Unrelenting Somatic Interests

Health issues are personal, often demanding immediate and high levels of interaction and information. People view their health circumstance as unique and personal, yet health public relations can involve strategies and practices that apply across publics or audiences with many common traits. This tension between the individual experience of health and the state of health among populations often shifts the definition and perspectives of risk, for example.

Above all, interests are shared about the possibility of health discovery, cure, treatment, or prevention. Medical science holds promise. People now operate in a hopeful state, one that features human suffering as “knowable, mutable, improvable, eminently manipulable” (Rose & Novas, 2005, p. 442). To be human is to endure, always knowing that one’s biology is fragile yet capable of protection and treatment.

This hopeful state, and adding a unique dimension to the study and practice of health public relations, contains the framework of “biological citizenship.” What counts as citizenship now includes novel practices and new identities (Bakardjieva, 2009). As noted by a remarkable number of scholars, our citizenship is now encased in our very existence as biological forms (Agamben, 1998; Epstein, 2007; Foucault, 1991; Isin, 2002, 2004; Rose, 2007; Petryna, 2004). Thus, our biological identities, in addition to political identities, increasingly ground claims to the idea of citizenship.

The biological citizen is the emerging identity, a new citizen who sees claims to rights prioritized on a cycle of creating, problematizing, and resolving issues of bodily experience as they link to their fellow citizens and distinguish themselves from others on biological terms (Rose & Novas, 2005; Rose, 2007). These claims involve people expressing their connection to a nation, and to each other, for their health needs, practices, and desires.

Most importantly, states have become highly visible as biopolitical by taking an active interest in population health. In turn, the rise in the number of health‐related technologies continues to increase the scope and scale of diagnostic and therapeutic interventions. Citizens respond by turning their gaze toward concerns for their own health. This interest leads to claims to certain biological rights, including health‐care systems, treatment, and healthier standards of living. Thus, biological concerns have become a shared point of both interrogation and concern among the state, related companies, and its citizens. In this evolving landscape, for example, the role of the media and public relations practices intensifies the focus by all interested parties.

Mobilizing Online around Health Concerns

Just as people demand certain health rights based on their biology, they also mobilize as disease‐ and illness‐related groups and forums, actions made simple through digital communications. Social media suit health concerns well, for example. And people favor immediate information online when faced with a troubling health condition (Avery et al., 2010).

It is no surprise, then, that health information is one of the most riveting topics for news consumers (Brodie et al., 2003). In 2013, 72% of US internet users said they had looked online for health information within the past year (Fox & Duggan, 2013). The most commonly researched topics are specific diseases or conditions, treatments, or procedures and doctors or other health professionals. Most adults turn to a medical professional, family, or friends when faced with a serious health issue. However, those living with chronic and rare conditions are much more likely to go online to find others with similar health problems (Fox, 2011).

“Health information seeking behaviors” is a phenomenon that can be traced to several trends. Patients are increasingly active in treatment choices, self‐monitoring, and self‐care. Some have argued that health blogs allow patients to deal with their illness just as they inform and influence others (Sundar, Edwards, Hifeng, & Stavrositu, 2007). Integrated and cross‐promotional health public relations efforts are another trend influencing this behavior. For example, one study found that the likelihood of people changing their online search behavior can be associated with media coverage of public figures or celebrities with similar health problems (Abedi et al., 2015). Another found that health websites that include blogs and wikis are vibrant forums of discussion and viewed as credible sources of information (Kovic, Lulic, & Brumini, 2008).

Ethical Considerations

Rising interests in health concerns among many actors strengthen the need for more scholarship and reflection about the ethical considerations of practice in this specialized area of public relations.

Key ethical dilemmas involve, for example, the role of public relations in persuading publics to adopt certain treatments or modalities to diagnose, treat, or prevent illness or injury. Such persuasion always seeks to instill confidence and trust in organizations, or actors, involved in health such as hospitals, health‐care facilities, governments, and medical device manufacturers and pharmaceutical firms.

