“Public health without effective health communication is really nothing”: Key informant interviews and thematic analysis as part of a multi-step research process to develop modernized public health communication competencies

Theme 1.1: Public health communication is essential for all functions and roles in public health and the credibility and success of public health efforts

This theme emphasizes that public health communication is both a science and an art that advances population health and well-being and is foundational to the success of public health initiatives. Participant 10 emphasized that “public health without effective health communication is really nothing,” highlighting its centrality and necessity. Effective communication supports individuals and communities in adopting safer, healthier, and more protective behaviors, underscoring its role in public health efforts.

Health communication is a core strategy across public health and government and the most important asset because it impacts credibility and the impact of their work . . . the one truly renewable and impeccable resource that they do have is their credibility. – Participant 6

The process of effective public health communication involves meaning-making between public health organizations and practitioners and communities. It must go beyond mere information transmission by being responsive to community needs. Participant 8 emphasized the responsibility of public health practitioners and organizations “to participate in those public health communication practices [participatory practices] and give rise to this meaning.” The focus on the needs of the communities is not only essential for credibility and trust, but it also directly impacts behavior uptake and the success of initiatives. “Effective communication underpins the work of public health in supporting individuals and communities to engage in safer and more protective behaviours” – Participant 4. These comments emphasize that communication should be understood as a shared process of meaning-making that focuses on the values and needs of communities and thereby increases the credibility of public health and the success of public health initiatives.

Theme 2.1: Practitioners in public health roles need to possess communication competencies to engage with communities and partners effectively

This theme highlights the need for public health practitioners to possess specific communication competencies that enable them to engage communities meaningfully, advocate effectively, and build credibility. These competencies form the foundation upon which organizational communication capacity and system-wide partnerships must be built. Participants described gaps in specialized health communication competencies that significantly contribute to ineffective communication practices in public health contexts and, in turn, waning public trust. They noted that the communication-focused roles within public health often emphasize public relations and organizational communication rather than public health communication. Public health communication is a unique and multidisciplinary field that aims to influence and empower individuals, communities, and populations to improve health. Participants emphasized that public health communication needs to include a focus on participatory action that involves diverse communities and partners.

It [participatory approaches] is the next revolution in public health. It’s a foundational value or an approach in everything that we try to do, whether it’s with the community or whether it’s, you know, with people across your agency. – Participant 11

The skills required to lead participatory and deliberative processes are complex, communication-focused, and challenging to acquire on the job:

Well-intentioned people, they’re trying really hard. Some of them stumble upon how to do that [engage with multiple stakeholders in meaning-making]. Some of them don’t, and I think there’s a real kind of haphazardness to the way those kind of consultative processes are managed. – Participant 8

Participants conveyed the need for an increased focus on using effective communication to advocate for the value and role of public health to government, politicians, decision-makers, and the community. As Participant 6 observed, “It’s advocacy, it’s policymaker oriented, but it’s very rarely thought of and very rarely practiced.” During the COVID-19 pandemic, public health had an influx of resources and a heightened profile, much of which was directed to communication initiatives. Participants observed that more recently, public health systems have transitioned to recovery and other priorities, such as the health impacts of climate change. They noted that public health has receded to the background within the larger context of government activities and is not as visible:

It’s kind of like being pushed to the side and now there’s other sectors of government that are getting more attention and a lot of this also has to do with, you know, the fact that we’re not that great, actually communicating what we know and what solutions we might have and the perspective that we might have at the table. – Participant 11

It is crucial to communicate the value of public health initiatives and advocate for resources and continued involvement in pressing issues like climate change and housing.

Theme 2.2: Community engagement and a focus on equity in public health communication are critical to public health impact

Public health has a strong community- and equity-focused orientation. Participant 8 noted, “Community-based . . . that’s . . . the strength I’ve always seen more so than in other countries and other models that I’m aware of.” Participants explained that program and local/regional level public health form collaborative relationships with community-based organizations to develop successful programs:

I think that there’s a lot of great collaboration that happens across different types of sectors and organizations . . . things that . . . done really well, are almost like at the program level or maybe even done like regionally you’ll see like a really cool campaign or a really effective rollout of [a campaign]. – Participant 10

A focus on equity, rather than solely on vulnerable and priority populations, has enhanced our ability to understand audience needs and values, ensuring that the appropriate information reaches the right audiences. Participant 12 emphasized that public health’s role is to:

. . . be more in tune with the audience and what their real true needs are and how we can support them . . . because a massive amount of our role in public health is communications and sharing the right information at the right time to the right people.

This equity-focused approach promotes inclusivity and improves the effectiveness of public health initiatives by ensuring responsive and relevant communication. Such collaborative and equitable communication efforts are crucial for public health success, fostering trust and engagement across diverse communities.

