The Science Behind Effective Health Communication: Dr. Tesfa Alexander, Lerner Center for Public Health Advocacy at the Johns Hopkins Bloomberg School of Public Health

Lindsey Smith

I'm Lindsey Smith, welcoming you to Raise the Line with Osmosis from Elsevier, an ongoing exploration about how to improve health and healthcare.

We've spoken to many guests about the challenges of health communication in today's world of information overload, but none have the kind of expertise Tesfa Alexander has acquired in a career that has taken him from Madison Avenue to the halls of government and academia.

From guiding tobacco education research at the FDA to leading public health initiatives at MITRE, Dr. Alexander has shaped behavior change programs that influence national policy and public understanding. He's currently the Deputy Director of the Lerner Center for Public Health Advocacy at the Johns Hopkins Bloomberg School of Public Health and an associate practice professor at the university.

We're going to tap his expertise to understand the key elements to effective health campaigns and how public health professionals can successfully communicate in a time of mistrust in science and government.

Thank you very much for joining us today. 

Tesfa Alexander

Thank you so much for having me, Lindsey. Great to be here.

Lindsey Smith

I'd like to start with just learning a little bit more about you and what first got you interested in the field of public communication.

Tesfa Alexander

Yeah, you're taking me back. I think back to my days as being a youth and being really interested in the arts from painting to airbrushing to poetry and I went off to college with my mom wanting me to be an engineer and me saying, no, I really want to be a poet. And there was a bit of a tug of war there and eventually neither of us won. She realized that engineering was something that I could do, but it wasn't a topic that I was passionate about and I quickly realized that she had a good point that being a poet wasn't going to lead to a fruitful career. 

So I went on to study organizational communication and writing and moving on from there from undergrad going to graduate school to study organizational communication at Emerson College and while at Emerson College I had a variety of great internships in the educational space and then I landed a job basically to pay the bills by sheer coincidence at the Department of Public Health for the state of Massachusetts, where I was processing EMT applications.

During that time, my world just exploded and my worldview was widened in a variety of different ways in understanding public health and the aspect of what public health is and the great work that public health practitioners do. Up until that time, my understanding of health was just about the healthcare system, doctors, nurses, so on and so forth. And I had an introduction to public health at the Department of Public Health for the state of Massachusetts. I saw that there's a lot of great work that's happening in public health and it was an opportunity to combine my skills and interests with the experiences of the various public health practitioners that I worked with.

Lindsey Smith

That's a great story. So, aspirations of being a poet to getting into the communication space and then eventually landing in public health communications. So what are some of the core principles in health communication science, particularly as it relates to behavior change?

Tesfa Alexander

I would tell you the core principle really is understanding who your audience is. And I'll talk about health communication science, but at the end of the day, it's really about marketing and effective marketing. When we think about marketing, typically in the general public, we think about the promotion aspect of marketing and marketing as being the advertisements that you see, the sales promotions, so on and so forth. That is one of the four P's of marketing. And I actually like to talk about the eight P's of marketing. People, product, partners, place, price, process, evidence, and then promotion. And it starts with the people at the very beginning.

So who is your audience? What's your overall goal? What are their lived experiences and how do their lived experiences match with what your overall goals are? That's a core principle of health communication science and effective health communication science. It's not just about messaging. Messaging is important, but that's a tactic. That's the approach that we use to help us achieve our overall goals. 

And within marketing and advocacy and public health advocacy -- which is directly related to my role -- is playing the long game. So successful health communication campaigns, successful marketing campaigns, successful advocacy initiatives keep the long game in mind where you want to develop a long-term relationship with your target audience, the communities that you serve or the policy makers that you're working with. 

If you identify what are the things that are important to them, what are the goals and the values that they have and how can you fit within their story, within their lives, you could be a lot more successful in your health communication science efforts or your marketing efforts or your advocacy efforts.

Lindsey Smith

That's a really helpful framework. So to put some of this into context, can you talk a little bit about the tobacco education efforts you were involved with and how you evaluate their effectiveness?

Tesfa Alexander

Yeah, definitely. I am fortunate to have had the opportunity to work within the Food and Drug Administration Center for Tobacco Products for nearly a decade and work with a tremendous group of people, tremendous team, tremendous scientists, marketers, practitioners, stakeholders, the list goes on and on and on. And in that role, I led the health communication research and evaluation team where we were responsible for all of the formative research as well as the evaluation of a number of national tobacco education campaigns ranging from educating youth about the harms of cigarettes and e-cigarettes to smokeless tobacco, as well as educating young adults about the harms of intermittent use of cigarettes and other tobacco products. There are so many to choose from. 

The most notable campaign is the Real Costs campaign and that campaign has a number of variations. When I think about the success and the variations of the campaign, the primary flagship campaign was focused on reducing use of cigarettes among youth. Within the first two years of that campaign, we successfully exceeded our goal, where over 500,000 youth were averted from smoking cigarettes, and importantly, we led to billions of dollars in cost savings in the healthcare system from our work. 

We were able to evaluate or determine those outcomes from a number of valuation studies that we ha. Going back to my point before about playing the long game where we were patiently tracking awareness of the campaign, attribution due to awareness of the campaign associated with changes in beliefs -- not just that smoking causes cancer, smoking is going to cause you to die prematurely --but changes in beliefs that mattered to youth. 

So if you smoke, you will have wrinkled skin or if you smoke, you are going to have yellow teeth or lead to tooth loss. You may ask yourself, why would we pick those messages? And that's because we found research that found that those were the messages that resonated with youth. They were not interested in the long-term health effects of smoking. They were interested in the cosmetic effects of smoking and how that might inhibit them from being attractive to a partner or members of their peer group.

