Abstract
Since the key to effective health communication lies in its ability to communicate well, some of its core problems are those that relate to the sharing of meaning between communicators. In elaborating on these problems, this paper offers two key propositions: one, health communication has to pass through the filter of a particular world view that creates a discrepancy between expected and actual message reception and response. Two, the assumption of a rational human actor made implicitly by most health psychological models is a contestable issue, as many times message recipients do not follow a cognitive judgment process. The phenomenon of resisting health messages by reasonable people asks the question whether we ought to rethink our adherence to a particular vision of human health as many times the adverse reaction to behaviour modification occurs as the result of a particular dialogical or discursive situation. At the same time, most motivational decisions in people’s daily routines are automatic and use a concept known as self-identity to give stability to their behaviour patterns. Finally, health communication as part of organised government practices adheres to predominant value perspectives within health promotion practice that affect the manner in which health issues become problematised. This paper proposes a humanistic model that aims to pay attention to the intricacies of human communication by addressing all of the above problems in turn. It interprets the sharing of meaning element in human communication and addresses the question of how the idea of health is created through discourse. As such, it offers a complementary and constructive paradigm and set of approaches to understand health, its meanings and communication.
Keywords
The greatest problem in communication is the illusion that it has been accomplished.
Introduction
The conventional idea of communication is the process of delivering and/or exchanging information, and this notion is a well-practiced principle in public health promotion. But the other equally important property of communication – the one that speaks to the word’s Latin root (communicare = sharing together) – defines it as a way to share meaning, the foundation of (communicative) relationships. Communication scholars know about the importance of factors other than the message and channels that determine whether or not communication leads to liking and acceptance. The sharing of meaning in communication highlights the importance of people openly discussing and arriving at an understanding of each other’s positions and accepting them as legitimate in the context of exploring and realising a desired outcome. Not coincidentally, it is mostly in this aspect of communication where many of the barriers to effective health communication surface.
Since the key to effective health communication lies in its ability to communicate well, an accepted axiom is that a health promoter needs to identify relevant antecedents to behavioural responses and translate those into convincing but uncomplicated message cues that are designed to overcome barriers (1,2). Those largely come from research about the correlation between psychological constructs (beliefs, attitudes, efficacies and so on) and resultant behaviours. Yet, barriers that pertain to the ‘sharing of meaning’ concept might benefit from a more humanistic vision of health communication discourse, one that values individual autonomy and liberty, human sense and reason as a guide for decision-making, and decentralised participatory democracy. A humanistic approach accedes to the idea that people are able to make choices, have responsibility, and seek or create their own meanings and values (3–5).
Since universally accepted best health practices do not really exist, any message has to pass through the filter of a particular worldview on both the senders’ and receivers’ sides. This often creates a discrepancy between the expected and actual message reception and response (6–9). Moreover, the assumption of a rational human actor made implicitly by health psychological models is a contestable issue. In many instances message recipients do not follow a cognitive judgment process of message elements but, to the contrary, follow automatic or instinctive processes that guide behaviour choices (10,11). It is actually quite surprising that a discipline that borrows so heavily from psychological models has not looked at humanistic psychological perspectives to create foundations for interventions.
This paper aims to provide ideas for a humanistic model of health communication. After providing a critical review of the major problems in communicating health from a humanist perspective, the paper suggests a model that focuses on individual freedom, co-created decision-making through dialogue and mutual responsibility in its communication.
Three problems with communicating health
1 – Resistance to health messages
Research on health resistance (12) has contributed explanations for the deliberate disregard or dismissal of health messages by seemingly reasonable people. In fact, in response, studies in health resistance have increased in recent years to explain unsuccessful campaigns and efforts to sustain an original positive outcome (13). Meta-analytical studies comparing empirical research on preventive efforts toward a particular disease burden (e.g. drinking, obesity prevention) have found varying results between studies following the same aims and methods (14,15).
Health resistance, as Crossley (16) argued, is not an issue of lack of understanding, skills or any other barrier found in what we know as response ability. It is also not a result of problems in opportunity (e.g. access issues or divergent rules). Resistance is found to be squarely the result of lack of motivation to comply with the appeal or call to action.
From a humanist perspective, the causes for this can be traced back to two main forces (12). The first one relates to scepticism toward science and medicine, from funded research to government sponsored public campaigns. While science had to compete with doctrines (17th century astronomy, evolution, global warming) for centuries, due to a more dispersed and uncontrolled media landscape, science now faces an opposition that is organised and often furious, empowered by multiple scientific and non-scientific sources and interpretations (e.g. ways of being infected by viruses like the human immunodeficiency virus (HIV) and Ebola, the autism and vaccination debate).
From a humanist perspective, in Western culture and thought the second force is derived from a high value placed on the need for individuality, individual freedom and decision-making. It includes the phenomena of risk-taking and sensation-seeking but also includes personal (subjective) definitions of health and healing and meaning-creation of life and living in general.
