Planning a health message through sender, message, medium and receiver
A health message passes from a sender, through its wording and the medium that carries it, to a receiver, and at each of the four points it can fail the reader's ability to read it, understand it and act on it. Who sends health messages, whether the message is accurate and suits its audience, which medium reaches the reader, and who the receiver is all decide whether the message works, and in clinical practice written materials reinforce what is said to the patient.
The four-part model and its limits
Developing effective health communication messages can be challenging, so it is imperative that health and medical communicators understand the conceptual framework of health communication and how each of its components is an essential and complex piece of the communication process. In the health communication model of the health educator Jerrold Greenberg, health communication flows in a linear fashion through four components, sender, message, medium and receiver, and is influenced and moulded by various factors. This may be true in some settings, but others posit that communication is more of a cyclic or interactive process. One leader in multicultural health education, for example, argues that culture is a powerful force through which communication flows and is influenced, so that a linear model would not be applicable in many global settings. Because of the limitations of the classical linear model, the Action Guide for Health Communication, a framework to help medical communicators promote functional health literacy, uses Greenberg's model as just a starting point. The model can serve as a useful guide when each component is considered within the three functional health literacy skills of reading, understanding and acting.
The receiver must be able to read, understand and act on the information provided. As George Bernard Shaw said, "The main problem with communication is the assumption that it has occurred", and the Action Guide is designed to give medical communicators a practical way to make sure that communication has truly occurred.
The sender
The sender is the originator of the message, and in Greenberg's model the sender is society, not the health professional or communicator. Society conveys health-related messages through advertising, television, movies, music and other mass media, and society and its associated cultures often impose a powerful influence on individual and group attitudes, beliefs and behaviours. That influence creates a lens through which a person views what is acceptable, predisposing them to a particular behaviour. For example, a message may say that smoking is unhealthy or exercise beneficial while an underlying societal or cultural attitude may be that smoking is acceptable and routine exercise too much work and not truly critical for day-to-day life. A person who first hears the societal message that smoking is acceptable and exercise unimportant may then be reluctant to pursue or accept another message on stopping or avoiding smoking or on the benefits of exercise.
The Action Guide adds two senders to Greenberg's. The first is pharmaceutical companies and other for-profit health industries that promote their products and services, which can contribute to health literacy in positive or negative ways. Many pharmaceutical companies provide accurate and useful information, but some for-profit senders provide distorted and inaccurate messages that can confuse individuals and make it harder for them to sort through conflicting health messages, particularly when the messages promote ineffective products or products with little to no proven impact. The second is institutional health systems: research institutes, professional education schools and programmes, health care delivery systems, health promotion agencies and organisations, and other institutions, which serve as valuable sources of health information and service resources that, if properly packaged, can enhance health literacy and promote health and well-being. But it is often up to individual health professionals, or teams of professionals on the front line of health care and health promotion, to interpret the messages of society, for-profit health industries and institutional health systems in ways that make sense to individuals and community groups and that they can use.
For the receiver to understand and act on the information, they must believe that it is relevant and culturally appropriate, congruent with their cultural beliefs, and that the action it requires is within their skill level. The Action Guide's guidelines for the sender, by skill, are:
- Reading: verify that the information originates from a reputable, accurate source; help the receiver distinguish between reliable and unreliable message senders; and identify two or three specific sources that are consistently reliable, accessible and receiver-friendly.
- Understanding: learn from senders the key points of understanding that receivers should possess to use information effectively and navigate systems, and emphasise to senders the need to adapt information and systems to receivers' values and health literacy levels.
- Acting: promote and assist with adaptations to systems and procedures to make them more receiver-friendly.
The message
The message must be examined for accuracy and for appropriateness. With health messages carried by magazines, newspapers and electronic sources, individuals can easily find information on almost any health subject, but that does not mean the information is accurate or appropriate. A study of 200 websites presenting cancer information, which recorded how often each was accessed and the quality of its information, found that the more popular sites did not necessarily have the best quality of information. A study of online information about fever in children found that only a few of the 41 websites it identified had complete and accurate information about that simple and common health concern. Because the availability of information is not a reliable indicator of its accuracy, a reliable system for evaluating message accuracy is needed. A structured analysis of 100 websites identified three common indicators of website quality that medical communicators and receivers can use to identify accurate message sources: display of the HONcode logo of the Health on the Net Foundation's Code of Conduct, use of the organisation as part of the domain name, and the existence of a copyright statement. It is also imperative that medical communicators understand how to evaluate current information for accuracy, have a working knowledge of research methodology, and be able to distinguish between evidence-based and sensationalised information.
