the, “pre-television era” when health communicators mainly used radio and newspapers, but the achievements were not effective at all (Ibid). The second era was marked by the use of television and was hailed as an era of “success” due to television’s demonstrably powerful impact (Ibid).

During this era, scholars tested the use of extensive mass communication in order to promote health but didn’t include community support or personal counselling (Abroms & Maibach, 2008a; Alcalay, 1983; Basil, 2014b; Beato &

Telfer, 2010). Some examples of health communication campaigns using mass media tools that were considered successful: the Stanford Three Community project and the Stanford Five-city Project in 1970s-80s (Basil, 2014a; Basil, 2014b; Leshner, 2014), Minnesota’s Heart Health programme in 1980 (University of Minnesota, 2012), Rhode Island’s Pawtucket Heart Health project in 1980 (Carleton, Lasater, Assaf, Feldman, & McKinlay, 1995; Eaton et al., 1999; Hunt et al., 1990), Missouri Bootheel Heart Health in 1989-90 (C.

Brownson, Dean, Dabney, & Brownson, 1998; R. Brownson et al., 1996), and

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the famous, long-running North Karelia project in Finland started in 1972 (Puska, 2002).

All the community-based programmes above focused on cardiovascular diseases, as non-communicable diseases had begun to attract physicians’

attention from the late 1970s. Generally, all the above programmes have demonstrated that the use of integrative interventions can bring positive results in reducing risky-health practices (Abroms & Maibach, 2008a; Basil, 2014b;

Puska, 2002). Integrative interventions refer to the use of more than one approach or mix of approaches including education-based, community-based and mass media-based approaches to the implementation of health communication programmes (Helme et al., 2015; Wilkinson, 2013). In fact, combining approaches has become a popular tactic in the implementation of health communication programmes (Ibid).

Finally, the 21st Century has become known as the “communication age era” (Ratzan et al., 2004). This era is more alternative from the earlier eras in terms of reaching the public due to the huge technological development such as the internet, the prevalence of wireless, increase in the use of mobile phones, smartphone applications, websites and software’s (Kreps & Neuhauser, 2010;

Neuhauser & Kreps, 2003; Noar & Harrington, 2012; Wright et al., 2012), in addition to various achievements and effects relating to changes in health behaviours (Ratzan et al., 2004). Nowadays, the key challenges facing health communicators are health disparities, inequality and a range of socioeconomic factors.

Since the early studies of the 1960s, health communication as a field has achieved academic recognition and academic scholarly organisations have multiplied (Kreps, 2014; Wright et al., 2012). The first academic body to create a division with a specific focus on health communication was the International Communication Association (ICA) in 1975 (Kreps, 2014; Thompson, 2003;

Wolff, 2007). In 1985, this was followed by the National Communication Association of the USA while the American Public Health Association officially recognised health communication in 1997 (Ibid). Across the Atlantic, the field has also been acknowledged by the European Communication Research and Education Association (ECREA) and the European Association for Communication in Healthcare (Schulz & Hartung, 2010).

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The first dedicated academic journal in the field, Health Communication, was launched in 1989 and started to cover various issues of communication in health settings (Kreps, 2014; Thompson, 2003; Wolff, 2007). The second journal, the Journal of Health Communication, was launched in 1996 with the intention of focusing more internationally and practically on health communication (Ibid). Both journals are based in the United States. The Communication and Medicine Journal currently publishes in the UK, while the Patient, Education & Counselling journal is based in Europe (Schulz & Hartung, 2010)⁵.

Unfortunately, academic research into health communication in the Arab world, and in Saudi Arabia in particular, has not reached anything like the level seen in the United States or in Europe. The reasons for this imbalance will be discussed below in further chapters. I will now turn to the theoretical section of the health communication development story.

2.2.2 Health communication; perspectives and nature of research