Health Communication

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Theory and Practice in Health Communication

Campaigns: A Critical Interrogation

Mohan J. Dutta-Bergman

To cite this article: Mohan J. Dutta-Bergman (2005) Theory and Practice in Health
Communication Campaigns: A Critical Interrogation, Health Communication, 18:2, 103-122,
DOI: 10.1207/s15327027hc1802_1

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HEALTH COMMUNICATION, 18(2), 103–122
Copyright © 2005, Lawrence Erlbaum Associates, Inc.

Theory and Practice in Health

Communication Campaigns:
A Critical Interrogation
Mohan J. Dutta-Bergman
Department of Communication
Purdue University

In recent reviews of the body of work on health campaigns, communication scholars

discussed the importance of reflective thinking about the capacity of campaigns to af-
fect change; this reflective thinking is especially important in the realm of the in-
creasing gaps in society between the health rich and the health poor and the increas-
ing marginalization of the poorer sections of society. This article critically reviews 3
central theories of health communication campaigns that represent the dominant
cognitive approach: theory of reasoned action, health belief model, and the extended
parallel process model. After articulating the limitations of these theoretical ap-
proaches, the article summarizes new directions in theory, methodology, and applica-
tion of health communication campaigns targeting marginalized populations.

The literature on prevention campaigns documents a long history, with important

contributions in understanding individual-level behavior change (Community In-
tervention Trial for Smoking Cessation, 1995; Hornik, 2002; Luepker et al., 1994).
A meta-analysis by Snyder (2002) demonstrated that health campaigns reach small
and short-term effects when strategically planned. In addition to the small and
short-term effects of campaigns, a review by Viswanath and Finnegan (2002)
pointed out that low socioeconomic status groups, which face the greatest threats
of ill health, fail to benefit equally compared to higher socioeconomic groups. The
at-risk populations are most often left behind while campaigns continue to benefit
the health rich; a substantive body of evidence on knowledge gap theory points out
that health communication campaigns contribute to the existing gaps between the
rich and the poor (Finnegan & Viswanath, 1997; Freimuth, 1990; Viswanath &
Finnegan, 1995).

Correspondence should be addressed to Mohan J. Dutta-Bergman, 2477 Musket Way, West Lafay-
ette, IN 47907–2098. E-mail: [email protected]
104 DUTTA-BERGMAN

Addressing the increasing societal chasm between the haves and have nots,
health communication scholars have called for a reconfiguration in the realm of
campaigns, a reconfiguration that focuses on serving marginalized people (Mar-
shall & McKeon, 1996). Such a reconfiguration is closely aligned with Viswanath
and Finnegan’s (2002) call for profound reflection about the capacity of campaigns
to achieve population behavior change and has already been initiated within the
fields of health communication and public health via novel individual campaign
efforts. Although the different alternatives to extant health communication ap-
proaches have been developed in the form of individual campaigns, they have hith-
erto been systematically integrated within a single framework and positioned
against the backdrop of the dominant approach to campaigns. In the following
pages, I offer a critical review of the three most widely applied theoretical ap-
proaches that inform much of the published scholarship on campaigns: the theory
of reasoned action (TRA), the health belief model (HBM), and the extended paral-
lel process model (EPPM). I juxtapose my analysis against the backdrop of cur-
rently emerging reconfigurations in the field (Glanz & Rimer, 1995; Hornik, 2002;
Witte, 1992; Witte & Allen, 2000). The analysis of the dominant theoretical ap-
proaches is contextualized by recent developments in the fields of health commu-
nication and public health, providing an exploratory platform for new solutions in
the realms of theory building, methodology, and application development.

CAMPAIGN THEORIES/MODELS

Theory of Reasoned Action

The TRA explains volitional human behavior, proposing that one’s intention to
perform or not perform a behavior is the most critical determinant of human behav-
ior. Behavioral intention is dependent on the individual’s attitude toward the spe-
cific behavior, and his or her perception of the evaluation of the behavior by impor-
tant others. The attitude of the individual, in turn, results from his or her salient
beliefs about the outcomes of the behavior. Similarly, the individual’s motivation
to comply with salient others in his or her social network accompanied by the nor-
mative beliefs regarding the target behavior ascribed to these salient others pro-
duce his or her subjective norms (Fishbein, 1990; Fishbein & Ajzen, 1975).

Health Belief Model

The HBM is founded on six components: severity, susceptibility, benefits, barriers,
cues to action, and self-efficacy (Janz & Becker, 1984; Mattson, 1999; Rosen-
stock, 1974). Whereas perceived severity refers to the individual’s assessment of
the outcomes associated with the preventive behavior, perceived susceptibility fo-
HEALTH COMMUNICATION CAMPAIGNS 105

cuses on the individual’s assessment of the extent to which he or she is likely to

succumb to the negative outcomes. Both susceptibility and severity need to be high
for the individual to consider altering his or her behavior. Benefits are the individ-
ual’s beliefs regarding the effectiveness of the proposed preventive behavior in re-
ducing the vulnerability to the negative outcomes (Mattson, 1999; Rosenstock,
1974). Barriers decrease the individual’s ability to engage in the preventive behav-
ior and are described as the evaluation of potential negative consequences that
might result from the enactment of the espoused health behavior (Mattson, 1999;
Rosenstock, 1974). Self-efficacy taps into the amount of confidence individuals
have in their ability to perform the health behavior, and it positively predicts the
adoption of the preventive behavior. Finally, cues to action are the specific stimuli
that are needed to trigger the appropriate health behavior (Janz & Becker, 1984;
Mattson, 1999).

