To establish some common ground about health communication, we begin with an overview of communication science and then use an adapted version of the HIV/AIDS continuum of care1 to identify roles that communication can play. Health communication is a subset of a much larger communication science discipline2 that in the latter half of the 20th century grew from diverse roots in sociology, psychology, anthropology, political science, electrical engineering, cybernetics, and, more recently, neuroscience. Thus, it is no wonder that there is sometimes confusion about what it is and how it affects health outcomes. Just as medicine and epidemiology are vast fields of research and practice of which no one can claim to have comprehensive knowledge, the field of communication science is also diverse and far ranging. Few, if any, communication scholars would claim expertise across the entire field, and so, it should be of no surprise that health and communication scholars trying to work together on HIV/AIDS prevention and care often understand each others' disciplines incompletely. This is not meant as criticism, but rather as an acknowledgment of the disciplinary boundaries that challenge our field—boundaries we hope the collection of articles in this issue of JAIDS will help to bridge.
What is Communication?
Even before we consider health communication and its application to HIV/AIDS, it may be helpful to briefly review how communication scientists tend to think about their own discipline. Communication is a fundamental human process without which most individual, group, organizational, and societal activities could not happen, including how people think about and respond to HIV/AIDS. Through communication, people come to know what is happening around them, both nearby and far away and, by talking to others, make sense of it.3 Communication is the mechanism by which teachers teach and learners learn,4 by which marketers promote products and services, and consumers decide what to buy and to consume.5 It is the means by which communities build consensus6 and enforce norms, and the means by which conflicts arise, discrimination is expressed, and convergence can eventually emerge.7 It is the process by which policies are negotiated and publicized to set political and institutional agendas.8 Of course, it is a critical aspect of how health professionals provide care and patients seek and use it,9 and the process by which a person is persuaded to do something healthy or unhealthy.10
Communication science2,11 seeks to understand these diverse processes and effects, including how different channels and types of information can be mobilized instrumentally and strategically in domains such as public health. Communication scientists recognize that communication occurs at multiple levels of a social ecological system, namely, intrapersonal (the realm of emotion, cognition, and decision making), interpersonal (the realm of social relationships), networks and organizations (the realm of norms and social structures), and macrosocietal (the realm of large social systems and culture).
However, there is a tendency outside of the field to think of communication not as a social process but rather as the messages or materials that communication produces, such as a pamphlet in a doctor's office, a pharmaceutical advertisement on television, or a home visit by a front-line health worker. Such a view narrows down the range of possibilities we can imagine for communication in HIV/AIDS prevention, care, and treatment. The Oxford English Dictionary 12 provides these process definitions of communicate:
Communicate, v. (1) to impart (information, knowledge, or the like) to a person; (2) to convey one's thoughts, feelings; to gain understanding or sympathy; (3) to take part in an exchange of information, ideas; (4) to have dealings, relations; to enter into social interaction or contact. From the Latin: communicare, to make common.
The mechanism through which these processes of information delivery, self-expression, exchange, and social connection and social regulation influence behavior are reflected in Cleland and Wilson's concept of ideation (as developed by Kincaid et al13,14). Ideation research shows that behavior (eg, going for an HIV test) is influenced by multiple factors, often simultaneously, including knowledge and attitudes about the behavior (eg, whether or not testing is beneficial), one's self-image (eg, as healthy or responsible), perceived risks (eg, of HIV infection), self-efficacy or confidence (eg, to protect oneself from HIV), emotional reactions to the health issue or situation (eg, fear of AIDS or of transmitting it to an unborn child), perceived social norms (eg, how common testing is), and the social influence of other people around you (eg, whether or not friends or partners approve of getting tested).
In the context of particular HIV/AIDS interventions, theory-based research about which of these factors are most strongly associated with desired behavioral outcomes informs the communication strategy, the design of messages, and the choice of communication channels. Strategically designed HIV/AIDS communication can influence all those factors in a positive direction, creating more positive attitudes toward HIV testing, shifting perceptions about HIV risk, increasing confidence to prevent infection, increasing the salience of social norms about testing, and encouraging friends to encourage each other to get tested. Kincaid et al13 have shown that these ideation factors have a kind of dose effect—the more factors that come into play at a moment of decision and the more that are favorable to the behavior, the greater the probability of the behavior.
