definition of communication, health behavior in health and disease

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CHAPTER VI
COMMUNICATION AND HEALTH BEHAVIOR
Objectives:
1- Define communication, health education, knowledge, attitudes,
belief and behavior.
2- Describe the communication process
3- Plan a session of health education
4- Describe the process of behavior change
Definitions:
Communication: It is a requirement for life in any society. It is the
process in which feelings or ideas are expressed as messages: sent, received
and comprehended.
The process of communication is dynamic, continuous, irreversible and
transactional. Communication is used in the medical field in history taking
through questioning skills and active listening. In counseling: by active
listening, and giving information and in health education for giving health
information.
Health education: To raise awareness of people to prevent disease and to
improve knowledge, attitude and practice of individuals for healthy living.
Knowledge: confident understanding of a subject with the ability to use it
for a specific purpose. Example: I know that vegetables contain vitamins. I
know that Egypt is in Africa. Sources of knowledge are: spoken or written
words, T.V, radio, internet.
Attitude: positive, negative or neutral view of a person, behavior or event.
Example: I hate smoking (-ve attitude to smoking habit). I prefer going to
private clinic rather than governmental health service (+ve attitude to
private care, -ve attitude to public care). It makes no difference to listen to
singer A or B (neutral attitude to both singers).
Belief: a subjective mental interpretation derived from perception,
reasoning or communication. Example: I believe that Quraan can cure
diseases. I believe that experience is better than knowledge.
Behavior: actions or reaction of a person in relation to certain
circumstances. Example: I go to doctor when I feel severe pain. He quarrels
if anything bothers him.
COMMNUICATION
Human communication is the process of creating meaning between two or
more people. It is the transferring of a thought or a message to another
party so that it can be understood and acted upon.
We can communicate : Ideas - Information - Norms - Values - Attitudes

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Elements of the communication process : Source - Message - Channel -
Receiver – Feedback.
Why do we communicate? (The importance of communication):
 To make people understand us and to understand others.
 To make us accepted.
 To undertake something.
 To strengthen the human relationships and social links.
 To spread the human spirit of friendship and cooperation.
Benefits in the medical field:
 To improve patient compliance
 To improve patient satisfaction
 To improve health outcomes for patients
 To improve the accuracy and efficiency of the consultation and
hence is more rewarding for the doctor
Elements of Communication
The Sender Who Sends the message: doctor, nurse,
parents, actor, teacher
The Message What Ideas, Information, Feelings,
Emotions. Can be at personal
hygiene, nutrition guide, safe
motherhood, risk factors etc
The Channel How Means of message transmission.
Face-face, group discussion, radio,
newspaper, conference, T.V,internet.
The Receptor To whom The personto whom we talk or the
one who receives the message.
Illiterate or highly educated, culture,
habits, traditions, language.
The Feedback With What
Effects
The information or the reaction
given to the receptor
Obstacles of Communication
What can interfere with communication?
1- At the source or emissionlevel
 Does not know the subject.
 Cannot communicate the message.
 Does not formulate clearly the objectives.
 Does not formulate well the message.
 Does not choosethe language of the receptor.
 Does not change the tone.

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2- At the message level
 Difficult words.
 Is not of interest to the receiver.
 Is not related to the stated objectives.
 Unclear, confusing.
3- At the channel level
 Noise.
 Not adapted to the message transmission.
 Not accessible to the receptor.
4- At the receptorlevel
 Indifferent to the message.
 Could not decode (understand) the message.
 Cannot receive the message.
 Poorlistening conditions.
5- At the feedback level
 Feedbacknot well prepared.
 Limited time.
 Selection of those who respond.
 Question poorly formulated.
Forms of communication
Verbal: By saying or writing words e.g. talk, discussion, conferences, or
Presentation, books, newspapers.
Verbal Communication Skills: the communicator must be
CLEAR= C: Clarify L: Listen E: Encourage A: Appreciate R: Reassure
Do not give orders. Do not attack. Do not be aggressive or ridiculous.
Non–verbal: Intentional (signs and movements), Unconscious (Feelings)as
way of client walking, sitting, hand movements, facial expression, vocal
characteristics (pitch, volume, rate).
Examples of communication skills used in the medical field:
(1) Skills of history taking
 Welcome the patient, stand up, shack hands.
 Call him/her with his/her name
 Asking in voice tone showing your care
 Asking one question every time.
 Giving open questions.
 During the client's answer, help her to continue.
 Asking the question in different ways to be sure that the client is
understanding.