Extended Parallel Process Model

The EPPM posits that the evaluation of perceived threat and perceived efficacy re-
lated to a specific intervention determine the pathway taken by the target audience
after exposure to a threatening message (Witte, 1992; Witte & Allen, 2000). On ex-
posure to the message, the individual either attempts to control the danger by ad-
hering to the recommendations of the message (engaging in the preventive behav-
ior that minimizes the danger) or controls the fear through defensive avoidance or
denial, not adopting the recommended action. Audience members first evaluate
the perceived threat of the hazard. If the perceived threat elicited by the message is
low, the individual is not motivated to further process the message; however, if and
when perceived threat is moderate to high, the individual moves on to the second
step—appraisal of the efficacy of the recommended action. In situations when both
the perceived threat and the perceived efficacy of the recommended action are
high, the message recipient is prompted to follow the recommended action. How-
ever, on processing a message triggered by high perceived threat and not being
convinced of their ability to deter the threat, individuals use a defensive mecha-
nism to cope with their fear (Witte, 1992).

A CRITICAL PERSPECTIVE

Foundation of a Critical Approach

In her essay Toward the Development of Critical Health Communication Praxis,
Lupton (1994) locates and critiques some of the foundational issues that underlie
health communication. She argues that communication in the health context is tra-
ditionally conceptualized as a top-down approach, with communication flowing
from the centers of authority to peripheral locations. The critical perspective con-
106 DUTTA-BERGMAN

structs health communication as a political process, marked by power relations

that determine the relationship between the bourgeoisie and subaltern classes. De-
fined as “the ability to shape social contexts” (Wilkins & Mody, 2001, p. 198),
power is central to how problems are defined and how solutions are framed (Mody,
2000; Wilkins & Mody, 2001). Campaigns, critical theorists argue, are dictated by
the capacity of those with power to “select and frame social conditions and groups
as problematic, legitimizing particular approaches to their resolution and not oth-
ers” (Wilkins & Mody, 2001, p. 393). With its primary objective of persuasion, the
epistemology of campaigns is based on a “desire for control and domination, for
the act of changing establishes the power of the change agent over that other” (Foss
& Griffin, 1995, p. 3).
Taking a critical stance allows scholars to raise typically taken-for-granted
questions (Lupton, 1994). In this essay, I apply a critical stance to interrogate TRA,
HBM, and EPPM, with the ultimate goal of using the criticism for creating a con-
stitutive space that encourages the articulation, comparison, and synthesis of alter-
native approaches to health communication campaigns. A critical analysis of the
theoretical, methodological, and practical issues in health communication cam-
paign scholarship reveals that campaigns (a) are individualistic, (b) ignore the con-
text within which communicative meanings are constructed and negotiated, and
(c) are cognitively oriented.

Individualistic Bias
With their roots in the social psychological tradition, campaign theories and mod-
els typically focus on the individual (Wallack, 1989). A specific aspect of the indi-
vidual’s attitude, belief, and/or cognition is selected as the target of the campaign.
The individual serves as the object of theory development and guides the method-
ological and practical choices of scholars and campaign planners (Airhihenbuwa,
1995; Lupton, 1994; Wallack, 1989). The primacy of beliefs in the TRA and the
perceptual assessments in the HBM and EPPM are founded in an individualistic
epistemology where the locus of choice is the individual. Located within the indi-
vidual’s cognitive space, the enactment or nonenactment of a behavior is a result of
individual-level processes that precede the behavior. Consider, in this realm, a
collectivistic culture in which the emphasis is on collective identity, and the barri-
ers to action are located within this collectivistic context. The behavior then gets
located in the characteristics of the collective and becomes a part of the collective
being of the culture (Triandis, 1994). The meanings associated with the behavior
and the behavioral outcome might very well be located in the social networks, the
collective fabric of the community.
Although proponents of the TRA might argue that subjective norms explain the
role of the collective in individual decision making, it may be counterargued that
subjective norms are driven by an individual motive orientation and, therefore, are
HEALTH COMMUNICATION CAMPAIGNS 107

