Urban health settings present many similarities but also several distinguishing fea- tures from other geographical, cultural, and/or physical contexts. Several authors have dwelled on the key characteristics of urban environments and their implica- tions for public health interventions and outcomes. While some of these factors include social determinants of health that are not unique to urban environments, they are often “transformed when viewed through the characteristics of cities such as size, density, diversity, and complexity” (Vlahov et al. 2007, p. 16) and contribute to health challenges that may be unique to or exacerbated by urban environments, including “poverty, violence, social exclusion, pollution, substandard housing, the unmet needs of elderly and young people, homeless people and migrants, unhealthy spatial planning, the lack of participatory practices and the need to seriously address inequality and sustainable development” (Waelkens and Greindl 2001, p. 18). Such differentiating factors include but they are not limited to (Hynes and Lopez 2009;
Vlahov et al. 2007):
• Physical Environment such as access (or lack of) to clean air, safe drinking water, garbage collection, etc. This also includes the built environment, which includes the quality and structure of buildings and transportations, access to facilities for physical activity and other indoor and/or recreational activities, etc.
• Social Environment which is defined by different authors both as differences in socioeconomic status (and resultant health inequalities, potential segregation, neighborhood violence, etc.) as well as the social structure and characteristics of people’s relationships within their communities, which may result in different levels and quality of the social support individuals and families may rely upon.
• Population Composition/Diversity as a result of migration, culture, gender and age distribution, language diversity, genetics, epigenetics, etc.
• Influences on People’s Health including government, health and social services, and civic society (including community and nonprofit organizations, and related community-based services and events).
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Implications for Health Communication Interventions and Training Efforts
All the above factors—and many others that may be specific to one urban setting—
influence public health and community development outcomes and interventions.
As expected, they also influence or should influence the planning, implementa- tion, and evaluation and refinement of strategic health communication interven- tions for behavioral, social, and/or organizational change/results. (Strategic health communication for behavioral, social, and organizational change/results is an area of theory, research, and practice that relies on the integrated, strategic, and pro- grammatic use of multiple communication areas and platforms. More specifically,
“health communication is a multifaceted and multidisciplinary field of research, theory, and practice. It is concerned with reaching different populations and groups to exchange health-related information, ideas and methods in order to influence, engage, empower, and support individuals, communities, health care professional, patients, policymakers, organizations, special groups and the public, so that they will champion, introduce, adopt, or sustain a health or social behavior, practice, or policy that will ultimately improve individual, community, and public health out- comes” (Schiavo 2013, p. 9.).
Because of the diversity and complexity of urban environments, health com- munication interventions often need to take into account the unique characteristics of the different communities that share the urban space. As for other contexts, “the term community can indicate a variety of social, ethnic, cultural, or geographical associations, and it can refer to a school, workplace, city, neighborhood, or orga- nized patient or professional group, or association of peer leaders, to name a few”
(Schiavo 2013, p. 181). In urban settings, the broader urban or city community is divided in many other communities, each tending “to share similar values, beliefs, and overall objectives and priorities.” According to UN-AIDS (2005), a commu- nity is a “group of people who have shared concerns and will act together in their common interest” (Schiavo 2007, p. 150). Within urban contexts, “equity, intersec- toral cooperation, and community involvement and sustainability” are key guiding principles to achieve healthy cities (World Bank 2010), which is something that requires the efforts and commitment of many different communities. Since health communication aims at achieving behavioral, social, or organizational results that would lead to improved public health outcomes, all differentiating characteristics of urban health settings apply—or should apply—to health communication interven- tions. In fact, health communication is an “evidence-based” and “people-centered”
discipline (Schiavo 2013), so the need for understandings contributing factors, situ- ations, needs, and preferences that shape a health issue is not unique to urban set- tings. Training modules on health communication in urban settings should focus on the entire communication cycle (Schiavo 2013) in order to equip participants with practical knowledge and tools they may apply to their areas of interest.
Yet, “when asked to identify key factors that may differentiate health com- munication interventions in urban health settings from those in other settings, respondents to an online survey chose social environment (and more specifically
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the component that refers to social support and social networks, potential isolation of people and groups, etc.), disparities in the availability and access to health and social services, diversity, and population density” as the top four differentiating fac- tors that distinguish health communication interventions in urban and nonurban set- tings (Schiavo and Ramesh 2010). Following is a brief description of how each of these factors influence or should influence the “health communication cycle—plan- ning; implementation and monitoring; and evaluation, feedback and refinement”
(Schiavo 2013, p. 28) in urban settings. Still, all these topics should be covered within comprehensive training modules on health communication theory, methods, and case studies.
• Social environment (and more specifically the component that refers to “the level and quality of social support and social networks, or potential isolation of people and groups, etc.” (Schiavo and Ramesh 2010), which may affect people’s ability to adopt and sustain positive health and social behaviors. For example, school and parental support have been shown to be protective against the effects of peer victimization, such as maladjustment, psychological problems, etc.
