This glossary collects the key concepts, people, and ideas you will meet in this lesson. Use it as a reference while you work through the material, or as a review before assessments. Type in the search box to filter entries.

A message is more than the information it carries

This lesson continues the tour of theories that locate the causes of behaviour outside the individual. Lesson 4 covered theories in which behaviour spreads through models, networks, and markets; this lesson moves farther out, to communication, to communities and organizations, to political and economic structure, and to culture. Each is a field in its own right that a single lesson can only sample, and each answers a question the individual-level theories could not: what happens to a message, an intention, or a program once it meets the social world.

Communication is symbolic

Start with a deliberately wide definition. Communication is the transmitting, receiving, and processing of information that matters for behaviour, and every organism does it. What makes human communication almost unique is that it is symbolic: a person can assemble a sentence from components of meaning, rearrange them, deliver it with humour or a picture, or compress it into a text message, and each change alters the meaning. For health promotion, the forms that matter most are interpersonal, Internet and wireless, and mass communication, and the same questions run through all three: who is speaking, in what code, through what medium, to whom, and with what result.

The technical model

The mechanical basics come from two mid-century sources. The communications theorist Harold Lasswell defined communication as who says what, in which channel, to whom, and with what effects (Lasswell, 1948). Claude Shannon, a mathematician at Bell Laboratories, laid out the process that has been known since as the Shannon-Weaver model (Shannon and Weaver, 1949). The model can be summarized in five steps: a sender encodes a message, packaging the content in text or symbols; the sender transmits it through a channel such as speech, a telephone, or email; during transmission the message may encounter noise, meaning any interference; a receiver decodes it so that it can be used; and the receiver may send feedback.

Call this a very technical description, and treat the phrase as a caution. The diagram says nothing about the factors that decide whether a message means to the receiver what it meant to the sender. Open each item below to see what a fuller account adds.

Encoding is a code

Encoding deserves the most attention, because it is where health communicators most often lose the audience. When you send a message you do not utter a string of information units; you put the information into a code that will make sense to the recipient in the way you want. The first illustration is gossip: a rumour that a certain Mr. Smith goes to the dog races is really a message to Smith, carried by his peers, that the group will think less of him unless he behaves as it expects. The second is advertising, where a luxury car paired with a rock anthem encodes an identity rather than a set of specifications. The third is diction: slang or polite speech, and whether you open with a formal greeting, encode the relationship before the content arrives.

Decoding is the mirror image. The receiver interprets with their own tools, which include cultural background, socioeconomic class, gender, and institutional connection. If sender and receiver share an understanding of the symbols, the message survives the trip; if not, the sender has to encode it so that it will be decoded as intended, which requires knowledge of the recipient's interpretive patterns, which requires research. This process is called message design.

Channels and agenda setting

A channel is the medium through which a message travels: the Internet, social media, mobile phones, television, print, and rallies, or narrower outlets such as community-language newspapers, college radio, and churches. Channel selection matters for two reasons. The channel is itself part of the meaning of the message, and some channels reach a particular group far better than others: a magazine aimed at women is an unlikely route to men, and a tabloid will not make a message credible to highly educated readers.

The last idea in this overview is agenda setting. People act on information they see as important and relevant, and many issues compete for attention, so health communication, like a political campaign, tries to move its issue higher on the public agenda. The first step is to find where the issue currently sits on the agenda of the target population, which is again a research task. The simulator below lets you try all three decisions on a single message.

Using communications theory

Take a worked example: a smoking message for young people deeply involved in a Star Wars subculture who interact mostly at conventions and on social media. Formative research at conventions found film characters used as everyday metaphors and in usernames. That is the code. The message was tied to an admirable reference inside the culture, voiced by an authoritative source within it, and phrased in that character's word order; the channels, conference posters and a social media page, were already known; and follow-up research checked the decoding. Research the code, encode in it, use the audience's channels, check the decoding: the method in miniature.

