SECTION I
RESEARCH AND METHODOLOGIES
Communication for health promotion: history and identification of effective methods
La comunicazione per la promozione della salute: storia e identificazione di metodi efficaci
Annarosa FratiI; Anna Maria LuziII; Anna ColucciII
IDirezione Generale Comunicazione e Relazioni Istituzionali, Ministero della Salute, Rome, Italy
IIDipartimento Malattie Infettive, Parassitarie ed Immunomediate, Istituto Superiore di Sanità, Rome, Italy
SUMMARY
This work aims to delineate the long journey of health communication, from the beginning to the present, stressing how the concept of health service and human health have been evolving together with the kind of political approach to the problem. First, the approach was mainly repressive and based on the surveillance of territory, so that jurisdiction in health matters was centralized and entrusted to the Ministry of Interior. Consequently, communication had little space and was directed to an elite group of insiders, who were able to cope with any public health emergencies, using a very technical and essential language, confusing for most people. In the course of the years, we understood that the reaching of the objective health could be realized with the involvement of citizens, organized groups, public and private institutions. Therefore, it is necessary to ensure citizens the right to receive a clear and correct information, enabling them to be self responsible and better manage their health, in a more and more personalized way, using an authoritative but confidential language and all the modern media.
Key words: communication, health promotion, information, counselling.
RIASSUNTO
Questo lavoro intende delineare il lungo cammino della comunicazione sulla sanità e sulla salute, dagli esordi ad oggi, sottolineando come il concetto di salute sia andato evolvendosi di pari passo con il tipo di approccio politico al problema. Dapprima, l'orientamento era soprattutto repressivo e di vigilanza, tanto che la materia sanitaria era affidata al Ministero dell'Interno. Di conseguenza, la comunicazione era ridotta al minimo e rivolta agli addetti che potevano fronteggiare eventuali emergenze sanitarie, utilizzando un linguaggio tecnico e scarno. Solo nel corso degli anni, si è compreso come il raggiungimento dell'obiettivo salute si realizzi con il coinvolgimento diretto dei cittadini e debba fondarsi sull'integrazione tra gruppi, persone, istituzioni pubbliche e private. Pertanto, è necessario assicurare alla popolazione una corretta e chiara informazione che consenta alla persona di migliorare la gestione della propria salute, in modo consapevole e responsabile, usando un linguaggio autorevole e confidenziale, utilizzando tutti i moderni mezzi di comunicazione sociale.
Parole chiave: comunicazione, promozione della salute, informazione, counselling.
INTRODUCTION
Communication on health in Italy has been developing and evolving together with the political approach to the problem of the health system and people health care.
In 1880, during Crispi government, the setting was rather repressive and based on the surveillance of the territory, so that jurisdiction in health matters was centralized and entrusted to the Ministry of Interior and, in particular, to the Prefect.
Consequently there was a reduced, minimum communication and it was not directed to the general population, but to an elite group of insiders, who were deemed able to cope with any public health emergencies. The few media devoted very little space to the existing problem and used a technical and essential language, confusing for most of people.
During the 20th century, the concept of prevention and care of individuals has been growing and for that reason the Ministry of Interior was gradually leaving its jurisdiction relating health problems to the High Commissioner of the Council of Ministers Presidency which was later joined by the National Institute of Health and by the Board of Health.
In 1948, art. 32 of our Constitution entrusted the State with the task of assistance to the citizens and speaks explicitly about health care and health system: "The Republic protects health as a fundamental right of the individual and collective interest and provides free care to the indigents. Nobody can be obliged to undergo medical treatment except for certain provisions of law. In any circumstances the law can not violate the limits imposed by respect for the individual". Article 3 affirms the principle of equality and same opportunities of all citizens before the law of the state, without any distinction. In this period communication is more and more affirming its role, but it is still and above all directed to the area operators and its tone was, therefore, predominantly scientific and not popular [1].
Ten years later, in 1958, the Ministry of Health was established and both the health service and health care began to have their parallel but particular and autonomous history. Both areas went through various reforms to extend more and more strategic goals of health promotion, linking them to diffused partnerships in the country, which have become essential for the success of the programme on health protection and promotion.
This kind of approach includes a real involvement of the population based on integration among people, groups, public and private institutions.
Despite these significant changes, communication interventions on health are still sporadic. The population still whispered about health problems giving fanciful names to some illness, such as "mal sottile", "brutto male" and others. The population is not actively helped to take responsibility of its own health and that of the others, nor it is clearly informed about the transmission of diseases, symptoms, treatments, methods of prevention and the dangers of using chemicals both privately and professionally.