Tensions flourish among these health actors related to motivations and interests. For example, a clinic promotes its diagnostic imaging – x‐rays, computerized tomography (CT) scans or medical resonance imaging – for people to gain insight about their health. However, the medical community gets concerned when CT examinations are used without a proven clinical rationale, when alternative modalities could be used with equal worth, or when CT scans are repeated unnecessarily (Hall & Brenner, 2008). Physicians are also influenced by pharmaceutical companies. From the mid‐1950s, pharmaceutical companies began thinking systematically about nurturing key opinion leaders such as physicians and other respected medical researchers to speak and write positively in articles and books about their products (Sismondo, 2013). These activities now stretch around the world.

We may also question the ethics of persuasive appeals related to health. Is it ethical to slightly exaggerate risk to persuade people to avoid potentially unsafe practices? Related, are highly emotional appeals moral, such as stories or images of disease victims?

How journalists construct media stories about health can involve public relations decisions about the use, or absence, of certain information. Public relations tactics happen in an environment where, as noted by Hinnant, Len‐Ríos, and Young (2013), journalists tend to select examples to inform, inspire, or sensationalize a health issue or product. An additional ethical concern is the use of information subsidies, or information from public relations sources and others, among journalists. General assignment journalists depend on subsidies because they may know less about the story subject, and specialty reporters may use them to meet deadline pressures (Len‐Rios et al., 2009).

Risk Communication

Risk surrounds us. We make sense of threats based on our beliefs and the tone, type, and sources of information received. Risk communication as a field of study and practice finds its foundation in this subjectivity because health risk includes factors that can be calculated but not always. These factors include genetics, other health problems, age, lifestyle, and environmental exposure. However, an individual’s perception of risk is crucial to how they determine their course of action.

Risk communication is a body of communication theory that offers insights into how crises and worrisome situations alter the usual rule of communication (Covello, Peters, Wojtecki, & Hyde, 2001). Risk communication as a practice and area of theory development and study offers principles and tools to communicate effectively during times when publics or individuals are most worried about their health and well‐being.

However, the study of risk communication theories is more than understanding how people process immediate concern in the face of a health threat. We should take a more proactive view of publics as informed, involved, interested, and solution oriented. Success is measured by people’s ability to make sound decisions. Most often, the communication process is characterized by the receiver’s perspective, the message perspective, and how to communicate risk numerically and visually (Turner, Skubisz, & Rimal, 2011).

Within the body of risk communication theory, the social amplification of risk framework offers a window to examine the role of public relations in communicating levels of threats to health (Kasperson et al., 1988). This framework calls for the study of how hazards interact with psychological, social, institutional, and cultural processes in ways that may amplify or attenuate public responses to the risk or risk event. Risk is amplified at two stages: the transfer of information about the risk and the response mechanisms of society. The news media, for instance, are one “amplification station” that processes signals about risk.

Cultural Theory of Risk Communication

The cultural theory of risk communication is a politicized view because all societal actors are seen as interpreters of risk. The meaning of risk is negotiated across institutional and organizational levels under a “risk democracy” perspective (Coman, 2013).

Risk is socially constructed with a host of meanings attached to various individuals. Public relations practice in health is informed by this theory to analyze population segments based on their experiences and perspectives of risk. A new waste treatment facility, for example, may be perceived as a source of jobs to some members of the community or the cause of a worrying cough in local children. Depending on the perspective, the cultural theory of risk communication gives us pause to think about those who may be seen as creating or bearing the risk.

Anthropologist Mary Douglas broke ground by using cultural theory to research risk as a cultural phenomenon. Risks are crises and often scientific events, but are also political and cultural. In her later work, Douglas (1992) links risk to a “blaming system,” a process where blame is aimed at villains such as large corporations while scientists and technicians whose work may have initially produced the risk remain blame‐free.

This theory is a way of interpreting how and why people make decisions about threats to their health. Such judgments are part of an evolving social debate about rights to know, justice for those likely to be affected by damage or loss of peace of mind, and about blame, responsibility, and liability (Tansey & O'Riordan, 1999).

Cultural theory provides health public relations scholars the opportunity to view receivers of information as powerful actors who actively shape the type of communication they need. The theory is based on the presumption that those receiving risk messages are active and that those creating the messages interpret the information to suit their interests. Meanings of health risks are constantly negotiated between the organization and its publics, with power at the center of these deliberations. The levels and types of health risks are inherently political and controversial among these active publics.

