health communication in practice a case study approach

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Health Communication in Practice

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Health Communication in Practice: A Case Study Approach offers a comprehensive examination of the complex nature of health-related communication. This text contains detailed case studies that demonstrate in-depth applications of communication theory in real-life situations. With chapters written by medical practitioners as well as communication scholars, the cases included herein cover a variety of topics, populations, contexts and issues in health communication, including: *provider-recipient communication and its importance to subsequent diagnosis and treatment; *decision-making; *social identity, particularly how people redefine and renegotiate their social identity; *communication dynamics within families and with health care providers through unexpected health situations; *delivery of health care; and *health campaigns designed to disseminate health-related information and change behaviors. Reflecting the changes in health communication scholarship and education over the past decade, chapters also explore current topics such as delivering bad news, genetic testing, intercultural communication, grieving families, and international health campaigns. A list of relevant concepts and definitions is included at the end of each case to help students make connections between the scenario and the communication theories it reflects. With its breadth of coverage and applied, practical approach, this timely and insightful text will serve as required reading in courses addressing the application of communication theory in a health-related context.

TABLE OF CONTENTS

Part i | 66  pages, issues in provider-recipient communication, chapter 1 | 8  pages, the first three minutes, chapter 2 | 15  pages, staying out of the line of fire: a medical student learns about bad news delivery, chapter 3 | 12  pages, problematic discharge from physical therapy: communicating about uncertainty and profound values, chapter 4 | 13  pages, “i want you to put me in the grave with all my limbs”: the meaning of active health participation, chapter 5 | 14  pages, direct marketing directs health care relationships: the role of direct-to-consumer advertising of prescription drugs in physician-patient communication, part ii | 53  pages, issues in decision making, chapter 6 | 12  pages, communication and shared decision making in context: choosing between reasonable options, chapter 7 | 14  pages, negotiating cancer care through communication, chapter 8 | 15  pages, explanations of illness: a bridge to understanding, chapter 9 | 9  pages, talking to children about illness, part iii | 59  pages, issues in social identity, chapter 10 | 11  pages, a treatment team approach: the negotiation of rehabilitation goals for survivors of traumatic brain injury, chapter 11 | 9  pages, communication accommodation in counseling, chapter 12 | 12  pages, social identity and stigma management for people living with hiv, chapter 13 | 13  pages, “every breast cancer is different”: illness narratives and the management of identity in breast cancer, chapter 14 | 9  pages, “they make us miserable in the name of helping us”: communication of persons with visible and invisible disabilities, part iv | 62  pages, issues in family dynamics, chapter 15 | 11  pages, communicating about family history in an age of genomic health care: expanding the role of genetic counseling, chapter 16 | 16  pages, catching up with down syndrome: parents' experiences in dealing with the medical and therapeutic communities, chapter 17 | 11  pages, grieving families: social support after the death of a loved one, chapter 18 | 10  pages, negotiating communication challenges while experiencing alzheimer's disease: the case of one hispanic family, chapter 19 | 10  pages, finding the right place: social interaction and life transitions among the elderly, part v | 80  pages, issues in health care delivery, chapter 20 | 16  pages, role negotiation, stress, and burnout: a day in the life of “supernurse”, chapter 21 | 10  pages, medical care, health insurance, and family resources: complications to otherwise good news, chapter 22 | 13  pages, enhancing culturally competent health communication: constructing understanding between providers and culturally diverse patients, chapter 23 | 11  pages, the patient in 4: framing and sense-making in emergency medicine, chapter 24 | 13  pages, reorganized medical practice: an institutional perspective on neonatal care, chapter 25 | 12  pages, making empowerment work: medical center soars in satisfaction ratings, part vi | 42  pages, issues in information dissemination, chapter 26 | 9  pages, no, everybody doesn't: changing mistaken notions of the extent of drinking on a college campus, chapter 27 | 11  pages, personal stories and public activism: the implications of michael j. fox's public health narrative for policy and perspectives, chapter 28 | 10  pages, journey of life: a radio soap opera on family planning in ethiopia, chapter 29 | 8  pages, narrowing the digital divide to overcome disparities in care.

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• DOI: 10.4324/9781410612779
• Corpus ID: 116670130

Health Communication in Practice : A Case Study Approach

• Published 23 March 2005

26 Citations

Health communication and caregiving research, policy, and practice, corcoran n. (ed.). (2007). communicating health: strategies for health promotion, diabetes and the motivated patient: understanding perlocutionary effect in health communication, short communication monthly communication skill coaching for healthcare staff, the complexity of patient participation: lessons learned from patients' illness narratives., monthly communication skill coaching for healthcare staff., health literacy and healthcare system navigation for people who have had, or are at risk of, a cardiac event, medical professionals as effective communicators, consulting with a surgeon before breast cancer surgery: patient question asking and satisfaction, the influence of intercultural communication on maternal mortality in kibera slum, nairobi county., related papers.

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Health Communication: Approaches, Strategies, and Ways to Sustainability on Health or Health for All

Patchanee malikhao.

Fecund Communication, Chiang Mai, Thailand

This chapter starts from a holistic perspective on health in the society. It makes a statement that, in order to become effective and sustainable, health communication needs to be studied, assessed, and practiced from a rights- or social justice-based position. Such an approach implies the use and integration of multidisciplinary perspectives that try to grasp the complexity of health issues from both global and local, individual, interpersonal, group, and community levels.

Health is a core element in people’s well-being and happiness. Health is an important enabler and a prerequisite for a person’s ability to reach his/her goals and aspirations, and for society to reach many of the societal goals (Minister of Social Affairs and Health, Finland, 2013 : 3).

Health communication has been a part of development communication or communication for development for the past five decades. Royal Colle ( 2003 : 44–51) explains that health communication has been one of the threads of development communication together with population information, education, and communication (IEC) since 1969. Then, it was concerned with population and family planning programs, with an emphasis on reproductive health that includes family planning, maternal and infant death and disability prevention, sexually transmitted diseases (STD) and HIV/AIDS prevention, harmful cultural practices such as female genital mutilation (FGM), violence against females, human trafficking, and female health (Colle 2003 : 46).In her book, Effective Health Communication for Sustainable Development , Patchanee Malikhao ( 2016 : 6–7) explains how the history of health communication, as a separate field of study, has emerged from being only a part of health education and training in medical and public health to the integration of health-related aspects of individuals, communities, and organizations or their environment, with appropriate communication and mass communication theories. These communication theories borrow models and frameworks from (1) social science fields such as psychology, social psychology, anthropology, and sociology; (2) humanities subjects such as culture, linguistics, and languages; (3) ecological and environmental science; and (4) medical science fields.

Today health communication has expanded its scope from biomedical interventions at a personal level to more context-based communication about health, which includes the socials and the environment that have impacts on an individual’s health. Robert Rattle ( 2010 : 130–141) affirms that these are the social determinants of health, apart from the physical determinants, and above all the health policies that impact health behaviors.

What Constitutes and Has Impact on Health

Let’s try to understand what constitutes health before we discuss what determines good health. Some scholars think that health means only the absence of disease or infirmity. That is not enough, because, during our life course, we all experience discomfort, disabilities, and pains along the way, such as child teething, babies being unable to act as adults do, women having menstruation pain or having labor pain, and certain conditions such as pregnancy (Janzen 2002 : 69). These kinds of pain do not indicate that we are not healthy. Janzen ( 2002 : 69) also includes aging, fatigue, birth impairs, and growth disorders as diseases. Our individual health is indeed hardwired with intrinsic diseases, pains, and discomforts. It is a fact of life! Each individual is subject to different healthy degrees, depending upon the physical determinants of health – the physical environment, biology and genetic endowment, and medical service (Rattle 2013: 181). A twin, who lives in a good and clean environment where medical service is well-organized, would be healthier than the other twin who lives in a polluted environment with poor medical service. New medicines and vaccines could save lives, but some people can get access to these innovations easier than others.

Some people are born with birth defects and that makes them less advantageous than others. Some people inherited genes from their ancestors which makes them prone to high blood pressure, diabetes, anemia, etc.

How we think, feel, cope with issues, and manage our life should not be neglected. That is how we differentiate the terms “ well-being” from “wellness.” Wellness is more related to the physical abilities of a person to perform tasks up to the full potential (Dunn 1977 : 9–16), but well-being indicates that there are intangible elements that we cannot miss out. We therefore need to look at other dimensions of health apart from focusing on only our physical health: fitness, agility, body mass index, etc. That’s why Hunter, Marshall, Corcoran, and Leeder (2013) categorize four aspects of health: (a) psychological/emotional, which includes positive attitudes, awareness, resilience, etc.; (b) intellectual/cognitive, which constitutes the ability to learn and to be creative and critical; (c) spiritual, which includes one’s values and beliefs, a sense of meaning and purpose in life, inner peace, and an ability to transcend one’s own self, and occupational, which means the satisfaction from working unpaid or paid and recreational activities; and (d) environmental.

Rattle ( 2010 : 190) explains that there are eight factors in the socials that have impacts on our health. They are relative income and socioeconomic status, education, employment and working conditions, social support networks, health practices and coping skills, healthy child development, culture, and gender. All of these are socially constructed, which means that it is shaped by our interactions with others within the context we live.

People with higher incomes seem to have a higher education, and those with higher socioeconomic status can afford private health insurance and have regular health checkups. People with a higher income tend to live in a safer neighborhood and do not face depression that is often the result of living in unsafe public spaces. Those with better incomes can enjoy better outdoor life with access to more sports facilities and recreation. Better income guarantees hygienic sanitation and healthier living conditions that could prevent respiratory diseases, health hazards, and epidemics.

Better education would result in better personal hygiene and better access to knowledge on diseases and their prevention. Better education is closely related to meaningful job opportunities which in turn brings in satisfaction/self-contentment, inner peace, self-esteem, and self-control/self-power/self-autonomy among other life qualities (Mirowsky et al. 2000 : 50–56). Moreover, good working conditions will prevent employees from hazards and bad physical conditions caused by a nonsafe environment.

People with good social networks can get more access to self-help medical knowledge, health practices, and have a better basic knowledge of hygiene and sanitation, first aid, vaccinations, etc. With social supports, an individual benefits from inner peace and is better able to cope with traumatic experiences and loss.

Healthy childhood development depends upon the socioeconomic status of the parents and the health-care services within the community. One can notice a higher mortality at birth, poorer overall health, and the development of chronic illnesses in adulthood among individuals from a lower socioeconomic status (Sarafino 2006 : 158).

Culture is socially constructed and dynamic. It is what we pass on from generation to generation. It influences the way we interact and how we experience the world, including suffering, pain and its articulation, healing, mental health, and self-help. According to Brown (1995: 8–9), the tangible aspects of culture can be seen as artifacts, norms and behaviors, heroes and symbols, the media, languages and expressions, stories, myths, jokes, rites and rituals, ceremonies, and celebrations. Its intangible aspects are beliefs, values, attitudes, and the worldviews of people. The worldviews of people in different cultures are influenced mostly by their religion and beliefs (Malikhao 2016 : 78). In Caring for Patients from Different Cultures , Galanti ( 2008 ) explains at length how different cultures, influenced by different belief systems and religions, affect the way people express pain and suffering, perceive and discuss mental health, perform healing practices, develop culturally bound syndromes, and organize support networks.

Now it comes to the last social determinant: gender. Gender is socially constructed as well. Males seem to have more social burdens than females, as more males are still expected to be the breadwinners. They tend to be more stressed than females and use more drugs, tobacco, and alcohol to cope with stress (Malikhao 2016 : 72).

It is worth noting that the physical and social determinants can be intertwined, and induce cross-link effects, and that can be messed up with biological determinants such as age, sex, and more importantly the genes or our DNAs and the lifestyle of the people in this postmodern era. All of that makes an individual’s health different from one another. Pollard ( 2008 ) explains in her book, Western Diseases: An Evolutionary Perspective , how our genes adjusted themselves when people changed their lifestyle and dietary pattern from the East to the West, and that caused the so-called Western diseases or noncommunicable diseases such as type 2 diabetes and colon and breast cancer among other diseases mostly found as the cause of death among people in the Western world – North America, Western Europe, Australia, and New Zealand. Pollard states clearly in her book that the Western diseases are also found among the rich populations in the Third World as a result of imitating the lifestyle of those living in the West. This can be explained with the term “aberrant epigenetics.” It means that a change in the environment and/or change of dietary patterns in an early stage of life could have an impact on the DNA of our cells, not as much to alter the genetic makeup of our body but enough to cause certain diseases such as Alzheimer, schizophrenia, asthma, and autism (Marchlewicz et al. 2015 :4). Western diseases are one of many indicators of how globalization affects the health of the world population. Postcolonial or contemporary globalization has been speeded up in both degree and kind by advances of information and communication technologies (ICT). The moving of labor, goods, production sources, technology, etc., with driving forces such as the marketing and advertising industry across the globe, results in unequal affluence and instigates new patterns of consumption and lifestyle and new diseases and the comeback of almost eradicated diseases (Lee 2005 : 14; The College of Physicians of Philadelphia 2018 ; CDC 2010 , 2014 ; Emedicinehealth.com 2018 ). To elaborate, some parts of the world or sectors within the same country benefit from globalization more than others, which causes unequal opportunities in accessing basic needs for city dwellers: clean water supply, proper sanitation, waste disposal, proper housing, clean air, public playgrounds, good schools, good working conditions, adequate primary health-care services, or a good marketplace that provides fresh, clean, and nutritious foods. Respiratory diseases; dysentery diseases; tuberculosis; plague; depression; mental health and health issues due to tobacco, drugs, and alcohol use; and other epidemics happen more in less developed, mainly crowded areas. As more and more people migrate in pursuit of better opportunities, communicable diseases could spread far and wide. Patchanee Malikhao explains at length in her 2012 book, Sex in the Village: Culture, Religion and HIV/AIDS in Thailand , how the pandemic HIV/AIDS occurred due to a complex factors including migration of labor, unsafe sex practices, the change of sexual norms due to globalization, discourses on safe sex education, HIV/AIDS prevention public health policies, the localization of the global HIV/AIDS prevention, discourses on the religious HIV/AIDS interventions, gender inequality, and poverty to name a few (Malikhao 2012 ).

As people have more sedentary lifestyles, triggered by using automations and performing white-collar work, together with eating fast food and processed food that contains too much sugar, salt, and fat, they are prone to develop noncommunicable diseases (obesity, cardiovascular diseases, diabetes, among others) (Lee 2005 : 14).

Globalization brings in advantages and disadvantages in disease prevention and eradication. Malikhao ( 2016 : 51–52) reports the resurgence of diseases that broke out because either the bacteria have become antibiotic-resistant (such as avian influenza, cholera, influenza, and chikungunya) or there have been cross-links between the virus that used to cause diseases in animals in previous days with that used to cause diseases in humans resulting in new hybrid diseases such as mad cow disease, bird flu, or swine flu. At the same time, thanks to vaccinations, certain diseases such as small pox and rinderpest have been wiped out, and some diseases such as polio, measles, and mumps are on the way to die out.

Malikhao ( 2016 : 51, 52, 55, 112) reports that, in a developed world, the haves are not much healthier than the have-nots; some people face health problems such as stress, anxiety, depression, burn out, sleep deprivation, obesity, or risk-taking behaviors such as smoking, alcohol abuse, and drug addictions due to unemployment and underemployment. The developed world can impose more health threats to the less developed world by exporting, in the name of advertising and marketing, unhealthy products such as tobacco, alcohol, fast food, chemical waste, etc. While, in the developing world, some people face starvation due to poverty, some in the developed world develop eating disorders such as anorexia nervosa and bulimia as a result of the change in perception of one’s self-image, partly due to the complexity of mediatization (change of social interactions modulated by the media – Hjarvard 2013 : 17), mediation, and new forms of individualization with symptoms of depression, anguish, apprehension, and anxiety found among the haves (affluenza) in the contemporary globalization period (Lemert and Elliot 2006 ; Twenge and Campbell 2010 ; James 2007 ).