The appropriateness of the message is critical for effective communication, and what applies to one audience might not be relevant to another. Encouraging a person to exercise five times a week may be good advice for someone already semi-active but may not be appropriate for someone sedentary. Sometimes a well-intended message can even cause adverse effects on the receiver, a condition Greenberg calls iatrogenic health education disease, which occurs when a person feels overwhelmed by the health message or takes it to an unhealthy level. Examples are a person bombarded with so many messages about unhealthy foods that trying to eat healthfully feels futile, and a person who begins to exercise to improve their health and becomes "addicted" to exercise. To prevent it, a medical communicator should tailor the message to the receiver's health needs and to what is reasonable for that individual.
The message also needs to be delivered in a way that increases the receiver's functional health literacy. In 2010, English was not the first language of a growing number of people in the United States. Messages should be linguistically appropriate for their intended receivers and translated from the original English when necessary, and back translation is highly recommended to maintain accuracy. Working with a qualified translator and a cultural expert can help in designing a message the receiver accepts. For the receiver to read, understand and act on the information, the message must be developed so that it is culturally and linguistically appropriate for that receiver.
Focusing on the desired behaviour and giving simple instruction on the steps needed to achieve it is important for the receiver to act on the information. Piloting the message with a small sample of the target audience can give the medical communicator important insight into the group's level of health literacy and the appropriateness of the message. The Action Guide's guidelines for the message, by skill, are:
- Reading: use back translation; work with qualified translators and cultural experts to identify and develop appropriate materials; use plain language, pictures and culturally relevant symbols; and limit the number of messages.
- Understanding: adapt the message to the receiver's values and goals; emphasise its utility to the receiver; and pilot materials in small groups of health clients to test for accurate interpretation and perceived utility.
- Acting: focus on behaviour; simplify the steps and actions needed; and tailor the message to the specific needs of a particular group of health clients.
The medium
A medium is a way to package the message. Greenberg argues that there are several types: a medium can be the message itself, such as a radio announcement, website content or a brochure, or the person who delivers it, such as a physician, medical communicator, health educator or nurse. The choice of medium is the critical step in the communication model and probably has the largest influence on health literacy. If the message is not readable, understandable or culturally acceptable, the desired health outcome will be jeopardised.
Health information is abundant and available in many forms, but not everyone can reach it. In figures cited in 2010, 88% of all internet users lived in industrialised countries, which represent 15% of the world's population, and eight of every ten websites were in English, while only one in every ten people worldwide spoke English. So, by the same 2010 figures, even though messages can be delivered electronically or on paper, approximately 876 million adults in the world would not be able to understand them.
The receiver's capacities need to be considered when determining the most effective medium for a message. According to the 2003 National Assessment of Adult Literacy, the medium a person selects for information is greatly influenced by their level of health literacy. Adults with intermediate or proficient health literacy typically received health information through traditional and non-traditional printed material and other sources, such as newspapers, magazines, the internet, friends, family, radio and television, while adults with basic or below-basic health literacy relied more on non-print sources, such as the radio and friends. This means that over a third of adults rely more on non-print forms of communication, and the numbers increase when age, ethnicity and education level are factored in.
A comprehensive evaluation of health literacy in a specific population may not be feasible for every programme, but simple guidelines can be used when preparing health information. Such guidelines, as outlined in the 2003 National Assessment of Adult Literacy document, are particularly useful with low-literacy adults, a population considered the greatest priority because adults make critical medical decisions for themselves and their families. The general guidelines of the US Office of Disease Prevention and Health Promotion can also be a good preliminary checklist for developing effective health education messages. Its checklist for improving the usability of health information is:
- Identify the intended users.
- Use pre-tests and post-tests.
- Limit the number of messages.
- Use plain language.
- Practise respect.
- Focus on behaviour.
- Check for understanding.
- Supplement with pictures.
- Use a medically trained interpreter or translator.
An important consideration in selecting the medium is how it will affect the receiver's ability to understand the message and act on the information. It is the medical communicator's responsibility to use a medium that is both culturally acceptable and comfortable for the individual. Low reading and health literacy levels embarrass some individuals, and that embarrassment, as well as cultural influences, results in their not asking questions about their health or medications. A person who reads at a fourth-grade level and is asked to fill out a patient information sheet may not understand all of the words and will simply mark "no" so as not to be questioned about the answers. Oral communication can help validate understanding, especially if it is conducted in a way that does not embarrass the receiver. Many cultures, for example, rely heavily on storytelling to transfer information, and storytelling is an effective medium that should also be considered beyond the more commonly used written form. For the medium, the Action Guide advises being aware that many health clients with low reading and health literacy levels are embarrassed by their lack of these skills, practising respect by avoiding situations that cause individuals to feel embarrassed, using oral communication to validate understanding, and recognising that for some health clients situational storytelling and active listening may be more effective than direct questions about understanding.