Functions of Communication
Ultimately, most of us want to know how we can purposively use communication to achieve better health outcomes related to HIV/AIDS. Over the past 50 years or so, communication scientists in the “uses and gratifications” tradition, which studies how people use forms of communication to achieve personal goals and satisfy needs,15–18 have cataloged a wide variety of formal and informal communication functions, updating them as new technologies and modes of communication emerge, such as e-health,19,20 m-health,21,22 and social media.23
Although there are many nuanced variations of uses and gratifications, most communication scientists would agree on 4 major functions of communication: (1) to inform someone or to seek information about something, such as HIV risks, (2) to motivate or persuade someone to think about something in a particular way and to act accordingly, such as to appreciate the benefits of male circumcision and be motivated to seek the procedure, (3) to connect with others and to participate in interpersonal and small group relationships, such as peer support groups that provide social support for prevention among positives, and (4) to express and maintain culture and the norms through which social identities and values are shared and the social–structural environment is sustained, such as voicing approval (or disapproval) of homosexuality or sharing values related to support for people living with HIV. Another widely recognized function of communication is diversion, through which we seek entertainment and/or escape. Communication in this last category is relevant to the present discussion primarily because it relates to the use of entertainment–education strategies24 for persuasive purposes. For the purposes of this article, we focus on the information, persuasion, social connection, and social structural/cultural functions.
As health care providers and professionals, we instinctively think about communication directed at patients or clients for the purpose of health promotion. In the domain of HIV/AIDS, this means communicating with sexually active men and women, vulnerable women and girls, sex workers, men who have sex with men, and other high-risk groups to reduce risky behavior, encourage the uptake of gateway services, such as HIV testing, promoting uptake of services, such as voluntary male medical circumcision (VMMC), and encouraging treatment adherence.
But what about communication with families, schoolteachers and officials, work groups in the office, and even whole communities? How can we encourage a positive group influence over their members? What about communication with and among doctors, nurses, midwives, and other service providers who have underdeveloped interpersonal communication skills or who are unaware or distrustful of the latest science? How can we best communicate with them to increase their technical knowledge or improve their capacity for counseling? What about communication with community leaders or policy makers who do not understand or who ignore the feminization of HIV/AIDS or who support policies and laws that drive homosexual behaviors underground and exacerbate HIV risks? Communication can help to create and sustain a positive, supportive environment within which positive HIV-related behaviors can occur, and promote behavior change itself.
Channels of Communication
The channels or modes through which these types of communication occur usually include some combination of nonverbal/visual, oral/spoken, and written forms, with or without the aid of technology. Television, for example, projects nonverbal images and spoken words, sounds, and text, whereas interpersonal communication consists largely of nonverbal and oral content, and print media (even with pictures) are primarily written. Further, some channels, such as cell phones (which allow oral and—if it is a smart phone—visual communication), are portable, whereas others (eg, a television in one's home, landline telephony, a consultation space in a health clinic) occupy a fixed location.
Some channels allow interactivity—communication that occurs simultaneously or in a rapidly sequential way in >1 direction, such as a conversation between friends or a client–provider interaction—whereas some channels are primarily unidirectional, such as a radio or television broadcast. Channels that can deliver more complex and nuanced combinations of information, that can convey more personalized and more emotional content, and that are interactive—such as face-to-face communication and some emerging digital technologies—are considered “richer” media25,26 and are, therefore, more engaging.
What Can Communication Do for HIV/AIDS?
Of course, communication has no effect on the virus that is responsible for AIDS. It does, however, have powerful effects on knowledge, attitudes, social norms, risk perceptions, and behavioral decisions that affect if and when the virus is transmitted, where and when testing and/or care is sought, how care is delivered, and how well adherence to antiretroviral therapy (ART) is maintained. Communication scientists recognize that communication is a social process, not a discrete event. For example, a televised public service announcement about HIV testing may flash on the screen for 30 seconds, but—if it is an effective message—conversation about it between sexual partners may go on for days or months. Imagine a client reading an AIDS prevention poster on a clinic wall. While reading the poster may have immediate affective or cognitive effects, these may be only the beginning of an impactful process: the client remembers the poster information when she enters the clinic's consultation room, discusses it with a provider, returns home to talk about it with her husband, sees an AIDS prevention television spot in the neighborhood tea shop that reminds her of the poster and of her discussion with the provider, compares experiences over tea with her neighbor whose husband continues to refuse to practice safe sex, then returns home to demand that her husband use a condom until he has an HIV test. A single message can set a chain of message events and conversations in motion. It is this process—this series of events—not any one alone, which results in behavioral decisions and sustained behavior over time.