Above all health policies of each state or country do influence the health behaviors of a population in major ways (Rattle 2010 : 141). That includes the food-producing and food-marketing industry which has strong relations with the politico-economic and legal systems and the public health policy of a country. Pesticides, insecticides, hormones, antibiotics, and controls in the agriculture and food industries would benefit the health of the consumers a great deal. Moreover, the systems of health-care services are also determined by the public health policy of a country. Malikhao ( 2016 : 80–81) uncovered four basic health-care systems in the world, as presented on the PBS Frontline documentary in 2015:

• The Beveridge model. It is a government model that supports the health system totally with the tax payers’ money. It is used in Great Britain, Hong Kong, Spain, most of Scandinavia, and New Zealand.
• The Bismarck model. It is a nonprofit model in which health care is privately funded by payroll deduction of employees and funded by the employers. It is used in Germany, Japan, Belgium, the Netherlands, France, Switzerland, and somewhat in Latin America.
• The National Health Insurance model. It is a model funded by a government-administered insurance program through private providers. It is used in Taiwan and South Korea.
• The out-of-pocket model. This is used in the USA. It is the nonmedical care for the have-nots and medical care for the haves.

Having said all of that about health, one could not agree more with the definition of health principles in the constitution of the World Health Organization (WHO 2018a ).

Constitution of the World Health Organization: Principles

Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.

The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, and economic or social condition.

The health of all people is fundamental to the attainment of peace and security and is dependent on the fullest cooperation of individuals and states.

The achievement of any state in the promotion and protection of health is of value to all.

Unequal development in different countries in the promotion of health and control of diseases, especially communicable disease, is a common danger.

Healthy development of the child is of basic importance; the ability to live harmoniously in a changing total environment is essential to such development.

The extension to all people of the benefits of medical, psychological, and related knowledge is essential to the fullest attainment of health.

Informed opinion and active cooperation on the part of the public are of the utmost importance in the improvement of the health of the people.

Governments have a responsibility for the health of their people which can be fulfilled only by the provision of adequate health and social measures.

The Constitution was adopted by the International Health Conference held in New York from June 19 to July 22, 1946, signed on July 22, 1946, by the representatives of 61 states and entered into force on April 07, 1948. Later amendments are incorporated into this text.”

The WHO acknowledges the multidimensional nature of health, that health involves complete physical, mental, and social well-being and not just the absence of disease. Moreover, everyone has the right to maintain and enjoy the benefits of being healthy regardless of their socioeconomic-politico and religious status. That means everyone has the right to medical, psychological, and related knowledge necessary to attain health to the fullest capacity. The health inequality caused by unequal development should be attended to by each government. Each government should be responsible for the health of their population by providing appropriate health and social measures.

We can draw three important notions from the constitution of the WHO: that “rights to health care,” “health inequality reduction,” and “health for all” are essential to devise good communication strategies to achieve the health goal. This leads to the next topic.

Health Communication Perspectives

In the 1980s and early 1990s, health communication was known as a form of health education and health promotion and preventive medicine and focused on communication at many levels (interpersonal and organizational communication) in health-care settings. Mainly in the USA, but also in the UK, the focus was even more down to communication among the patients and the health-care provider (Lupton 1994 : 56; Irwin 1989 : 32, 40).

Health communication theories that originated in the USA have focused on mainstream quantitative research perspectives for about four decades. Malikhao ( 2016 : 19–26) reports that these theories are borrowed from the fields of psychology and social psychology, which emphasize cognitive and behavioral changes at the intrapersonal, interpersonal, and group/organizational level. Popular models for intrapersonal communication are, for instance, the health belief model, theory of reasoned action (TRA), theory of planned behavior (TPB), the integrated behavioral model (IBM), the transtheoretical model and stages of change (TTM), and the precaution adoption process model (PAPM). Models used for interpersonal communication are social cognitive theory (SCT) or social learning theory (SLT). Models used for organizational communication are stage theory of organizational change, diffusion of innovation, and social marketing and edutainment.

Malikhao ( 2016 : 16–17) reports that the signature of these kinds of models is that they rely heavily on positivism which is based on natural science models of cause and effect. They flatten the well-rounded facts of life into a linear line for prediction with inferential statistics. The models used for intrapersonal communication seem to assume direct relationships between knowledge, attitude, and behavior regardless of the context within which people live. The models used for interpersonal communication pay attention to the simplicity of the stimulus-response formula and the modifications of it, such as Laswell ( 1948 ) formula, “Who? Says what? Through which channel? To whom? With what effect?” and Katz and Lazarfeld ( 1955 ) two-step flow of communication, which relays on the spreading of messages from opinion leaders received via the mass communication to other people. Moreover, at the societal level, these models focus on the ability of humans to act in stages from being laggards to people who adopt innovation completely. However, they pay less attention to the socio-politico-cultural context that impinges on the ability to change those individuals. The organizational models assume the one-fit-all models and technology transfer from a more developed country to a less developed country.

These American-based models are built under the modernization paradigm which assumes that the Western way of living is a desirable goal for development everywhere. It is a positivist perspective that emphasizes empirical observations and statistics. Health communication within the modernization paradigm involves a high-tech, top-down, and unilinear approach from health professionals either directly or through the mass media to the receivers aiming to educate, upgrade, or train them to be informed in public health, have good attitude toward biomedical interventions or health-related advice/information, and have self-efficacy to change health-risk behaviors to a healthy lifestyle and health behaviors.

The modernization paradigm has been challenged since the 1990s in the multiplicity paradigm proposed by Servaes ( 1999 ). This paradigm is more than a many-roads-lead-to-Rome approach as one can go by foot, by plane, or by boat and one can mobilize others to join them to Rome without having to listen to the commands from Rome. Health communication within this paradigm emphasizes human rights: freedom from exploitation, the right to access adequate health care and health insurance, equity, community efficacy to come up with one’s own solutions to manage resources and health4 issues, participatory democracy, and sustainability in health or health for all in a given socioeconomic and cultural system at all geopolitical levels. With the help of the new media (which is going to be elaborated in the next section), the dream of managing community health and disease prevention by the people and for the people has come true.

Malikhao ( 2016 : 31–40) researches communication perspectives within the framework of the multiplicity paradigm at the individual level, interpersonal level, and group or community level:

At the individual level, the Self Determination Theory of SDT by Ryan and Deci ( 2002 :5) is preferred. This theory focuses on the context where an individual lives or the extrinsic factors that motivate that person to motivate oneself to engage in behavioral change. The internalization process of a person comes from having opportunities to make a choice that is meaningful to oneself in the socialization process and receive a positive feedback to encourage the change of behavior. That means one cannot change his/her behavior by just receiving messages, one has to have an enabling environment to foster desirable health behaviors.

At the interpersonal level, life skill training and education are essential to build up intrinsic factors of an individual to prevent health risk behaviors and health hazards. Intercultural competency training is important for health care professionals to empathize patients and people in the community.

At a group/community level, some social capitals such as support groups and peers together with positive rewards can help reinforce the change of habits into desirable ones. Theories of social network and social support, community organization and community building theories as well as the PRECEDE/PROCEED Model and the Ecological Models of Health Behavior are having common characteristics of enabling environment, including advocacy communication, participatory communication, communication for structural and sustainable social change. Advocacy communication for health is about using the mass media to empower the voiceless to be heard regarding health hazards, issues on environment, and health-related issues. Participatory communication for health enables the locals, regardless of sociocultural and politico-economic status, to act and have dialogues in a democratic way to discuss and prevent diseases, hazards, and pollutions, and promote healthy life style, safety and clean environment. Participatory-based advocacy diversifies advocacy communication by adding the idea that the locals could get together and manage the content of the mass media used to advocate solutions on health issues, pollution, hazards, and clean environment. Health communication for structural and sustainable social change uses mix and match approaches, to advocate change and participation according to the situation, felt-needs of the locals, the budget, and available resources. A health communicator in the Multiplicity Paradigm can be called a social mobilizer who cultivates his/her attitude to empathize with others to achieve capacity building and empowerment and be able to mobilize the community to research, plan, and execute projects that are useful for the sustainability on health of the community (Malikhao 2016 : 99).

All of these models in both paradigms have been used by many scholars for research. According to Babrow and Mattson ( 2003 : 47–53), based on Craig ( 1999 ), historic traditions of research on health communication can be summarized under seven categories:

• The rhetoric tradition focuses on how the health communicators persuade the policymakers to act upon health projects.
• The semiotic tradition pays attention on how health communicators are mediated in intersubjectivity fashions by signs and sign systems.
• The phenomenological tradition studies an individual’s and others’ health experiences in the process of the patient and health-care provider communication.
• The cybernetic tradition looks at the process of health communication in linearity, which implies the encoding of a message, the transmission of the data, decoding of the data, feedback, and the impact on the environment.
• The sociopsychological tradition is about what affects the cognition, emotion, and behaviors of an individual when she/he interacts with the socials.
• The sociocultural tradition studies how health communication produces new sociocultural patterns which have been shared.
• The critical tradition relies on the critical theory used to study discursive reflection of health and illness.

The interdisciplinary research on health communication encourages to gain rich, insightful, and meaningful data to accompany the empirical observations.

Sustainability in Health and Health Communication

Sustainability is what many people talk about in this postmodern era. It seems as if one realizes that, within the limited resources on Mother Earth, we should manage, conserve, and nurture our own habitat in line with an ecological balance, so that new generations to come can enjoy it as well. That is only one part to reach sustainability. Apart from having a healthy environment, we should consider a healthy social (social justice) and healthy economy as sustainability as a whole (Cox and Pezzullo 2016 : 264). Sustainable development implies five different areas that we need to pay attention to: water and sanitation, energy, human health, agricultural productivity, and biodiversity and ecosystem management (Wallington 2014 : 170).

Sustainability on health is to uplift equality of the quality of life for everyone. Poverty, discrimination, less opportunities to get education and employment, living in substandard housing and environment, and less opportunity to access primary health care are the underlying assumptions of inequality in health. According to Malikhao ( 2016 : 99), sustainability on health is a process of social mobilization empowered by both stakeholders, some of whom can be health communicators, and health communicators from outside who have empathy toward the stakeholders, to achieve two goals: first, to engage the people in the community in upgrading the health and media literacy status so that they can make an informed choice on their body and health and health care and, second, to build up community capacity and networking with other communities so that the people can solve problems related to community health, achieve social justice in health, prevent diseases, maintain well-being, and cultivate health knowledge, good attitude, ethical values, cosmopolitan worldview, and health behaviors, including advocating for structural change for a local healthy lifestyle and accommodating environment. In addition, we should call for a rights-based health communication which means everyone should have the equal right to access primary health care regardless of his/her socioeconomic status. We should cultivate intrinsic values, such as self-contentment to instill inner peace that is opposite to short-term pleasure from mindless consumption triggered by the advertisement and marketing industry. Moreover, we should economize on natural resources and energy consumption, including the reduction of carbon footprints to prevent the acceleration of global warming. Extrinsic factors are those that enable people to think, rethink, assess own and community values, empower themselves to improve one’s own health, and participate to improve community health. They are families; schools; communities; the governmental sectors related to public health, energy, and the environment; the NGOs related to health and environment; the mass media and new media; man-made environment; and natural habitats.

Health communication advocating for sustainability ought to be operating under the framework of the multiplicity paradigm mentioned above. To achieve the status of “health for all,” “rights to health care,” and “health inequality reduction,” the integration of five different approaches is needed: behavioral change communication, mass communication, advocacy communication, participatory communication, and communication for structural and communication change. The recipes for each case vary according to each setting, but we can summarize what Patchanee Malikhao suggests in the section of Communicating for/about Health for Sustainable Development in her book, Effective Health Communication for Sustainable Development (Malikhao 2016 ):

Behavioral Change Communication for Health for All is about interpersonal communication on health literacy, health control and management, disease prevention, food and nutrition, wellness and well-being, etc. The main aim is to engage the stakeholder to become a health agency who has an autonomy of own health and can make informed decision. The media used can be both the mass media of the new media that encourage social supports.

Mass Communication for Health for All is about using the mass media convergence to empower the stakeholders and ease the participation process in addressing a health problem in a community. The mass media convergence is the ability of the modern mass media, thanks to the new media, to have more platforms that can interact among one another. For instance, a newspaper can have a digital TV channel, a Facebook page, an Instagram page, a Twitter channel, and a website which allows the audience to follow life video/audio clips or stock audio files for podcast or stock video clips to be watch on a laptop, smartphones, or digital TV screen. Media literacy should be as important as health literacy for health communicators.

Participatory-Based Advocacy Communication for Health for All means empowering the grassroots to interact with key decision-makers on health issues aiming at influencing them to support policy changes at all levels (and also international) and to sustain accountability and commitment from governmental and international actors (WHO 2018b ; Servaes and Malikhao 2010 : 43).

Participatory Communication for Health for All employs both interpersonal communication and multi-community media as well as social media to cultivate community interests and participation, by taking diversity and pluralism into account, in health-related areas. Participatory social marketing on health is the added values on the traditional social marketing to communicate about/on health. That can be both online and offline campaigns using the social interconnectedness online and face-to-face dialogues to buzz news, information, events, and other social media entries. Self-management and production of the media and access of both media producers and stakeholders are emphasized (Berrigan 1979 : 8).

Communication for Structural and Sustainable Social Change for Health for All is a combination of all of the above approaches to empower the stakeholders to upgrade and advocate for their own and community health on correct information on health, health and media literacy, disease prevention, environmental health, health behavior, and access to affordable and quality health-care system.

In order to achieve sustainability, health communicators should possess essential knowledge and skills of intercultural communication. Malikhao ( 2016 : 102-105), adapting from the framework of Martin and Nakayama ( 2010 : 50–52), elaborates on intercultural competency in health in five aspects: First, understanding personal and contextual way of communication. Health communicators should be able to discern personal health behavior (such as brushing teeth two times daily) from the behaviors that are results of social construction (such as sharing syringes among prisoners).

Second, understanding the differences and similarities between cultures. People from different cultures may have different ways in verbal and nonverbal communication. Pain expression, treatment option, or healing rituals can be different from culture to culture. The similarities are obvious that everyone needs respect, kindness, and a nonjudgmental attitude.

Third, understand the local cultural context in which we are operating. If the health communicators can speak the local language, it would be a plus to create rapport between them and the stakeholders. Understanding one’s own culture and biases in one’s own culture, but at the same time having sensitivity to other cultures and appreciation for the differences, should be the characteristics of health communicators (Galanti 2008 : 2).

Fourth, understanding the privilege and disadvantage in the socials. Health communicators have advantages in the sense that they may have good connections with the community leaders and policymakers and they may already know the strengths and weaknesses of the community. But they may face resistance from the stakeholders. They may need to step back and assess the situation.

Fifth, history and past understanding. Knowing the history of the health situation of the unit of analysis is important to assess the present situation and plan ahead. The unit of analysis varies from small to large: individual, family, ethnic group, group, community, institution, or a country.

Next, we need to understand the media, especially the new media, to assist health communicators to do the right job.

Media Literacy and the Media to Assist Health Communicators for Sustainable Development

As summarized from Malikhao ( 2016 : 109-123), it should be clarified here that the media is not the message, but the type, format, and limitation of each medium shape the content of the messages. In our mediated world, fueled by digitization, no matter whether we like it or not, we are in the process of mass self-communication, a term coined by Castells ( 2013 : 55), as we are parts of a digital network. We are using the new media every day. According to Fuchs and Sandoval ( 2015 : 165), new media are the media that are based on the World Wide Web, which includes social networking sites such as Line, WhatsApp, Facebook, etc., or video-sharing sites such as YouTube, Vimeo, etc. They can be wikis or a website on which users are allowed to modify the text from the web browser in collaboration with others such as Wikipedia. They can be blogs such as Blogspot, WordPress, etc. or microblogs such as Twitter and Sina Weibo. They can be online pinboards such as Tumblr and Pinterest. They can be a photo-sharing site such as Instagram. While sending texts that we create and sharing images and motion images we create ourselves or repost from someone else, with friends and our circles or networks of contacts, we are acting as both an interpersonal and a mass communicator.