Television either, the new media arrived in Italy during the fifties, didn't devote specific space to health topics, except for some chronicle episodes, such as the death of Fausto Coppi due to malaria or some films containing some hints to tuberculosis, plague and leprosy.
Hospitals care was still charitable and it was often entrusted to religious institutions, institutes of assistance and, only marginally, was entrusted to the municipalities.
During the next two decades (1958-1978), they understood that the involvement of citizens and the promotion of their decisional autonomy must be based on effective information campaigns, aimed to the change of behaviours and life styles which can be harmful for health.
Aspiring to preserve their health and their psychophysical and social wellness, it is essential to ensure citizens the right to receive information, enabling them to better manage their health and ensure a rational access to care and health services to receive interventions, satisfying their real needs.
For this reason, institutions have the duty to educate and inform citizens, without using an alarming tone, but using an authoritative and confidential language to meet individual needs.
A great ability in communication is necessary to obtain these complex interactions, with the aim to adopt simple and understandable languages, facilitating links between the different subjects with the support and participation of everybody. An effective communication involving politicians, public administrators, experts, stakeholders and media which has been increasing and developing along the years, has been fundamental. They have been offering more and more articulated methods of information, education, specialist training for healthcare operators and effective communication suitable for different kind of people.
This innovative approach is defined and stated unequivocally in the Health Reform Law n. 833 of December 1978 (article 2) which sets priorities such as "the creation of a modern health consciousness on the basis of adequate health education of citizens and communities, prevention of diseases and injuries in every area of life and work, promotion and safeguarding of natural environmental health of living and work" [2].
The new legislative system focuses on prevention and health education suggesting the individual and the community to become actively involved in changing lifestyles and behaviours harmful to health. For the first time, the focus is on the process of empowerment of the individual in becoming a promoter of good health for himself and for the entire community.
Empowerment processes require specific measures of information, both through modulated educational campaigns on the mass media and through personalized interventions of information.
THE ROLE OF INFORMATION IN THE HEALTH AREA
Currently the main health problems in Italy are mainly due to acute and chronic diseases related to the lifestyle of individuals. For example, a large proportion of cases of ischemic heart disease and cancer can be attributed to smoking and improper nutrition; most sexually transmitted diseases are due to the non-use of condoms. As for many behaviours that affect health, high-quality studies confirmed that we can change the behaviour of people through specific interventions of information and health education. In this context, the role of media is fundamental; as the World Health Organization (WHO) underlines, information diffused through programmes based on interviews to well known scientists or testimonials beloved by the chosen target, or based on spots or advertisements, or on events and shows are more effective and more accepted and loved then those officially diffused by institutions or by health authorities, using an official and polished language, which doesn't affect the spreading of news concerning health.
It would be, therefore, desirable for the professionals of health and information to work together to rethink and review the fundamental principles of health promotion.
Now the request and offer of scientific but popular information in Italy is very high and bio-medicine alone represents the 55% of information published by newspapers and the 64% of those broadcasted by televisions [3]. As for the contents of such an information, disease takes precedence over the sick person as individual, meaning that technical-scientific information prevails on psychological aspects.
In fact, we rarely talk about fear, anxiety, sense of isolation or problems related to the relationship between doctor and patient, all elements strictly connected with serious pathologies.
Anyway, language tends to be simpler and more comprehensible both in print and television, radio and internet; the media try to treat a few central arguments in support of the subjects treated.
As far as the subjects are concerned, the area of research and new technologies prevails on assistance and health services. There are many services on prevention and arrangements for their practical implementation [3].
Then, the state of health communication is closer to a dissemination of knowledge and skills, more than a form of education and promotion of correct behaviours. Much more could be done to improve this aspect of health communication, in front of the new and growing awareness of the citizen-patient in favour of his responsibility and his personal commitment in prevention, improving his level of health.
In the present historic phase, the health communication frontier is represented by Internet: web sites are understandable as for the purpose and object, as well as easy to use and also the 33% of them are certified by Health on Net Foundation (HON), a European Commission card, which has the aim to evaluate the quality of web sites dedicated to medicine and health [3].
Web sites allow a real time and global communication, both among public and private institutions and among citizens, helping them to move more freely between the various services offered and to meet immediately their growing and very articulated information needs. Think of help given by the interested citizens themselves in solving problems related to the treatment of rare diseases.