However, the most effective communication programs do not leave this chain of events to chance. Communication interventions are strategically designed to simultaneously address multiple psychosocial and behavioral determinants that may act as barriers to risk reduction or as motivators of service or product uptake. These are carefully and strategically framed and sequenced, based on rigorous, theoretically informed formative research to have an optimum effect on the intended audience. For example, formative research might indicate that the “active ingredient” in an effective ART adherence program should be stigma reduction, whereas VMMC uptake might need to be driven by support from traditional community leaders, and condom use might need to be encouraged by stronger couple communication. Each of these core communication strategies might be supported through a coordinated set of reinforcing messages delivered through multiple complementary channels.
Health communication is an important tool in the prevention and treatment of HIV/AIDS, as it is for many other aspects of public health,27–29 and, to be sure, much has already been written about uses of communication to combat HIV/AIDS. What is missing is a systematic and strategic approach to thinking about the roles communication can play in addressing the complex range of issues across the HIV/AIDS continuum of care1 or treatment cascade.30 First described by Burns et al31 in 2010 and elaborated by Gardner et al32 in 2011, the continuum of care (or treatment cascade) is used to characterize the stages of engagement by a patient with HIV/AIDS with the health care system and to illustrate the attrition that occurs from one stage to the next, with a decreasing number of patients at each stage. A version used by the Centers for Disease Control and Prevention (CDC),32 and slightly modified by the Department of Health and Human Services1 (Fig. 1), features 7 stages that begin at the point of infection.
The continuum of care, however, omits prevention efforts, which we view as a critical aspect of care for the uninfected. For the purposes of this article, we have adapted the United States Department of Health and Human Services continuum to include the prevention of infection because the comprehensive set of goals of HIV/AIDS communication should include minimizing the number of people who enter the continuum of care in the first place, and to minimize the attrition that occurs from one stage to the next among those who are already infected. Clearly, communication can play a role in various ways across these stages.
HIV/AIDS Communication Across the Continuum of Care
To date, the roles of health communication have not been conceptualized systematically across the stages of this continuum, taking advantage of what communication science indicates are appropriate and effective applications in other areas of health. Using this continuum as an organizing framework, we have linked it (Table 1) to the 4 main functions of communication described earlier: Information, Persuasion, Social connection, and Social structure.
Some communication functions may be more relevant at some stages of the continuum than others. Information and persuasion, for example, tend to be more important when new ideas or information are being introduced—such as the idea of condom use at first sex, VMMC for prevention, or treatment as prevention—or when it is necessary to create positive attitudes toward a behavior, to strengthen particular skills or persuade or motivate someone to practice it—such as communicating through mass media or through counseling in clinical settings about the benefits of HIV testing for oneself and one's partners, what testing entails, and where to get it. It may also be necessary to persuade individuals to seek care once they have received a positive HIV diagnosis, to maintain contact with service providers, and to initiate an ART regimen.
Social connection and social–structural functions of communication, however, tend to be more important when behaviors need to be reinforced or when people need the support of others to practice healthy behaviors successfully. For example, DiClemente33 showed that adolescents who believe their peers are using condoms are more than twice as likely to use condoms compared with teens who do not believe their peers use condoms. In prevention programs, it is often necessary to create normative support by encouraging communication between peers or partners about safe sex,34,35 about risk factors, and about multiple partnerships. In the postdiagnosis part of the spectrum, strong trusting relationships between partners and between patients and providers facilitate maintenance of care and treatment. A supportive professional work culture is important, too, where policies are strong and counseling skills, confidentiality, and commitment to delivering quality services are the norm. Finally, the public culture needs to be supportive in the sense that certain lifestyles are not stigmatized to the extent that they prevent engagement with testing and treatment programs, and communities are committed to protecting their vulnerable members and expressing support for people living with HIV. Additional roles for communication can be identified within each of the stages of the continuum.
