Author: BBC Media Action's Caroline Sugg, November 3 2016 - Drawing on her new policy briefing, Caroline Sugg reflects on why communication is often a peripheral part of public health interventions, looking at challenges around evidence, the ‘messy' nature of behaviour change and cultural differences within the field.

The Executive Summary can be accessed at this link

The full Policy briefing can be accessed at this link


Fear shaped the public response to Ebola in West Africa. Stigma can affect people living with HIV as much as ill health. Rumours that polio vaccinations are part of a plot to sterilise Muslims or spread cancer have at times dogged the campaign to eradicate the disease.

All of these are colossal challenges and all have been tackled through sharing information, dialogue, debate and consultation. Yet health communication is often an afterthought within public health interventions – poorly funded, planned and integrated into wider responses. Why? And what can be done about it?

Embracing messy human change in an era of quick wins

In public health, clever policy tweaks can be appealing. ‘Nudges’, like offering financial incentives or changing how choices are presented, can sometimes shift health behaviours quickly. But such measures can only get us so far.

Beyond the low-hanging fruit, much behaviour is underpinned by social norms and stubborn human habits, which makes changing it a demanding and often indirect process. Bringing about such change also involves contending with complex, interconnecting issues like attitudes, perceptions and culture, which can be addressed by communication – but often in unpredictable ways and over significant timeframes.

These hard truths are well-known to communication specialists but can frustrate public health policymakers who often favour easily quantifiable variables, quicker wins and technical solutions to human problems.

Alongside a rightful excitement about new medical developments and the potential of ‘apps in the cloud’, communicators need to continue to make the case for the importance of ‘sandals on the ground’ to talk to mothers about breastfeeding their babies and to advise teenagers about sex. Until norms shift, conversations need to be ongoing rather than one-off, in order to engage each successive generation of children, of parents, of communities.

Bridging the evidence gap

Compared to other health interventions, communication has a reputation for having a weak evidence base. This reputation stems, in part, from disagreements about ‘what counts’ as evidence of impact in public health – a field in which where you often need a randomised control trial to back what you’re saying to get taken seriously.

Luckily, times are changing. Important figures in public health are realising the need to embrace a wider range of robust, yet practical, methods to evaluate the impact of complex community-focused health interventions. More resources are going into mapping the mountain of evidence that already exists around these approaches, helping build the case for investment and identify research gaps.

There’s also far more that communication specialists themselves can do. Under-researched areas, like communication for improved maternal health and addressing malaria, should be explored in more depth. Questions of cost-effectiveness and how to scale up successes deserve closer attention. Health communicators need to get better at insisting that their work gets evaluated and opening up what they do to external scrutiny. All of this would help build the quality and scope of the health communication evidence base, helping gain the respect of the public health sector as a whole.

A clash of cultures?

These issues remind us of the ‘culture clash’ that occasionally occurs between health communicators and other public health professionals. While public health programmes are typically run by people with backgrounds in the biomedical sciences, health communicators tend to be trained in anthropology, sociology or the media. A communicator’s instinct is often to start with questions rather than solutions, to focus on context rather than easily prescribed solutions. This tendency can be frustrating to those planning and funding public health interventions.

In addition, there are few academic qualifications in health communication, which matters in a field led by clinicians with lots of letters at the end of their names. In some countries, this has been addressed by including modules on health communication in post-graduate public health qualifications. However, much more needs to be done to build bridges between those with biomedical backgrounds and those offering important communication solutions to public health challenges.

Within health ministries, communication capacity strengthening needs to be approached in a more sustained and systematic way. Otherwise, there’s a risk that weaknesses in this area will lead to communication being approached without real strategy or scope. This would perpetuate underinvestment, increasingly so, as more and more public health funding is directly tied to the strategies of governments in the developing world.

Developing the field, building a brand

Finally, health communicators need to get better at collaborating and learning from each other’s work to help strengthen and raise the profile of their field. Communicators should also continue to integrate useful concepts and tools from new and exciting fields like human-centred design and behavioural economics into their work. It’s a crowded market place though, so they must simultaneously find ways to establish a distinct and inspiring ‘identity’ for themselves. In short, health communicators need to get out there and build their brand.

If we, as a public health community, are able to take on these challenges together, we may finally be able to channel the potential of communication to truly accelerate progress towards better global health and wellbeing.

Caroline Sugg is Head of Special Projects at BBC Media Action and is the author of Coming of age: communication’s role in powering global health. She tweets as @carolinesugg.

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Image credit: BBC Media Action

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