fundamentally unable to capture the locus of the decision in the collective. Subjec-
tive norms, although targeted on the individual’s evaluation of the important others
in the interpersonal network, do not effectively tap into the complexity of the social
fabric that constitute the health behavior. Social influence moves beyond the realm
of a few important others to the broader sociocultural context of the community.
The individual might engage in a behavior because it is inherent in the broader col-
lective rather than simply being motivated to comply with the important others
within his or her immediate network. For instance, research on HIV/AIDS in India
demonstrates the embeddedness of attitudes and beliefs regarding extramarital sex
within the broader cultural context. In cultures such as the Phillipines and Thai-
land, young men visit brothels as a rite of passage (Brown, 2000). In these in-
stances, attitudes and beliefs regarding visits to brothels are not located in, or lim-
ited to, the important others. Instead, the source of influence is the broader
community.
The important role of culture might be particularly evident in the realm of habit-
ual behaviors where the enactment of the behavior is based on an existing script
without thoughtful and systematic assessments each time the behavior is enacted.
Also, the role of the culture might be particularly highlighted in collectivistic cul-
tures in which individual decision making is simply a reflection of cultural mores
and rituals. For instance, in Cambodia, where buying sex is integral to almost all
forms of evening entertainment for men, women are expected to contribute to the
family’s income at a very early age, leading to a sense of family obligation that
drives women to enter the sex industry in the face of poverty (Mony, Salan, Youthy,
Piseth, & Brown, 1999). In other instances, the individualistic messages of behav-
ior change developed through the TRA, the HBM, or the EPPM might fundamen-
tally counter the values of the collective. The proposed behavior might not exist in
harmony with the values and goals of the collective. Take for instance, a campaign
targeting middle-class high school students in metropolitan cities in India to use
condoms for safe sex. Although an EPPM-based message might create a high
threat and subsequently high response efficacy with respect to condoms, the use of
condoms or the prospects of having extramarital sex do not gel with the mores and
values of traditional Indian society.
To emphasize the location of the collective at the core of much health behavior,
scholars have recently introduced the concept of collective efficacy and applied it
in the realm of health campaigns (Bandura, 1995; Sood, 2002). Conceptualized as
a system-level manifestation of Bandura’s social cognitive theory, collective effi-
cacy is defined as “people’s beliefs in their joint capabilities to forge divergent
self-interests into a shared agenda, to enlist supporters and resources for collective
action, to devise effective strategies and to execute them successfully, and to with-
stand forcible opposition and discouraging setbacks” (Bandura, 1995, p. 33).
Communities with collective efficacy are able to mobilize their efforts and re-
sources to overcome external obstacles to the social change project (Bandura,
108 DUTTA-BERGMAN

1995). In their examination of an entertainment–education program in India called

Tinkha Tinkha Sukh (TTS), Papa and colleagues (2000) reported that the program
led to the formation of informal listening groups, which became formalized into
men’s and women’s radio listeners clubs. Members of the clubs “listened to the
program collectively and discussed the content, charting new courses for environ-
mental action” (Papa et al., 2000, p. 45).
Recognizing the critical nature of the collective in constituting health behavior,
campaign planners working in collectivistic cultures have launched campaigns at
the group or community level rather than at the individual level. An example of a
campaign located at the collective level is the Sonagachi project on HIV/AIDS pre-
vention started in Calcutta in 1992 (Jana et al., 1998). Involving sex workers, their
clients, local organizations, and political leaders, the Sonagachi project sought to
alter the sociocultural rubric surrounding unsafe sex by setting up health care ser-
vice centers, recruiting sex workers as peer educators, forming cultural groups,
and empowering sex workers to start their own organization dealing with relevant
sociocultural issues including unsafe sex (Jana et al., 1998). The effectiveness of
the Sonagachi project in gaining an increase of approximately 50% in the use of
condoms in a red-light district was achieved by its use of group settings and com-
munity interactions as conduits for identifying the problem in the sociocultural en-
vironment and implementing a community-level change strategy that responded to
the sociocultural system and enhanced collective efficacy.
Another campaign that moved beyond the individual level was the Bienvenida
Salud! campaign fostering reproductive health in the Peruvian Amazon (Daven-
port Sypher, McKinley, Ventsam, & Valdeavellano, 2002). In addition to using a
mass media component, the campaign trained a network of peer promoters to fos-
ter interpersonal communication among community members (Davenport Sypher
et al., 2002). Yet other campaigns have focused on a social/ecological approach
with the goal of influencing social policy and the community environment as pre-
requisites to transforming individual behavior (Mittelmark, 2001). The impor-
tance of expanding the locus of social change from the individual to the interper-
sonal context is also supported by a significant number of studies documenting that
mediated campaigns often spur interpersonal communication about the media pro-
gram (Valente, Poppe, & Payne-Merritt, 1996).

Minimizing Context
The applications of the TRA, the HBM, and the EPPM do not typically capture the
structural, measurement, and mediated contexts of the health behaviors being stud-
ied (Marmot & Wilkinson, 1999).

Structural context. By assuming that individual beliefs and perceptions

hold the key to explaining health behavior, the theories/models ignore the con-
HEALTH COMMUNICATION CAMPAIGNS 109

straints that might operate in the individual’s environment, particularly in severely