Hence, the term mass self-communication is quite handy to describe our way of communication. Mediation was the old term, that we are mediated by mostly traditional media (newspaper, radio, television, or the classic media) as well as the new media or alternative media such as Indy media (or independent media – which are the media that do not aim for commercial profits and tend to stand up for the underdogs). However, there is another term coined by Hjarvard ( 2013 : 17): mediatization, that is, the long-term influence of mediation creates changes in the culture and institution. Mediatization makes contacts across the globe a reality, makes people think about their identity, and creates digital divides, meaning the gap between those who can access the new media and those who cannot is wider (Martin and Nakayama 2004 : 6).

Let’s discuss the concept of “ media literacy,” which any health communicator should understand apart from being a health literate. As summarized from Turow ( 2014 : 20-21), a health communicator should know that, first of all, media are not the reflection of a reality. Media are constructed, constrained, and influenced by those who produce them and the media business owners. Second, media are related to power and profits. The larger the company, the more power it has to media convergence, more power to control the entire process of media making, and more chances to dominate other cultures with the media products as cultural products: that is called the “soft power.” Third, the media contents are shaped by a political ideology, worldview, and values of the creators. Fourth, the format of the media shapes the characteristics of the media. Fifth, different audiences interpret the same media message in different ways due to their own worldview, background, and education. Sixth, each medium is unique aesthetically. Seventh, the media are the mirror of the visions in society.

Media literacy can be categorized further into four different subgroups, explains Share ( 2015 : 192-197): visual, aural, multimedia, and alternative literacy. Do keep in mind that different lighting, lenses used, types of cameras, camera angles, distances between objects and cameras, and so forth create a different visual image. Aural literacy makes us aware that the same sentence that was spoken and heard in a different context will convey different messages. Multimedia literacy calls for the understanding and capability in the process of making multimedia from the beginning to the end. Alternative literacy calls for the ability to analyze the mainstream media how they create hegemony, how the main stream media represent the power from the dominant ideology, and how to represent underserved perspectives.

The alternative to the mainstream media is community media (Carpentier et al. 2012 ). They can assist health communicators to become health mobilizers. They can help raise awareness, amplify, and engage the stakeholders and solicit solutions or immediate response from the community. These media can be community radio, community television, community video, community-based telematics systems, or just a community folk media, or the same old print media that can be displayed at the places where people gather together temporarily, such as a fair, or permanently, such as in a railway station.

Community new media offer interactive responses. They can be various media, such as telemedicine technology, e-health, Internet radio, Internet television, geographic information system (GIS), and Webs 2.0, 3.0, and 4.0, which allow a community website or community social media platform where everyone can exchange information and voice his/her concerns on health-related areas, environment, and well-being of the community. This author would like to call them participatory new media.

Health Communication Strategies for Sustainability

Stakeholder analysis, recognizing and defining the public health problem, setting goals and objectives, identifying resources, and maintaining control of the problem are steps useful for participatory action research on health-related issues (Malikhao 2016 : 127).

According to the WHO Europe ( 2013 ), to achieve sustainability in health, these strategies can be categorized fourfold:

• To improve health through a life course of empowering people.
• To tackle local major health challenges of noncommunicable diseases, injuries and violence, and communicable diseases.
• To strengthen people-centered health systems, public health capacity, and emergency preparedness, surveillance, and response.
• Communication strategies to create resilient communities and supportive environments, including a healthy physical environment.

Malikhao ( 2016 : 143–164) Modifies the abovementioned strategies by introducing the integration of five different approaches: Behavioral change communication, mass communication, advocacy communication, participatory communication, and communication for structural and communication change health communication but with a stress on the last three approaches. The integration of traditional media, new media, and/or alternative media is possible depending on cases. In order to come up with tangible strategies, we should keep in mind that women development must come first in order that they can bring up their children (WHO Europe 2013 : 73–74). Then, we can focus on children and adolescent, adult, and elderly health.

Communication Strategies to Improve Health Through a Life Course of Empowering People

In all of these age groups there are similar strategies aiming at an individual level, a group level, and structural level. The following communication strategies are summarized from Malikhao ( 2016 : 144–153), aiming to improve on health quality at an individual level:

• Inviting stakeholders to a training program on health and media literacy via a community website or letter, emails, tweeting, phone calls, leaflet distribution, posters, and messages on social media applications and on cell phones.
• Promoting health education on sex education, communicable and noncommunicable diseases, and rights and justice, for the female group and each age group in public institutions, and by using folk media and community media.
• Promoting information on female health and each age group’s health on social media, community media, and the mass media. The community website can be created with built-in podcasts, vodcasts, links to YouTube videos, and links to urls that give information on gender equality, reproductive health, healthy lifestyle, parental skills, preventive information on diseases, clean environment and sanitation, dementia and mental health, etc.
• Raising awareness for routine immunization program for each age group by using emails, letters, posters, blogs, websites, twitter, and community folk media.
• Promoting the inclusion of females, people from each age group, and people from other ethnic groups in any community event.
• Promoting values for healthy lifestyles and advocating for an alcohol-, smoke-, and drug-free life on new community media such as blogs, websites, podcast, digital storytelling, and community media such as theater plays, posters, banners, walls, community radio and TV, social media, and the mass media.
• Promoting nonviolent and nondiscriminating ways to solve problems by using digital storytelling, theater plays, podcast, community radio, and TV.
• Using personal contacts can help unlearn undesirable health behavior like eating fast food and consuming sugary drinks and replace old habits with new habits of eating fresh vegetables, whole grains, and fruit, exercising, and diet control. A workshop and a follow-up program can be designed to accommodate offline discussions.
• Promoting benefits of living in good and clean housing, settings, and environment by using video clips shared in the social media as well as mobile exhibitions with videos and digital storytelling.

The following are communication strategies that aim at improving health quality at a group level:

• Advocating for a school-based curriculum on media and health literacy and courses on media and health literacy in college.
• Advocating for a school-based sex education which includes respect for female rights, gender equality, sexual debut, contraception, and STD and HIV/AIDS prevention.
• Training health-care and medical personnel and interested stakeholders media literacy, communication, and digital media skills. Promoting the training courses can be done by using traditional media as well as the new media.
• Using participatory community media to air information on many topics such as maternal health, teens and adolescent forums, family planning, parenting skills, etc.
• Facilitating collaborating among families, age groups, and members in a community by producing participatory video clips or vodcasts on healthy lifestyle for teens, tweens, adults, the elderly, pregnant women, etc.
• Forming a peer-to-peer online and offline group to exchange views and information on maternal health, mental health, adolescent health, elderly health, etc. brainstorming sessions are recommended to come up with cue, routine, and reward for building up healthy lifestyle such as eating fresh vegetable and fruit, exercising, etc. filming the sessions and upload video clips on the community website or air them on the community media.
• Organizing an online or offline group on preventing alcohol and substance abuse among women and other age groups.
• Participating in the evaluation of all programs and coming up with recommendations and plans for improvement.

The following are communication strategies that aim at improving health quality at a structural level:

• Advocating for rights of the women, children, and the elderly. Video clips made by the collaboration of community members are encouraged to tackle on a particular issue. Sending those clips to the public health authorities and writing articles about these rights on websites, social networking pages, and blogs are recommended.
• Advocating for improving of women and men education. This includes anti-domestic violence and rapes. Digital storytelling or interview clips of women in the community can be displayed on diverse social media platforms.
• Advocating for the equality of men and women in employment and organizing media campaigns to raise awareness to policymakers and business owners.
• Advocating for the inclusion of the marginalized groups. Promoting video clips participatory made by the members of the marginalized groups on websites, social media platforms, and community media.
• Advocating for intercultural communication sessions on community media programs.
• Advocating for a clean and safe environment to work and to live by producing video clips or writing articles in both traditional and new media.
• Advocating for recreation spaces in workplaces and community. Video clips can be shown and uploaded on websites.

Communication Strategies to Tackle Local Major Health Challenges of Noncommunicable Diseases, Injuries, and Violence

Communication strategies aiming at an individual level are the following:

• Promoting eating right and exercising right by using video clips, messages, interpersonal contacts, and social networking sites.
• Raising the awareness of monitoring weight, blood pressure, blood sugar, and blood cholesterol by a concert of campaigns and social marketing by using the new media.
• Promoting nonviolent solutions and gender respect with interpersonal communication and new media communication.
• Promoting the knowledge of noncommunicable diseases such as type 2 diabetes mellitus, heart infarct, coronary diseases, etc. by using print media, electronic media, new media, and interpersonal media.
• Engaging the stakeholders in a community to obey the traffic rules by encouraging them to report the violators in a social media site of the community.

Communication strategies aiming at a group level are as follows:

• Empowering the stakeholders to form peer-to-peer and support groups on any noncommunicable disease triggers such as smoking, lacking exercise, etc.
• Advocating for primary health-care units to monitor noncommunicable diseases with the collaboration of public health officials, the private sectors, and the civil society.
• Empowering for first aid courses at workplace, schools, and community.
• Advocating for a school-based training/education on noncommunicable diseases.

Communication strategies aiming at a structural level are the following:

• Advocating for poverty reduction to reduce mental health problems among multiple sectors. Personal media together with video clips or digital storytelling are to solicit support from policymakers.
• Advocating for the reduction of salt, sugar, trans fat, and saturated fat in processed food. This can be done with MPs, authorities, civil groups, and consumer groups.
• Advocating for monitoring, control, and penalties of pesticides and insecticides in fresh produce; and hormones, antibiotics, heavy metals, and other chemicals in meat, poultry, fresh water fish, and seafood.
• Advocating for stronger penalties for gender-based violence, including sexual harassment, and traffic rule violators.

To Tackle Vaccine-Preventable Communicable Diseases

In order to tackle vaccine-preventable communication diseases at an individual level, mass communication and various forms of community media can be employed to raise awareness. URL links to online information can be provided to share information on new vaccines and vaccines that bridge communicable and non-communicable diseases such as Hepatitis B and human papillomavirus.

At a group level, advocating on any collaboration among risk groups and authorities by using participatory videos. Develop a surveillance and early-warning system in a community and monitor the outbreaks of diseases and keep the stakeholders informed by new media, traditional media, and interpersonal media.

At a structural level, advocating contacts with international organizations on sharing vaccine-preventable epidemiological data, laboratory data, evidence-based and cost-effective interventions, etc. Mobilizing for social support across the board. This includes lobbying for law enforcement on every childhood vaccination, subsidies for vaccination, food and water safety, etc.

Communication Strategies to Tackle Non-vaccine-Preventable or Not-Yet-Vaccine-Available Communicable Diseases Such as Malaria, Dengue Fever, Tuberculosis (TB), and HIV/AIDS and Respiratory Diseases Such as SARS, MERS, H1N1, and H5N1

Communication strategies aiming at an individual level are as follows:

• Advocating via the social and community media to emphasize the cause of the disease, the transmission, symptoms, and prevention of the disease.
• Empowering the stakeholders via personal media and community media campaigns, complemented by training courses of how important the sanitary and hygienic environment is in preventing some vector-borne diseases such as malaria and dengue fever and airborne diseases such as SARS.
• Participatory videos, digital storytelling, podcasts, and vodcasts can be uploaded to promote better education. Better education implies better occupation and thus better HIV prevention as HIV prevalence is partly related to poverty and low socioeconomic status.
• Using participatory community media to promote HIV counseling and testing, especially to mothers to be.
• Advocating for an early warning and surveillance system for vector- and airborne diseases via the community media, new media, and traditional media.
• Use participatory short film of video to advocate the government for multi-sectoral collaboration, and raise funds to provide budget for bed nets in case of vector-borne diseases and budgets for helping dwellers in crowded and substandard housing to prevent airborne diseases.
• Empowering the stakeholders to support outreach and peer education activities by community and personal media.
• Social marketing by using the mass media, social media, and community media on anti-discrimination against people living with HIV/AIDS. Use personal media to include the people living with HIV/AIDS in community forums and activities.
• Advocating school-based interventions to teach students about hygiene, respiratory diseases, HIV/AIDS, TB, malaria, and dengue fever.
• Empowering the stakeholders to take the mosquito-free environment and clean environment in their own hands.

Communication strategies aiming at a structural level are as follows:

• Using the mass media to gain social support on HIV/AIDS prevention in sex education curricula. Gender education should be done in a way of role plays and brainstorming to emphasize gender respect and learn that violence toward females can lead to HIV transmission.
• Mobilize social supports for alcohol control, improving housing standard, etc. by using participatory films, clips, photos, or audio files.
• Using participatory new media to promote a political environment that supports access to antiretroviral therapy for people living with HIV and employment for them and promote a well-informed civil society and nongovernmental bodies.
• Using integrated media to promote the linkage and integration of national programs on HIV/AIDS prevention and malaria, TB, dengue fever, and airborne epidemic prevention with broader health and development agendas.

Communication Strategies to Strengthen People-Centered Health Systems, Public Health Capacity, and Emergency Preparedness, Surveillance, and Response

• Empowering the health-care professionals to produce participatory video or audio files to advocate better working conditions, social supports, and recognition.
• Engaging health-care professionals in dialogues and skill training to increase competencies in intercultural communication, fiscal and budget, decision-making, etc.
• Empowering the stakeholders with participatory media to let them take part in designing, implementing, and evaluating health policies and services.
• Integrated media can be used to empower patients to make informed decisions and/or shared decisions between health-care providers and the patients.
• Empowering the disables, the elderly, and people with chronic diseases with integrated media to advocate access and services for them.
• Using community media and new media to advocate for quality in primary health care.
• Using integrated media to call for good governance and collaborating with other health-care services. The media can be used to engage the stakeholders in helping forming ideas for a people-centered health care.
• Contacting all actors and stakeholders to discuss indicators for success of such a health care service.
• Using integrating participatory new media and mass media to advocate national strategies for developing public health services; assessing present public health laws; revising the laws, if needed; and evaluating partnerships for their effectiveness.
• Using participatory new media to mobilize public health workers, health-care providers, patients, and the public at large to solicit more funding to pay off the operating costs of the health-care services.
• Using participatory media to promote social support for capacity building and assess good governance and efficiency in sharing data and networking with accredited public health organizations abroad.

Communication Strategies to Create Resilient Communities and Supportive Environments, Including a Healthy Physical Environment

• Setting up forums to discuss online on participatory media or offline to engage stakeholders in the environmental management of their community.
• Empowering each person in the community to act as a citizen journalist on outbreaks of diseases and natural disasters by engaging them in the activities of sharing video clips and audio files discussions online and offline.
• Empowering individuals by integrated media to monitor climate change and conserving the natural habitats, including reporting on pollutions.
• Engaging the entire community by integrated mass media, community media, and new media to promote garbage management and recycles within the community.
• Empowering individuals to use bicycles instead of motor vehicles by using traditional social marketing and new media social marketing.
• Offering new media platforms in a community operated by peers to discuss ways to help improve the environment.
• Advocating for safe water, standard sanitation, and clean energy by integrating the mass media, community media, and new media.
• Using new media social marketing to promote the surveillance and preparedness systems for extreme weather events and disease outbreaks.
• Using traditional and new community media to promote events and engage the community dwellers to see the importance of recycling and garbage separation.
• Gaining social support on measures, policies, and strategies to monitor and mitigate climate change by using participatory media.
• Mobilizing social support on educational and awareness programs on biodiversity, ecology, and climate change by using participatory media.
• Mobilizing support for research and development on conservation of natural habitats by using integrating mass communication, community media, and new media.