Prevention of HIV acquisition and transmission to others requires changes in behavior, including risk reduction behaviors, and the acceptance and uptake of condom use or of high-impact biomedical interventions. As the prevention portfolio expands to include VMMC, prevention of mother-to-child transmission of HIV, and preexposure and postexposure prophylaxis, promotion of these procedures on a large scale at low cost becomes important. Mass media are well suited to publicize and convey the benefits of many of these options. For example, Cleland and Ali36 attribute large increases in condom use in Africa between 1993 and 2001 to HIV prevention condom campaigns, and Kincaid et al14 and Kincaid et al in this issue37 document the impact of Scrutinize and other mass media campaigns in South Africa on condom use and infections averted. Short-term change in behaviors after such campaigns are more often (but not only) reported by people who were already considering use and less often among people not already committed to use.27 Therefore, communication programs should aim to create those predispositions in the first place, if they are lacking. The early stage of a campaign can create demand and influence behavioral intentions through ideational change, encourage interpersonal communication about behavior, and model positive risk reduction,13,38,39 so that subsequent phases of the campaign can cue the already interested to action.
The original continuum of care begins with a diagnosis of HIV infection, which must be determined through an HIV test. A systematic review in 2005 found that communication plays a critical role here, as well, by creating demand for testing.40 People must know that testing can detect the presence of HIV, know where to obtain a test, and believe that the benefits of getting a test and knowing one's status outweigh the costs and risks. Because media penetration is so extensive in most countries now, media can help to overcome socioeconomic inequalities in access to information through traditional health systems and reduce stigmatizing attitudes in the general public that might suppress a person's motivation to get tested.41 Regardless of the outcome of an HIV test, communication follow-up is needed, often in the form of patient–provider communication, either to reinforce and maintain protective behavior so the patient can remain uninfected or to help the people who test positive to cope with their own emotional reactions, to increase self-efficacy to disclose their status to others, and to understand the social and behavioral implications of the positive test result.
Linking to Care
Once one's HIV-positive status is known, it is important to be linked to counseling and treatment. Networks of peers can be activated to provide psychosocial support, encourage healthy living, and advocate for preventing transmission of the virus to others. Referral to treatment and care services and communication about where and how to obtain them are critical at this stage, as well. Wamyenze et al42 found that counseling immediately after testing increases rates of successful referral to follow-up care. But patients need communication to help them realize that receiving care is beneficial and feasible, that the quality of available services is good, and that they should seek those services. Counseling and job aids can help providers encourage patient care seeking.
Staying in Care
Once a link with care is established, staying in care, including getting ART and adhering to treatment, are important because treatment and the counseling that goes with it is a lifelong process. ART does not eliminate HIV, and so taking a combination of drugs correctly every day is necessary. Long-term adherence to treatment requires constant patient education, encouragement, and reinforcement by providers, by peers, and by partners. Muhamadi et al43 found that counseling communication improves the uptake of care, and several meta-analyses confirm that effective communication during medical care leads to better adherence to treatment in general and in the context of HIV/AIDS specifically.44,45 Although quantitative evidence of the impact of new digital communication technologies on HIV/AIDS outcomes is still fairly limited, a 2013 systematic review indicated that mHealth tools (eg, alerts and reminders, direct voice communication, and information on demand services) can support linking to and retention in care, and adherence to ART.46
Maintaining a Low Viral Load
Lowering the viral load and keeping it low indefinitely controls the immunosuppressive effects of HIV, keeps the patient healthy, extends life, and greatly reduces the chances of transmitting HIV to others. Patients must maintain confidence in the treatment and its benefits, continue to obtain ART drugs, and adhere to the treatment regimen. In many cases, this means overcoming the fear of disclosure of one's HIV-positive status and convincing one's partner or partners and family to support the treatment process. Consistent use of condoms to prevent reinfection or infection of one's partner, in the case of a serodiscordant couple, is also necessary over the long term.
Patients are more likely to stay in care if its quality is high, so effective provider communication is critical at this stage, too. Communication programs can help ensure quality by training health workers in counseling and health education, by providing materials and job aids, by linking health workers to each other in referral networks and communities of practice, and by linking health workers to their clients through m-health technologies47 such as text messaging.48,49
New York City Health Department Case Study
To see what the integrated use of communication looks like, we turn to the example of HIV/AIDS communication delivered by the New York City Department of Health and Mental Hygiene during 2005–2013. As of 2012, there were 114,926 persons diagnosed, reported, and presumed living with HIV/AIDS in New York City.50 Just over 85% of those diagnosed had ever been linked to HIV care, and 41% of those estimated to be HIV-infected individuals were virally suppressed.51 To compete in an already saturated media market for the attention of >8.3 million New Yorkers,52 the NYC Health Department used multiple strategies to deliver HIV-related health messages. The following highlights some of the approaches this local health department has taken to promote improved outcomes along the HIV care continuum.