resource-deprived spaces such as third world nations (Marmot & Wilkinson,
1999). Structural resources and the access to such resources might be central to the
development of an understanding of health communication in many Third World
countries or resource-starved areas such as inner cities (Dutta-Bergman, 2003;
Marmot & Wilkinson, 1999; McClelland, 1991). A media-based approach that ad-
dresses the benefits or barriers by providing information does not address the key
structural elements of barriers that impede the enactment of behavior in particu-
larly deprived parts of the world where individuals do not have the basic capabili-
ties of life such as food, clothing, and shelter (Narayan, Chambers, Shah, &
Petesch, 2000; Narayan, Patel, Schafft, Rademacher, & Koch-Schulte, 2000; The
Synergy Project, 2002). Worthwhile to point out here is the fact that many of the
structural barriers experienced in marginalized populations that are typical targets
of health interventions might not be overtly related to the specific behavior being
proposed or might not present themselves directly to the scrutiny of the external
observer (Mony, Salan, Youthy, Piseth, & Brown, 1999; Sarkar et al., 1997).
Health decisions might be located in the capability of community members to gain
access to some of the primary resources of life, such as food, clothing, and shelter.
In the face of the absence of these basic resources, engaging in higher order health
behaviors such as getting mammograms, not smoking cigarettes, or having safe
sex might seem irrelevant. Prioritization of risks therefore needs to fundamentally
change, and this can happen only by the application of a bottom-up approach that
puts the community at the center of decision making and focuses on equipping the
community with basic resources (Narayan & Petesch, 2002; Nyamwaya, 2003).
Emphasizing the importance of addressing poverty and undernourishment in
marginalized communities, multiple public health campaigns in marginalized
populations have developed poverty and food-based components as the first step
to creating healthy communities (Nyamwaya, 2003). The microcredit program
of the Bangladesh Rural Advancement Committee successfully improved health
knowledge among poor women in rural Bangladesh by tying it in with a grass-
roots poverty reduction program that gave collateral-free credit to poor rural
women, accompanied by support services such as group meetings, skills train-
ing, basic literacy, and primary health care services. Study results demonstrated
that the program successfully served as a conduit for disseminating health in-
formation among the hard-to-reach at-risk rural women (Hadi, 2001). The
Sonagachi project in Calcutta recognized that an HIV/AIDS campaign in a se-
verely resource-undernourished, high-risk sex worker community would fail if it
simply focused on distributing condoms and generating behavioral change
through message design (Jana et al. 1998; UNAIDS, 2000). Instead, the project
emphasized the imminent contextual risks such as lack of access to money, argu-
ing that the women in the community might need to sell their bodies to earn just
enough money and might, therefore, be willing to forgo condom use if threat-
110 DUTTA-BERGMAN

ened by a client (The Synergy Project, 2002; UNAIDS, 2000). The sex workers
of Sonagachi formed a consumer’s cooperative called the Usha Multipurpose
Cooperative Society that would “help the sex workers save money and avoid the
exorbitant interest charged on small loans by money lenders in the area”
(UNAIDS, 2000, p. 70). Recognizing the strong interlinkage between economics
and safe sex practices among sex workers, the Shakti project in Bangladesh of-
fered skills training in alternative modes of supplementing income, such as em-
broidery and sewing (UNAIDS, 2000). On a similar note, the SWEAT project in
South Africa fostered the development of exit programs, support programs, job
creation schemes, and skills training programs for sex workers, while the
Prerana project in India provided education, shelter, and health and vocational
training to the children of sex workers (The Synergy Project, 2002).

Measurement and message context. The measurement techniques of the

TRA, the EPPM, and the HBM are typically unable to capture the actual context of
behavioral enactment. The measurement of perceptual indicators and belief struc-
tures is typically conducted in a cognitively loaded scenario in which the respon-
dent fills out a survey. In other words, the method of measurement perhaps lends it-
self to the cognitive orientation of the theoretical framework (to be discussed in the
next section) although it might be far removed from the reality of the situation un-
der which the individual engages in the behavior. Instead of, prior to, and/or com-
plementary to using survey-based instruments, formative and evaluation research-
ers need to use methods such as participant observation, ethnography, and focus
groups in deciphering and unraveling the meaning of structures that circulate
within cultures. For instance, Davenport Sypher and colleagues (2002) applied a
social constructionist approach to develop a preliminary understanding of the cul-
ture in the Peruvian Amazon before conducting a large-scale survey. They argued,
“the social constructionist approach in this project demanded an understanding of
local knowledge before conducting a meaningful, large-scale audience survey of
the radio listeners” (Davenport Sypher et al., 2003, p. 202). The researchers ana-
lyzed letters received by the radio station, conducted focus group interviews, and
utilized participant observation and in-depth interviews (Davenport Sypher et al.,
2002).
Ignored in the conceptualization of individual response is the surrounding con-
text within which the individual might be embedded while viewing, reading, or
hearing the message (Nathanson, 2001; Nathanson & Botta, 2003; Schmitt, Woolf,
& Anderson, 2003; Steele, 1999). The recipient is highlighted; his or her media en-
vironment within which the message is received is ignored (Steele, 1999). A col-
lege student watching a message alone in a dorm room will perhaps respond very
differently to the message as opposed to being exposed to the message amidst a
group of friends at the student union. Or take, for instance, the case of audience ex-
posure to a fear-inducing advertisement right after watching a positive, emo-
HEALTH COMMUNICATION CAMPAIGNS 111