All of these tangible strategies are just examples of how to reach sustainability in health. People can be empowered to take health- and environmental-related issues in their own hands to ensure capacity building and networking.

Conclusion and Recommendations

By now the reader should be familiar with health communication for sustainability. Thanks to the advances in information and communication technologies or ICT, we can engage the community by media convergence and multimodal digital communication. As the media are not the messages, health communicators should research the strengths and weaknesses in communities regarding health and environment and get to know the stakeholders in order to devise the right communication strategies to suit the needs of the community.

The World Health Organization (WHO) acknowledges the multidimensional nature of health, that health involves complete physical, mental, and social well-being and not just the absence of disease. Moreover, everyone has the right to maintain and enjoy the benefits of being healthy regardless of their socioeconomic-politico and religious status. That means everyone has the right to medical, psychological, and related knowledge necessary to attain health to the fullest capacity. The health inequality caused by unequal development should be attended to by each government. Each government should be responsible for the health of their population by providing appropriate health and social measures.

Three important notions can be drawn from the constitution of the WHO: that “rights to health care,” “health inequality reduction,” and “health for all” are essential to devise good communication strategies to achieve the health goal.

Health communication is no longer a top-down fashion commanding the public to listen and act. We need to consider the enabling environment that would influence the decision-making process, attitude, and health behavior of an individual. Empowerment and advocating are the two terms health communicators as social mobilizers should be acquainted to. In order to do that, a health communicator should possess empathy and intercultural communication skills, apart from being media literate and health literate. This requires training and work experience. Apart from knowing public health, journalism, and communication, a health communicator should also have good knowledge of sociology, anthropology, environmental science, and management. Thus, interdisciplinary training would be a plus for a health communicator.

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Communication Case Studies for Health Care Professionals: An Applied Approach, by Pagano, M

2017, Health Communication

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Dr.Moulya B

moulya baladi

“Extensive research has shown that no matter how knowledgeable a clinician might be if he or she is not able to open good communication with the patient, he or she may be of no help.” Patients’ perceptions of the quality of the healthcare they received are highly dependent on the quality of their interactions with their healthcare clinician and team. There is a wealth of research data that supports the benefits of effective communication and health outcomes for patients and healthcare teams. The connection that a patient feels with his or her clinician can ultimately improve their health mediated through participation in their care, adherence to treatment, and patient self-management. Research evidence indicates that there are strong positive relationships between a healthcare team member’s communication skills and a patient’s capacity to follow through with medical recommendations, self-manage a chronic medical condition, and adopt preventive health behaviors. The present study intended to understand the communication strategies followed in the health clinics which were selected randomly. We followed observation and interview methods to understand the effective communication methods and tried to understand the lacuna and strength in health communication. Present research paper tried to suggest few communication strategies which could be used in the medical camps and clinics for the better understanding of patient’s decease and to have knowledge of the medication. Two private and one government hospitals, two private clinics of Moodubidire have been taken for the present study. Keywords: health camp, clinics, communication, strategies, lacunae

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• Research article
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Health communication in primary health care -A case study of ICT development for health promotion

• Amina Jama Mahmud 1 ,
• Ewy Olander 1 ,
• Sara Eriksén 2 &
• Bo JA Haglund 3  

BMC Medical Informatics and Decision Making volume  13 , Article number:  17 ( 2013 ) Cite this article

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Developing Information and Communication Technology (ICT) supported health communication in PHC could contribute to increased health literacy and empowerment, which are foundations for enabling people to increase control over their health, as a way to reduce increasing lifestyle related ill health. However, to increase the likelihood of success of implementing ICT supported health communication, it is essential to conduct a detailed analysis of the setting and context prior to the intervention. The aim of this study was to gain a better understanding of health communication for health promotion in PHC with emphasis on the implications for a planned ICT supported interactive health channel.

A qualitative case study, with a multi-methods approach was applied. Field notes, document study and focus groups were used for data collection. Data was then analyzed using qualitative content analysis.

Health communication is an integral part of health promotion practice in PHC in this case study. However, there was a lack of consensus among health professionals on what a health promotion approach was, causing discrepancy in approaches and practices of health communication. Two themes emerged from the data analysis: Communicating health and environment for health communication. The themes represented individual and organizational factors that affected health communication practice in PHC and thus need to be taken into consideration in the development of the planned health channel.

Conclusions

Health communication practiced in PHC is individual based, preventive and reactive in nature, as opposed to population based, promotive and proactive in line with a health promotion approach. The most significant challenge in developing an ICT supported health communication channel for health promotion identified in this study, is profiling a health promotion approach in PHC. Addressing health promotion values and principles in the design of ICT supported health communication channel could facilitate health communication for promoting health, i.e. ‘health promoting communication’.

Peer Review reports

Primary Health Care (PHC) has been singled out as the most suitable health care setting to meet the increasing need for health promotion interventions and to curb the rising number of chronic diseases [ 1 – 3 ]. A majority of people depend on health care services for health information, yet PHC is poorly equipped to provide this service [ 4 ]. Developing Information Communication Technology (ICT) supported health communication in PHC could contribute to increased health literacy and empowerment, which are foundations of health promotion and the notion of enabling people to increase control over their health and its determinants, and thereby improve their health [ 5 , 6 ]. It is however essential to conduct a detailed analysis of the setting and context prior to implementing an intervention in order to “avoid murky water and increase the likelihood of success” [ 7 ] (pg 506). The aim of this study was to gain a better understanding of health communication for health promotion and factors affecting such communication in a PHC setting, as a first phase in the development of an ICT supported health channel.

• Health communication

The development of health communication for promoting health has mainly taken place outside the health care services [ 1 ]. When health communication does occur within the health care services, it lacks a broad socio-ecological health promotion approach, needed to tackle lifestyle related ill health and health inequalities [ 8 , 9 ]. An ecological health promotion approach addresses socioeconomic and cultural factors that determine health as well as providing information and life skills to make appropriate health decisions. Such an approach includes both promoting health and preventing diseases [ 10 ], and is referred to as a health promotion approach in this paper.

Consistent with this health promotion approach, health communication in this article is defined as ‘the art and technique of informing, influencing and motivating individuals, institutional and public audiences about important health issues’ [ 11 ]. The communication adopts a participatory approach whose main aim is empowerment through dialogue and mutual learning; the process is as important as the outcome [ 12 ].

Participatory communication could facilitate collaborative learning for both provider and receiver of health communication [ 13 ]. Health communication providers can learn about receiver’s needs and preference for health communication through collaboration process; an insight that could enable them to construct health communication resources that is relevant and accessible to intended receivers. Likewise, receivers may gain more knowledge on health and health management as well as relationship between health and lifestyle through the same dialogue process. Raising health literacy of both parties is important for sustainable health care services [ 14 ].

Improving health literacy is critical to empowerment [ 15 ]. As a concept, health literacy encompasses more than transmitting health information and developing skills. It entails improving people’s access to health information and support capacity to use it effectively; in order for them to make informed choices, reduce health risks and increase quality of life [ 14 , 16 ]. In this light, health literacy is an important public health goal to reduce inequity [ 6 ]. The Ottawa Charter identified creation of supportive environment, developing of personal skills and reorienting health services as important action areas [ 17 ]. These action areas are incorporated in the Swedish Public Health policy [ 18 ], whose overarching goal is ‘to create societal conditions to ensure good health, on equal terms, for the entire population’. To achieve this, eleven goal areas have been identified, two of which are; to enable citizen participation in social and health care services; and to re-orient health care services into a more health promoting health services [ 18 ].

ICT- mediated health communication

ICT mediated health communication media, with internet at the forefront, are increasingly becoming an accepted strategy for communicating health. Internet’s flexibility and accessibility through different channels makes it an ideal platform for communicating health [ 19 , 20 ]. Health channel in this paper is defined as a mode of transmission that enables messages to be exchanged between “senders” and “receivers.” In the context of internet, senders of the communication may have to contend with participants who engage, contest, reframe and deepen the messages in the communication process. This may take place either in an on-going dialogue in real-time or via other feedback avenue [ 21 ]. Implementation of ICT for health communication or aspects of ICT in health communication, as in eHealth applications, is essential to meet growing demands for cost-effective, appropriate and individually tailored health care as well as to increase accessibility to health services [ 22 ], improve population health outcomes and to achieve health equity [ 19 ]. Yet the implementation of ICT supported health communication for health promotion within health care services has been slow in uptake [ 8 , 19 ]. Criticism has been leveled at the existing ICT mediated health communication in health care as it is perceived to be predominantly individual based and pro-medicine in its approach [ 4 , 23 ], lacking a holistic approach and ability to address determinants of health [ 22 ]. Thus there is a need to rethink health promotion in planning for ICT mediated health communication [ 8 , 22 ] for a holistic approach in conceptualization and design of ICT systems in health care [ 24 ]. Innovative ways to design ICT systems in health care can contribute to individual wellbeing and quality of life, and achieve improved public health and sustainable e-services in general [ 25 ].

In the light of the challenges facing PHCs and opportunities presented by ICT in health care services outlined in the background, there is need to conduct a feasibility study prior to implementation of a new ICT supported health communication tool; in order to situate practice in its context and increase the likelihood of success [ 7 ]. Implementation of ICT is expensive, time consuming and often quickly outdated [ 8 , 26 ]. In order to develop sustainable ICT systems that fulfill health promotion goals in PHC, there is a need for both the system developers and health personnel to understand what functions the system is supposed to fulfill and the contexts in which it is to function [ 27 ]. This need informs the aim of this study which is to gain a better understanding of health communication for health promotion and factors affecting such communication in a PHC setting. This study has the potential to guide researchers and PHC managers in future feasibility studies and/or the implementation of ICT systems.

Study setting

The study was conducted within a county council owned PHC and its health promotion center ‘ Hälsotorg ’ in the southeast of Sweden which provides health services to approximately 10,500 inhabitants. The PHC center houses several units: General Practitioner (GP) and District Nurse (DN) consultations services, Child Health Services (CHS), Hälsotorg, Pharmacy, Dental and Psychiatric Clinic.

The Hälsotorg was partly owned and managed by the PHC. Hälsotorg emerged in several county councils in the 1990’s as a collaboration between the then, state owned, pharmaceutical company and PHC in a bid to increase health promotion within the PHC services [ 28 ]. According to local evaluation reports, the concept and ambitions of Hälsotorg were appreciated by health personnel as well as visitors [ 29 ]. As it contributed to the alliance building with other actors working in the field of health, opened up PHC to the non patient segment of the society and thereby increasing citizens’ accessibility to and participation in health care as stipulated by the national public health policy [ 18 ]. This makes PHC a natural entry point for reorientation of health care towards a more health-promoting health services as proposed by the World Health Organization (WHO) [ 17 , 30 ] and the Swedish National Public Health Policy [ 18 ].

To improve accessibility to health promotion initiatives for the local community, a research and development project entitled ‘Virtual Hälsotorg ’ (VHT) was initiated to make Hälsotorg activities more accessible to the local community through an internet supported interactive health channel. The main objective of the VHT project was to develop an interactive digital health channel for health promotion, a virtual “meeting place” for health issues between community members and health care personnel in PHC. According to the project goals, VHT channel was to be specifically adapted to the socio-cultural context of PHC and the local community. The VHT project was part of an EU funded research and development project exploring how ICT can be used to increase citizens’ accessibility to and participation in health care, and development of health care services.

Study design

The Virtual Hälsotorg (VHT) research project adopted a Participatory Action Research (PAR) approach [ 31 ]. A model, entitled Spiral Technology Action Research (STAR) [ 27 ], was used to guide the design process. The STAR model combines health promotion and social theories, PAR approach, critical pedagogy and ICT systems design approaches using rapid cycle of change strategies [ 27 ]. The iterative nature of the STAR model allowed continuous feedback and dialogue between partners in the research project which resulted in action/improvement of the product thereby making it a tangible method for realize the PAR approach of the project. The STAR model consists of five developmental cycles entitled; Listen, Plan, Do, Study and Act . For the VHT project, these cycles were combined to form three developmental phases; phase 1; Listen, phase 2; Plan and Do, phase 3; Study and Act. This article covers the first phase Listen ; which entails ‘scanning the setting’. This article had a dual purpose. First, to familiarize with the setting for the intervention. Second, to assess health communication needs and identify subject’s interaction with technology. The goal of this phase in the VHT project was to ensure that the development of the system was guided by the users, both health professionals and the local population, needs as expressed by them [ 27 ].

A qualitative exploratory case study [ 32 ] methodology with multiple data collection methods; field study with participatory observations, document studies and focus groups were applied in the study to facilitate a holistic view of health communication practiced at Hälsotorg and PHC (Table 1 ). PAR approach, provided possibilities to understand individual and organizational factors as well as the relationships between these factors [ 32 , 33 ]. Since the boundary between Hälsotorg and its context (PHC) were not clearly evident, the whole context was treated as a single case study [ 32 ]. The case and unit of analysis was the phenomenon ‘health communication’ in the context of PHC in general and Hälsotorg in particular. According to Yin, use of multiple sources of evidence allows the investigator to address a broader range of issues comprehensively thereby contributing to convincing and accurate findings or conclusions [ 32 ] hence increasing credibility and trustworthiness of the results [ 33 ].

Case description

Hälsotorg in this study was managed by health professionals from the PHC and the Pharmacy. It offered a range of health promotion activities including health information in print and electronic media, individual health counseling on life style related health problems like stress, physical inactivity, overweight and chronic diseases such as hypertension and diabetes. It also offered group activities such as: open public lectures, ‘power walking’ and aerobics for people with physical disabilities. A customer computer placed at the Hälsotorg; provided access to free, trustworthy internet-based health information sites and self-administered lifestyle tests. All activities were open to all citizens free of charge.

The term ‘visitor’ was used to describe all who visited Hälsotorg, regardless of how or why they came, in contrast to ‘patients’ in other PHC units. Hälsotorg personnel did not have an obligation to document visitors in the electronic patient record, thus all visitors had the right to be anonymous. Hälsotorg had two types of clientele; visitors, who visited of their own accord and visitors who came on referral from GP, DN or CHS.

The case was expanded to include experiences of personnel from the other three Hälsotorg in the region to get a broader perspective of health promotion services offered and to solicit input on the content and development of a VHT model usable in all county council owned PHC in the region. The GP and DN consultations services, CHS and Hälsotorg belong to the same organization and will henceforth be referred to collectively as ‘PHC’ in this paper, likewise, personnel from respective units will be referred to as ‘health personnel’, unless the need to separate them arises.

Fields study

To familiarize with the setting for the intervention, find and assess needs, and identify how subjects interacted with technology, a field study was conducted under a period of three months, twice a week, in 2008–2009. AJM took part in Hälsotorg activities and staff meetings in the PHC, collecting data using participatory observations [ 33 ]. A total of 251 people visited the Hälsotorg during the period of the field study, some of whom took part in the informal interviews which formed part of the field notes.

Participatory observation as a method contributed to a better understanding of the context, its actors and their interrelations. Thereby a nuanced understanding of the context as a basis for understanding data collected through other methods such as focus groups and document studies [ 33 ]. Furthermore, findings from the participatory observations were used to identify key actors (study sample) and to design questions for the focus group. Participatory observation was useful as expression of needs, especially for technology based resources, is often tacit and hard to deduce for the majority of the people [ 31 , 34 ].

A field study manual covering; activities conducted at Hälsotorg , participants and reason for participation. The manual also focused on how health communication was framed and communicated as well as tools and strategies used to communicate health. The interaction between health personnel and between health personnel and Hälsotorg visitors were also covered. The manual observations notes, impromptu conversations and personal reflections were recorded in field notes. The notes were then expanded when the situation allowed or at the end of the day to identify assumptions, make sense of the data, and record personal insights that might have affected the data [ 34 ] and discussed with the DN at Hälsotorg .