Preventing HIV Infection
In 2010, the CDC cited scientific support for including structural-level condom distribution interventions to increase condom use and reduce incident STIs (including HIV), especially among populations in high-risk areas.53 Traditional and digital social marketing (radio buys, subway ads, and website banners) plus earned media helped increase distribution from 2.5 million condoms per year in 2007 to >38.5 million in 2013. Branding the NYC Condom and promoting it through social media helped publicize and normalize condom use.
In early 2009, the Health Department developed the NYC Condom Facebook page to build condom awareness and increase user engagement, product/program visibility, and direct customer service. Currently, with >19,700 “likes,”54 the NYC Condom Facebook page was among the first applications of this social media platform in the United States to address programmatic questions and concerns, and to dispel misinformation.
By the end of 2009, the Health Department leveraged the audience from the NYC Condom Facebook page to launch an on-line condom wrapper design contest, which generated 11,300 new Facebook fans, and local, national, and international earned media attention. In 2011, the NYC Condom Finder smartphone application was unveiled. This free global positioning system-enabled condom finder and sexual health education guide allows NYC residents to find the 5 nearest places (clubs, bars, hair salons, and social service agencies) that distribute free condoms. To date, the NYC Condom Finder smartphone app has been downloaded >35,000 times. By 2013, all key Health Department condom distribution information had been fully enabled for a mobile environment (all mobile platforms) so that New Yorkers could obtain sexual health information when and where they needed it most.
Promoting HIV Testing
The NYC Health Department began to scale up HIV screening on a large scale in 200555 through a combination of traditional and new media marketing approaches. These efforts targeted New Yorkers ≥aged 13 years who had never tested for HIV. One strategy involved identifying heavily trafficked subway stations in the highest-prevalence neighborhoods and taking over every available media space (billboard space, tiled walls, and even the turnstile arms)—a tactic known as “station domination”—to increase public discussion and normalization of testing. In the Bronx, an area of intensive scale-up focus, the borough President allowed the Health Department to “wrap” clean air transport vehicles (vans that reached communities not otherwise well serviced by subways or other public transportation) with HIV messaging. Passengers began asking for more information, so the Health Department provided palm cards for drivers to make available to riders.
Starting in 2013, the Health Department partnered with the Kaiser Family Foundation to customize videos previously created for the Greater Than AIDS campaign.56 The videos featured prominent black celebrities promoting HIV screening and were shown before popular feature length films in movie theaters in high prevalence neighborhoods. An estimated 120,000 moviegoers watched the 30-second spot developed and released during the last month of 2013. Most recently, the Health Department has piloted the use of geographic and demographic targeted messaging during nationally recognized HIV testing awareness days. Examples include sending promoted Tweets, paid Facebook timeline posts, and Grindr pop-up ads, which all link back to Tumblr posts to promote community partner events.
Recent New York City community health survey data suggest that these approaches have succeeded: nearly 7 in 10 New York City residents aged ≥18 years reported in 2012 that they had tested for HIV, well above national averages and significantly higher than the 46.2% of adult New Yorkers who reported having ever HIV tested in 2004, the year before citywide expansion began. In the Bronx, a jurisdiction that has been the focus of enhanced, boroughwide social marketing and community mobilization,57 nearly 8 in 10 adults reported having ever tested for HIV in 2012.58
Linking to Care and Promoting ART Adherence
Health care disparities and low rates of viral load suppression among black and Latino men who have sex with men (MSM) lead to the launch of “HIV Care” on World AIDS Day 2013, a multimedia campaign primarily focused on encouraging prompt linkage to and engagement in medical care among young black and Latino MSM. The campaign's secondary aims include reengaging all HIV-infected MSM who may have fallen out of medical care, and reducing secondary HIV transmission.