This social theory is important for health public relations because it considers different meanings of risk in terms of its construction and relevance. For example, journalists have different views about the risks of a new health product based on interviews with families than members of the medical profession. The cultural theory of risk communication reminds us to analyze wide groups and individuals when dealing with health risks, to understand how risk is translated and moderated.

Relationship Theory of Risk

Another social theory useful in the study of health public relations is the relationship theory of risk. According to this theory, a perception of risk results from the same object or practice being framed as threatening or useful. Our perceptions are shaped by the associations made in communications between dangers and benefits.

In their study of antibacterial silver, Boholm et al. (2015) noted that although the material is increasingly used in health‐care products such as bandages, clothing, household products, and makeup, it is also controversial because of its risks. The controversy over antibacterial silver was constructed from two adversarial positions, using the relational theory of risk. Silver is a risk object, endangering organisms, public health, the environment, and sewage treatment. However, the association between silver and objects at risk is obstructed by referring to it as “safe” and characterizing it as suitable for consumer and health‐care products. Their study highlights that the actual concerns of stakeholders should be considered in risk communication.

The same could be said about communications involving the risks of radiation. Radiation saves lives in medical diagnosis and treatment, yet high doses of radiation can damage health and kill. This theory is instructive for the study of messages with respect to the uses of radiation as both curative and dangerous.

Uncertainty Management Theory

Uncertainty management theory challenges scholars to take a neutral stance about the strength or weakness of ambiguous information. At its core, it is rooted in the assumption that uncertainty is appraised for its meaning and is not inherently negative (Brashers, 2001). Only the appraisal of uncertainty influences subsequent behaviors, such as seeking information or taking other actions (Rains & Tukachinsky, 2015).

Illness is unpredictable and people cope with these uncertainties through communication. Just as wrong or contradictory information can raise more questions than it answers, too much information can create uncertainty and concern. However, minimizing uncertainty may not be the only solution to deal with doubt. Instead, according to this theory, we should examine the free will of people to determine how they want to cope with uncertainty. For example, people facing a terminal illness may maintain or increase their uncertainty, particularly if this option means that they can stay hopeful about their chances of living longer.

For health public relations, this theory reminds us of the costs of communication actions. Too much information may overwhelm people, while information that forecasts disease may be counterproductive if it decreases rather than increases people’s attention to health and well‐being (Brashers, 2001).

Uncertainty Reduction Theory and Problematic Integration Theory

Reducing uncertainty must surely be a goal for health public relations scholars and practitioners. Two related theories in interpersonal communication, uncertainty reduction theory and problematic integration theory, provide a foundation to study, analyze, and strategize in public relations related to health.

Uncertainty reduction theory asserts that people need to reduce uncertainty about others by gaining information about them (Berger & Bradac, 1982). Information comes from observation, asking others, and direct interaction. In public relations, we can theorize that uncertainty is inherent in health matters and that these three modes of information gathering inform and reduce the ambiguity. The landscape of health public relations is variable due to changing perceptions of disease and illness, medical treatments and technologies, and health outcomes. Even though total reduction of uncertainty is impossible to achieve, uncertainty reduction theory reminds us that relationships can be managed and considered.

On the other hand, and as a complement to uncertainty reduction theory, problematic integration theory helps us understand how messages are received, processed, and made sense of. Two kinds of orientations are found in this theory: assessment of how something will happen, and whether we feel positive, negative, or neutral about the outcome. We experience problematic integration when these orientations do not match.

Using problematic integration theory could help health public relations scholars theorize why certain campaigns fail or succeed. For example, messages about the importance of safe sex practices may misalign with an infrequent occurrence of sexually transmitted diseases among certain populations.

Uncertainty has a powerful place in health public relations as an ethical imperative. For example, a drive to reduce uncertainty about the state of health and illness has led to a culture of chronic illness (Brashers, 2001). Public relations plays a role in this culture. In particular, society operates within a “political economy of hope” that links many actors, including patients, families, medical practitioners, states, markets, scientists and researchers, with therapeutic practices, research funding, and the search for treatments and care (Rose, 2007).