When Hälsotorg visitors allowed it, AJM actively participated in the activities which gave the opportunity to closely observe the activity and ask questions in an unobtrusive way [ 34 , 35 ]. Similarly, AJM, helped in the planning of two public lectures during the field study, thus giving insights on how health communication via mass-media was articulated and executed. Field notes were read repeatedly to make sense of the collected data and get a sense of whole. The data was later coded and categorized using qualitative data analysis [ 34 ].

Document studies

Purposive sampling was used to identify documents, printed materials and records [ 34 ] that were of importance to health communication and health promotion in PHC. A total of 13 documents and other printed materials used at Hälsotorg were identified as crucial to understand how health promotion in PHC was articulated in text and how it is interpreted in praxis as basis to understand the what, how and why of health communication for health promotion practiced in PHC and factors influencing it (Table 1 ).

The national documents; the public health policy 2007/8:110 and pharmacy (Apoteket AB) Action plan 2002, were identified through an earlier study of Hälsotorg implementation analysis [ 28 ]. The county council documents were identified during field studies data collection period and obtained through internet searches on the county council website. The rest of the documents included; an evaluation report of Hälsotorg in the region, meeting protocols, monthly reports (mainly activities offered and statistics of visitors) kept by all Hälsotorg during the field study. All the documents related to the development, visions and goals for health promotion in PHC. Qualitative content analyses were conducted whereby phrases describing health promotion, health communication in PHC as well as PHC’s missions, role and responsibility in health promotion were highlighted and coded [ 34 ].

Focus groups

To explore the knowledge and experiences [ 34 , 36 , 37 ] of the different actors in the PHC, focus groups were conducted with actors involved in health promotion in PHC (Table 1 ). Purposive sampling was used to identify potential information rich sources and main actors [ 37 ] among health care personnel in PHC and local community members. To gain a better understanding of health communication for health promotion in PHC and capture perspectives and experiences of the different actors who affect or are affected by it, effort was made to include providers, receivers and decision makers of health communication in PHC.

Focus group participants were recruited using snowball methods [ 38 ] where PHC manager and DN in Hälsotorg played a key role in identifying and recruiting of informants. A letter containing project information and a request for participation was sent out to prospective informants in PHC and to a Swedish language class for immigrants. Respondents to the letter, were later contacted to decide on dates and places for focus groups. Five focus group interviews were conducted. Group 1 and 2 consisted of DNs in PHC (n=9). Group 3, was Hälsotorg’s network (n=10) consisting of PHC managers, a pharmacy manager, dental clinic manager, psychiatric clinic manager, Hälsotorgs personnel across the region, and a public health strategist. Group 4 consisted of immigrants from a Swedish language school while group 5 was made up of Hälsotorgs’ personnel in the PHC of this case study. The total number participants in focus groups was 30 (Table 1 ).

The immigrant group was a strategic choice as Hälsotorg personnel recounted that from their experience, immigrant groups had low health literacy and were hard to reach. During the period of this study, Hälsotorg had contact with immigrants in the Swedish language instruction school (SFI). The immigrants were informed about the study and requested to participate.

Data was collected using semi-structured, open ended interview guide [ 34 , 39 ] divided in two parts. The first part pertained informants’ personal experiences of designing, delivering / receiving health information/ health communication in or from PHC. The second part concerned informants’ knowledge and experience of ICT supported tools for health information and suggestions for improvements of health communications for health promotion. The interview guide was modified to adapt to the different groups of informants in order to capture the varying perspectives, experiences, roles and needs. Focus groups with health personnel were conducted in private rooms within the PHC, while focus group with the immigrant group was conducted in their classroom which was a familiar environment [ 31 ]. AJM functioned as the principle moderator in all the focus groups assisted by EO who took notes. A post meeting analysis of the session was held by the researchers at the end of every session to compare notes and identify new ideas (if any) that needed to be explored in the next focus group [ 37 ]. Focus groups discussions were audio taped and transcribed per verbatim [ 34 ]. Data was read repeatedly to achieve immersion and obtain a sense of whole, then coded and categorized using inductive qualitative content analysis [ 34 ].

Data analysis

Data from focus groups, participatory observations and document analysis were analyzed, coded and categorized separately using inductive qualitative content analysis [ 34 ]. Emerging categories from the different data sets were constantly compared to each other and integrated into themes (Table 2 ) to form a rich description of the case [ 32 ]. Coding was initially done by AJM and thereafter negotiated and checked for comprehension with the other co-authors. The derived results were then presented to the DN in Hälsotorg for validation. Two main themes emerged from the data analysis namely; communicating health and environment for health communication.

Ethical considerations

The informants were informed on the nature of the study, in accordance with the Swedish Ethical Review Act (SFS 2008:192) and informed consent was obtained from participants. Permission to a conduct field study was granted by the PHC manager. One of the main aims of PAR is to create equality between the researcher and research subjects [ 31 ] as well as making explicit the researcher’s assumptions, values and motives [ 40 ]. To achieve this kind of transparency, AJM kept the participants informed of the project through; talking to the personnel, taking part in workplace meetings and holding debriefing sessions with the other research members to ensure that personal values and motives did not affect the outcome of the study. Debriefing sessions provided useful arena to discuss difficulties caused by AJM’s dual role of a researcher and health worker when actively taking part in the activities in Hälsotorg . However, since the participatory element of enquiry was limited to participatory observation, few problems were encountered as the researcher was sensitive to the participants’ wishes [ 31 ]. AJM would always seek their permission prior to engaging in any activity. The study was approved by ‘The regional ethical committee for Lund/Malmö region’, at Lund University in Sweden. Diary number 2009/120.

The overall analysis shows that health communication is an integral part of health promotion practice in Hälsotorg and PHC but there was a dearth of consensus among health professionals on what a health promotion approach is, causing discordance in approaches and practices of health communication. Two main themes emerged from the analyzed data: Communicating health and Environment for health communication (Table 2 ). The results are presented in these themes with their categories and sub-categories. Quotations are included to illustrate how the interpretation is grounded in the data.

Communicating health

Communicating health was identified as a major function for PHC by all informants. This theme captures how health was communicated, understood and practiced. Health personnel identified a number of strategies and tools used for health communication as well as types of health communication carried out in PHC.

Strategies for health communication

This category mirrored two different approaches used by health personnel to accomplish objectives for health communication; empowerment and behavior change strategies . Empowerment was indicated in the policy documents, and acknowledged by health personnel, as the ultimate goal for health communication in PHC. Field studies and focus groups indicated however that the empowerment strategy was more evident in Hälsotorg and in CHS compared to the rest of the PHC units.

In the empowerment strategy, health personnel assumed the role of a dialogue partner and facilitator for the learning process of patients and visitors. Decision were made based on the receiver's understanding of the information. This approach was commonly referred to by DNs as ‘m eeting the clients where they are, in order to guide them to where they want to go in terms of better health ’. In most Hälsotorg this empowerment strategy mostly focused on building capacity and providing tools for visitors to make informed decisions or creating solutions to health problems or lifestyle changes through a dialogue, while in CHS, it focused on facilitating empowerment of parents and creating a supportive environment for families. As one Hälsotorg visitor expressed:

“ Here (in Hälsotorg ) I can discuss different things at the same time, I was referred here by my Doctor because of my high cholesterol but then, I ended up discussing my sleep patterns that is more disturbing to me really more than high cholesterol (laughter)…You can’t do that at the PHC ” ( Hälsotorg visitor 1)."

Or as another informant expressed;

"“That’s how we work all the time, promoting health and preventing ill health in the home now we focus a lot on unhealthy drinking and we routinely ask both mothers and fathers about their drinking habit not just mothers. It is important that children are safe and parents who need help, feel they can get it” (FG 1)."

In contrast to the empowerment strategy, the behavior change strategy focused on disease and risk prevention. Health personnel were more or less authoritative and ‘instructed’ the patient/visitor, assuming the role of expert, who ultimately informed the patient /visitor, what was best for them. One of the (health) personnel explained the health communication process as follows:

"“We normally go through their (patients’) eating habits and daily exercises together if any and then I show them what they are doing wrong. Then I “teach them” the right diet and tell them that they have to exercise at least half an hour per day. Some do not follow our advice but that’s their own responsibility” (FG 2)."

Comparison of data from interviews and field studies showed that the different strategies could be traced to health personnel’s understanding of the health promotion concept and the exhibited discrepancy between their intentions to promote health and the existing praxis for health communication in their respective units.

Tools for health communication

This category included tools as channels, tools as methods, and tools as competencies.

Tools as channels for health communication included telephones, printed and electronic materials, and Internet-based resources. These were used for health communication with patients/clients/visitors separately or in combination, depending on the nature or purpose of the activity and the desired outcome. According to informants and observations, telephone, printed and electronic materials were common channels for health personnel’s communication with patients and visitors. Health personnel used Internet mostly to search for health information for the purpose of updating their knowledge or to retrieve health information materials for their clients/visitors. Patients and visitors used telephones mostly for health communication with health personnel, while Internet was used to seek knowledge in an area of interest or concern;-mainly chronic diseases and self care.

Tools as methods included questionnaires, brochures, and electronic or printed health tests . Almost all individual counseling sessions were initiated using a printed or electronic health questionnaire followed by a dialogue. Health personnel were positive towards these tools, as they gave structure to health communication activities. However, according to health personnel and visitors these methods could potentially encourage an expert-laymen driven approach, reducing health communication to filling of questionnaires instead of having a dialogue between partners. Health personnel acknowledged the shortcomings of the questionnaires as an effective tool for promoting health as follows:

"“…yaaa (hesitating) …we don’t produce them (questionnaires) ourselves…they are standardized and most people have more than one health concern, there is a risk that you focus too much on the questionnaire instead of listening to the patient” (FG 2)."

Tools as competencies for health communication encompassed knowledge, abilities and pedagogical skills for health communication, which were perceived as necessary tools for imparting or working with health promotion. Knowledge and abilities refer to skills necessary for health personnel to impart health related knowledge that influences individual health choices and self-care. Pedagogical skills refer to health personnel’s ability to apply those skills appropriately and in a way that fosters empowerment in their clients/patients. DNs, in particular, expressed a desire for internal courses to improve their pedagogical skills and capacity to act as health promotion agents. As expressed in one of the focus groups:

"“…of course we can be better at communicating when it comes to health promotion and disease prevention…but it is not always easy. For instance, when you get a patient with hypertension who is a bit fat, you can talk about diet…but to apply it generally in the day to day activities is hard..that needs a different kind of structure, skills and knowledge …pedagogical skills that unfortunately are not there in us…” (FG 1)."

Types of health communication

Three types of health communication were identified from the data: interpersonal, group and ICT mediated health communication. Interpersonal communication was the most common type of communication used in PHC and at Hälsotorg as the majority of activities/services targeted individuals. Motivation Interview (MI) was the recommended method for individual health counseling in the county council policy document and also acknowledged and used by the DN’s. Face-face verbal communication between patients/visitors and health personnel in either planned individual counseling or during ‘drop in’ sessions. The patient/visitor’s needs and abilities were the main focus of interpersonal communications. According to health personnel, it is important to identify patient’s source of motivation as opposed to health personnel’s. As exemplified in the following quotation by health personnel:

"“… it is hard for people to change their habits…but we try to help them identify things that would make them want to change, for example if a visitor is diabetic and overweight…to us it is natural to say diabetes is the problem, but maybe the person wants to lose weight because they want to look beautiful…(all informants nod in agreement)…then beauty is that person’s motivation but in the end the results (of losing weight) would be good for their diabetes too” (FG5)."

Group communication was mostly used at Hälsotorgs during group activities such as physical training and open lectures on different lifestyle related ill health. Different kinds of physical training sessions were offered for example; aerobics for physically challenged persons (including wheelchair- bound persons) and power walking. Open lectures also varied in content, from stress to cardiovascular diseases. These activities paved way for group communication and facilitated dialogue on varied health issues between health personnel and community members.

Findings show that group activities were appreciated by both Hälsotorg personnel and visitors. Hälsotorg personnel saw these sessions with group discussions, as opportunities to communicate health to a larger population, something that is not always easy to accomplish in the day to day work. For visitors, these sessions were more than just an opportunity to exercise or get health information; they presented an opportunity for collaborative learning and opportunity to act on the knowledge acquired for health gains. This would not have been possible if Hälsotorg had not created supportive and inclusive environment for all citizens, regardless of health condition. As expressed by a Hälsotorg visitor:

"“ Hälsotorg has saved my life…I come every Tuesday and walk with this group…it is nice…I made some friends…and the DN can see when somebody is having difficulties…I have a bad heart and I would never dare go on long walks like this if I didn’t know there was somebody to help me if I collapse…she sometimes tells me and the whole group to reduce our pace…because she “sees” when I am struggling…” ( Hälsotorg visitor 6)."

ICT mediated health communication , especially the Internet, was regarded as an important media for health communication by all informants. Younger Hälsotorg visitors and immigrant informants were more positive to the use of internet as a source of health communication; they reported using Internet for health information needs more extensively than health personnel and older Hälsotorg visitors. Younger Hälsotorg visitors and immigrants reported using internet to search information on lifestyle related ill health. Mainly information on weight loss, diet, smoking cessation and stress as well as cardio-vascular diseases. Information on how to contact the local PHC clinics and hospitals was also reported. Immigrant informants used both Internet and digital television, as these channels offered health information in their native languages. Hälsotorg personnel frequently used web based-lifestyle questionnaire on the Pharmacy’s website apoteket.se to tests the visitors’ diet, sleep, exercise, smoking and drinking habits.

Results from the web based-lifestyle questionnaire was used as a basis for individual counseling sessions regardless of what health problem the visitors came in for. A clear irritation was noted among some of the visitors who did not see the connection in for example the hypertension control they came in for and answering the long questionnaire while others appreciated the questionnaire, noting that it has helped them realize that they need to eat better balanced diet or stop smoking for example.

A common phenomenon noted during the field studies was the number of Hälsotorg visitors coming in with health information acquired from the Internet, wanting to discuss the content and validity with the personnel. A DN expressed criticism of the Internet as a source for health information as follows:

"“…patients come with all kinds of information, sometimes wrong information and it’s hard to counter that kind of misinformation…the new health channel would be good because we will be able to give them access to health information that we know is correct” (FG 3)."

Environment for health communication

The environment for health communication was seen as both a facilitator and barrier to health promoting communication efforts in PHC. Two important factors affecting the environment of health communication were identified: Strategic positioning and Collaborating for health communication . Positioning of Hälsotorg within a PHC center affected health communication at the PHC units and Hälsotorg , as well as the collaboration efforts between the different actors.

Strategic positioning

According to the analyzed policy documents, Hälsotorg were strategically placed both organizational and physically within the PHC context to provide local citizens with health promotion and disease prevention services; and to help them navigate the health care system using health information and health communication as strategies. Provision of these services was aimed at increasing health literacy and capacity for self-care among the population, which was supposed to reduce pressure on the PHC medical services.

Organizational and physical positioning were identified as important factors shaping health communication practice in PHC. Organizational positioning referred to the placement of Hälsotorg within the PHCadministrative organization. According to the National Pharmacy Action plan, placing Hälsotorg within the PHC and the pharmacy organizations was a strategy to profile health promotion and disease prevention services in order to involve local citizens in a health dialogue, help people manage their health problems and stay healthy. The Pharmacy, which already had counseling services and a large flow of mainly healthy customers, could play an important role in promoting health at population level in collaboration with PHC. The county council plans also highlighted the importance of adopting a health promotion approach and the creation of a supportive environment for health within the health care services. Hälsotorg was pinpointed as an important setting for realization of these esteemed goals in the first plan (2007–2009) but was not mentioned in the second plan (2008–2010).