Theme 2.3: Sustained and well-resourced collaborations and partnerships are necessary for tailored, consistent, and effective public health communication

This theme explores collaboration as a structural strategy for improving the design, delivery, and consistency of public health communication across jurisdictions and organizations. While trust and community engagement are important outcomes of collaboration and partnerships, the focus here is on the enabling conditions, such as sustained investment and strategic partnerships, that support communication systems. Choosing the right partners and nurturing the relationships are critical to improving communication between jurisdictions, silos, and organizations to meet the information needs of diverse communities. “Collaboration is crucial for communication to ensure consistent and effective messaging across the health unit into the community and across the province” – Participant 12. A consistent and clear approach to public health communication across organizations, sectors, and geographic regions relies on collaboration and partnerships.

Collaboration and partnerships are also essential for understanding the diverse needs and wants of communities, a significant aspect of effective public health communication. However, these partnerships are often reactive and not sustained, limiting their ability to engage communities meaningfully and tailor public health messages to resonate with diverse populations.

Building capacity [through partnerships and collaboration] in community organizations helps public health deliver programming while also developing skills within the organizations. There is an absolutely essential obligation to build and sustain good, trusting and valuable partnerships with local health providers, local communities, local influencers and opinion leaders and so on. But often what happens is those partnerships are established too late and they’re not nurtured. They’re underfunded, under-resourced and undervalued – Participant 1

Participants explained that this leads to the need to rebuild these connections every time a public health action, such as a crisis, arises. Maintaining these partnerships is further complicated by the constant flux within public health and partner workforces; as individuals move to different positions and sectors or leave the workforce, the competencies and relationships also dissipate and must be rebuilt. A strategic approach is necessary:

There needs to be a clear, Pan Canadian strategy about how do we do that, how do we support community organizations both to help deliver the things that we need to deliver, but then also to develop the skill set so that when some when something comes at us by surprise, we’re not then reskilling and continually playing catch up, but that they’re ready to go. – Participant 1

Attention needs to be paid to power dynamics and what is prioritized within the partnership:

We need representation of choosing whose knowledge and whose priorities are most important when working with partners and collaborators. If groups have differing opinions, how do you choose where to head? – Participant 5.

Additionally, fostering partnerships between public health organizations and researchers can support more effective public health action. Participant 1 noted, “I think we are missing really, really valuable opportunities to strengthen system capacity by looking outside of our organizations as opposed to just looking internally.”

Theme 2.4: Constraints from a lack of resources and political influence contribute to ineffective public health communication

This theme includes constraints caused by communication being an afterthought rather than a central component of the larger public health strategy.

I think too often questions around communication come at the end and that leads to a lot of the problems we see with everything from uptake for vaccination to difficulties in other kinds of public health areas. – Participant 1

Participants observed that although the importance of communication for the success or failure of public health initiatives has been clearly demonstrated, there is significant duplication of communication efforts across public health organizations with little coordination at the provincial or federal level. This lack of coordination leads to inefficient communication practices, such as focusing on providing information rather than also engaging directly with communities to understand their beliefs, wants, and needs:

I think during the pandemic, the government made no attempt to construct people’s beliefs about what masks were, why they were good, why they were helpful, and subsequently I think there was not a lot of belief or behaviour change resulted from official public health communication related to mask-wearing. – Participant 8

Participants expressed frustration having to do more with fewer resources, which constrains their ability to communicate and engage with the community effectively. Participant 6 pointed out, “Public health agencies, both federal, state, and local, are expected to do much more with many fewer dollars, and so that just puts a chokehold on everything, including communication.” Although coproduction and codesign are critical aspects of public health practice, the lack of time and resources often makes direct community engagement unfeasible. Participant 2 outlines this issue, “codesign, which I agree is a super important part of our practice, but it’s not always feasible based on timelines, especially if we’re in an emergency.”

Participants explained that political influence on public health further complicates transparent communication: “We’d like to be able to say this, but we can’t for XYZ reason, and those XYZ reasons had more to do with political pressures than with a lack of information” – Participant 1. Participant 3 echoed this sentiment, stating, “So there’s that balance of like we can do the advocacy and we can inform policy and practice, but only to the extent that we are politically allowed to do.”

Theme 3.1: Trustworthy public health communication requires an understanding of the information ecosystem, cultural safety, and transparency

This theme focuses on trust and transparency as core conditions for effective public health communication. While trust is shaped by communication capacity and built through long-term collaborations, here we explore how trust is actively maintained through culturally safe, audience-centered strategies and transparent communication within complex information ecosystems. Audience-centered approaches are necessary to move beyond just transmitting information to using “broader social behavior change approaches to generate demand for the services and the program” – Participant 11. Participants noted that public health operates within a complex communication ecosystem, requiring an omni-channel approach to effectively reach and understand diverse communities.