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 Ask him/her about his/her interests in health, needs, fears
 Treat his/her feelings: shyness, worry, fear and anger.
 Sit facing the client.
 Look directly to the client but not continuously.
 Use encouraging movements as nodding and leaning forward.
 Care with the non verbal expressions shown by the patient.
 Avoid the movements that cause distraction as looking at the
watch or papers or around the room.
(2) Skills of communication in Counseling
Definition: Counseling is not guiding, recommending, persuading,
instructing and advising. Counseling is helping one person at one time. Or
several together, in a group or family to live in more satisfying and
resourceful way i.e. counseling is helping a person (or a group) to develop
self-help and self-care abilities.
Through counseling individuals are encouraged to think about their
problems and their causes and take personal decisions and actions that are
appropriate to them. For proper counseling: time, spaceand privacy should
be planned for.
Importance of Counseling
Counseling is valuable at any age, in health and in illness, whenever
adaptation to physical psychological changes is required. It is helpful to the
elderly and their care giver, as well as to children and their parents. With
regards to women's health counseling is appropriate at all her life stages,
e.g. puberty and family planning, motherhood and menopause.
It is also helpful for women undergoing hysterectomy, mastectomy, or
seeking treatment for infertility.
Counseling skills
I- Preparing Fora Counseling Session
Create the optimum environmental conditions for the development of an
effective therapeutic interaction, namely: physical setting, timing and
interpersonal space.
Physical Setting:
The ideal context is a quiet, calm, setting in which there is little chance of
being interrupted.
Timing: The maximum time allowed for each session ranges between 45-
60 minutes. The best timing is when the counselee is more likely attentive
not sleepy or in pain. Therefore it is inappropriate to attempt to counsel
family planning in a delivery room at time of labor.
The interpersonal space:

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The counselor should set a 90 degrees angle to the counselee, or side by
side, never opposite or across a desk. The degree of proximity between
counselor/counselee depends upon social factors. The greater the cultural
difference between the two, the greater is the inter space.
II- During the Interaction:
To be able to help the counselee to talk, disclose, reflect, think and take
decisions. The counselor should master the following skills namely:
 Ability to build trust
 Ask questions
 Respond therapeutically
 Listen attentively, summarize the problem to be clear
Building the trust:
People are more likely to talk about their problems with someone they
trust. Trust gives a sense of safety, decreases anxieties and allows for self-
disclosure.
Trust is built by keeping appointment; being on time, respecting secrecy,
privacy and confidentiality, by exhibiting an attentive behavior. To sustain
trust counselor should be unambiguous, i.e. verbal and nonverbal messages
should be consistent with one another.
Most important the counselor should be genuine, '' Dependably real, i.e. to
be whatever one deeply is '' this can only be achieved by developing a
positive sense of self and a therapeutic identity.
Asking questions:
Counseling is all about asking questions that will help the counselee to
work at their problem, to see for what it is, that is a problem that they must
do something about. The type of questions used in counseling is open-
ended questions as" tell me about your feeling". Such questions are
therefore richer and more informative than close-ended questions, because
they give the opportunity for a full answer. And clarifying questions as " do
you mean that ---". Clarification responses are expressed as a question or
statement followed by a restatement or a paraphrase of communicable
message.
The therapeutic responses that should be mastered by the counselor are
the ability to reword, paraphrase and summarize.
Reward or Restatement:
It highlights and defines elements of a verbal message. It is particularly
effective when the counseled over generalizes or seems stuck in a repetitive
line of thinking.

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Paraphrasing:
In both paraphrasing and summarizing the counselor reorganizes and
synthesizes the essential parts of the message into a concise statement. The
main points or recurrent themes are highlighted and understood.
Examples: A nurse says '' Today I left my mother at home alone, and I had
to come to work''. Paraphrase: You mean, you feel you have a conflict
between home and work responsibilities.
Summarizing:
A summary is a brief restatement of the main cognitive content and
feelings a speaker has expressed throughout a conversation. A summary
should be accurate, brief and complete. Its purpose is to:
 Shorten a lengthy interaction or discussion into brief sentences,
without missing the important points.
 Highlights progress in the therapeutic process: what has been
achieved and what is to be achieved.
 Acts as ending.
Counseling implies the following 4 steps:
1-Helping the counselee
2-Helping the counselee
3-Encouraging the counselee
4-Helping the counselee
To identify what is the problem
To discover why it is the problem
To look at possible solution
To choose an appropriate solution
Situations that need counseling skills:
 Any crisis situation- breaking bad news.
 Bereavement or grief.
 Terminal illness / palliative care.
 Marital problems. Family problems.
 Sexual dysfunction. Infertility.
 Chronic pain.
 Anxiety and stress. Depression.
 Intellectual handicap in child.
 Any disease or illness, especially severe illness.
 Sexual abuse/ child abuse. Domestic violence.
 Insomnia and other sleep disturbances.
(3) HEALTH EDUCATION
Aims at changing behavior of individuals towards healthy behavior.
It gives new information (unknown before) or change old wrong
knowledge.
 Health education covers all the areas of community medicine,
in health promotion (to give information to people how to be