(Stadler et al. 2010). Moreover, smoking cessation programs that include social support and the resulting enhancement of people self-esteem are “usually more effective than those that ignore these elements” (Ma and Agarwal 2006). Social support is usually provided by significant others, such as family, friends, collea- gues, teachers, spiritual leaders, and other groups with whom people interact in their everyday life. In addition to its well-documented impact on emotional and psychological wellbeing, “the presence of social support has been implicated in alleviating the negative effects of several physical and health-related ailments”
(Ma and Agarwal 2006). Several existing communication models, e.g., Commu- nication for Behavioral Impact (Hosein et al. 2009), P-Process (Bertrand 2008), Communication for Development (UNICEF 2010), Communication for Social Change (Figueroa et al. 2009), already recognize the importance of key “influen- cers” and stakeholders on individual and community behavior (Schiavo 2013).
Key influencers are also referred to as “secondary audiences” or “secondary participant groups” in different planning models. Regardless of the terminology being used, communication planning should always include an in-depth analysis of the level of social support being received by different groups in urban cities as well as a profile of the key characteristics, values, attitudes, behaviors, and social norms of key influencers, so that communication interventions could be also effective in helping create and maintain social support as well as influen- cing attitudes and behaviors of those who may help achieve health and social behaviors results among key groups (for example, grandmothers or healthcare providers who may both influence the behavior of new mothers in reference to breastfeeding). Training efforts should include an overview of different ethnic, cultural, and socio economic groups as well as the level of social support or iso- lation they may experience within urban contexts at different times (for example, recent immigrants versus immigrants who have been already working and living in a new country for a few years). This should help raise awareness of the im-
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portance of social support among trainees, and increase the likelihood that this topic would be covered as part of the research being conducted to analyze situa- tions and to profile key groups during early phases of communication planning (Schiavo 2013).
• Disparities in the availability and access to health and social services: This relates both to the physical and social environments (see definitions earlier in this section). In fact, while availability and access to health and social services is often related to the physical presence of adequate institutions and infrastruc- tures within a given neighborhood (the physical environment), too often access is also conditioned by awareness (or the lack) of existing resources and/or health literacy levels that may create differences in the way such services are utilized.
Both resource awareness and health literacy levels are influenced by socioe- conomic conditions (which are part of the social environment). Since this is a very complex and multifaceted topic that may be influenced by different factors in different groups and neighborhoods, special attention should be given to a careful analysis of situations and needs (Schiavo 2013) and to structural inter- ventions that aim at modifying both the physical and social environments. More- over, changes in the policy environment, which is critical to removing physical barriers to access (for example, by creating structure and services within a given neighborhood), would further bolster impact. Training efforts on health commu- nication in urban settings should dwell—among others—on several topics that influence availability and access to health and social services—including but not limited to:
− Strategies to communicate with policymakers to achieve behavioral change within this important group and encourage them to prioritize and act upon specific public health issues (Schiavo 2013).
− Health literacy and its influence on: (1) provider–patient communication; (2) patients’ ability to navigate the health system; and (3) levels of community participation and engagement on key health issues.
− Sample strategies and tools to inform vulnerable and low socioeconomic populations and other key groups about existing resources and include and engage them in the health communication process.
• While the above topics are not unique to urban settings, they may gain added complexity in such a context and therefore should be considered for inclusion as part of case studies or interactive exercises during training sessions.
• Diversity: The importance of culture, socioeconomic conditions, age, geogra- phical location, ethnicity, and other key factors that affect people’s concepts of health and illness as well as their ability to act upon the health information they receive from a variety of source is a well-established concept both in public health and health communication literature in a variety of settings. Health com- munication planning relies on an in-depth understanding of all these factors so that interventions can be tailored to address and engage specific groups within planning frameworks, activities, and materials that are specific to their needs and preferences. In urban settings, the impact of diversity is magnified because of
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cities’ appeal to a variety of ethnic and socioeconomic groups and migrant popu- lation. Therefore, it is important that training interventions provide participants with skills and methods to segment relevant audiences/key groups of health communication interventions so that such segmentation not only informs health communication programs but also allows organizations to evaluate their ability to reach and engage different groups vis-à-vis past experiences, organizational capacity, budgets, and other key items to be considered as part of communication planning.
• Population density is an increasingly important factor in planning and managing health communication interventions. In fact, “cities are exerting growing influ- ence on the health of both urban and non-urban residents” while at the same time are shaped by “municipal determinants and global and national trends” (Galea et al. 2005, p. 1017). For example, population density is a key factor affecting rehospitalization and outcomes of people with severe mental illnesses (Husted and Jorgens 2000). Because of the limited number of support services and day hospitals, high population density has been associated with relapse of severe and persistent mental illnesses (Muijen et al. 1992). Moreover, “as Scott and Dixon pointed out, one of the difficulties in treating individuals with serious and persistent mental illness may be the lack of similarity between the stimuli that occur in treatment and those that occur in everyday living. In rural areas, where there is a relative absence of distracting stimuli in daily life, whatever happens in therapy may be assimilated more effectively” (Husted and Jorgens 2000 p. 604).
Outside of mental health, population density may also affect the ability of people to adopt and sustain health and social behaviors promoted by health commu- nication programs during outbreaks of infectious diseases. For example, high population density—which may result in crowded living conditions and high patient numbers in hospitals and other clinical facilities—may be an obstacle to the implementation of public health emergency measures such as social distan- cing and/or may undermine the adoption of safety behaviors in taking care of patients and loved ones (Schiavo 2009). Therefore, population density should be explored as one of the topics to be featured as part of case studies and other rele- vant sections of training modules and efforts on health communication in urban settings.