Case study: an alert that did not arrive

Measuring effect, and keeping up

The main critique of communications approaches is about evaluation. Assessing the effect of a communications effort is difficult because there are many levels of possible impact. Exposure, the share of the intended audience who report seeing the message, is the easiest to measure and where many evaluations stop, but it does not translate automatically into behaviour change. The next level is to find how many of those exposed thought about or made a change, which means tracking a sample of exposed people for a period after the campaign.

One more thing to think about is technology. Formats change quickly enough to make last year's channel obsolete, a message can go viral in hours, and each new format attracts particular population segments, so a proliferation of channels also produces a proliferation of subgroups. The consequence is that the research step never becomes optional: the audience's code and channels have to be learned again for each campaign.

When the setting has to change first

Consider two situations no message could fix. People will not attend diabetes screening, however informed and motivated, if there is no facility to attend. People will not get tested for HIV if their community and its institutions exert strong pressure never to admit any risk. In both cases the barrier is a community, an organization, or a system, and the general point follows: these settings can support or inhibit behaviour change, so one area of theory and practice is about changing them. Community mobilization and organizational change are treated separately here, though both belong to a general community change effort.

Community mobilization

Public health is activist by nature, and community mobilization is where that shows. The reason for changing a community is ecological, in the sense from Lesson 1: many conditions that help or block health are community-level situations that no amount of individual change will remove. Examples include a lack of health facilities for underserved populations, regulations that allow cigarette sales within easy reach of young people, a toxic waste site, and a lack of sidewalks and green space. Mobilization means collective action to raise awareness, advocate for policy change, and act on the condition itself. The result to single out is empowerment: the community takes charge of the issue, defines the goals, and acts, gaining experience and a sense of efficacy that becomes a resource for the next problem.

The category draws on the history of social and political movements: the labour movement, the civil rights and women's movements, anti-smoking activism, HIV/AIDS activism, the anti-abortion movement, and community-based movements such as Mothers Against Drunk Driving (MADD Canada is its counterpart here). Two figures anchor the practice. Saul Alinsky, organizing in Chicago, pioneered many grassroots and advocacy strategies now taken for granted (Alinsky). Paulo Freire, a Brazilian educator working for the liberation of poor and marginalized people in Latin America, founded an approach to participatory social change (Freire). Both hold that the people affected by a problem should organize to act on it. Open each stage below to follow a mobilization effort, with the three key issues at the front.

Organizational and systems change

The reason for changing organizations parallels the reason for mobilizing communities. Health promotion, prevention, and care are accomplished through organizations (agencies, hospitals, programs) and systems (healthcare systems, linked service systems, policy coordination systems), and any one may facilitate or block a health goal. A standard example is substance abuse, where prevention and treatment grew up as separate fields, one clinical and one community-based, funded by separate agencies, and collaboration has been slow because of entrenched differences from the federal level to the community. Improving that integration is a health promotion objective in itself. Canadian readers will recognize the same silos between mental health and addiction services, or between a hospital and the agencies its patients are discharged into.

Organizational development, usually abbreviated OD, began with business performance and the quality of work life. The psychologist Kurt Lewin shaped it through his work on group dynamics; Elton Mayo in the 1920s and 1930s, the Tavistock Institute of Human Relations in London, and Abraham Maslow were other influences. OD is both a philosophy and an approach that views organizations as systems of human beings, so that change means applying behavioural science to planned strategies and building shared goals and motivation among members. The cards summarize the concepts you need.

The second approach treats organizational change as a staged process, somewhat like the stage models of individual behaviour from Lesson 3. Lewin's version runs through unfreezing, movement, and refreezing; another runs from unsatisfied demand through determination of alternatives, decision, adoption, and institutionalization. The stages describe both how an organization adopts a health policy itself and how it moves to advocate for change beyond its walls, and organizational climate, culture, and capacity shape the process. The stepper below takes a regional hospital through the stages and asks you to choose the action that fits each.

The two approaches side by side

The table below sets the two approaches side by side, and the pairing is the point: changing a community without the organizations that serve it, or the reverse, usually stalls.

