Health equity and health communication: A new dawn?

There is a sense of a new beginning among public health communication professionals about Healthy People 2020's framing of health communication goals over the next decade. ‘Use health communication strategies … to improve population health outcomes and health care quality, and to achieve health equity’, reads the goal of the Health Communication and Health IT section from HP2020.¹ It is not that the contribution of health communication to advancing health equity is a new topic. Such contribution is already validated by existing literature.^2,3 It is that the mandate is now clear: make sure that health communication interventions achieve their objectives among the most vulnerable and disenfranchized segments of the U.S. population! It is also that talking more specifically about ‘equity’ instead of ‘disparities’ forces us all to think in terms of measurable parameters to define equity and evaluate progress.

We have a long road ahead of us … so, we should clear all bumps as soon as possible by tailoring interventions to specific groups; encouraging – and actively pursuing – community engagement and participation in defining equity and progress indicators; and raising consciousness of what works and what effective planning models may have in common – regardless of their name or any specific organizational branding. Healthy People 2020 define several action areas, many of which will be shaping health communication practice over the next decade together with other trends and models^4–6 both in the United States and globally. It would be great if most of them became part of an action- and partnership-based roadmap to advance health equity.

So, what are some of the areas and trends to keep in mind in designing health communication interventions in the next decade? Many of us are quite excited about the potential of new technologies … but technology alone will not advance health equity. The internet and other new media reach people within the complexity of their own living environment, where the opinions and support of family, friends, neighbors, co-workers, healthcare providers, employers, and community members still matter at least as much as the information to which we are exposed via new and traditional media. Also, health media use is still ‘patterned by race, ethnicity, language and social class’,⁷ and so it may take sometime to get to the underserved.

All of us believe in the importance of improving health literacy, which is essential in shaping the quality of provider–patient encounters, and increasing levels of community engagement, and improving people's ability to understand, interpret, and evaluate information they receive from different sources and media.⁸ We all know that achieving health literacy is a very important step toward action, but action is our ultimate result. After all, the return on investment in public health communication is always the sum of behavioral results at different levels of society (individual, community, social, policy, etc.), and this is also related to a variety of other competencies, and cultural and issue-specific factors.^9,10 In fact, the social environment in which health communication interventions fall is quite complex. Owing to this complexity, it is important to rely on an integrated approach^5–7,9 in which health communication is a fundamental component of overall strategic planning – and not an afterthought. Equally essential is the use of a variety of approaches and communication areas to mirror how people speak about health and illness and take decisions in their everyday lives (by speaking with friends and family and reading news and relying on new and social media and seeking advice from healthcare providers and community members … .and …).^9,11 Increasing health literacy is fundamental but this might work best if we take into account the interplay with other factors and never lose track of our commitment to behavioral and social results.

Healthy People 2020 identifies ‘many ways health communication can have a positive impact on health’. Some of them particularly resonated with effective health communication practice: ‘Building social support networks … Providing new opportunities to connect with culturally diverse and hard-to-reach populations …. Providing sound principles in the design of programs and interventions that result in healthier behaviors …’ (HP2020).¹ In many ways, these three areas may encapsulate all others.

For example, it probably does not take too many scientific studies to validate the impact of social support networks on people's health behaviors and well-being. Yet, such evidence exists and spans different disciplines.¹⁴ Being able to count on a caring network of people may:

•.	improve our ability to cope with disease, participate in treatment decisions, and navigate health systems;
•.	motivate different groups to adopt and/or sustain health and social behaviors that contribute to overall health outcomes;
•.	promote adherence to emergency measures at times of crisis;
•.	support people's engagement in the health equity debate;
•.	help give voice to all in shaping policies and social norms.

Traditionally, social support networks have referred only to family, friends, and peers.¹⁴ Yet, since behavior change does not take place overnight, the support of an expanded social network, including neighbors and community members, healthcare providers and leaders, teachers and community organizations, employers and policy makers (just to name a few) might give strength to and validate individual and group behaviors. For vulnerable populations, such an expanded network is essential. In underserved contexts in which family members and friends may be dealing with extenuating circumstances, support may be found in the caring and proactive approach of a healthcare provider; in the cheering and validation of community members or colleagues; in the example of teachers and leaders; in the social contribution of employers and business; etc. Technology can help in some contexts but we need to keep in mind how to integrate it with other program areas and channels as well as how to translate virtual communities into real-life action.