Thompson and Kumar (13) succinctly summarised the key defiant responses as resistance, denial and ‘othering’. An increasing number of health messages telling the public what they should eat, how they should act and what they have to do not only irritate or alienate the very groups that are targeted (17), but are also perceived as paternalistic infringements by the government on one’s autonomy (18). In addition, when individuals believe that they are less at risk of an illness or risk-prone lifestyle than others, they tend to engage in denial (19,20).
The humanist concept of individual responsibility also highlights what appears to be a moral issue. Judgments by health campaign audiences of what is ‘right’ or ‘wrong’, ‘healthy’ or ‘unhealthy’, influence not only their own health behaviour but also their attitudes towards those who are not engaging in the same behaviours (12). This discourse of moral disapproval highlights a phenomenon that is the product of social interaction. As Stevenson and Burke (21) pointed out, ‘the problems in the field of health promotion discourse result from a contradictory conceptualisation of health, community empowerment and the role of the state as policy maker and enabler of community action’.
In psychological and communication studies the concept of reactance is not new (22–24). In essence, psychological reactance is motivated by an individual’s basic need for self-determination in affecting his or her own social and physical environment. When these perceived freedoms are threatened by proscribed attitudes or behaviours, an individual will experience a motivating pressure towards restoring these threatened freedoms (25). Since cognitive responses are usually accompanied by the affective response of anger, the literature has discussed whether reactance is best explained as a dual or intertwined process, whereby anger precedes cognition (26). The two examples of government-imposed lock-out laws for late-night bar patronage and college administrations’ attempts to create alcohol-free campus events, which both attempt to reduce binge drinking and the health risks associated with it, might illustrate the idea of reactance when observing public responses to them. The forceful opposition to either intervention appears to be aimed more at the source of the message rather than at the message itself. It is not a reaction that says ‘I do not understand what you want from me’ but rather one that says ‘you do not tell me what to do with my life’. And, as the above examples have also shown, the tendency to favour information that confirms one’s pre-existing beliefs and attitudes – a phenomenon known as confirmation bias – aggravates the resistance to perceived outside control (27).
A humanistic approach to this phenomenon argues that the message needs to take into consideration a person’s individuality. It pertains to a deeper understanding of the quality, types and confidence in counterarguments when they occur during reactance responses. While not well understood as of yet, there appears to be a difference between direct rebuttals of message arguments, source derogation, pure negative affect (irritation) and ‘stubborn’ insistence on one’s own point of view. Understanding the types of resistance strategies that people use will improve the effectiveness of health messages in that they pick up on and reflect arguments that directly address the specific kinds of thoughts raised by individual audience members (27–29).
2 – Rational vs. intuitive response processes
The typical canon in health promotion is that a campaign is the result of credible facts, gathered via scientific research, and translated into logical cause–effect messages. To achieve this ‘translation’ and hence the desired response, the message needs to predict and then communicate a single memorable behaviour proposition, akin to commercial marketing’s unique selling proposition (30). Reflecting desired states or accepted truths, the message becomes part of the target public’s knowledge base and eventually leads to desired behaviour responses.
This frame of thinking is widely based on a rational actor assumption, prevalent in many sciences. In fact, the idea of a rational human actor is as old as Western philosophy and science. From Plato and Aristotle to Hume, Descartes and Russell, a common notion was that a person’s output or reaction can only be understood if an assumption of rationality and logical thought pattern (that is, predictability from our perspective) is made.
In the case of disease prevention, the stimulus is composed of a scientific argument supported by solid empirical evidence wrapped in a persuasive marketing tool (e.g. humour). A rational human being will not only understand this message but also come to accept it as the most reasonable course of action. Admittedly, behaviouristic research has incorporated some affective responses (e.g. fear appeals) and peripheral or heuristics processing (20,31). But stripped to its core, the average health promotion effort is a unidirectional argument linking scientific evidence with corollary expected responses.
The standard psychology models used in public health promotion, like the Health Belief Model (32), the Transtheoretical Model (33) or the Theory of Planned Behaviour (34), emphasise a logical cognitive path toward the ultimate behavioural response. Where empirical findings diverge from this path, explanations tend to converge on lack of skill or educational attainment, or the aforementioned rationally based counterargument response (23). Not surprisingly, at the time these models were proposed, an analogous trend occurred in psychological therapy research. The cognitive–behavioural perspective related cognitive structures and processes (thoughts, beliefs) to resulting behavioural consequences. These became known as reciprocal determinism (35). It has later come under criticism for – among other reasons – its lack of evidence that rational thinking is the sole reason for psychological well-being (36).