Using both approaches

Take an applied scenario: a California county whose hospitals face an influx of patients with little or no English. The possible responses combine both approaches: enlist community organizations in a public campaign, perhaps pressing the county to create a task force; advocate directly with key units of the health system in terms they must take seriously, such as liability when a patient cannot read dosage instructions; and train providers in culturally competent care while helping them adopt practices such as bilingual staff or hours that suit farm workers. The third response is staged change: training unfreezes, new practices are the movement, and policy is the refreezing. The tabs describe three evaluated programs that used these approaches.

Critiques

The critique of these approaches is measured. Mobilizing a community or changing an organization is complex, and there are typically no off-the-shelf solutions with clear evidence. If a health promotion effort addresses a pressing problem, mobilization and organizational change may be best directed at the enduring factors around it, such as policies, regulations, and access to care, or combined with activities that address more immediate needs; even early mobilization can galvanize other work. The second point is humility: change is often affected by factors nobody controls, including a sudden change in leadership, a budget crisis, or a disaster. A plan that depends on one champion staying in post is not yet institutionalized.

The context that sets the range of choices

You might think this area belongs in a political science or economics course. The reply is that some of the issues gathered under political economy bear directly on why and how people do what they do, and therefore on how they change what they do. The claim is more careful than the aphorism that money changes everything. There will always be a political-economic context that affects what people do and what they can or cannot do, and an explanation of behaviour that leaves it out is incomplete. Political economy as a whole is a vast field about the links between politics and economics and their functions in society; this section touches only the part that has been applied to health behaviour. It follows that path, from Singer's work on HIV/AIDS to microcredit and structural violence, and then turns the analysis on Canadian policy.

Singer and the syndemic

The main example is the medical anthropologist Merrill Singer, who follows an explanatory approach pioneered by Eric Wolf and Sidney Mintz (Wolf's Europe and the People Without History and Mintz's Sweetness and Power, a history of sugar, are the sources cited). Singer's question was why HIV/AIDS has had such a disproportionate effect on poor, minority, urban communities in the United States. The political-economic approach answers by first rethinking the disease as something more than a health problem: it is treated as a product of a larger set of social relationships, in particular relationships of socioeconomic structure, class, ethnicity, and gender. Singer then links HIV/AIDS with a list of other problems found disproportionately in the same populations, including tuberculosis, infant mortality, hypertension, diabetes, cirrhosis, and substance abuse, and calls the aggregate a syndemic: several epidemics that exist together because conditions promote their coexistence (Singer, 1994).

What are the conditions? The list includes the prevalence of poverty and unemployment in core urban areas, including a lack of access to health care; deteriorated and substandard schools; economies of the street in communities with few links to economic resources, where the available jobs are more likely to involve drug trafficking and other illegal activity; the relationship between lack of employment and unstable family structures; and the overall relationships in society between minority and majority ethnic groups. Each condition raises the probability of several of the epidemics at once. That is why they cluster, and it is why a program aimed at one behaviour in one epidemic tends to be swamped by the conditions it leaves untouched.

The approach in three steps

The approach reduces to three moves. Start with a health problem and rethink it as a product of a larger set of social relationships, particularly socioeconomic structure, class, ethnicity, and gender. See the problem, or co-occurring problems, as part of a trajectory of risk or exposure shaped by those relationships. And accept that solutions must address, in part, the relationships themselves, such as economic patterns or relationships of ethnicity, that contribute to the problem. The table applies the three steps to Singer's HIV/AIDS example and to a Canadian one.

It is worth being candid about why this approach is funded less than behaviour-focused approaches. Carrying it out ultimately means addressing significant social configurations, which is neither a short-term project nor one free of controversy. Yet many who have worked with health issues immersed in these conditions know that progress on the health problem is difficult without some change in the contributing conditions. The Canadian column above shows both halves: the elimination framework is a long project involving federal, territorial, and Inuit governments, and the reason it exists is that decades of screening and treatment alone had not closed the gap.

Follow the resources

A political-economic analysis is easiest to learn by tracing where resources and power move when a policy changes. Canada offers several policies that act on price, revenue, and access rather than on individual knowledge or motivation. Choose one below and follow the chain, then answer the question at the end.