Community and social mobilization (or citizen engagement as other authors may refer to it) has become an integral component of the U.S. Federal Government agenda (for example, via the Office of Public Engagement or a lot of the work of the U.S. DHHS Office of Minority Health) as well as international health communication models.^4–6 Community mobilization has been credited with: ‘greater ability to govern and maintain trust during a crisis; increased capacity to complement services or provide services that neither national authorities or the market can provide; cultural/group-specific validation of strategies and expected results; increased outreach to vulnerable/hard-to-reach populations; and the development of key constituency groups of citizens/community members who are invested in the success of public health interventions and work toward achieving behavioral results in their communities’.¹² Yet, surprisingly enough too many health communication programs continue to focus only on messages and media.

Perhaps we should ask communities what is ‘health equity’ for them, what their key priorities are, and what they may be able to contribute to achieving them. Perhaps, we should expand on the concept of ‘community’ to include not only geographical, ethnic, and cultural communities but also a variety of professional communities from the public, policy, nonprofit, healthcare, and private sectors. Perhaps, we should start thinking in terms of ‘communities of practice’,¹² where different professionals and community members who have a passion for improving health outcomes among vulnerable and underserved populations learn how to perform better toward achieving health equity objectives as they interact regularly.

Of equal importance is embracing a view of the world for which we believe that in all sectors (public, policy, nonprofit, healthcare, private, etc.) the majority of people share a common sense of human decency and may want to leave a better world for their children. By avoiding any temptation to divide the world into good and evil, and starting to act as if no one has any choice other than contributing to health equity, we may achieve more than when we are less inclusive or too quick to assign labels. This is a communication challenge in itself, and one that resonates with the call to action for all sectors to help reduce disparities delivered by prominent leaders, such as WHO's Director General Dr Margaret Chan.¹⁵

In summary, what can we wish for health communication in the next decade in order to fulfill the mandate of Healthy People 2020? That health communication is integrated in each organization's strategic planning; that it becomes part of organizational assessments for core competencies and capacity; that it is always strategic and focused on behavioral and social results; that it is inclusive of vulnerable populations and all segments of society; that it goes beyond organizational agendas and specific models and disciplines, and rather focuses on effective practices and lessons learned; that it relies on rigorous planning and evaluation frameworks; that it continues to be prominent in academic curricula across the world; and that it fosters teamwork, partnerships and community involvement.

So, is this a new dawn? I am optimistic and look forward to contributing. Hopefully, the brainstorm on how to fulfill and execute this new promise may start here today.

Additional information

Notes on contributors

Renata Schiavo

Renata Schiavo, PhD, MA is the Founding President and CEO of the Health Equity Initiative, a NY-based non-profit organization dedicated to building community, capacity, and communication resources for health equity. She also holds adjunct academic appointments at the CUNY School of Public Health at Hunter College, and New York University, where she is on the faculty of the MPH program. She is the author of a book on Health Communication: From Theory to Practice (San Francisco, Jossey-Bass, 2007) and several other publications. Renata is also a Senior Fellow at the Center for Health, Media, and Policy at Hunter College, and serves on the board of directors of Solving Kids' Cancer as well as on the advisory board of The Nation's Health, the APHA official newspaper. Dr Schiavo has recognized public health, health communication, and global health expertise on 20 + public health and/or disease areas and has served on scientific panels, expert consultations, review panels, and advisory boards for leading national and international organizations, including the World Health Organization, the US National Institute of Health, and the American Public Health Association. Her recent work has focused on promoting health equity among vulnerable populations, child and adolescent health, infant mortality prevention and preconception health, public health emergencies, malaria, pediatric cancer, training paradigms for health communication in urban health settings, global handwashing, and pandemic flu. Prior to founding the Health Equity Initiative, Dr Schiavo had the pleasure of serving as Associate Professor and Director, Community Health/COMHE at the CUNY School of Public Health at Hunter College; Founder and Principal, Strategic Communication Resources; Chair of the American Public Health Association (APHA) PHEHP Health Communication Working Group; Governing Council Member, APHA; and Executive Vice President for Cooney Waters Group, among other senior leadership positions.