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  See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/223722061 Advocacy strategies for health communication  Article   in  Public Relations Review · March 2010 DOI: 10.1016/j.pubrev.2009.08.017 CITATIONS 15 READS 328 2 authors:Some of the authors of this publication are also working on these related projects: The unbearable lightness of Communication Research   View projectJan ServaesUniversity of Leuven 171   PUBLICATIONS   744   CITATIONS   SEE PROFILE Patchanee MalikhaoUniversity of Massachusetts Amherst 16   PUBLICATIONS   43   CITATIONS   SEE PROFILE All content following this page was uploaded by Jan Servaes on 17 July 2014. The user has requested enhancement of the downloaded file. All in-text references underlined in blue are added to the srcinal documentand are linked to publications on ResearchGate, letting you access and read them immediately.  Public Relations Review 36 (2010) 42–49 Contents lists available at ScienceDirect Public Relations Review Advocacy strategies for health communication   Jan Servaes a , ∗ , Patchanee Malikhao b a Communication for Sustainable Social Change (CSSC), University of Massachusetts, Machmer Hall 415, Amherst, MA 01003, USA b School of Public Health and Health Sciences, University of Massachusetts, Amherst, USA a r t i c l e i n f o  Article history: Received 18 June 2009Received in revised form 27 August 2009Accepted 29 August 2009 Keywords: Health communicationAdvocacyCommunication strategiesCommunity health studiesHealth policy and managementPolicies and planningHIV/AIDSWHOSocial change a b s t r a c t This article presents a new way of using advocacy communication strategies for healthcommunication. The traditional perspective on advocacy, promoted in mainstream publicrelationsandmarketingcircles,isbeingreplacedbyamoreinteractiveandintegratedviewontheroleofadvocacycommunication.Newertheoreticalandappliedcontributionstothehealthcommunicationfieldsupporttheneedtoexplore(a)abroaderunderstandingoftherole of   communication to promote and sustain health behavior  ; (b) a broader  social scientific approach to public health  as a social construct and the social determinants of health withstronger emphasis on health policies and management such as governance, accountabil-ity and leadership; and (c)  policy perspectives  that deal with resource allocation, humanresources and capacity building, enabling environments for health communication, andrecognition of the value and contribution of health communication to public health.Advocacy combines social networking and mobilization, interpersonal communicationand negotiation, as well as the use of media for generating public pressure. The authorssuggest that the power of supportive evidence as generated by professionals and aca-demics must be effectively utilized through all these means in presenting a powerful casefor sustainable social change.© 2009 Elsevier Inc. All rights reserved. While health communication interventions have been around since the 1960s, especially through family planning pro-grams, health communication found itself at the center of the international agenda in the 1980s. The Declaration of AlmaAlta (1978) and the Ottawa Charter (1986) represented a fundamental point of departure from approaches centered ontechnologyandhospital-basedcaretoincreased  participatoryandempowerment-basedapproachesinhealth .Theassumptionis that individuals and communities can play an important role in determining their health (see WHO, 1990). In the 1990s, during the post-Cairo and Beijing conference years, the field moved to a  rights-based approach , while in the last decade anew momentum has been established with a range of new initiatives such as the Millennium Development Goals (MDG)(UN, 2000), the World Health Organization’s 3 by 5 initiative (WHO, 2003), and specific issues that emphasize leadership, participation, and empowerment (Yamin, 2009). Inthe1980sandintothe1990s,mostofthehealthcommunicationliteraturefocusedonbehaviorchangecommunication(BCC) approaches. Communication for health promotion was used primarily as a tool to convey information with disregardto the context in which its recipients live. However, new approaches have been developed and gradually incorporated intopraxis. A contemporary definition of health communication is:  AnearlierversionofthisarticlewaspresentedasaKeynotePaperattheInternationalForumonPublicRelationsandAdvertising,‘CrisisManagementand Integrated Strategic Communication’, Hong Kong, December 6–7, 2008. ∗ Corresponding author. E-mail address:  jservaes@comm.umass.edu (J. Servaes).0363-8111/$ – see front matter © 2009 Elsevier Inc. All rights reserved.doi:10.1016/j.pubrev.2009.08.017   J. Servaes, P. Malikhao / Public Relations Review 36 (2010) 42–49  43 “the study of the impact of communication on health and health care delivery, with attention to the role that communi-cation plays in the definition of health and wellness, illness and disease, as well as in developing strategies for addressingways to deal with those health issues” (Lederman, 2010: 236). It is clear from this definition that the social determinants of health, the basic underpinning of health promotion, should