PHC was associated with being sick in most people’s minds, according to DNs. ‘Healthy people’ rarely visited PHC, a statement that was echoed by immigrant informants and Hälsotorg visitors. They only contacted or visited PHC when they were ill, prior to their knowledge of Hälsotorg’s existence. The most frequent visitor was a middle-aged woman or an elderly male pensioner with multi-health problems. Some of the health personnel perceived the clientele as being the ‘wrong type’ for health promotion interventions. They expressed a wish to relocate Hälsotorg in order to attract a ‘younger’ and healthier clientele. As expressed below

"“ It is perhaps about the kind of people who walk through our walls (referring to the PHC building)… am I being mean? It is the wrong target group. I feel like…maybe we ought to go to schools, year 7, 8 9, those are the ones we should be aiming at” (FG 2)."

However, not all health personnel held the same view. Some regarded the placement of Hälsotorg within PHC context as perfect as related by other health personnel

"“ …we cannot only target the healthy, we have an obligation to help those who already experience ill health like those with diabetes, they really consume a lot of resources and the best place to “capture” them is in PHC where they come for regular controls. If we can help them prevent further health deterioration like kidney failure, then it is worth the effort” (FG2)."

In ambition to reach out to a larger and ‘different’ audience with health communication, Hälsotorg personnel conducted ‘ Hälsotorg on wheels week’ where they set up camps in the town centre and offered their services to the general public, a move that was much appreciated by both the personnel and the public, according to Hälsotorg personnel’s own documentation. The DNs’ opinion about the positioning of Hälsotorg was not shared by informants in FG 3, who regarded Hälsotorg’s positioning to be the best location to intercept people suffering from minor health problems with services geared towards primary and tertiary disease prevention.

DNs in the focus groups (FG1 and 2), indicated that the organization leadership promoted the image of PHC as a setting for ‘sick care’ through policies on the physical environment of the clinics. An example given by informants was a policy where no posters or information leaflets with health information were allowed in the GP waiting rooms while it was allowed in the CHS and Hälsotorg. This differentiation caused frustration among the personnel, as one of them expressed:

"“Sometimes, I feel like we could be more proactive and put up information pamphlets and posters on HEALTH! But no, we are not allowed, no reasons or discussions! ”(FG2)."

Another informant suggested that the PHC management thwarted their efforts to use health communication proactively, expressing disappointment as follows:

"“.we don’t have notice boards here, I tried to put up some notices on health promotion activities but was summoned and told that I cannot do that by the management!…I don’t understand how they reason” (FG 5)."

Physical positioning refers to the placement of Hälsotorg in the entrance hall of a PHC and/or a Pharmacy or a hospital. Field study observations revealed that Hälsotorg’s physical position made it easy for people to stop by and discuss health concerns, obtain help to navigate the health system e.g. to find the appropriate health clinic at which to seek help. On arrival at the Hälsotorg , curious passersby and referral patients from PHC were introduced to a variety of free services offered. These included universal health information, individual health counseling and access to trustworthy Internet-based health information sites for health promotion .

For visitors with a high risk for lifestyle-related diseases like diabetes and cardiovascular diseases, disease prevention services such as hypertension control, lifestyle tests and group physical activities were offered. The most popular group activity was aerobics for people with physical disabilities.

A disadvantage of the openness of Hälsotorg , was the surrounding noise and lack of privacy during consultations and individual counseling. This was observed during field studies and later acknowledged by the informants. The noise often led to irritation and disgruntlement, thereby affecting the quality and outcome of the sessions. Hälsotorg personnel expressed that the planned Hälsotorg channel would partly solve this problem:

"“This virtual Hälsotorg channel can be good for us; it presents a totally new way of planning individual counseling we can offer a quieter, individual based counseling in the comfort of their homes” (FG 3)."

Adding that the privacy presented by the VHT would enable them to increase the range of services offered to their clients as follows:

"“We can even put up programs (in VHT) where clients can work at their own pace and convenience, without stress or worrying about being disturbed” (FG 3)."

Collaborating for health communication

Collaboration within and outside the health care services such as NGO’s, churches, local communities and municipalities was highlighted as very important for promoting health and providing a supportive environment for health (County Council plan 2007–2009). Hälsotorg was specifically pointed out as a significant converging arena for the different actors to collaborate in creating a supportive environment to achieve health services’ health promotion goals, a setting for communicating health with both patients and local citizens (ibid).

Locating Hälsotorg within the organizational and physical boundaries of health care services resulted in successful collaboration between different professionals and health care organizations for many years, according to the informants and document analysis. Informants acknowledged that making use of the available resources within the different sections of the PHC organization would benefit patients/visitors especially, in health services where lack of resources and time constraints was the norm. However, different structural and organizational factors served as facilitators or obstacles to collaboration efforts. Three categories; interests , resources and trust were identified as factors affecting collaboration efforts and thereby health communication for health promotion purposes.

Collaboration between organizations/professions depended on shared common interest in terms of either the same target group and / or similar organizational demands. PHC organization in this study was made up of specialized units; CHS, GP and DN consultation. Each unit was allocated resources to work with specific or prioritized target groups. Hälsotorg personnel expressed a feeling of marginalization, which they attributed to the fact that they targeted ‘healthy clients’ as opposed to sick/ill patients targeted by the other PHC units. During the field study it was noted that Hälsotorg personnel unsuccessfully tried to enlist the help of DNs with special competencies such as diabetes or incontinence, to give a public lecture at Hälsotorg . Promoting health was conceived as ‘non-urgent’ and was not prioritized, which explained the difficulty of establishing collaboration with Hälsotorg .

Organizational demands of “need-based” prioritization resulted in prioritization of curative and risk-disease prevention in most PHC units. External organizational demands such as national directives and policies were also cited by health personnel as factors affecting interests and, thereby collaboration. For example prioritization of child and geriatric health in the policy years 2008–2010, led to PHC units prioritizing collaboration around these two target groups. Since Hälsotorg did not have a specified ‘target group,’ it experienced difficulties finding collaborating partners in PHC. In an effort to bridge the gap between Hälsotorg and the other PHC units, all the hypertension controls were relocated to Hälsotorg . This was a decision that was not popular among Hälsotorg personnel as it was seen as ‘medicalization’, of their services, as expressed below:

"“…it undermines the whole purpose of my work…I don’t mind them coming but I have to document in their medical journal…I have to talk about their medical history, diseases…that becomes the focus!…Hälsotorg becomes the extended arm of their medical clinic..” (FG5)."

Availability of resources was identified as pre-requisite for communicating health to the public. However, resources were scarce in PHC according to the health personnel. Thus lack of or poor collaboration between different professions and organizations was attributed by the DNs to the scarce resources. Two types of resources were identified from the data: time and economy. Lack of time was attributed to a high workload and little time allocated to each patient, often ageing and multi-morbid patients. However, some DNs suggested that unwillingness to think ‘outside the box’ and negative attitudes towards collaboration more than workload contributed to poor collaboration. Lack of economic resources was also cited by health personnel as a hindrance towards engaging in activities outside the prioritized areas. Health personnel pointed out that they operated on a tight budget, with constant cutbacks which forced them to focus on ‘their’ areas of responsibility.

Trust was identified as an important collaboration factor in and for health communication between health personnel and visitors; and between health personnel in different PHC units. Hälsotorg visitors related that they came to Hälsotorg and took part in the activities because they had confidence in the professionals who worked there. The information they received was perceived as trustworthy, correct and evidence based as it came from a health care authority. DNs in other PHC units also expressed that it was easier to collaborate with Hälsotorg when it was managed by ‘one of them’, meaning a DN

"“…We try to refer our patients to Hälsotorg they are not used to it but we explain that it is one of our own that will help them and the only difference is that there are no medical records. Once they hear they’ll meet a District Nurse, they go willingly…” (DN 8)."

The planned VHT was regarded as an opportunity to overcome some of the collaboration obstacles faced by health personnel. According to health personnel, VHT could be a converging “virtual space” where PHC units could work together but at the same time profile their specific services and communicate with respective target groups.

The aim of this study was to gain a better understanding of health communication for health promotion and factors affecting such communication in a PHC setting, as a first phase for developing the ‘Virtual Hälsotorg’ (VHT), an interactive health channel. According to Kreps [ 8 ], understanding the context is central to planning of health communication interventions, especially within the health care services, where a myriad of individual, organizational and societal factors influence health related decisions and practice. Findings from this study highlight the interrelation between individual and organizational factors, tools and strategies that affect framing of health communication and, how health communication is communicated, received and understood. These factors need to be addressed by researchers and PHC actors in the planning and designing an ICT mediated health channel for health promotion [ 8 , 24 ], to achieve its goal of improving health literacy [ 4 , 14 ], and to realize the national public health goal of re-orienting health care services into a more health promoting services [ 18 ].

PHC in this study is expected to act as a single organization; working towards the same goal of preventing diseases and promoting health for individuals and the community, according to the health policy documents. However, analyses show that the studied PHC faces challenges of catering for a clientele of different ages and health status, as well as serving both individuals and the community as a group. Furthermore, the PHC units were assigned different target groups and adopted different strategies for health communication, making it difficult to achieve the cohesive organization and stated goals. This study therefore highlights a discrepancy between what is stated in policy documents and expressed intentions by health personnel, from the health communication in practice at the PHC.

Collaboration between different actors within and outside the health care settings is an important principle in health promotion. to increase effectiveness and validity of programs [ 41 ]. Division of the PHC into specialized units, each with a given target group, ear marked resources for the target group and prioritization were important factors in contributing to the poor adaptation of a health promotion approach in PHC. This demarcation affected content of, and approaches to health communication as well as collaboration between the different PHC units and other partners. Similar results were reported in Johansson et al. [ 42 ], where health personnel exhibited both the will and skills for promoting health but lacked the chance to implement them due to perceived lack of opportunity or support from the organization. Thus, organizational structures play an important role in creating a supportive environment to enable integration of health promotion [ 43 ]. Health promotion in the PHC studied was regarded as a non-urgent service and as such was not prioritized, which confirms findings from earlier studies showing that health promotion in PHC is sidelined from the rest of PHC activities [ 42 – 44 ].

Health personnel in PHC possess competencies of working with a range of strategies, tools and types of health communication; competencies that could contribute to better ICT based health communication channels such as the planned VHT. DNs in this study have experience of, and skill for working with individual counseling, knowledge and experience that can be used to inform the design of interactive services of the VHT channel; such as tailoring of health information to better suit the intended end users. Tailoring of health information is believed to be one of the most effective strategies for health promotion and lifestyle-changing interventions [ 23 , 45 , 46 ].

The results also revealed a need for skills development in health promotion approach among health personnel in this study. Majority of informants equated health promotion to primary prevention, disease prevention and/or prevention of risk for diseases. Prevention was the dominant approach in health communication strategies and health professionals’ repertoire. This despite policy documents clearly stated the need for a health promotion approach in PHC and Hälsotorg even when working with primary, secondary and tertiary disease prevention. Similarly, health promotion was understood as activities to promote health as opposed to an approach to health promotion . According to Irvine [ 47 ], health professionals in primary care settings, including nurses, lack adequate knowledge to integrate health promotion in their daily work in an effective and planned manner. Thus there is a need to prioritize education and training of health personnel in health promotion knowledge and skills. By involving them directly in the development process of the planned health communication channel, collaborative learning could be facilitated through dialogue between different professionals and lay people.

Allocating Hälsotorg within the PHC context resulted in a symbiotic relationship between Hälsotorg and PHC. Hälsotorg contributed to a more health promoting PHC services through its health promotion activities while PHC’s narrow and “reactive” prevention approach were forced upon Hälsotorg despite protests from Hälsotorg personnel , like the hypertension controls. However, results also show that Hälsotorg and PHC collaborated in the planning and hosting of theme weeks and public lectures despite their differences. Establishment of VHT could benefit from this existing mutual relationship as it aims to promote health by providing accessible and empowering health communication, and creating a supportive environment for health for individuals and the community. VHT could be a potential and ideal converging point for PHC and Hälsotorgs’ health promotion and prevention approaches. This collaboration could further strengthen the PHC’s health promotion ambitions as stated in the policy documents.

DN’s in this study blamed the poor adaptation of health promotion approach in PHC to the lack of support and interest from the management. Similar results were displayed in Johansson et al. study [ 42 ], where health personnel had both the will and skills but lacked the chance to show them due to perceived lack of opportunity or of support from the organization. In this study however, there seems to be contradictions, as participatory observations and meetings with the PHC leadership revealed a willingness among PHC leaders to create infrastructures to improve health communication for the purpose of promoting health. These different perceptions could be the result of the lack of dialogue between PHC leadership and DNs.

According to previous studies [ 19 , 45 , 48 ], trust can be a defining factor for health information seekers ’ use or rejection of the content of health information on the internet. Trust in content and professions were also cited as two most important factors for choosing health communication resources by local citizens in this study. Pilemalm et al. [ 45 ] suggest that involving end users in the design process increases trust among them and thereby probability of their using the system. There is therefore a need to involve all the actors; from PHC managers to DNs in a dialogue during the process of developing VHT; in order to create trust between PHC actors, facilitate sense of shared ownership and sustainability [ 45 , 49 ].

Communicating health is given as an important function in PHC however; results show that there was a lack of synthesis in approaches, strategies and tools to achieve this common goal of promoting health and preventing diseases at individual and community levels. Similarly, empowerment was stated as the ultimate goal of health communication initiatives in PHC but results show that behavior change was the most common approach. Earlier studies have shown that health communication for the purpose of promoting health within health care services, lack a broad socio-ecological health promotion approach [ 8 ]. An approach that is necessary to increase individual and population health literacy in order to tackle the determinants of health and the growing burden of chronic diseases [ 4 , 6 , 8 ]. In order to identify a common health promoting approach and strategies based on health promotion values and principles, a participatory design involving both end users and providers throughout the design process will be used. Participatory design is attributed to contribute to capacity building as participants learn with and from each other while working towards the same goal, making it an appropriate method for development of VHT [ 24 , 45 ].

Data analysis revealed that PHC personnel face a growing challenge of addressing health queries from informed patients and visitors who are more versed with internet use than themselves. In order to meet this, and other future health communication challenges, health personnel need to improve their capacity for using internet-based information [ 19 , 50 ]. Lack of health information in other languages, besides Swedish, is another aspect that needs to be taken into consideration as studies indicate that immigrants generally experience poorer health than native Swedes [ 43 ]. According to the Swedish board of statistics, immigrant communities in Sweden increased from 95750 in 2006, to 96467 in 2011. Prognoses indicate that this trend will continue [ 51 ]. An accessible Internet-based health communication could be a strong motivation for immigrants to seek health information frequently and manage their own health. One of the major challenges to introducing a new technology in PHC is the need to increase the capacity of health personnel’s ability to use ICT resources effectively while paying attention to the eminent risk for contributing to communication inequalities and digital divide [ 19 ]. Equity and inclusion of the needs of non- Swedish speakers will need to be considered by enabling participation of these groups in the design process of health promoting services.

Study strengths and limitations

Use of triangulation of methods and involving other researchers and informants in the data analysis process provided a rich description of the case and context. Furthermore, this study revealed that a multi-method approach unearths more details that are difficult to identify using a single method, for instance, the discrepancy between policy and what is practiced. This provides readers with information to make their own judgments on the study’s applicability in similar contexts, thereby increasing the study’s transferability [ 52 ].

Prolonged participatory observation of three months increased the study’s credibility [ 53 ] and enabled the researcher to study not only what was present but also what was ‘missing’. Two important observations made were; the lack of communication between PHC and Hälsotorg personnel and absence of pharmacy personnel at Hälsotorg [ 34 ]. Participatory observations also gave a detailed documentation of the methodology used for health communication and transparency of decisions, which increases the dependability of this study [ 52 ].