tion-inducing television program (a situation comedy). The viewer might simply

be likely to avoid the message to maintain his or her positive emotional state
(Kamins, Marks, & Skinner, 1991; Shapiro, MacInnis, & Park, 2002). Similarly,
Mitchell (2001) demonstrates that sad moods generate greater perceptions of sus-
ceptibility and severity. By simply highlighting the basic elements of a message,
the dominant approach fails to take into account the role of the context in driving
the reception of the message.
It is important to point out that the theories/models reviewed in this article are
likely to find support when studied in a laboratory setting; the student is exposed to
the single message and a response is elicited (high internal validity). However, the
artificiality of the very laboratory setting removes the contextual factors that sur-
round the reception of a message and therefore suffers from problems of external
validity. These issues of external validity are important because mediated mes-
sages are almost always embedded within the context; the loss of the surrounding
context is not something that can be written off in the limitations section of a study
on message effects.
The highly contextualized nature of media consumption is particularly critical
in collectivistic cultures in which individuals consume media in family and com-
munity settings, necessitating the development of measurement tools that capture
the media consumption context (Davenport Sypher et al., 2002; Steele, 1999). For
instance, research documenting the listenership of TTS indicated that community
members formed informal groups that later became formalized into radio clubs
that listened to the program as a group and subsequently discussed the program
content; these radio clubs actively participated in their local and surrounding com-
munities, spreading the message of the social change project (Papa et al., 2000).
The example of TTS documents the interpenetration of the intrapersonal, interper-
sonal, mediated, group, and community levels of communication. The communal
nature of radio listening is also captured in a project conducted in the Peruvian
Amazon by Davenport Sypher and colleagues (2002).

Cognitive Orientation
Central to all three theories/models is the role of cognition in shaping audience
outcomes. The TRA emphasizes beliefs in the formation of attitudes and subjec-
tive norms. Rooted in the ability of humans to reason, the theory suggests that indi-
viduals systematically identify and weigh outcomes to form attitudes. Behavioral
change is induced by adding a new belief, increasing or decreasing the favorability
or unfavorability of an existing belief, and increasing or decreasing the belief
strength, depending on the nature of the behavior (Fishbein, 1990). Similarly, the
HBM assumes that rationally acting individuals go through a cost-benefit analysis
to determine the severity, susceptibility, barriers, and benefits related to a health
behavior before adopting the behavior (Mattson, 1999). Pointing to the cognitive
112 DUTTA-BERGMAN

orientation of earlier models and theories, Witte (1992) argues that EPPM is an im-
provement over earlier models and theories of health communication because it
takes into account the role of emotions in information processing. However, it is
worthwhile to point out that much of the experience of emotions in EPPM is de-
pendent on cognitive appraisal.
The persuasive process documented in the theories/models discussed in this ar-
ticle is primarily information based, providing the target audience with necessary
pieces of information to create the desirable attitude toward the behavior (Budd,
North, & Spencer, 1984; Hausenblas, Carron, & Mack, 1997). This emphasis on
information and rational choice becomes particularly problematic in the case of
certain choices that are made on the spur of the moment or choices that do not in-
volve deliberate cognitive evaluation (habitual behavioral choices). Affective-
laden behavioral choices are not accommodated within the framework of the cog-
nitive-based theories/models. This is a critical drawback of the theory, given the af-
fect-laden nature of decision making involved in many health-based behaviors
(Dutta-Bergman, 2003). For instance, although an individual might engage in cog-
nitive elaboration and decide to use a condom during sex after a detailed conversa-
tion with the sex counselor at a university clinic, he or she might forget about the
entire conversation when encountering the possibility of a one-night stand with an
attractive target at a bar (Mattson, 1999). Acknowledging the affective element of
health decision making, health communication researchers are increasingly using
affect-based campaigns (Dutta-Bergman, 2003; Singhal & Rogers, 2002; Stephen-
son & Palmgreen, 2001). The growth in health communication research on person-
ality factors such as sensation seeking and self-monitoring underscores the impor-
tance of emotions in audience reception of messages and the choice of health
behaviors (Dutta-Bergman, 2003). Highlighting the importance of affect in health
behaviors, a study of the TTS entertainment–education campaign in India reported
that those individuals who “engaged in high levels of referential-affective involve-
ment with TTS were more likely to communicate interpersonally with their friends
and family members” (Sood, 2002, p. 168).
Campaign planners typically use information-heavy communicative materials
such as booklets, brochures, and public service announcements. Selective expo-
sure theory documents that individuals selectively orient their attention to those
stimuli in their environments that match their existing predispositions, values, and
behaviors. Therefore, campaign materials that propose to alter the belief structure
of the receiver of the message are not likely to be adhered to. Instead, those individ-
uals who are already interested in the issue end up learning from the message. This
selectivity in the reception and processing of the message contributes to the in-
creasing knowledge and behavioral gaps between the healthy and the unhealthy in-
dividuals within a population. Also, such information-based campaigns do not rec-
ognize the low literacy levels, the lack of access to media types, and the contextual
noise that often prevent the exposure and processing of the message among
marginalized populations (Dutta-Bergman, 2004; Hadi, 2001).
HEALTH COMMUNICATION CAMPAIGNS 113