Not surprisingly, many motivational decisions and modifications in our daily routines are automatic and at a level of consciousness that we often fail to explain after the behaviour occurred. From a humanistic perspective, behaviour change need not proceed in a linear fashion as our senses and our reason both play a role. Changes from one attitude to another (e.g. exercise, not exercise) can occur in a single complete transformation, happen unintentionally, involve periods of going back and forth on the issue, or occur in response to apparently insignificant triggers (e.g. a not-to-be-missed TV show). This means that, unlike linear models, our behaviour is often chaotic, i.e. our wants and needs compete in a messy system for control over our actions (37).
3 – Different values and political philosophies between power holders and publics
Critics of health policy point to the politicised nature and prevailing ideologies in medicine and policymaking (38,39) that blur the line between facts and opinion and drive policy more so than factual evidence (40). This pertains to questions of how those in charge make choices about prioritising health problems, target audiences and intervention strategies. For instance, stress being addressed as a personal problem rather than the result of workplace or relational exploitation potentially marginalises disagreeable rival explanations and systems (40).
From a humanist perspective, health communication can become part of organised government practices through which citizens are not only governed but through which they govern themselves. By undertaking government-induced actions for their health and well-being through management of lifestyles, citizens may reduce reliance upon governmental supports. As the right to health is re-constructed as the responsibility for ‘accepting and adopting the imperatives issuing both from the state and other health-related agencies concerning the maintenance and protection of good health to prevent placing a burden on the healthcare system’ (41: 65), it creates subject positions from the self-satisfied ‘good citizen’ to the stigmatised, who require increased levels of surveillance and intervention (42).
The manner and circumstances in which health issues become problematised at any given time indicate that health practitioners and related entities of power (e.g. the media) hold particular values and political philosophies. The overreaction related to infectious disease outbreaks (e.g. Ebola, Zika virus) or the creation of a moral panic around obesity provides fitting case studies for this assertion (43–45). The movement toward ‘positive health promotion’ or ‘well-being promotion’, resulting from the redefinition by the 1986 WHO Ottawa charter of what health means, seemed at first glance beneficial in its attempt to disentangle health promotion from disease models (46). At an individual level, it has complicated matters further as, once the disease grounding is lost, all that remains are points of view about how people should behave, associate and act toward each other – which lie in the domain of political philosophy (40).
From a humanist perspective, the communication of a health condition has rhetorical significance beyond the epidemiological reality as it creates a moral imperative for self-management of that very issue. Humanists would say that once a health issue is called a national health problem every individual ought to contribute to its solution as a matter of common concern for the public good (44). Non-humanists might expect the government to change unhealthy conditions in a top-down approach, such as policies and some campaigns, rather than attempt behaviour change via dialogue and participation. As the ongoing example of obesity prevention via proper nutrition exhibits, suggested solutions tend to disproportionately impact families, who are economically vulnerable or lack other forms of capital, and identify certain population groups as being ‘at risk’ and in need of intervention to meet a ‘norm’ (47,48). This has not only led to resisting behaviour of those most in need of support (as many obesity statistics illustrate), but the one-directional communicative approaches are in themselves antagonistic to an inclusive, i.e. humanistic, communication model.
Toward a humanistic model
While not much research in health communication actually studies the intricacies of the communication process itself, it appears that current practice largely follows Shannon and Weaver’s communication loop (49). The emphasis is on functional communication, focusing on information transfer over a noisy channel, while paying little attention to the meaning of communication (50).
At the individual level, a humanistic model of health communication connects with the idea that communication in its core is about sharing of meaning. While the precise definition is still contested, Coulehan argued that an example of humanistic communication relates to the art of medicine, known as ‘doctoring’. Doctoring requires communication skills, empathy, self-awareness, judgment, professionalism and mastering the social and cultural context of personhood, illness and health care (51).
A vital element of communication should then be the idea that both parties have goals they wish to achieve. Therefore, a humanistic communication model in its simplest form regards communication as a dialogue between equal partners. This includes personal values and responsibilities, spirituality, culture and self-actualisation as equally relevant as the usual constructs of attitudes, normative adherence, self-efficacy and cognitive learning ability. A key difficulty faced by this humanistic model is the lack of equality between the sender and receiver of messages in the usual government context, and the challenge of so many different personal values and cultures in any communications beyond the individual level. A humanistic model offers a focus on human communication as a dialogical process between equals (which would be able to learn about why people resist a message) rather than a one-directional instructional statement that appears not to ask for feedback other than behavioural compliance. In the following, we describe in more detail how a humanistic communication approach will address the three problems raised above in this paper.
From health resistance to representation
In order for people in communities to communicate, they need a system of common understanding, in particular of concepts and ideas that have particular meaning for that group. Words thus become imbued with special meaning within particular social groups. Our identities, and the ways we see and represent ourselves shape how we communicate, what we communicate about, and how we communicate with and about others. It explains the discontent with the ambiguous results of employing individualistic, asocial and acultural constructs of mainstream cognitive social psychology in messages (52). To account for a person’s individuality, a humanistic approach would say it is useful to include elements from social representation and identity theories in the model, which argue that self-awareness and involvement is only possible through the communication of differences and commonalities (53,54).