Narrative Theory

Above all, health public relations surrounds stories, narratives that describe human experiences of struggle, demand, resistance, and triumph. Public relations theorists and scholars help explain this storytelling phenomenon.

Knowledge of the basic elements and purposes of narratives is foundational to health communication scholarship (Sharf, Harter, Yamasaki, & Haidet, 2011). The story of someone escaping health danger by taking measures and precautions is a cautionary tale for people suspicious of immunization for their family. An improved quality of life from a new regimen of antidepressant treatment offers others hope.

Public relations scholarship examines the field as a bridge for health‐care providers who often know the plot of the story yet struggle to adequately impart this to their patients. On the other hand, public relations can give voice to patients and worried members of the population to tell their stories as the ignored or powerless in health systems.

Narrative theory provides a perspective about why all stories are not equally powerful. Two criteria determine a story’s strength: coherence, how much sense the story makes, and fidelity, the degree to which the story fits with our views and experiences (Fisher, 1987).

Kent (2015) dissects narrative theory into 20 “master story plots.” Three of these plots are most useful for health public relations scholarship: the transformation, metamorphosis, and underdog plots.

According to the “transformation” plot, complete change happens when someone experiences a life‐changing event like the loss of a loved one from heart disease, a patient dies waiting for treatment in a hospital emergency ward, or a child hears for the first time because of cochlea implant technology.

The “metamorphosis” plot involves an about‐face change from one form to another. Health technologies enable these physical transformations, while activist organizations and others communicate, for instance, about emotional changes to people resulting from greater discussion and understanding about transgendered identities.

The “underdog” plot involves stories about a fight against a larger entity, a person or a group who struggles yet wants little spotlight on their concerns. The underdog narrative brings focus on ignored or unknown health issues and concerns, helps raise funds for charities, and fights for causes.

Organization–Public Relationship Theory

Organization–public relationship theory emphasizes the relationship as a unit of study (Ki, 2014) and has been regarded as one of the most critical concepts in public relations. The premise is that an organization will increase the likelihood of achieving certain goals if its public relations efforts emphasize building and maintaining mutually beneficial relationships with publics (Bruning & Ledingham, 1999). Mutual benefit can be economic, social, political, and cultural, involve all parties, and is characterized by mutual positive regard.

While the field of public relations inherently involves publics, or the public, organization–public relationship theory explicitly defines and studies what constitutes these relationships themselves (Broom, Casey, & Ritchey, 1997). One key element of this theory is that public relations researchers and practitioners can study relationships as phenomena that are separate from the perceptions held by the individuals, groups, or organizations in the relationships.

Time and again, scholars have proven that the strength and quality of organization–public relationships depends on organizational effectiveness, recovery from crisis, public attitude and behavior, and the organization's reputation.

Nowhere is this transformation more obvious than in health. The application of the dimensions within organization–public relationship theory to health public relations is crucial to understanding how and why quality relationships are built and cultivated to achieve goals and objectives.

As a theory focused on the qualities of the best relationships, this theory provides great flexibility for the study of health public relations. For example, one study of the organization–public relationship in a hospital emergency department found that structural barriers and an overreliance on asymmetrical communication strategies fostered a culture of mistrust, cynicism, and noncompliance among internal publics (Seltzer, Gardner, Bichard, & Callison, 2012). The study suggests that the relationship management perspective could extend to include organizational culture. Here, the use of organization–public relationship theory in a health‐care setting allowed for study of how the quality of internal relationships could affect the relationship with publics depending on health services.

Situational Theory of Publics

The situational theory of publics reasons that publics can be identified and classified to the extent that they are aware of the problem and do something about the problem.

Grunig (1997) describes three factors that influence whether a public passively takes in information or actively seeks further information and then is more likely to change its attitudes and behaviors: problem recognition, constraint recognition, and level of involvement. These factors are relevant to health public relations with its inherent focus on bodily issues, risk, and the need for involvement among often large publics and audiences.