I feel like everybody knows that right now it’s doing that [public health communication] in a transparent, trustworthy, tailored, informative and persuasive and impactful way in a variety of channels and recognizing that the things that constitute persuasive, impactful, transparent, trustworthy aren’t exactly the same from channel to channel. – Participant 8

As stated by participants, trust (or credibility) is the most important asset in public health and transparent communication plays a key role in trustworthy communication. Participant 1 noted, “Any whiff that the public or that a stakeholder has that public health officials are withholding or shading information . . . is going to destroy and damage trust.” Practitioners need values like empathy, compassion, reciprocity, and reflexivity to be culturally safe and responsive. Positionality is important for transparency “so that it is transparent where the public health practitioner is coming from and the privileges they hold” – Participant 5.

Public health practitioners also need to stay abreast of the constantly changing environment and counteract misinformation. Participant 9 noted, “They have to consider what other competing messages they’re exposed to and all different channels that they are receiving with different weights.” Further, Participant 10 emphasized the importance of understanding how people use technology and consume information and how this impacts culture, behavior, and health.

Theme 3.2: Implementation of a public health communication competency framework will require tools and dedicated training

Supporting the effective implementation of public health communication competencies in practice will require a variety of tools and multiple levels of integration.

So that’s again like focusing on prioritization and efficiency-focused communication tools that are quick and easy. I don’t want to sound cheap about that, but it’s just that’s for public health units that’s helpful because there’s just so much to do that it’s almost overwhelming. – Participant 12

The tools participants suggested include competency self-assessment tools, guidance on integrating competencies into performance indicators, evaluation, and professional development, examples of competencies in practice contexts, a community of practice for understanding implementation of the framework, and resources for mapping competencies to public health curricula. Moreover, the importance of resource accessibility was emphasized: “So if there is a way to give leaders in public health the tools to take this information and apply it to their teams, I think that would be super helpful” – Participant 2.

Additionally, participants suggested cost-effective training resources such as webinars, factsheets, communities of practice, or social media videos that could help practitioners comprehend and implement the competencies. Prioritization of the competencies with what is needed to address current public health issues to upskill the workforce may also help practitioners focus their limited resources effectively.

Theme 3.3: Specialized public health communication education and training are needed to build the required competencies across the workforce

This theme emphasizes the need for specialized education and training in public health communication to ensure consistent competency across the workforce. Public health communication cuts across all roles and functions, requiring a shared foundational skillset that integrates theory, data, equity, and practical application: “it touches all aspects of public health and every single job in public health” – Participant 7.

. . . when I actually think about the public health professional, we can have very, very different roles and this [public health communication competencies] is in my opinion, such a fundamental skill set. – Participant 11

Specific health communication education and training are crucial:

I’ve noticed people that have been trained in communications, there’s a lot of people that work in public health that came in from communications training, not health communication training, but just general communications that aren’t familiar with the public health approaches. – Participant 11

Public health approaches focus on the population level to address underlying social determinants of health and health inequities.

Education and practice in applying theory, data, research, and lived experience to public health initiatives are crucial for connecting evidence to action. Participants 4 and 6 stressed the importance of building competencies in the practical application of theory, data, and research to practice. “They [public health students] don’t make the connection between the two [theory and practical skills] and I think this is a really important missing part of most people’s training” – Participant 6.

Participants described significant variability in training backgrounds – many professionals enter the field with general communication experience but lack grounding in public health theory and population health approaches. Participant 1 critiqued current approaches:

So what ends up happening is many public health organizations will take somebody whose background is in something else and try and teach them about communication. And my own narrow view is a lot of the time they get it wrong because they aren’t themselves communication experts.

A peer-to-peer training model may be beneficial for upskilling the workforce, where those with particular expertise in public health communication conduct training or mentorship:

because we are actually doing the job, we . . . have a particular expertise around training professionals and helping professionals learn skills that really benefit them in their work because we’re also doing it. – Participant 4

This approach facilitates bringing together diverse expertise, as health communicators are often adept at finding common ground and facilitating discussions.

I think people who are good at that, who are good at health [communication] often can be the ones kind of doing that facilitation, finding common ground because it’s something they are often very good at. – Participant 4

Peer-to-peer training also allows for realistic expectation setting for what can and cannot be accomplished through public health communication in practice.

We need to be aware of the limitations of health communication initiatives- as in they are not the be all end all and can’t do everything. This is similar to the competency about attending to the barriers and unintended consequences of initiatives but more focused on the actual limitations of a campaign, program, etc. and what it can achieve. – Participant 5

Partnerships between academia and public health organizations can also support capacity building in communication across the workforce:

more collaboration, certainly between departments of public health or public health organizations with the universities and university-based experts to support the kinds of things [upskilling, capacity development, surge capacity] that we’ve been discussing. – Participant 1

Participant 1 suggested these partnerships may also help support our ability to connect with communities and the community-based organizations that serve them, in turn supporting more effective public health communication.