In an attempt to mitigate the increasing knowledge gaps in society, current com-

munication campaigns are increasingly using entertainment strategies to place
messages in entertainment programs that are more likely to be consumed by those
at risk (Davenport Sypher et al., 2002; Singhal & Rogers, 2002). The increasing
popularity of the entertainment-education strategy led to the dedication of an en-
tire issue of Communication Theory to the topic. Campaigns are also effectively
using communities as conduits for reaching out to those who are most at risk and
who are difficult to reach via the traditional mass media (Hadi, 2001; Jana et. al.,
1998; Mittelmark, 2001). Finally, more and more campaigns are focusing on
fine-tuned segmentation and message targeting to reach at-risk groups (Marshall
& McKeon, 1996).
The criticism of the dominant approaches to health communication demon-
strates that these approaches typically are individualistic, ignore the context, and
are cognitively biased. The critical exercise, however, remains incomplete with-
out the discussion of new possibilities based on the criticisms offered in this es-
say (Deetz, 1994). Whereas one of the roles of critical scholarship is to open up
the discursive space to excavate the taken-for-granted positions in the dominant
discourse, yet another important role is, I believe, to suggest a constructive space
for dialogue and collaboration for further development of theory and practice. In
that spirit, the criticism of the popular social psychological models and theories
in the campaigns literature is offered as a stepping stone for new directions and
possibilities.

NEW DIRECTIONS AND POSSIBILITIES

IN HEALTH CAMPAIGNS

As my review of the three most popular theories/models of health communication

campaigns demonstrates, the dominant approach to health behavior change is
fixed at the level of the individual. This location of the health behavior in the indi-
vidual is problematic because it reflects an individualistic cultural bias, ignores the
role of context and structure, and is cognitive oriented. With an emphasis on medi-
ated communication that seeks to produce individual change, communication
scholars have traditionally focused on developing mediated message materials
rather than engaging in articulations about the location of the health behavior and
its enactment (Hornik, 2002).
Current trends in communication campaign research direct us to new vistas
beyond mass media messages; they point out that to accomplish social change,
scholarship of health communication campaigns needs to integrate and join the
efforts of the mutually disparate subdisciplines of mass communication, inter-
personal communication, and organizational communication. Mediated mes-
sages fail in certain scenarios and are limited by structural barriers, especially
when marginalized groups are addressed. In the following sections, I summarize
114 DUTTA-BERGMAN

some new directions for looking at communication and its role in the realm of
health campaigns, making specific recommendations for theorizing, methodol-
ogy, and application in the realm of health campaigns.

Recognizing the Role of Structures and Basic Capabilities

Structure defines, limits, shapes, and constrains the nature of communicative
practices; this is especially the case when the campaign seeks to impact the
health of underserved populations (Senderowitz, 2000; The Synergy Project,
2002). Given the fact that underserved populations are at maximum risk, it is es-
pecially important to orient current and future health communication practice to-
ward such populations. To get individuals to engage in behaviors such as using
condoms and wearing seatbelts, campaign planners need to ensure adequate sup-
ply of the basic resources of food, clothing, and shelter. Elucidating the role of
basic resources in human health, Sen (1992) articulates that capability building
is the first and foremost step toward greater and better health of people and com-
munities. Capability building involves providing cultural participants with fun-
damental life resources such as food, clothing, and shelter, which members of
at-risk communities need to continue living (Sen, 1992). Theoretical approaches
to health campaigns ought to locate poverty and the lack of basic resources at
the center of human behavior and communicative choice; basic capabilities need
to be taken into account in theorizing. Practical approaches incorporating struc-
tural deprivation are currently under way in different marginalized sectors of the
globe, with an emphasis on skills training, income generation, education and lit-
eracy, cooperative loan programs, food drives, etc. (Gillis, 1999; Jana et al.,
1998; The Synergy Project, 2002; UNAIDS, 2000). The focal point of the struc-
tural approach, therefore, is not just the targeted individual, but also the individ-
ual’s social network of partners; family members; friends; communities; the in-
frastructure and the institutions in his or her environment; and the legal,
political, and economic realities that encompass his or her life (Senderowitz,
2000; Sweat & Denison, 1995; The Synergy Project, 2002).
Methodologically, individual-level surveys and measurement techniques need
to be complemented by focus groups, group discussions, participant observations,
ethnographies, network analyses, and geographical plots. The “People Assisting
Their Health” (PATH) campaign in Nova Scotia, Canada is an example of a cam-
paign approach that shifted the locus from the individual to the community (Gillis,
1999; Mittelmark, 2001). Applying a structural approach aiming to create social
responsibility for health within the community, community members participated
in citizen meetings, designed community health impact assessment tools, and en-
sured the implementation of the assessment tools in community health planning
and in municipal decision making.
HEALTH COMMUNICATION CAMPAIGNS 115