By familiarizing with the target groups, the researcher also gained ‘access’ to the field as well as an opportunity to recruit participants for the continued VHT project. According to Smith et al. [ 40 ], the success of a PAR research project, like the VHT, depends upon the establishment of an environment for trust between the researcher and the subjects of the study. Furthermore, this phase resonated well with the ‘listen’ phase of the STAR model [ 27 ] which entails interacting with the target groups, familiarizing with the context, identifying how target groups interact with technology and carrying out a needs assessment.

A limitation of the study is that it is built on one Hälsotorg and one PHC, and as such, based on a small number of informants. This may have had an impact on the results, as the experiences of the other Hälsotorg have not been explored fully.

Confining the field study to only one Hälsotorg may have narrowed the results as a previous study [ 28 ] showed that Hälsotor g offer different services and some had existed longer than others. However, expanding the case to include workers from the other Hälsotorg , was an effort made in order to compensate for the above mentioned limitations.

Exclusion of GP’s and other health professionals, like dieticians and physiotherapists, from the study is a shortcoming as they could have contributed with valuable information to the study. However DNs, included in this study, was the professional group in PHC who were responsible for health promotion services. Including GP’s was considered, but was not feasible as a majority of the GP’s working at the PHC, at the time of the study, were hired on temporary assignment basis.

This study identified challenges facing the development of health communication for health promotion in PHC. Understanding the opportunities and obstacles for health promotion and health communication in PHC makes it possible to start a dialogue with the different actors identified in the study i.e. health care personnel, PHC managers and local citizens. Engaging the actors in a dialogue could facilitate a consensus on common strategies to overcome the hindering factors and capitalize on the opportunities.

The most significant challenge in developing an ICT supported health communication channel for health promotion identified in this study is profiling a health promotion approach in PHC. To achieve VHT’s health promotion intentions, the development of VHT channel will have to be based on health promotion values and principles of empowerment, participation, holistic and intersectoral approach, equity, sustainability and multi-strategy. There is a need for a shift of focus from individual to a more population- based orientation, placing emphasis not only on people at risk but also directed at health determinants [ 22 , 23 , 25 ]. Furthermore, there is a need for a combination of different strategies, aiming at effective participation of all stakeholders on equal terms, and on professionals taking an enabling role instead of an expert role when communicating with patients/PHC visitors [ 8 , 23 , 45 ]. Finally equity issues need to be addressed through the creation of accessible health communication to improve health literacy [ 14 ], even for non- Swedish speakers as well as those with low literacy [ 53 ]. By addressing these factors in the design of e-Health services, health communication via an ICT supported channel could be health communication for promoting health, i.e. ‘health promoting communication’.

Although this study provides valuable insights to factors that need to be taken into consideration prior to development of an ICT supported health channel, there is a need for further research to better understand the needs for health communication among non-Swedish speakers and to further explore the relationship between the different organizational and social factors affecting health communication.

Abbreviations

Information Communication Technology

Primary Health Care

Virtuellt Hälsotorg’ (Virtual Health Channel)

World Health Organization

Spiral Technology Action Research

Participatory Action Research

General Practitioner

District Nurse

Children Health Services.

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Acknowledgements

This study was part of the ‘Syster Gudrun Fullskalelabb I Blekinge för IT i vård och omsorg’ research and development project (Nurse Gudrun’s full-scale lab in Blekinge for IT in nursing and caring). We would like to thank all the participants who have contributed to this study. We would also like to thank the Blekinge Research Board for generously funding the VHT project. Last but not least, we thank the School of Health Sciences, Blekinge Institute of Technology, for the support and opportunity to work in research.

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Amina Jama Mahmud & Ewy Olander

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Sara Eriksén

Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden

Bo JA Haglund

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AJM, EO and BH contributed to the conceptualization and design of the study. AJM conducted data collection, analysis and drafting of the manuscript. AJM, EO, SE and BH contributed to interpretation of the results and critical revision of the manuscript. All authors have read and approved the final manuscript.

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Mahmud, A.J., Olander, E., Eriksén, S. et al. Health communication in primary health care -A case study of ICT development for health promotion. BMC Med Inform Decis Mak 13 , 17 (2013). https://doi.org/10.1186/1472-6947-13-17

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Health communication in primary health care -a case study of ICT development for health promotion

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• 1 School of Health Sciences, Blekinge Institute of Technology, Karlskrona, Sweden. [email protected]
• PMID: 23363566
• PMCID: PMC3568410
• DOI: 10.1186/1472-6947-13-17

Background: Developing Information and Communication Technology (ICT) supported health communication in PHC could contribute to increased health literacy and empowerment, which are foundations for enabling people to increase control over their health, as a way to reduce increasing lifestyle related ill health. However, to increase the likelihood of success of implementing ICT supported health communication, it is essential to conduct a detailed analysis of the setting and context prior to the intervention. The aim of this study was to gain a better understanding of health communication for health promotion in PHC with emphasis on the implications for a planned ICT supported interactive health channel.

Methods: A qualitative case study, with a multi-methods approach was applied. Field notes, document study and focus groups were used for data collection. Data was then analyzed using qualitative content analysis.

Results: Health communication is an integral part of health promotion practice in PHC in this case study. However, there was a lack of consensus among health professionals on what a health promotion approach was, causing discrepancy in approaches and practices of health communication. Two themes emerged from the data analysis: Communicating health and environment for health communication. The themes represented individual and organizational factors that affected health communication practice in PHC and thus need to be taken into consideration in the development of the planned health channel.

Conclusions: Health communication practiced in PHC is individual based, preventive and reactive in nature, as opposed to population based, promotive and proactive in line with a health promotion approach. The most significant challenge in developing an ICT supported health communication channel for health promotion identified in this study, is profiling a health promotion approach in PHC. Addressing health promotion values and principles in the design of ICT supported health communication channel could facilitate health communication for promoting health, i.e. 'health promoting communication'.

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Healthcare providers’ communication experience in the pediatric intensive care unit: a phenomenological study

• Jooyoung Cheon 1   na1 ,
• Hyojin Kim 2   na1 &
• Dong Hee Kim   ORCID: orcid.org/0000-0002-9514-9734 1  

BMC Health Services Research volume  24 , Article number:  956 ( 2024 ) Cite this article

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Metrics details

Healthcare providers must effectively communicate with other professionals, multidisciplinary teams, and parents of patients in pediatric intensive care units (PICUs) to improve outcomes in children and satisfaction levels of parents. Few studies have focused on healthcare providers’ communication experiences, which are crucial for identifying current problems and suggesting future directions. This phenomenological study was conducted to address this gap.

A qualitative study using online and face-to-face interviews was conducted from January to June 2021 by a trained researcher in PICUs of two tertiary hospitals. Participants were five physicians and four registered nurses who worked in the PICUs and had over five years of clinical experience. The interviews were audio recorded with the participant’s consent and analyzed by the researchers using Colaizzi’s seven-step method.

Healthcare providers’ communication experiences revealed four categories: facing communication difficulties in PICUs, communication relying on individual competencies without established communication methods, positive and negative experiences gained through the communication process, and finding the most effective communication approach.

Conclusions

Without adequate support or a systematic training program, healthcare providers often have to overcome communication challenges on their own. Therefore, support and training programs should be developed to facilitate better communication in the future.

Peer Review reports

Communication among patients, caregivers, and healthcare providers can affect overall satisfaction with hospital care, improving healthcare outcomes, clinical safety, and effectiveness of care [ 1 , 2 ]. Communication is especially important in a pediatric intensive care unit (PICU), a highly sensitive treatment environment for children who are critically ill and involves multiple teams and patients’ family members [ 2 ].

PICU staff must synthesize and use a vast amount of information for patient/parent education so that parents can understand and utilize it. This empowers parents to make important decisions about their child’s care [ 3 ]. High-quality communication is accurate, comprehensive, and timely [ 4 ]. It enhances parents’ information-seeking and decision-making capacity, resulting in greater parental involvement in children’s daily care, greater advocacy for children, and better symptom control [ 5 ].

However, a PICU setting has several communication barriers because the conditions treated here are complex and require considerable coordination among diverse healthcare providers [ 2 , 5 ]. In a PICU, communication takes various forms such as one-on-one dialogues, group meetings, and information exchanges using medical records. Furthermore, it occurs in different contexts, including stable daily rounds or acute stress situations and in separate, designated conference rooms or random locations outside the PICU, such as hallways [ 6 ]. The limited work hours of the PICU staff is another key barrier [ 3 , 7 ].

Despite the growing research on communication in intensive care units (ICUs), the difficulty of communicating in PICU persists. To date, most studies conducted in PICU settings have only emphasized specific communication situations such as handoffs or visits, patient populations, technologies, or clinical situations [ 2 ]. Therefore, attention should be paid on communication throughout the care process to deeply understand the experiences of the parties and ensure effective communication, both between healthcare providers and between providers and caregivers.

To address this gap, our study used a phenomenological method to identify and describe healthcare providers’ communication experiences in PICUs. This study can serve as a resource to provide solutions to the communication challenges experienced in PICUs and help both healthcare providers and caregivers. In addition, it will broadly highlight hospital culture, communication practices, and their impact on patients and families in Korea.

Study design

We applied Colaizzi’s [ 8 ] phenomenological analysis approach to identify the essence of the communication experiences of physicians and nurses in PICUs. The study adhered to the consolidated criteria for reporting qualitative research (COREQ) [ 9 ].

Participants

Participants, identified through purposive sampling [ 10 ], included five physicians and four nurses working in the PICUs of two tertiary hospitals in Seoul, Korea. The inclusion criteria were physicians and registered nurses (1) working in the PICUs and participating in direct patient care, (2) with over five years of clinical experience, and (3) who voluntarily agreed to participate in the study and provided informed consent. In-depth semi-structured interviews were conducted with open-ended questions. Participants were recruited until saturation, when no additional data emerged.

Data collection

A trained researcher (HK) conducted in-depth interviews from January to June 2021 using semi-structured interview guidelines developed based on a literature review and expert opinion (Table  1 ). The participants could choose either online or offline (face-to-face) interviews when they were contacted initially, depending on the COVID-19 pandemic situation. All interviews were conducted based on the participants’ convenient time and location which included a secure, quiet conference room in the hospital where they could talk freely. The interviews were audio recorded with the participant’s consent. The researcher made field notes during and after the interviews to describe the participants’ nonverbal expressions, such as facial expressions, behaviors, postures, loudness, and tone. Emotional expressions of the interviewees, such as crying, were included in the interview transcripts based on when it was recorded in the field notes.

Ethical approval

was obtained from the Institutional Review Board of Sungshin Women’s University (Approval No. SSWUIRB-2021-005). All participants provided informed consent after understanding the study’s purpose, methods (including audio recording), anonymity, confidentiality, and the right to withdraw participation at any time. The collected data (transcripts, field notes, etc.) were coded and stored on a secure computer. The recordings were destroyed after data analysis. Personal information was deleted after the study’s completion. All participants received a small monetary compensation for their participation.

Data analysis

The transcribed data was analyzed using Colaizzi’s [ 8 ] seven-step method: (1) three researchers independently coded the data after repeatedly reading the transcripts to determine the meaning and essence of the participants’ experiences; (2) meaningful statements were collected from the phrases and sentences that were directly relevant to the phenomena of communication experience; (3) meanings of the extracted phrase or sentence were formed and the latent meanings were identified; (4) the meanings were organized into themes formed by grouping similar codes into meaningful sentences, and categories were formulated based on similar themes; (5) the themes were integrated into a full and inclusive description of the phenomenon; (6) the phenomenon’s fundamental structure was identified by condensing it into a short, concise statement and ensuring the validity of the research; and (7) the essence of the phenomenon was validated through participants’ feedback and researchers’ consensus after a final discussion.

Investigator training and preparation

The researchers have worked as nurses in ICUs and pediatric wards, which helped them develop a good understanding of communication with PICU patients’ parents. They have also completed courses in communication and qualitative research methods in graduate school and have adequate experience in conducting qualitative research.

Establishing data rigor

During data collection and analysis, we followed Sandelowski’s [ 11 ] method to establish rigor. For credibility, the researchers explained the research aim to the participants, secured a quiet place to ensure reliability, asked open-ended questions to help participants share their experiences freely, and solicited post-interview feedback to validate the extracted themes. For auditability, the researchers transcribed the interviews on the same day they were conducted to avoid distorting the participants’ perspectives, documented all research procedures, carefully discussed participants’ communication experiences during data analysis, and validated the essence of the phenomenon through consensus-building. For fittingness, researchers included participants with diverse clinical experiences, collected data until saturation was reached, and checked saturation through peer debriefing with others experienced in qualitative research. For confirmability, the researchers conducted interviews from a neutral perspective to prevent preconceptions and experiences from influencing the participants and to accurately capture their communication experiences.

All participants were women (Table  2 ) with an average clinical experience of 8.8 years (5–22 years). The average interview time was 54.7 min (45–70 min).

Analysis of the interview data on physicians’ and nurses’ communication experiences in the PICUs yielded 36 formulated meanings, merged into 13 themes and, ultimately, four categories (Table  3 ).

Category 1: facing communication difficulties in the PICU

Prioritizing children’s health condition.

The health condition of the children admitted to the PICU would often deteriorate within a few hours of admission. As the child’s condition can significantly affect the parents’ emotional state, the participants tended to prioritize restoring the child’s health condition before communicating with the parents. One physician said, “ The state of the parents is entirely dependent on the child’s condition , so the priority is to save the child’s life” (Physician 1). A nurse stated, “ If the child is ill , the life pattern of the entire family changes. If there is any improvement , the mother becomes hopeful , but in case of a deterioration , the mother is saddened…I feel bad” (Nurse 2).

Encounters with parents who had varying levels of knowledge experience and reaction to the child’s condition

Parents who are sensitively attuned to their children’s conditions tend to prefer experienced healthcare providers and question the judgments of less experienced ones. Sometimes, parents react emotionally to their children’s conditions and express anger or denial. This causes healthcare providers to experience considerable mental stress, emotional challenges, and, in severe cases, fear. A nurse stated, “ Mothers of children who have been ill since birth tend to demand certain precautions. They have a series of questions that serve to test whether we comply with them. Some mothers have panic attacks and cry a lot until they get used to the situation” (Nurse 1). Another nurse noted, “ Some parents tend to think that they know more than newbie doctors and sometimes express that they want a smarter doctor to take care of their child. Their attitude toward young nurses seems different as well” (Nurse 3). A physician stated, “ It is difficult to deal with parents who have a bit of a temper. We are scared if they are too angry—we are also humans , and that really scares us” (Physician 4).

Challenges communicating a child’s deteriorating condition

The task of explaining a child’s deteriorating condition or end-of-life situation to the parents deeply upset the participants, who would sometimes remain silent, not knowing what to say. Having years of experience in dealing with end-of-life situations did not make this task any easier. A nurse said, “ Actually, I’ve been through a lot of end-of-life situations but still find them difficult to deal with…I still don’t quite know what to say. I think now I say even less. Just silence…” (Nurse 3). A physician noted, “ Even as healthcare providers, we’re cautious when explaining to the parents that the child’s condition is deteriorating as we find it difficult…” (Physician 4).

Category 2: communication relying on individual competencies without established communication methods

Reliance on individual communication experiences and education.