The situational theory of publics is useful because it helps segment publics into four types that allow for greater communication effects: active, aware, latent, and nonpublic (Grunig, 1997). This theory could be used to develop distinctive messages for different publics and leaders, for example, as they prepare for a health outbreak. Here, communication effort would target community leaders with high involvement and medium‐to‐high problem recognition but potentially constrained by a lack of knowledge about how to prepare. Focus groups could pinpoint how leaders perceive the problem, their levels of involvement, and limitations, research that could shape information for these leaders.

Risk Communication

Risk communication theories help us understand how people process health threats and opportunities.

For example, a case study of public relations strategies among “downwinders” exposed to releases of radioactive iodine from the Hanford Nuclear Reservation in the 1940s and 1950s found that having the right message in an appropriate format is an important element of risk communication (G. Thomas, Smith, & Turcotte, 2009). Public relations about this potentially life‐threatening health concern worked better than advertising owing to mistrust among the target audience. “Downwinders” received key messages from existing and trusted community networks and opinion leaders. Those affected were part of two‐way interactions with public relations tactics that considered how these key publics preferred to receive personal or sensitive health information.

Cultural Theory of Risk Communication

The cultural theory risk communication allows us to analyze an expanse of groups and individuals to understand how health risk is translated and moderated.

In one study, US Congressional testimony was examined concerning regulation of tobacco advertising by three policy factions representing industry, government, and lay activists (Murphy, 2001). Using the cultural theory of risk, the study analyzed the ways these three groups framed the tobacco advertising issues. It found that testimony by each of the three groups reflected their cultural biases toward health risk. Some of the discourse patterns involved seeing tobacco advertising for the public health issues it raises, the challenges of regulating such advertising, and government intrusions into people’s decisions about their uses of tobacco.

The cultural theory of risk communication here highlights that cultural biases that underlie positions taken by groups often present the greatest barriers to negotiation. Using cultural theory to analyze health public relations efforts and results can reveal group concerns and similarities and differences.

Uncertainty Management Theory

Uncertainty management theory calls for scholars to take a nonjudgmental stance about the strengths or weaknesses of ambiguity. This theory holds considerable appeal for health public relations scholars because of its neutrality about the role of uncertainty. When uncertainty produces anxiety or other negative emotions, it is viewed as a threat, but when uncertainty excites or offers hope, it is appraised as an opportunity. For example, individuals diagnosed with a life‐threatening illness, such as AIDS, might fear the unknown and desire certainty, or they might prefer uncertainty to the inevitability of death.

Several case studies highlight the use of information to manipulate uncertainty. For example, the US Postal Service produced a prostate cancer awareness stamp to elevate public understanding of the disease. Instead, the stamp led to confusion, anxiety, and an unhealthy preoccupation with illness (Woloshin & Schwartz, 1999). Considering the public relations implications of employing stamps to achieve a certain health awareness did not foresee the effects of increasing uncertainty about the likelihood of cancer.

In another case, uncertainty management theory was used to study which participants were primed to feel and want more or less uncertainty about skin cancer (Rains & Tukachinsky, 2015). Participants were given the opportunity to search for skin cancer information on the internet. Findings highlight the complex relationship between information seeking and uncertainty management. The results show that the depth of information people seek relates to their desired level of uncertainty. Use of this theory in this case offers insights about the degree to which people will seek information to manage how much uncertainty they want.

Situational Theory of Publics

The situational theory of publics argues that publics can be segmented to determine whether they will passively take information or actively seek further information.

A study of Text4baby, a large national texting health initiative, uses the situational theory of publics to explain its success (Aldoory, Roberts, Bushar, & Assini‐Meytin, 2018). Text4baby aimed to lower the risk of infant mortality by responding to the information needs of pregnant women.

The study used this theory to analyze Text4baby messages and interview data with the project content developers. They used the situational theory of publics to understand the types of publics that might emerge from Text4baby’s audiences of pregnant women. Text4baby demonstrates how cues to pregnant women can allow them to become aware and active publics in their prenatal health‐care practices.

In another use of this theory, Meng, Pan, and Reber (2016) reviewed award‐winning public health communication campaigns from the National Public Health Information Coalition from 2010 to 2012. Among award‐winning campaigns that did mention health risk, about two‐thirds of them recognized situational problems relevant to unique public health issues. The emphasis on situational factors reinforces the value of the situational theory of publics in the public health arena.