A humanistic focus on cultural embeddedness also points to the idea that virtually all of human knowledge is based on stories constructed around past experiences, and that new experiences are interpreted in terms of old stories (55). Exploring the embeddedness of narratives about health within each community can help explain how communication receivers incorporate them into their ways of understanding and everyday talk and, as such, may help convert adverse reactions to health messages.
Making use of intuitive response processes
Thanks to the work of humanistic psychology scholars (56,57) we already know that both goal-directed (also known as reflective or logical) and habitual (also known as reflexive, intuitive or automatic) processes control human behaviour. This system of ‘forces’ directs our actions and shapes the flow of behaviour on a moment-to-moment basis (58). Studies in neuroscience and cognitive psychology (59,60) contributed insights that higher-order reflective motivation is more flexible (i.e. it can be influenced and changed by persuasive arguments) but can only influence resulting behaviour as a stimulus to lower-order intuitive motivation. After having been exposed to an anti-obesity message the persuaded ‘voice of reason’ in people’s heads still has to do battle with their habits and personal foibles to determine whether or not they exercise or remain on the couch.
Michie and colleagues’ behaviour change wheel (61) has already illustrated one possible direction to be more inclusive, assessing both reflective and automatic motivation and their complex relationship in testing responses to intervention approaches. As the literature into the sequential relationship between identity formation and behaviour changes has begun to show, there is benefit in understanding how human identity is formulated and reformulated (52). To the best of our knowledge, not too many studies (58,61,63) and popular literature (64) have attempted to study self-identity as a determining force in health behaviour and intervention. Such an approach would require accounting for less linear intuitive responses.
We already know that the human brain has developed a concept of self (known as self-identity) to overcome chaos and give stability to our behaviour patterns (59). Identity hereby refers to how we think and feel about ourselves. It is a major source of stability of behaviour and is regarded as the precedent to behaviour. Research efforts in social identity and social psychology (65,66) have shown the interplay between individual identity and habit forming through discourse and dialogue. For example, after exercise becomes an aspect of people’s lives and they start to define themselves as a gym rat, runner or swimmer (an element of identity known as a label or attribute), they do not only exercise on a regular basis but sustain this behaviour without being prompted. A humanistic approach to communications would focus more on the notion of self-identity and self-actualisation drives rather than attitudes and beliefs, and grow and foster those connected with healthy behaviour patterns.
Participatory values-driven communication
By the early 1990s, health promotion, based on the Ottawa Charter principles, was seen as embodying the ‘new public health’ era (67). Within it, the prominence of community development and participation (dubbed as a humanistic orientation toward public health) was seen as an important aspect of its framework (68–70). By and large, positive influences of democratic principles on population health have been demonstrated (71,72).
Indeed, the 7th global WHO conference on health promotion in 2009 (73, 74) concluded that community participation in decisions that affect their health plays a critical role in improving their health. Discussion and debate were seen as central to increasing critical thinking as they enabled people to make decisions and take an active part in their own and their community’s health. Consistent with a humanistic model, studies focusing on both individual and community involvement (75–77) have demonstrated that helping people to develop their own capacity for exercising autonomy and responsibility is not just more dialogical and participatory in nature (a fundamental human drive) but better suited at reaching reasoned agreement about the good life for all human beings (78,79), as such fulfilling the tenets of the Ottawa Charter.
Conclusions
Communicating for public health is – or should be – the area that can draw appropriately from multiple disciplines to redefine human health problems according to a humanistic understanding of human motivation. It can convey solutions in a way that is able to break down health complexities and instil participation and integration of stakeholders. This makes sense because communication as a discipline has always integrated contrasting research paradigms to explore and explain the objective, structure and dissemination of a communicative message and its reception and interpretation by a receiver. Hereby it pays particular attention to the political, cultural, economic, symbolic and social context of communicative acts.
A humanistic model of health communication aims to pay attention to the intricacies of human communication. Through actively listening, openness to other ideas and solicitation of input, it can not only achieve deeper insights into the reasons for people’s behaviours but use those insights to help people gain more self-awareness and formulate compelling arguments to consider for future behaviours, a method akin to the ancient skill of debate and rhetoric. This would address all of the above-mentioned issues of health resistance, habitual decision making and values-driven behaviours. It would also move closer to the goals of public health to improve or maintain people’s quality of life or well-being.
By interpreting the sharing of meaning element in human communication and discussing the meanings of health we each have, a humanistic model reaffirms the original meaning of communication.
Footnotes
Declaration of conflicting interest
The author declares that there is no conflict of interest.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.