The participants mainly learned about nursing and treatment during their undergraduate period and did not receive any systematic training on communication. Therefore, their communication with parents mainly depended on their personal capabilities, such as personality, experience, and clinical career, resulting in stark differences in communication skills. They expressed that a more systematic approach to communication training would reduce the impact of individual differences on communication skills. One of the nurses said, “ Actually , nurses and physicians learned how to care for and treat patients , but there was no training in communication. This was largely dependent on the skills , personality , or experience…Seniors tend to explain more , while juniors sometimes avoid the parents as they don’t know how to explain well” (Nurse 3). Another nurse stated, “ Communication is , in a way , an individual’s ability , so I think the problem is that there is a big difference between individuals. Most are doing a good job but there are some who are obviously not doing it right. I think that even a little bit of systematic education is needed in clinical practice” (Nurse 4).

Communication gap among healthcare providers and implicit role division

The participants had “their own rules” for communicating with parents, which entailed implicitly dividing roles depending on a child’s condition. However, this approach sometimes led to miscommunication between the physicians and nurses, revealing a conflicting understanding of the child’s condition. One physician said, “ Because each physician and nurse has their own rule , how they approach communication varies. The disease state is communicated by physicians and the nurses communicate the condition and daily matters of the child” (Physician 1). One nurse noted, “ The professor does not communicate to us his intentions during rounds and simply explains to the parents that it is getting better. When the parents tell us , ‘We heard that it is getting better?’ it makes us look bad” (Nurse 2).

Category 3: positive and negative experiences gained through the communication process

Importance of communicating with parents while providing treatment.

Participants regarded communication as critical for identifying a child’s condition and needs and considered parents as semi-specialists of their children’s conditions. Thus, they readily incorporated parents’ comments and assessments of their children’s conditions when deciding on the treatment course. A nurse said, “ In fact , mothers of children who have been ill for a while are semi-specialists , and there is nothing for us to train” (Nurse 2). Another nurse stated, “ If they can make sounds , they express themselves by crying , so it is difficult to identify their needs. So , we think that it is important to listen to the mothers who usually take care of them” (Nurse 4). A physician explained, “ Communicating with the parents is very important in pediatrics. I don’t think we can treat the child without communicating with their parents. The deeper the parents’ understanding , the better we can decide the direction of the treatment” (Physician 3).

Warm words of gratitude

The participants reported that parents’ warm words of gratitude made them feel appreciated. They recalled instances where parents expressed gratitude toward healthcare providers for their efforts, which, in turn, made the participants feel thankful. One nurse stated, “ Parents’ words of encouragement really make a big difference. In one end-of-life case , the parents of the child told us ‘Thank you for watching my child till the end.’ I know it must have been really difficult for the parents , so I was extremely grateful that they said those words” (Nurse 4). One physician noted, “ Some parents are really mature at the end of their child(ren)’s life; sure , they were extremely saddened by the death , but they called us and thanked us for taking care of the child and expressed gratitude to the medical staff. I still remember those parents” (Physician 5).

Feeling hurt by the communication process with parents

The participants reported feeling deeply hurt when parents criticized them for their care and treatment and did not trust them. Sometimes, despite the medical staff’s best efforts and good intentions, the condition of a patient who is critically ill continues to deteriorate, owing to the nature of the disease. Distrust and criticism from parents challenge the medical staff and, in extreme cases, force healthcare providers to quit their jobs. One of the nurses said, “ When the parents blame and express that they do not trust me , I start questioning myself , ‘Am I not good enough as a medical staff? Am I not qualified for my job? Am I a nurse who can’t even earn trust from the parents?…’ New nurses are hurt by this and some even quit their jobs” (Nurse 3). One of the physicians stated, “ Sometimes , the parents blame the healthcare providers when the child’s condition deteriorates by saying , ‘Are you sure this was the best decision? Maybe it was not necessary to do this…’ Good intentions do not always lead to good results , and it is difficult to predict the result when the condition is critical , and that’s what makes it difficult” (Physician 5).

Exhaustion from repeated questions and requests

The participants reported feeling exhausted by the parents’ repetitive questions and requests. Repeating the same information daily or witnessing parents approaching another doctor for the same information caused healthcare providers to doubt themselves and lose motivation. Cultural characteristics such as heightened requests for healthcare providers or frequent requests to see the child also fatigued the participants. One of the physicians said, “ Culturally , Korean parents request a lot and this makes our job difficult. Korean parents are sensitively attuned to their child(ren) … not allowing them extra services (such as additional time with the child(ren) leaves them with guilt” (Physician 2). Another physician described, “ They say the same thing again and again , even after I explain the same thing over and over again. That really tires us out…” (Physician 3). One nurse noted, “ Even when the nurses explain everything during visits , they (parents) ask the same question to the attending physician or professor when they come and it really makes the nurses lose motivation. Why did they ask me in the first place…I am the one who sees the child the most…” (Nurse 4).

Category 4: finding the most effective communication approach

Revising communication strategy through trial-and-error.

The participants reported that their communication methods changed significantly through trial-and-error and experience. Initially, they would quickly communicate the good news to give parents hope and provide detailed updates on their child’s condition. However, with experience, they began delivering only the facts, rather than explaining all medical procedures to parents. Instead of providing daily updates, they communicated the long-term plan for the child’s condition. One of the physicians said, “ In a PICU , the child is in critical condition and it can always go bad very quickly , so we do not explain all medical acts by the healthcare providers to the parents” (Physician 2). Another physician noted, “ When I was a resident , I focused on explaining the condition of the child , but now I focus on the long-term plan for the child and tell them we need to do this to avoid complications” (Physician 5). One of the nurses said, “ When I was a newbie , I wanted to tell the parents the good news as soon as possible , so I would call them even when I was busy…but now , I simply tell them facts and that’s it” (Nurse 3). Another nurse stated, “ I really wish I could tell them it will all get better soon. But if that doesn’t happen , problems can arise , so I try not to give false hope and try to convey facts as much as possible” (Nurse 4).

Approaching parents first to build trust

The participants emphasized building trust as a key aspect of communication. By approaching the parents proactively to explain their child’s condition, the participants aimed to earn even difficult parents’ trust, reassuring them that they were doing their best. One of the nurses said, “ Gaining their trust is the most important thing in communication. At the start of the visitation , I approached them first and said hello , and then gave them patient information to make them feel more comfortable” (Nurse 3). One of the physicians said, “ Rapport formation , detailed explanations by medical staff , and parents’ understanding are also important. Let the parents know that I am doing my best in caring for the patient…no parent will just complain , no matter how bad they are. There are difficult parents but not impossible parents. This is why I think communication is important” (Physician 3).

Empathizing with parents

The participants emphasized the need to think and communicate from the parent’s perspective. Accordingly, they attempted to comprehend the parents’ thoughts and feelings. Rather than treating the child as a patient, they treated them as if they were their own by referring to them by their names and using familiar expressions. One of the nurses stated, “ Some physicians who have children have a deeper understanding of parents’ minds and understand the discomfort experienced by the children. This makes them able to communicate from the parent’s perspective” (Nurse 3). Another nurse said, “ I think what’s most important is trying to understand the parents’ perspectives. Rather than using the word patient , referring to the patient by their name expresses familiarity and makes me think that I am performing the role of the parent” (Nurse 4). One of the physicians said, “ There are some who only take the words from the professor and focus on treatment only , instead of trying to think , ‘What would I do as a mother?’ I think this is wrong” (Physician 3).

Journey toward a better communication approach

For better communication, the participants suggested the following measures: implementing organizational-level communication training, having dedicated communication personnel for all medical staff, and using various auxiliary tools such as pictures, videos, and applications to improve parents’ understanding of the information. One of the nurses noted, “ As far as I know , if you apply at the hospital , you can receive an education. But I have to invest time when I’m off… It’s an opportunity to learn everything systematically , and if it’s an education that can be tailored to the actual situation , it will naturally help a lot” (Nurse 3). One physician said, “ Images , complications , etc. are difficult to understand even if explained. In foreign countries , such materials are already well-documented with pictures and videos. It would be nice to select only the necessary information for non-medical people and create an instruction manual for educational materials with illustrations” (Physician 2). Another physician stated, “ I think there are more ways to communicate as there is a dedicated professional nurse , which provides an opportunity for having personnel dedicated to communication. I always thought it would be nice for the parents to access applications (PICU diary) to see test results” (Physician 4).

In this study, the communication experience of healthcare providers in PICUs was expressed as a journey to find better ways to communicate when the answer is unknown while receiving positive and negative feedback in difficult situations. From their communication experiences, the following four categories emerged: “facing communication difficulties in the PICU,” “communication relying on individual competencies without established communication methods,” “positive and negative experiences gained through the communication process,” and “finding the most effective communication approach.”

As an integral part of hospital care, the PICU environment is urgent, complicated, unpredictable, and crisis-oriented; therefore, practitioners experience high stress and severe time crunch while stabilizing a child’s condition [ 12 , 13 ]. Given their deep concern about their children’s health, parents are sensitively attuned when their children are sick and receiving treatment; thus, healthcare providers must be more careful when communicating with such parents [ 14 ]. Parents are unprepared for bad news and may not fully understand the complex medical explanations provided by healthcare providers, leading to communication gaps [ 13 , 15 , 16 ]. How healthcare providers deliver bad news is critical because parents want to receive honest and complete information with care, even if it is bad; otherwise, they may feel angry, distrustful, or betrayed [ 13 , 17 ]. This aspect tests even experienced healthcare providers [ 18 , 19 ].

Communication with parents is essential in PICUs to help them understand their children’s health conditions. Simultaneously, parents’ knowledge of their children’s medical history and current symptoms is critical in determining the direction of their care [ 16 ]. Therefore, good communication is essential for parental involvement and family-centered childcare [ 13 , 16 , 20 ]. However, communication with parents is limited to 30 min at the time of hospitalization or twice daily based on hospital policy; given the lack of a systematic method, healthcare providers had to implicitly determine the best way to convey information and educate the parents. Additionally, healthcare providers who did not receive systematic communication training often relied on their past experiences, personal capabilities, and trial-and-error to communicate. This finding was consistent with those of previous studies suggesting that the reasons for lack of communication include limited time for ICU visits, differences in experience and roles of healthcare providers, not communicating plans directly to the PICU team, and a mismatch between theory and practice [ 2 , 12 , 21 ]. High-quality communication between healthcare providers and parents can lead to better patient satisfaction with care outcomes and processes [ 3 ]. Simultaneously, effective communication among healthcare providers can help reduce patient safety risks and improve treatment outcomes [ 22 ].

When the communication process is ambiguous, healthcare providers receive various types of feedback from the parents, which helps them gain new experiences. Parental distrust and heightened requests regarding their child’s treatment or care considerably can make healthcare workers question their role and competence. Conflicts commonly arise in two situations: (1) when parents of children who are acutely ill require more explanations and reassurance and especially (2) when parents of children with chronic illness challenge the expertise of healthcare providers based on their accumulated knowledge and deep involvement in their child’s long-term care [ 20 ]. Despite healthcare providers’ best efforts and intentions, negative experiences with communication can lead to emotional burnout and existential crisis regarding their decision to be healthcare workers [ 21 ]. However, many parents express their gratitude toward healthcare providers in difficult or stressful situations. Such positive feedback can motivate healthcare providers to become more engaged in communication, improve their psychological well-being, and enhance team performance [ 23 ]. In a study of neonatal ICU teams (physicians and nurses) in acute care simulation-training workshops, gratitude expressed by mothers was associated with positive medical team performance through enhanced information sharing [ 24 ]. Communication is an interactive aspect and the main component of human-centered care in the ICU [ 13 , 21 , 25 ]. Effective therapeutic communication programs could significantly help healthcare providers cope with the negative feedback they receive during communication and ensure that parents and families provide positive feedback for their efforts, which will lead to improved patient outcomes through improved quality of care.

Individualized communication, depending on the clinical situation and family characteristics, is a cornerstone of human-centered care in the PICU [ 13 , 21 ]. The study’s participants were experts with more than five years of pediatric experience; however, their communication skills and abilities were at the novice level. Despite making changes through trial-and-error and experience, their communication skills were insufficient compared with other competencies. They relied more on role modeling for existing communication problems and lacked professional training [ 20 , 26 ]. Nonetheless, participants expressed keen interest in finding the best way to communicate by reaching out, building trust, and empathizing with parents [ 21 ].

Healthcare providers receive continuous education for providing specialized care in the ICU using various approaches; however, communication skills training remains insufficient [ 27 ]. Accompanying verbal communication with visual and written tools (i.e., whiteboards, daily checklists, pictures, videos, and applications) may fulfill the need for multiple forms of communication and may improve communication among all parties to foster a better understanding of the children’s condition [ 12 , 16 , 28 ]. Specific training is especially required in dealing with stressful situations in the PICU [ 21 , 29 ]. Many simulation studies of communication with family involvement were conducted using standardized patients or role-plays. In a 3-hour interactive session on pediatric palliative care utilizing communication drills and role-play, students showed improvement in confidence in communicating with families [ 30 ]. After a 3-day pediatric critical care communication course featuring simulation with actors as family members, fellows reported increased confidence in difficult discussions (delivering bad news, having a family conference, eliciting families’ reactions to their child’s end-of-life situation, and discussing the child’s current status and religious issues) [ 31 ]. Moreover, previous studies have reported the effectiveness of simulation training for healthcare providers in the PICU on fundamental communication skills, sharing bad news, determining goals of care, discussing resuscitation preferences, conducting family conferences, forgoing life-sustaining treatment, and navigating conflict with family programs [ 32 , 33 ], as well as the provision of web and videoconference-based training platforms [ 34 ]. Therefore, it is essential for organizations to develop guidelines or education programs to deal with the communication needs of specific situations, which should be conducted continuously.

This study has some limitations. First, the study was conducted at a single site with female healthcare providers in the PICU. Therefore, caution should be exercised in generalizing the study’s findings and applying them to other ICUs in Korea. Second, healthcare providers’ experience of communication in the PICUs of South Korea may differ from those in other countries owing to cultural differences. Lastly, as the study was conducted during the COVID-19 pandemic, the post-pandemic communication experience may be different.

This study provided a phenomenological analysis of the communication experienced in a PICU. A key finding was that healthcare providers still faced communication difficulties and felt that they lacked a support system or training program and were left to deal with these challenges on their own. By revealing these experiences, we provided a discourse to improve the quality of patient care and professional practice in PICUs. Communication problems threaten teamwork among healthcare providers and can adversely affect children’s outcomes, hamper their and their families’ well-being, and generate professional burnout. In the future, various support programs to facilitate communication should be developed; become mandatory for institutions; and include all healthcare workers, in both interprofessional and interpersonal contexts with parents.

Data availability

Due to the nature of this research, participants of this study did not agree for their data to be shared publicly, so supporting data is not available.

Abbreviations

Pediatric intensive care unit

• Intensive care unit

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This work was supported by the Sungshin Women’s University Research Grant [No H20220052].

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Jooyoung Cheon and Hyojin Kim contributed equally to this work.

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College of Nursing Science, Sungshin Women’s University, 55, Dobong-ro 76ga-gil, Gangbuk- gu, Seoul, Republic of Korea

Jooyoung Cheon & Dong Hee Kim

College of Nursing, Seoul National University, 103, Daehak-ro, Jongno-gu, Seoul, Republic of Korea

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Jooyoung Cheon: Conceptualization; Data curation; Formal analysis; Methodology; Validation; Writing - original draft; Writing - review & editing.Hyojin Kim: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Validation; Writing - original draft; Writing - review & editing.Dong Hee Kim: Conceptualization; Data curation; Formal analysis; Funding acquisition; Methodology; Project administration; Resources; Supervision; Validation; Writing - review & editing.A: Jooyoung Cheon, B: Hyojin Kim, C: Dong Hee Kim.

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Cheon, J., Kim, H. & Kim, D.H. Healthcare providers’ communication experience in the pediatric intensive care unit: a phenomenological study. BMC Health Serv Res 24 , 956 (2024). https://doi.org/10.1186/s12913-024-11394-1

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DOI : https://doi.org/10.1186/s12913-024-11394-1

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