During the latest decades, health has become a global problem with the increasing moving of groups of population from a country to another; health institutions and the communication area have studied how to communicate with migrants of many different ethnic groups, coming from different geographic areas of the world. Countries with huge migration have the need to identify communication methodologies, instruments and means suitable for that specific target, which could be characterized by a greater vulnerability.
Communication is a very important priority for the effectiveness of information, prevention and awareness campaigns in the area of public responsibility about health education and health promotion of the individual and the whole community. Also we feel an increasing demand of our society for an accurate information about health and wellness in general from a side, and from the other an increasing flow of information coming from different sources, sometimes of uncertain scientific level, which risk to rise false alarms and unwarranted fears.
In this context, the planning and implementation of effective public campaigns of communication collides with the overcrowding of messages in all the media, due to huge investments by commercial companies.
In addition there is a lack of coordination of the strategic objectives and overlapping of efforts by different organizations who have provided the population with inconsistent or unclear messages.
Health institutions have to answer many demands about the complex issue of health, requiring an educational and information effort, with the risk of being lost in many streams of communication.
In the National Health Programme, communication has become an important element of the changing process, a very complex and strategic function, compared with the change from "Ministero della Sanità" to "Ministero della Salute" and compared with the rules to implement the regionalization process.
The National Health Programme should promote an adequate communication between users, health professionals, citizens and services and raise awareness throughout the community on issues pertaining the relationships between health and environment, food safety, drug addiction and all forms of health protection, as well as ensuring fairness and quality, strengthen healthy lifestyles, implementing control systems on user satisfaction, provide information tools to avoid the dangers and risks.
All that puts in evidence the need to change the institutional communication approach talking about health care and health system from an ethic point of view, if we want to obtain results coherent to values, criteria and objectives indicated by the National Health Programme. Health information must be considered a value that enriches the society and helps to improve heath care and the health system which are common property and belong to the whole society.
THE ROLE OF INFORMATION IN THE HEALTH EDUCATION INTERVENTIONS
Health promotion involves the construction of ways to provide scientific information, both to encourage the individuals to find the motivational basis for developing non-risky behaviours and to modify the existing ones.
An updated scientific information is a fundamental condition but it is not sufficient for an intervention of prevention and health education truly effective.
Therefore, preventive strategies must include health education through information and educational campaigns that can reach the entire population with general information. But they should include interventions of personalized information to promote the modification of risk behaviours and the adoption of adequate living styles, implemented within a relationship of professional help to put an emphasis on individual cultural and social features [4, 5].
The necessary integration between a generalized and a personalized information (counselling) has found its application in 1987 in the prevention of HIV infection with the establishing of the help line on AIDS by part of the Ministry of Health in collaboration with National Institute of Health.
In 1988 the first national public campaign was realized on the base of epidemiological data and technical indications of the National Commission against AIDS. During the following years other nine AIDS campaigns have been realized.
The characteristics of this syndrome have been modifying a lot along the years and it has been necessary to change the tone of the communication and evaluate again the aims every year. While the first campaigns were based on the primary need to spread basic knowledge on the disease and give fundamental information on the main aspects of the syndrome, in the context of a popular greatly felt emergency, the following campaigns were aimed to promote a more mature behaviours to teach people to live confronting this pathology, to reduce the risk with responsible behaviours and to spread a feeling of solidarity toward HIV+ people and people with AIDS [4].
These goals were pursued using all kind of media, together with leaflets an training courses. Preliminary and final market researches have been realized to understand the information needs of Italian population and to be used for the realization of future messages and strategies [6].
Beginning from the reform of the Ministry in 2001, theappropriateGeneralDirectionof Communication was established, just on the base of people information needs and many communication campaigns on health have been realized, among them the campaign on health of mothers and children, parents' indications for their children health, against cancer, AIDS, to promote organs donation, blood donation, a good national health system, correct life styles, to treat mental illness, sterility, obesity, against the abuse of alcohol and others.
They were all characterized by the co-ordination with other public institutions and private associations, by an easily understandable language, authoritative, without any blame, non-prescriptive, aimed at personal empowerment of the individual for himself and others.
Some hot lines were activated (against AIDS, against the abuse of alcohol, against drugs in collaboration with the National Institute of Health) to provide customized skilled and multi-lingual counselling, suiting the needs of Italians and foreign citizens. Trained psychologists and doctors answer to those lines to solve doubts, fear or practical information.