To create successful structurally resourceful programs such as the Sonagachi

and Prerana projects, communication scholars ought to interrogate, examine, and
develop best practices for mobilizing communities such that community members
can work together in identifying the structural impediments and in collaborating to
remove these impediments (Freire, 1970). It is both theoretically and practically
important to examine the role played by strategic communication in bringing peo-
ple together and in equipping them with necessary skills for securing structural ac-
cess to resources. Scholars studying interpersonal, small group, and organizational
communication would have critical theoretical contributions to make in under-
standing the processes of community mobilization and in developing projects that
focus on securing structural resources through mobilization. For instance, one area
of research might focus on theorizing, measuring, and applying individual-level
and community-level competence in target communities. Freire (1970) discusses
the central role of generating critical consciousness among the members of re-
source-deprived populations so they can play an active role in articulating their
voices and in determining their goals. Thus, members can actively participate in
creating conducive living conditions that support their health. Communication
scholars working within the structure-centered paradigm of health communication
could emerge as key players in the development of both theory and practice in
Freire’s critical consciousness raising. One area of inquiry might focus on the
communication skills needed by peer educators and opinion leaders within the
community to facilitate critical consciousness raising. Yet another area of scholar-
ship might emphasize identifying and minimizing the communicative barriers in
the process of critical consciousness raising.
The goals of the structure-centered approach are most recently informed by
findings that socioeconomic inequalities play a critical role in shaping the health of
communities; communities with the greatest inequities of health are also typically
the unhealthiest communities (World Health Organization, 1998). To generate
better health, therefore, a plethora of health promotion campaigns in recent years
have worked toward minimizing socioeconomic disparities and creating a more
equitable community/society. The advocacy role of communication is particularly
critical here, especially in the context of theorizing about and developing applica-
tions for media agenda setting by community groups. Public relations scholars
might play a critical role in documenting the processes and developing insights
about media relations and political relations for grassroots activist groups. Com-
munication that serves to create a more equitable society through processes of
redistributive justice achieved by policy changes, tax implementations, media cov-
erage, grant generation, etc. is much needed. However, it is also critical to remem-
ber that these community-based approaches will perhaps fail to achieve their ef-
fects if they are nontargeted; specific attempts will need to be made at targeting
the resource-deprived and marginalized communities to mitigate the patterns of
knowledge gaps documented in mass-mediated campaigns. In addition to foster-
116 DUTTA-BERGMAN

ing coalitions among deprived peoples, campaigns might also target key stake-
holders within the community with relevant themes such as social responsibility
(Mittelmark, 2001).

Culture-Centered Approach
The culture-centered approach locates culture at the center of theorizing about
communication processes; in other words, communication theories develop from
within the culture or community instead of originating from outside (Airhihen-
buwa, 1995; Dutta-Bergman, 2004; Escobar, 1995). Explanations of phenomena
and articulations of pragmatic solutions based on the nature of the phenomena
emerge from within the culture or subculture being studied; when fused with the
capability building and consciousness raising approaches discussed earlier, the
culture-centered approach becomes the conduit through which members of indige-
nous communities find ways to articulate their voices and participate in social
change (Airhihenbuwa, 1995; Dutta-Bergman, 2004; Escobar, 1995; Spivak,
1988). Problems are configured and reconfigured; solutions are generated and
worked on based on the needs of the community as defined by community mem-
bers. Theoretically, a culture-centered approach suggests that the thrust for con-
structing and explaining problems should come from within the culture, embody-
ing a community-based approach and epitomizing the interdependence of theory
and practice. Examples of the community-based approach include campaigns such
as PATH, Sonagachi, SWEAT, and TTS. The call for a culture-centered approach
resonates with Foss and Griffin’s (1995) articulation of an invitational rhetoric that
emphasizes mutual understanding rooted in “equality, immanent value and self de-
termination” (p. 5) as the goal of an alternative rhetoric beyond persuasion.
Methodologically, the culture-centered approach uses participatory communi-
cation methodologies such as focus groups, community meetings, team building
exercises, and ethnographies that focus on social construction of meanings consti-
tuted by the culture. It also suggests that researchers spend adequate time learning
about the cultures and immersing themselves within these cultures to better devel-
opment applications and assessment tools (Davenport Sypher et al., 2002). The
pragmatic solution of the culture-centered approach lies in community capacity
building such that community members can find the conduit to articulate their con-
cerns and problems and participate in solving these problems (Mittelmark, 2001).
Necessitating that researchers immerse themselves in the communities with which
they work, the culture-centered approach essentially and fundamentally captures
the intertwined nature of theory and practice in health communication.
The culture-centered approach becomes a conduit for legitimate theory build-
ing from marginalized spaces; social change is achieved through the presence of
the marginalized voices and through the participation of these voices in securing
resources and participating in redistributive justice. Instead of speaking for the
HEALTH COMMUNICATION CAMPAIGNS 117

subaltern, the culture-centered approach focuses on creating conduits for the ex-
pression of the subaltern voice. By talking to the subaltern participant, the re-
searcher finds an outlet for the subaltern voice within the dialogue between the re-
searcher and the subaltern speaker (Dutta-Bergman, 2004; Guha & Spivak, 1988;
Spivak, 1988). The researcher perhaps simply becomes a facilitator; the theories,
concepts, and explanations developed are those of the members of the culture in di-
alogue with the researcher (Airhihenbuwa, 1995; Dutta-Bergman, 2003, 2004;
Guha & Spivak, 1988; Spivak, 1988).