Microcredit: a tested strategy

A tested example of the approach comes from the developing world. Microcredit, originally the idea of Muhammad Yunus and the Grameen Bank in Bangladesh, addresses the socioeconomic position of women and the effect of that position on population, reproductive health, and other outcomes (Grameen Bank). Small loans allow a woman to start an economic enterprise, such as selling food or repairing clothes. The women involved usually have no access to credit at all, which is itself a political-economic fact, so the loans are structured so that people in the borrower's social or community network stand as guarantors and sign on to assure repayment. With the loan and the business it supports, the borrower gains an alternate source of income and of status. Many studies have found that when women have more opportunities they choose to have fewer children, so that more attention and resources, including health resources, go to each child they do have. The chain is worth stating plainly: a health outcome changed because poverty was reduced, and poverty was reduced by changing a woman's relationship to credit, which is a relationship of economic structure and gender. That is the third step of the approach in action.

Structural violence

The second approach with a political-economic focus is the idea of structural violence, associated with the peace researcher Johan Galtung (Galtung, 1969). It refers to systematic aspects of social structures, such as hierarchies, forms of inclusion and exclusion, discrimination, and inequities of wealth and resources, that harm some categories of people by denying them access to the benefits of society, including health. The perspective lays blame on the inequities of the world system: the gap between rich and poor nations and between rich and poor within nations, and the fact that basic needs such as health are treated as commodities, available to those who can afford them. This injustice is viewed as a form of violence in itself and as a central cause of other violence, including ethnic and racial violence, war, and domestic violence. The key figures in this perspective are described in the accordion.

Behaviour that cannot be separated from its context

The last section argued that structure sets the range of choices open to people. This one asks what gives those choices their meaning. Anthropology is the in-depth, comparative study of human behaviour, and it reads the subject in two ways: as an adaptation that enabled survival in an environment (biological or physical anthropology), and as shaped by culture (cultural anthropology). As anthropologists became involved in health, medical anthropology grew up as a subdiscipline, explaining behaviour without ever separating individuals from their sociocultural context.

Two questions, two readings

Anthropology became a separate discipline in the nineteenth century, the era of Darwin's Origin of Species, of prehistoric human remains, and of European colonial expansion. Two questions followed: how and when did we become the human beings we are today, and, given the diversity of ways of life, what makes us human and what is common across societies? The two readings follow from the two questions.

What culture is

The word culture is common enough that its meaning can be fuzzy. Start with E. B. Tylor's classic 1871 definition of culture as a complex whole including knowledge, belief, art, morals, law, custom, and the other capabilities and habits a person acquires as a member of society. Four elements of that definition have persisted, and the cards set them out. Culture applies to any group that persists over time, from societies to gangs and workplaces; organizational culture, from Section 2, is the same concept at the scale of a hospital.

A working definition, aimed at what a cultural anthropologist looks for, follows from those elements: culture is the shared and learned part of cognition and behaviour that lets us interpret the world and take meaningful action, an ongoing collective framework for integrating meaning with events, actions, and ways of life. A health behaviour is therefore guided by an understanding of its meaning, or grows from a pattern of living built around meanings, symbols, and values.

Obesity through cultural questions

Obesity is a good illustration, approached through questions a planner trained only in individual theories would not ask.

All five questions treat the behaviours behind obesity as inseparable from the meaning systems they belong to. The fourth is where anthropology and political economy meet: the cultural reading asks what a food means, the political-economic reading asks who can afford it, and a full account needs both.

Ethnomedical systems

The other direction connects behaviour to underlying epistemologies of health, that is, systems of knowing and beliefs about how we know things. Beneath everyday health behaviour sits a set of beliefs that answers four questions. What does it mean to be healthy? Which conditions count as illness? What causes illness? This question matters most, because many cultures understand at least some conditions as having spiritual causes, whereas Western cultures typically attribute most disease to biological causes. And how does someone become healthy again, who do they go to, and what are the remedies? Together the answers form what medical anthropology calls an ethnomedical system, a basic set of beliefs shared to one degree or another by most people in a cultural group.