be appropriately addressed through health communicationstrategies to create change and improve the health of individuals and communities (UNDP, 2006; UNESCO, 2003; WHO,2003). To achieve long-term goals of health for all, five levels of communication strategies for health behavior, as adaptedfrom the work of  Servaes (2007b, 2008) and Servaes and Liu (2007), can be integrated for health communication planning and implementation. They are:(a)  Behavior change communication  (BCC) (mainly interpersonal communication),(b)  Mass communication  (MC) (community media, mass media and ICTs),(c)  Advocacy communication  (AC) (interpersonal and/or mass communication),(d)  Participatory communication  (PC) (interpersonal communication and community media), and(e)  Communication for structural and sustainable social change  (CSSC) (interpersonal communication, participatory commu-nication and mass communication).Theresolutionofahealthissueortheinitiationofahealthpromotionprogramcanbeanendinitself,ifnopublicsupportis taken into account. A new definition of advocacy to empower the grassroots to let their voice be heard should become“participatory-based advocacy”, which focuses on ‘listening’ and ‘cooperation’ rather than on ‘telling what to do’, presumes a dynamic two-way approach towards communication.  Mass media can play two kinds of advocacy roles: (a) supportingdevelopment initiatives by the dissemination of messages that encourage the public to support development-orientedprojects; and (b) providing the decision-makers with the necessary information and feedback needed to reach a decision.Policy-makers usually respond to popular appeal, to lobby groups, and to their own social network of policy- and decision-makers.  Health advocacy should therefore be viewed in conjunction with social support and empowerment strategies  (for moredetails,seeServaes,1992,2000):(1)advocacygeneratespoliticalcommitmentforsupportivepoliciesandheighteningpublic interest and demand for health issues; (2) social support develops alliances and social support systems that legitimize andencourage development-related actions as a social norm; and (3) empowerment equips individuals and groups with theknowledge, values and skills that encourage effective action for change. 1. Choices of advocacy strategies The choiceofadvocacystrategies willvarywiththenatureoftheissueandtheexpectationofthepeopleorthestakeholders.In order to identify the  appropriate advocacy strategy , one or more of the following important characteristics of policyproblems have to be considered:1.  Interdependence of policy problems:  This implies that one should not only use an analytic but also a holistic approach.2.  Subjectivityofpolicyproblems :Besides‘objective’realities,subjectivejudgmentsandvaluescomeintoplayinthedecision-making process. Advocacy strategies must address both.3.  Artificiality of policy problems: Problemshavenoexistenceapartfromtheindividualswhodefinethem,whichmeansthatthere are no ‘natural’ states of society that in and of themselves constitute policy problems.4.  Dynamics of policy problems:  There are as many different solutions for a given problem as there are definitions of thatproblem. 2. Identifying the right health type and advocacy strategy  There is no single strategic communication response to health-related challenges. One problem remaining is  the riskof reproducing best practices from one health area to another.  For example, the social marketing of individual behaviors(condom use) in family planning strategies in the 1970s and 1980s was very rapidly transferred into a mainstream strategyin HIV/AIDS in the late 1980s and 1990s. This happened in part due to HIV/AIDS being conceived as primarily a problemevolving around practices of sexual behavior. In those days, most theories underlying the models and frameworks used inHIV/ADS prevention strategies and research methodology were based on health behavior change (see Catania et al., 1993;Glanz, Rimer & Viswanath, 2008; Jemmott & Jemmott, 1994; McKee, Manoncourt, Saik Yoon, & Carnegie, 2000; Sandfort, 1998; and UNAIDS, 1999: 18). UNAIDS (1999: 22–24) gradually criticized these models and theories for, firstly, seeking to influence only behavior in alinearfashionwithouttakingthesocialcontextintoaccount.Thisisnotsustainable.Secondly,theemphasisonquantitativemeasures,ratherthanqualitativeoracombinationofboth,resultsinadistortedinterpretationofthemeaningsandrealitiesinobservedbehaviors.Thirdly,theassumptionthatdecisionsaboutHIV/AIDSpreventionarebasedonrationalandvolitionalthinking is not realistic since the decisions involve more emotional responses to engaging in sexual practices. Hence, onestarted realizing that there is no sequential linear relationship between knowledge, attitude, belief, and sexual activities.Fourthly, the assumption that creating awareness through media campaigns will necessarily lead to behavior change doesnotholdtrueforHIV/AIDSpreventionsinceitimpliestheconsistentuseofcondomswhichisrelatedtotheimportanceand  44  J. Servaes, P. Malikhao / Public Relations Review 36 (2010) 42–49 centralityofasocio-religious-culturalcontext(Malikhao,2007,2008).Later,especiallysince2000,therehasbeenagrowing recognition of the need to complement and replace social marketing as the (exclusive) strategy in HIV/AIDS prevention.Therefore, to identify the right type of health issue and consequently appropriate advocacy strategy, some distinctionsmust be made within the world of health (Dutta, 2007; Seeger, Sellnow & Ulmer, 2008; Servaes, 2007; Storey, Figueroa & Kincaid, 2005; Storey, Saffitz & Rimon, 2008; Thompson, Dorsey, Miller, & Parrott, 2003; Waisbord, 2007, and Wallack, Dorfman, Jernigan & Themba, 1993). These are: 1.  