The receiver
The receiver comes last in the model and needs to be considered first. In health education the receiver, or health client, is not only the recipient of the health message but also the person whose health needs the senders are trying to address. A receiver could also be a gatekeeper, such as a key person in the community, or a person from whom the medical communicator is seeking funding for a special health intervention. Choosing the right message and the most effective medium starts with understanding the intended receiver, and the communication process is shaped and influenced by a person's educational level, socioeconomic status and cultural background. The more the medical communicator understands the receiver and develops a communication package that reflects that understanding, the more likely the receiver is to be able to read, understand and act on the information. To truly understand receivers, medical communicators need to "walk in their shoes and listen to their stories", and a leader in multicultural health education emphasises seeing a person not just as an individual but also as part of an extended family or neighbourhood.
Cultural beliefs can help the communicator or present barriers. The traditional African American belief that personal choices and behaviours affect one's destiny can be helpful when trying to encourage new health behaviours. Research on cancer rates in Asian women, specifically Hmong women, indicates that one of the significant barriers to health care is the women's belief about cancer and death. The traditional Hmong view is that disease is a loss of spirit, treated by a shaman who restores balance between the living and spiritual worlds, which differs from the traditional Western medical view that a disease is caused by a specific pathogen or physical condition. Health and medical communicators and health professionals should neither ignore culture-specific differences nor perpetuate stereotypes by applying cultural labels, and a balanced approach using multiple strategies is best for effective health communication.
Differences in learning styles also need to be considered. Whether culture influences learning styles or learning styles exist despite culture is still debated, but people think and process information in different ways. Two of the most common theories of how they do so are Kolb's theory of learning styles and Armstrong's theory of multiple intelligence. Kolb divided learning into perception and processing, each a continuum: people usually perceive information through concrete experience (feeling), abstract conceptualisation (thinking) or somewhere in between, and process it somewhere between active experimentation (doing) and reflective observation (watching). From this Kolb identified four learning styles:
- Divergers are best at viewing concrete situations from many points of view, like to brainstorm and have broad cultural interests.
- Assimilators are best at understanding a wide range of information and putting it into concise, logical form, and are less focused on people and more interested in ideas and abstract concepts.
- Convergers solve problems and make decisions by finding solutions to questions or problems, and prefer technical tasks and problems to social and interpersonal issues.
- Accommodators learn primarily from hands-on experience, enjoy new and challenging experiences, and tend to act on gut feelings rather than logical analysis.
Armstrong's slightly different theory suggests that a person's form of intelligence influences the way they learn, and names eight types of intelligence or learning style: bodily, visual, verbal, musical, naturalistic, interpersonal, intrapersonal and logical. Because individuals learn and process information differently, the message should be offered in multiple formats and channels.
For the receiver, the Action Guide advises learning about their reading skills, primary languages and learning styles; their values and goals and how the health message can be interpreted in terms of them; the culture-specific health terms, beliefs and practices that can provide context for understanding; and their self-confidence and self-efficacy, to understand what they believe they can do. It also advises identifying the receiver's preferred communication channels, such as oral traditions, and conducting follow-up interviews to learn how the information was used to access health care and change behaviours. To help the receiver act on the information, the Action Guide also advises serving as an advocate and support person for needed actions and helping to develop support networks such as volunteer mentors, accountability partners and training classes.
Spoken and written communication in clinical practice
In clinical practice, communication with patients is both verbal and written. In one clinical pharmacist's experience, verbal instructions can be easily forgotten, misunderstood or influenced by personal bias, and patients need written materials to reinforce verbal instructions. Most existing resources, however, are not accessible to people with lower literacy skills, which creates a barrier between patients' comprehension and the materials provided. Healthcare providers should keep in mind that not all patients are literate and that they need personalised instructions.
Effective verbal communication is essential: healthcare providers should listen actively to patients, understand their concerns and encourage dialogue through open-ended questions. The clinical pharmacy team should be empathetic, and empathy includes non-verbal cues such as eye contact and appropriate facial expressions, which improve the connection with patients. In the pharmacist's experience, the teach-back method is an effective strategy for patient education: she asks the patient to repeat key instructions and encourages them to ask questions, confirming whether they clearly understand the key information. She also emphasises simple, jargon-free language and everyday examples to make information relatable, memorable and clear.