“HIV Care” is an mHealth program that helps subscribers locate a clinic, set up their own appointment, medication, and medication refill reminders, and receive positive reinforcement messages. The texting program helps subscribers link to other ancillary services (ie, enrollment in the NYS health care exchange; information and enrollment in a peer-led health education workshop; the NYC Condom Finder app; and information on partner notification services).
Staying in Care and Maintaining a Low Viral Load
Short message service (SMS) reminders are known to improve HIV/AIDS antiretroviral (ART) medication adherence.46 “HIV Care” leverages this capability and incorporates it into a multiplatform approach that can reach different audiences through channels they prefer. The campaign itself was introduced on social media promoted Tweets; paid Facebook timeline posts; Tumblr posts; e-mail blasts through MANHUNT Cares (a social networking site for gay and bisexual men); and traditional media (press release, posters, palm cards). Once introduced, HIV Care functions primarily as a mobile health tool (with the SMS features listed above) and a web resource (an NYC Health Department-hosted web page).
Early data on “HIV Care” suggests great interest among the populations targeted. In its early release “HIV Care” ran Facebook ads that had average daily click through rates (ie, users clicked through to find additional content) that reached a high of 3.0%, much higher than the average of 0.04%–0.05%,59 and promoted Tweets that yielded an average of 7.28% engagement rates (ER) well above the typical rates of 1%–3% ER60 (the top promoted Tweet yielded 11.86% ER). Additional metrics being tracked for this campaign include overall site traffic generated to the dedicated campaign web page, unique visitors, traffic sources, bounce rates, and total number of subscribers for each SMS function.
Implications for Research
Although the impact of specific communication activities on specific HIV-related outcomes has been evaluated (eg, of text messaging on treatment adherence, mass media messaging on condom use), there has been little research on the effectiveness of integrated multimedia communication programs on HIV outcomes. For example, treatment adherence is most effective at suppressing viral load when several other behaviors occur simultaneously: consistent condom use, healthy lifestyle, routine care and testing, and so on. Each involves its own set of behavioral determinants that are influenced by communication, but the combined effects on viral load have gone untested. Other key research questions include the following: How does communication at one stage of the continuum (eg, about testing) affect subsequent communication (eg, between partners about prevention) and/or outcomes at later stages of the continuum? What are the most effective combinations of communication channels for specific outcomes (eg, does social media networking enhance the effects of mass media prevention or treatment messaging)? Finally, since suppressing viral load is a lifelong process among positives, how can we best measure the longitudinal effects of communication occurring through multiple channels over a period of years on maintenance, not just adoption, of protective behaviors? Also, how can communication help young adults maintain risk-free behavior over time and remain HIV-negative in the face of physiological urges, social pressures, and media content that encourages sexuality?
As the penetration of mobile telephony and social media into low-resource settings increases and as communication technologies become increasingly decentralized, the options for their use to combat HIV/AIDS expand. Portability makes it easier for patients to interactively control and personalize health information, exchanging visual and oral information and using local languages in a way that begins to resemble older, face-to-face communication channels.25,61 The explosion of e-health and m-health technologies and applications also illustrates the growing diversity of channels available to health professionals as we try to orchestrate the core functions of communication strategically for HIV/AIDS prevention and care.
Of course, communication interventions alone cannot overcome the challenges of HIV/AIDS in the absence of high-quality prevention and care services. But by the same token, biomedical interventions alone are unlikely to succeed without communication support that advocates for policies and services, publicizes and explains them to the public, and improves provider–patient interaction in service settings. Health communication interventions are more likely to succeed when they use multiple coordinated communication elements to reach people with consistent high-quality messages through a variety of channels (media, peer networks, and provider contact) and in a variety of forms (print, verbal, broadcast, informational, and entertaining). Communication expands both knowledge of and access to quality services and the products needed to practice healthy behaviors. At the same time, it creates demand and helps patients understand the benefits of new behaviors. Communication can strengthen social networks and reflect social norms that support healthy behavior, and it can help change norms that encourage unhealthy behavior. Communication helps providers explain services and treatments to patients and motivate them to use those services consistently and effectively. It helps shape and implement policies that ensure the availability of resources and services required to change and maintain behavior. Advocacy and public relations efforts shape public opinion, the content of the media, and the public health agenda.
The diversity of communication processes across the continuum of care—starting with prevention—suggests a growing number of ways that biomedical and communication interventions can be deployed in a complementary fashion to improve and sustain outcomes, if we are willing to seize the opportunity.
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