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healthy) in prevention of health hazards (give information
about vaccination, smoking hazards) in control of disease (to
take treatment according to doctor advice) and in rehabilitation
(to use the remaining health capabilities).
 Health education is concerned with physical, mental and social
wellbeing
 It is life long process
 It can be directed to individual, family or community
Stages of behavioral change:
It is very important to know how people think towards their health, how,
why and when they change their behavior in order to design preventive
strategies. Health providers must play role in increasing awareness of the
community (specially the risky groups) concerning health problems,
explaining seriousness of disease to create a positive attitude among them
thus encouraging proper healthy behavior.
Health belief model:
1- Awareness of the problem: to perceive that there is a problem (to be
aware of the bad effect of high cholesterol level on health)
2- Interest: to show an interest in the problem (he becomes interested in
that subject and he considers that he may be victim of that
complication/disease).
3- Knowledge: need to know more to decide to change and adopt an
innovation.(to know more about cholesterol bad effect).
4- Attitude: to decide to take action.(he forms positive opinion about
the bad effect of high cholesterol level).
5- Legitimization: is that subject in line with legal, cultural, financial
and social acceptance? If yes it is easily to practice it?(are friends
and relatives have the same attitude? Is it costly to decrease
cholesterol? Can I do it without harm by any way? What are the
other barriers to change?)
6- Practice (action): try it to see its feasibility and effectiveness.( I try to
decrease fatty diets to see its effect on my health).An action can be
taken immediately if one friend or relative had recently a heart attack
(cues to action)
7- Sustainability: to keep the change for life (keep eating healthy diet
with low fat content).
Factors that affect health/illness behavior:
1- Age, sex, level of education, culture, religion, past experience
2- Recognition of symptoms, signs.
3- Seriousness of symptoms/signs
4- If these symptoms affect his ordinary life

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5- Persistence and frequency of symptoms
6- Personal tolerance to symptoms
7- Level of knowledge, cultural opinion about these symptoms
8- Fear of illness to be fatal.
9- Stigma : community opinion towards patients of that illness
10-Availability of medical services
11-Trusted services and health providers
Health belief model:
Model for behavior of diseased individuals:
Do nothing &
wait
Feeling of
illness
Self treatment,
folk medicine
Ask
pharmacy
doctor
Go to
physician
Non
compliance
to ttt
Compliance
to ttt and
cure
Perception of disease/hazard & its severity
Benefits
versus
barriers
Personal factors
Age, sex,
education,culture
psychology
External factors
Mass media,
disease of friends,
news paper,
doctor advice
Motivation
Positive
Action
Cancel/
no action
RelapseMaintenance

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As we mentioned in the previous models, the change in human behavior
takes steps, to be aware, to know, to feel desire to change, to change and to
keep that change. In a simpler way health education process is to change:
KAP= knowledge, attitude and practice. (deduce when to do health
education program using the previous models as a guide).
Health education is subtitle of communication. Communication can be
done in other subjects other than health but health education is specific
entity related to health and hazards related to it. Therefore health education
follows the same principles as communication mentioned before.
Planning for health education program:
"Who says what to whom by which channel" i.e.we should consider the
following: the message, sender, recipient, method, barriers for change in
planning a health education program.
1- Assessment (situational analysis) why people behave that way in
certain health problem? This can be done by doing pre-test
assessment of knowledge, attitude and behavior.
2- Design an objective (create message for health education), plan
resources, personnel, place, method of communication, etc).
3- Do pilot study for your plan and revise if needed.
4- Implement your message through the selected channel.
5- Evaluate by post test to assess change in knowledge, attitude and
behavior.
Application of PRECEDE PROCEED planning model for health
education:
(PRECEDE stands for) P=predisposing, R=reinforcing, E=enabling,
C=construction, E=education, D=diagnosis, E=evaluation.
The predisposing factors are knowledge, attitude, cultural beliefs and
readiness to change that give reasons for change.
Enabling factors includes the available resources and supportive policies
that enable persons to act according to their suggestion.
Reinforcing factors are rewards or incentives that encourage repetition or
persistence of good behavior as social support by family or peers, praise,
symptom relief.
(PROCEED stands for) P=policy, R=regulatory, O=organizational,
C=constructs, E=education, E=environment, D=development.
All these factors are environmental factors related to policy, regulations,
laws. The relation between different organizations that have role related to
health as education, agriculture, commerce, industry. These factors can
affect the health education program either by helping or obstructing it.
Therefore, PRECEDE-PROCEED is a comprehensive model for planning
and evaluation of health education. It starts by identifying health problems,

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their determinants by situational analysis including epidemiological,
environmental and administrative conditions which that can help or hinder
the program. Then plan the educational program and evaluate the results.
Community mobilization: is the process of bringing together all feasible
and practical inter-sectoral social groups to raise people awareness, assist in
delivery of resources and to strengthen community participation for
sustainability. Community mobilization should focus on building
confidence, trust and respect, increasing knowledge and enabling different
community members to participate and become more active as regard their
own health behavior. Problems of the community need to be solved by
them with the co-operation of others. On the other hand, individuals can
not change without the support of the surrounding community. Community
stakeholders (leaders and trusted persons) must participate in research,
development of message, program design, decision making and in
implementation. Public participation is important because:
1. The complexity and specificity of environmental issues. i.e there are
specific hidden items not known by outside experts but well known
by local inhabitants as culture, beliefs and traditions.
2. Increasing democracy, transparency and human rights.
3. Develops community skills and capacities to do similar work in the
future.
4. Nothing concerning me without me! Community participation
strengthen the success of the message because they share in it and
feel that they own it.