As far as the personalized information is concerned, counselling is an effective instrument. This method involves a trained operator and an individual user and it is characterized by the specific knowledge, personal qualities and skills such as active listening and empathy, as well as strategies and communication techniques (rewording, clarification, the ability to survey and messages in first person) from part of the professional. This method is aimed to activate and empower the individual to realize choices and changes in difficult situations or to actively face problems and difficulties involving a specific person.
The process of counselling can structure the professional relationship of help in phases, characterized by well-defined steps through which it implements a comprehensive and effective professional interaction aimed at creating a climate of trust, acceptance, respect and cooperation, as well as the redefinition of the problem and the identification of possible solutions together with the individual.
Counselling has demonstrated to be an effective tool both in situations of face to face interview and in situations of telephone interview to give scientifically correct and personalized information on health subjects [7, 8].
Over the years, the extensive experience gained in telephone counselling by the experts of the help line on AIDS of the National Institute of Health, has enabled the activation of other "help lines" associated with various health issues such as abuse of alcohol, tobacco, rare diseases, organ transplantation.
The aim is to provide scientific answers, updated and customized to detect any risk behaviour, to direct the person to the closer diagnosis and treatment centres and to facilitate and support changes in behaviour.
CONCLUSIONS
In the XXI century, communication in healthcare is fundamental to the provision of prevention which has the main purpose to provide information regarding a specific medical condition and to make the citizen aware of the resources at his disposal and to protect his health and that of their social context of reference.
This is an innovative approach that has overcome the old one of monitoring and supervision in favour of an institutional approach based on the promotion and protection of health with the direct involvement of citizens. This orientation may facilitate the activation of processes that can change the lifestyles of the population and improve the standard of health as a state of complete mental, physical and social wellness (WHO) [9].
In this context the use of intervention methods and tools to reach different population groups is very important and at the same time it gives the citizen the opportunity to be informed. This is accomplished through the integration of general information, diffused through information and educational campaigns of the Ministry of Health and a personalized information delivered with the help of telephone counselling which can satisfy the specific needs of each person.
In a historical period in which there are a lot of easy access sources of information (such as Internet and the mass media) we must take into account the strategic importance that institutions can use modern and innovative methods and tools of communication to reach all sections of the population with an easy and direct language providing information on health based on scientific evidence.
Conflict of interest statement
There are no potential conflicts of interest or any financial or personal relationships with other people or organizations that could inappropriately bias conduct and findings of this study.
References
1. Italia. Costituzione della Repubblica Italiana. Available from: www.governo.it/governo/costituzione/costituzionerepubblicaitaliana.pdf.
2. Italia. Legge 23 dicembre, n. 833. Istituzione del Servizio Sanitario Nazionale. Gazzetta Ufficiale n. 360, 28 dicembre 1978.
3. Censis. Forum per la ricerca biomedica. Comunicare la salute: i media e le patologie ad alto impatto sociale. Convegno Roma 25/maggio/04. Roma: Censis; 2004. Available from: www.censis.it.
4. Frati A, Cordone MN. Le campagne informativo-educative sull'AIDS del Ministero della Salute 1988-2002. Boll Farmacodip e Alcoolis 2002;25(1-2):11-8. Available from: www.unicri.it/wwk/publications/dacp/journal/2002_12/j%20xxv%202002%2012%20frati%20cordone%20campagne%20infoedu%20aids%20msalute.pdf.
5. Luzi AM. L'intervento di counselling telefonico nella prevenzione dell'infezione da HIV. Not Ist Super Sanità 2007;20(4):7-10.
6. Consales E, Tagliaferri M. Prevenire e curare. Ricerca commissionata dal Ministero della Salute all'Accademia della Comunicazione di Milano. Roma: Ministero della Salute; 2004.
7. Luzi AM, De Mei B, Colucci A, Gallo P. Criteria for standardising counselling for HIV testing. Ann Ist Super Sanità 2010; 46(1):42-50.
8. Colucci A, Valli R, Gallo P. I bisogni informativi della popolazione generale e di target specifici nell'ambito dell'infezione da HIV. Not Ist Super Sanità 2007;20(4):11-5.
9. World Health Organization. Constitution of the World Health Organization. Geneva: WHO; 1948. Available from: www.admin.ch/ch/i/rs/i8/0.810.1.it.pdf.
Address for correspondence:
Annarosa Frati
Direzione Generale Comunicazione e Relazioni Istituzionali, Ministero della Salute
Viale Giorgio Ribotta 5
00144 Rome, Italy
E-mail: annarosa.frati@libero.it
Received on 3 May 2010.
Accepted on 12 July 2010.