A distinction at level of complexity of health problems : For example a communicable disease as malaria  versus  a cardiovas-cular disease. Malaria requires handling the problem of individual behavior vis-à-vis the risk of mosquito bites, but alsoattention to policies on access to both prevention (bed nets) and treatment, and ultimately and ideally malaria requiressomeattentiongiventothewaterswheremosquitobreed.Cardiovasculardiseaseshavemoretodowithlifestylesacquiredovertime,physicalactivity,smokingpatterns,foodpatterns,etc.However,cardiovasculardiseaseswillalsorequireatten-tion both to individual behaviors, policies and environmental factors. In other words, carefully tailored communicationinterventionsemergebasedonaprofoundunderstandingofthehealthproblemencountered and atthesametimedrawnon the generic options about individual behavior, policies and environmental factors.2.  A distinction at the level of the time-frame for health problems : Emergency diseases as for example SARS or Swine Flurequire very different communication responses compared to the long-term development-oriented health challenges,such as HIV/AIDS. Typically, responses to emergency diseases become very vertical and mass media borne, containinghighproportionsofinformationdisseminationandalsosocialmobilizationinresponsetotheimmediateneedsthathaveemerged due to the emergency. The participatory approaches are seen in the form of social mobilization, and less aslonger-term empowerment strategies. As for the long-term health challenges as HIV/AIDS, it contains both elements of urgency, due to the lethal dimension linked to each HIV transmission, but contains also strong elements of dealing withfundamentalissuesofpoverty,genderedpowerimbalances,lackofvoiceofPeopleLivingWithHIV/AIDS(PLWHA),issuesof stigma and denial, etc. The differences in how to respond lay both in the speed of response, the way to organize theresponse, the way to make use of the media and also the content of the media programme flow related to the healthproblem. Despite all the differences, in both long-term and short-term responses, there is the need to deal with a  mixof individual behavioral patterns ,  policy issues ,  and environmental factors . These are some of the common denominators inhealth communication.3.  Adistinctionbetweenabroad-based ( horizontal ) versusanarrow-based ( vertical ) definitionofthehealthproblem :Abroader-baseddefinitionofthehealthproblemwouldengageinarights-basedapproachandmoveintoissuesofpowerandgenderrelations,socio-economicdeterminantsoftheproblemandbothcollectiveandindividuallyorientedresponses.Whiletheverticalapproachfocusesononespecifichealthproblem,saytuberculosis,thehorizontalapproachentailsacross-cuttingapproach which may well tackle tuberculosis, HIV/AIDS, malaria and diabetes in one specific area. Communication-wise,the two different definitional approaches to a problem require each their strategic response, but both would ideallyrequire some longer-term intervention.These distinctions in type of health problems result in the need to define appropriate strategies, which reflect differentcriteria for strategy development. The criteria of all health communication interventions are generally well described (forinstance, in DFID, 2004; Lie, 2008; Piotrow, Kincaid, Rimon, & Rinehart, 1997, or McKee, Bertrand & Becker-Benton, 2004). However, some of the areas which are gaining increased attention include:1.  Level of intervention:  The strategic communication response may be defined in relation both to local community-basedconstituencies, but also to national fora of either ordinary people or decision-makers in parliament or government. Fur-thermore, and a rapidly growing phenomenon, the transnational, regional and often global response mechanisms aregaining growing attention. For example, there has in recent years been increased recognition of HIV/AIDS not only beingdefinedasalocalornationalproblem,butalsorequiringtransnationalresponsemechanisms,whichhavebeendevelopingover the last decade.2.  Thematic emphasis of intervention:  This ranges from focus on individual behavioral determinants to a broader socio-economic, cultural and political focus. If we take the example of polio, there has been a significant change in focus fromthe grand vaccination campaigns focusing on social mobilization in the late 1980s to today’s broader-based campaignswithstrongadvocacycomponents.Mostoften,however,manyorganizationsremainfocusedonbehavioralinterventionsascanbeseenfromthoseoflifestyle-relatedhealthproblemssuchasDiabetesType2.Infact,weneedtoalsoemphasizethe processes of urbanization and the consequential changes it has upon everyday life. We should keep in mind that thefood politics which is a special relationship between the agro and food industry, advertising industry lobbyists, and thegovernment cannot be neglected. For instance, Nestle (2009: 332–4) reveals how the food industry entices their target groups to believe that sugary food is healthy food.3.  