Polymorphic Communication Theorizing

That it is important to synthesize the levels of theorizing, application, and analysis
is one of the most obvious dictates of both the structure-centered and culture-cen-
tered approaches; this synthesis is epitomized in the philosophy of polymorphism.
Polymorphism focuses on the many realities that coexist in the experience of the
world. In other words, polymorphism articulates that there are many truths in this
world (Dutta-Bergman & Doyle, 2001). Mikhail Bakhtin (1981) sensitized us to
this concept of multiple possibilities and interpretations in any social situation in
his discussion of heteroglossia. How we see the world depends on how we ap-
proach it; the lens used by the researcher in locating and describing the practices of
the world is fundamental to the way the world is constructed (Bakhtin, 1981;
Cheney, 2000; Dutta-Bergman & Doyle, 2001).
A polymorphic approach to theorizing and application development focuses on
locating and harnessing the multiplicities of communication, on integrating the
rich body of communication theories, and simultaneously retaining their diversity
(Dutta-Bergman & Doyle, 2001; Mumby, 2000). As articulated in the previous
sections, no one level of analysis (intrapersonal, interpersonal, small group, orga-
nizational, or mass mediated) or no one paradigmatic approach is adequately posi-
tioned to capture the complexity of communication; for campaigns to be success-
ful, multiple levels of communication from multiple perspectives need to be
simultaneously activated (Cheney, 2000). Recent years have documented an expo-
nential growth in the number of campaigns that move beyond the intrapersonal and
mass mediated levels to include interpersonal, small group, organizational, com-
munity, social, economic, and cultural levels (Gillis, 1999). For instance, the mar-
riage of the theory of reasoned action (microlevel) with the diffusion of innova-
tions theory (macrolevel) would provide interesting and important guidelines for
the campaign theorist. The amalgamation of the health inequities research with the
TRA would locate the relationship between health inequities and the distribution
of specific health beliefs within communities.
Methodologically, the synthesized theories would need to be tested at the mi-
cro, meso, and macro levels, calling for multimethod approaches. For instance, the
combination of network analysis with survey instruments could inform a theory
118 DUTTA-BERGMAN

that combines diffusion of innovation with the theory of reasoned action. Also, to
tap into the multiple levels of communication embodied in a polymorphic ap-
proach, methodological tools would need to simultaneously interrogate different
stakeholders (the individual, spouse, parents, siblings, neighbors, community
members, etc.) using different instruments.
Although the initial attempts at theory building, informed by a social psycho-
logical approach, have emphasized parsimony, focusing on a singular level of
communication to minimize the complexity, increase internal validity, and tease
out the effects of individual communicative factors (mostly mass mediated in the
realm of campaigns), the reality of message exposure and behavioral change can
only be captured when the broader context is introduced into the framework.
The polymorphic framework therefore calls for collaboration among communi-
cation scholars in different subdisciplines (interpersonal, small group, organiza-
tional, and mediated) and with different paradigmatic approaches (positivist,
interpretivist, critical structuralist, and critical radicalist) to generate positive so-
cial change in resource-starved communities. A dialectical–dialogical engage-
ment among the scholars with the different paradigmatic approaches operating at
the different communicative levels will be fundamental to the development of
well informed programs of research. It is important to note the emphasis on dia-
logue among the multiplicity of paradigmatic approaches. The polymorphic
stance seeks to extend the conventions of critical scholarship by looking to syn-
thesize and construct, rather than merely to critique.
The polymorphic approach needs to be present not only in cross-paradigmatic
cross-level dialogues, but also within individual works of scholars; it is critical
for campaign scholars to engage in multiple realizations of the world, to see the
limits of particular discursive approaches, to acknowledge these limits and to
seek out complementary approaches and alternative paradigms that would throw
light on these limits (Deetz, 2000; Mumby, 2000). Although this article took a
critical approach to defining the boundaries of the dominant theories of cam-
paigns, it is also worthwhile to point out in the polymorphic vein that the three
theories/models (the TRA, the HBM, and the EPPM) have made vastly impor-
tant contributions to the way we understand health campaigns. The point of this
review was not to suggest that we throw these theories away as a part of the
deconstructive exercise; instead, the illumination of limitations was intended to
open up the space for alternative articulations that could very well complement
these theories and dialectically engage with them. Some or many of these limita-
tions can perhaps be effectively dealt with when the theory or model is inte-
grated or supplemented with other theories and models. For instance, integrating
the health belief model with network analysis (from organizational communica-
tion) might provide adequate opportunities for campaign development for secur-
ing access to structural resources and subsequently changing individual behav-
iors by addressing perceived barriers.
HEALTH COMMUNICATION CAMPAIGNS 119

As demonstrated throughout the article, one of the most important concerns of

the health communication campaign scholar of the new millennium is to find ways
of reaching out to marginalized groups. The paradigm shift in theorizing, method-
ology development, and practical solution to campaign research is sparked by a
growing emphasis on speaking from the margins, on building epistemologies from
the margins, on creating alternative discursive spaces for the conceptualization of
meanings of health (Airhihenbuwa, 1995; Dutta-Bergman, 2004; Mittelmark,
2001). The new direction evident in much of the growing research on commu-
nity-based campaigns puts importance on acknowledging marginalized people’s
capability to determine their own choices, model their own behaviors, and develop
epistemologies based on self-understanding (Dutta-Bergman, 2004; Escobar,
1995; Mittelmark, 2001). Future scholarship needs to theorize and empirically test
the roles of culture, structure, media, familial, and interpersonal contexts in the
realm of health communication campaigns.

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