The ethnomedical system guides both prevention and healing. Where a large body signals well-being, standard messages about body size make little sense; imagine members of such a group asking why anyone would want to look thin, and therefore poor. Where a condition is believed to have a spiritual cause, people consult a spiritual person rather than a physician. Where a condition is attributed to moral failure, it may be stigmatized, and the affected person may hide from any doctor or healer, as has happened with HIV/AIDS. The builder below shows how the four answers combine.

Using anthropological approaches

An applied scenario begins with a puzzle. Public money built clinics in urban, underserved areas, and a year later use is low. Research finds that in certain neighbourhoods people over 30 do not use them; that recent immigrant families live alongside longer-settled families from the same country; that recent immigrants are more likely to attribute some illnesses to spiritual causes; and that the clinics offer nothing that corresponds to those beliefs. Two responses suggest themselves: work with leaders from both segments so that recent immigrants hear the longer-settled families' experiences of the clinics, or co-locate traditional and spiritual healers so that services match the range of conditions as the community perceives them. Both change the clinic to fit the ethnomedical system rather than waiting for the system to change.

Working with culture: All Nations Breath of Life

The program example concerns smoking in an American Indian population, and it turns on a distinction Canadian readers will recognize from Indigenous tobacco programs here, which separate traditional from commercial tobacco. Among many American Indian peoples tobacco is a sacred plant used as a ritual symbol of peace and healing and for medicinal, religious, and instructional purposes; that use differs from cigarette smoking both culturally and physically. The All Nations Breath of Life program therefore targeted smoking and chewing tobacco, not tobacco use in general, and drew on the group-based, egalitarian features of American Indian culture. Components were developed through a participatory process: facilitator-led group discussion (deliberately not a counsellor), telephone counselling for issues people did not want to raise in a group, culturally oriented materials, and pharmacological support where needed. In preliminary results for the first 108 participants, the self-reported quit rate was 65 percent at program completion and 25 percent at six months after baseline, much better than other interventions with the same populations (Daley and colleagues, 2010). The First Nations Health Authority's Respecting Tobacco work in British Columbia makes the same distinction, for the same reason: a message that condemns tobacco as such condemns a sacred practice and is decoded, in the terms of Section 1, as an attack.

Critiques

Bringing It All Together

This lesson went farther out into society than any lesson so far. It began with communication, where the technical model of a sender encoding a message, a channel carrying it through noise, and a receiver decoding it turned out to be only the skeleton. A fuller account added what the diagram omits: the context and relationship between the parties, the meaning carried by the channel itself, the interpretive work of encoding and decoding, the shared knowledge of a speech community, and the discursive practices and institutions that decide what counts as credible. The practical result was a method, learn the audience's code through formative research, encode in it, choose channels the audience already uses, and check the decoding afterward, together with a warning that exposure is the easiest level of effect to measure and the least informative.

The second and third sections asked what happens when the barrier is the setting rather than the message. Community mobilization brings collective action, drawn from the movement tradition and from Alinsky and Freire, to bear on ecological conditions, proceeding by defining the community, assessing its capacity, and working with its agenda, with empowerment as its signature result. Organizational and systems change treats organizations as systems of human beings that move through stages, from unsatisfied demand to institutionalization, shaped by culture, climate, and capacity. Political economy went one level further: there is always a political-economic context that sets what people can and cannot do, and a health problem is often one strand of a syndemic with shared causes in poverty, exclusion, and the treatment of health as a commodity. Microcredit and the structural violence perspective showed that the response reaches beyond the individual to credit, housing, price, and access.

The final section turned to meaning. Anthropology reads behaviour as adaptation to an environment and as meaningful action within a culture, an integrated, learned, shared framework linking belief to action. The ethnomedical system, the shared answers to what health is, what counts as illness, what causes it, and who heals, decides whether a program makes sense to the people it is for, as the underused clinic and the All Nations Breath of Life program showed. Two critiques close the lesson and connect the anthropological family to the others: culture is never homogeneous, and cultural change takes time, so environmental and policy change often has to move first. Held together, the four families give you four questions to ask of any behaviour: how is it talked about, will the setting permit it, who can afford it, and what does it mean.

Final Knowledge Assessment

This assessment covers all material from this lesson. You must score 100% to complete the lesson. Review the feedback for any incorrect answers and try again.