Content of intervention:  Strategic communication – as it is understood in BCC – is embedded in the logic of producing messages directedatpassivetargetaudiencesashypodermicneedleinjection.However,asadvocacycommunication,par-ticipatorycommunicationandcommunicationforsustainablesocialchangearebecomingknown,wearenowwitnessinga growing emphasis on the assumption of the active audience that engages in collective reflection and action.   J. Servaes, P. Malikhao / Public Relations Review 36 (2010) 42–49  45 Fig. 1.  The RAPID framework: context, evidence and links. 4.  Coordination of interventions :  Natural disasters and emergencies have demonstrated the need to design and implementregion-widestrategies,whichrequirestrongcommunicationcomponents.The2004Tsunamishowedlackofcooperationbothintheimmediateemergencyandthesubsequentresponses.Onthecontrary,theinternationalresponsetotherecent(Mexican) swine flu pandemic suggests an increased awareness to coordinate, cooperate and implement regional plansand strategies. Also, several international initiatives have provided strategic guidance for global and regional responsesto health challenges, e.g., infant feeding, HIV/AIDS, child health. However, the communication component within theseregional and global strategies is often limited to dissemination efforts and lacks specificity on specific communicationstrategies. That’s why the UN-agencies have agreed to what they call a ‘One Country’ approach to development issueswith one agency (most often UNDP) in charge of the coordination and supervision of the implementation of projects inthe same region or country (see Servaes, 2007b, or UNESCO, 2007). 5.  The importance of process- and evidence-based intervention strategies :  There is an increased emphasis on moving from auniformfocusonresultstoanincreased  focusonprocessesofempowerment  .Whilemonitoringandevaluationapproachesfocused on health outcomes and impact communication indicators should remain essential to health communicationinterventions, a focus on process will provide deeper understanding of the nuances and particularities of developmentand health, especially those that remain embedded in cultural practices. Within HIV/AIDS communication it is seen inmoving from a narrow focus on individual behaviors (for instance, the  Abstinence ,  Be faithful and use a Condom  – ABC –modelinHIV/AIDSprevention)to,forexample,PANOS’sdocument(2006)onhowcommunicationcansupportHIVsocial movementstoachieveinclusivesocialchange,orwhatrolecultureandreligioncanplayinHIV/AIDSpreventioncampaigns(Malikhao, 2007, 2008). In the latter cases the expected outcome is a process of empowerment. As a result, a focus on context and communities as units of analysis has emerged as critical to understand the effectiveness of interventions inhealth promotion and communication (Omoto, 2005; Papa, Singhal & Papa, 2006).Independentresearchinstitutesanduniversitiescouldprovideaspacefordevelopinglongitudinal and externalmonitor-ingandevaluation.Thediscussiononmonitoringandevaluationalsohasbroughtincreasingattentiontoissuesofindicatorsinhealthcommunication.Perhaps,themostsignificantchangeovertimeistheincreasedattentiongivento  processindicators and to the role  qualitative approaches  could play in this context.Following Weiss (1977a,b); see also Weiss and Bucuvalas (1980), it is widely recognized that, although research may not have direct influence on specific policies, the production of research may exert a powerful indirect influence throughintroducing new terms and shaping the policy discourse. Overall, one can explore how research can influence policy-makershorizons,policydevelopment,declaredpublicpolicyregimes,fundingpattersandpolicyimplementationorpractice(Lindblom, 1990; Lindquist, 2003).The RAPID framework (Crewe and Young, 2003), as shown in Fig. 1, could be seen as a generic, perhaps ideal, model. In many cases there will not be much overlap between the different spheres or the overlap may vary considerably. 3. Advocacy health communication for decision-making   versus  decision-reaching  In order to reach or make the decision to plan for health communication, a number of important research and policyissues need further clarification:1.  Advocacyforpolicydesignanddecision-makingversuspublichealthadvocacyforpolicyimplementationorsocialmobilization: Confusion remains about what should be the main focus in health advocacy strategies. In general, one can distinguishbetween (a) advocacy for policy design and decision-making aimed at ensuring political, social and legislative supportfor a health issue (e.g. health care for all); and (b) advocacy for policy implementation which requires intensive effortsfor mobilizing social forces, individuals and groups for development actions. Both are important and must be addressed.The aim in advocacy strategies is to foster political and public engagement as well as professionals through a process of social mobilization.
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