So from there, we were able to assess the impact of the campaign, changes in beliefs, and ultimately changes in behaviors, as well as the economic impact and savings for the healthcare sector in the long term.

Lindsey Smith

Thank you so much for sharing that example. Incredible results. So 500,000 youth were averted from tobacco use and then billions in healthcare savings. As I mentioned before we started recording the interview, my very first internship was with the Truth Initiative in Washington, D.C. back when I was in college. So this topic of tobacco prevention and education is really close to my heart. 

Tesfa Alexander

Thank you for mentioning that. We learned a tremendous amount from the Truth Initiative and the work that they did. We very much stood on their shoulders and are grateful for them paving the path for us at FDA to be able to learn from their success, to inform the Real Cost campaign, as well as from the success of others.

Lindsey Smith

That's awesome to hear. I want to come back to something you said in your earlier response about storytelling. What role does storytelling play in communicating health information?

Tesfa Alexander

Storytelling is critical. Storytelling is to humans as water is to fish. If you take into consideration how we process the world, how our worldviews are shaped, it's all through storytelling. Storytelling is in our newspapers, our media. Storytelling is religion. Storytelling is sports. Yesterday was the Super Bowl and the Super Bowl wasn't a report out of all the X's and O's, but a story around the redemption of a player, the story around the Super Bowl halftime show and what does that mean or what does that not mean? Stories about everything in between the game, the commercials that we watch and the discussion around those commercials. So, if you take into consideration how story is all around us, story defines who we are, it shapes our worldview. 

It's really important to acknowledge the value of story in public health and in healthcare and what storytelling can do for us as a field. At the end of the day, our goal as health professionals, whether it be in the healthcare setting or public health, is behavior change. And what leads to behavior change? Often, it’s emotion. It's not what we know, but it's what we believe and what we feel. We've been taught historically that data and science move people to action, which is true in part, but data and science, don't speak. Data and science don't have emotion. It's what we do with that data and science and how we translate that into a story that's relatable, that causes or encourages folks to think differently, to be motivated. 

So, storytelling is, immensely critical and what I would say going back to the importance of health communication and not being focused on the promotion aspect of it in health communication and marketing is the same thing applies to story. Often when we engage in story we think if we tell a really good compelling story then that's going to move people to action and I encourage folks to not start there. Start at the very beginning. Who is it that you're telling a story to? Whose story are you telling? We're drawn to character, not data, not science. Who's telling the story? So it's really important to make sure that you have a credible messenger and then go into how are you telling the story? So the promotional aspect, the storytelling, the delivery comes last. What's really important is the strategic steps that I just outlined that comes prior to the actual storytelling to make sure that your story is in fact impactful.

Lindsey Smith

Totally, and stories can be so powerful if delivered correctly. I want to talk a little bit about audience segmentation and cultural awareness in this work. How important is it?

Tesfa Alexander

Critically important, critically important. I appreciate you asking that question. At the end of the day, if we try to reach everyone, we reach no one. And we see time and time again, whether it's in consumer marketing or public health marketing, the best approaches are the ones that take the time to appropriately segment their audiences, as well as understand what are the social norms, the psychographics, the behavioral norms surrounding that audience. 

One of the things that I love to do is to eat. I love to be active and I love to eat. So hopefully they have some counteractive effects with one another. And when I think about my favorite food, there's poke, there's roti, which is a wrap from the Caribbean -- I am Caribbean -- that has curry, et cetera. And then my other favorite dish is a dish called moussaka, which is basically a Mediterranean-baked casserole that was introduced to me by a good friend of mine two decades ago when I was in Greece. And so you take into consideration those three different meals from three different regions of the world. 

If I were to walk into a restaurant and they were serving poke, roti, and moussaka, and they said, come in, this is the best poke, roti and moussaka that you're ever going to eat, I probably would turn around. And that goes to segmentation, right? So if you take into account doing something really well and being able to really understand who someone is, you have to be focused, you have to tailor your approach, tailor not just your messaging, but your overall marketing strategy, and your health communication plan to meet their needs, to meet the interests that serve them and what they're passionate about. 

At the end of the day, we need to move people to action and take into consideration moving people to action. If you develop a story and you don't understand what's important to them, then you're telling a story to the void. And you don't wanna tell a story into the void. You wanna tell a story to a person that appeals to them that motivates them to action and motivating them to action over the long term, not expecting immediate gratification.

Lindsey Smith

So just to kind of play that back a little bit, what I heard there was you must have a tailored approach, must remain very focused, understand what the audience is passionate about and how do we move them eventually into action. So thank you for sharing those really important points there. 

So, what are some of the strategies that help build trust in communities that may be skeptical of public health institutions?

Tesfa Alexander
Yeah, I'd say one of the first steps to building a strategy with communities that may be skeptical of public health institutions is identifying partnerships. I discussed the four P's of marketing, which are product, place, price, and promotion. Those are the traditional four P's of marketing. And my recommendation is that we expand those four P's of marketing to include people, partners, processes and physical evidence. 

Partners are critically important to answer your question and partners should come very, very early in the process. So, the way we engage with communities who are skeptical -- and may rightfully be skeptical of public health institutions and health institutions -- is to engage partners who are a part of those communities to understand what is driving that skepticism and understand it and listen with a clear mind, listen to that skepticism, judgment free, and understand why do they hold those beliefs? 

Our goal is not to change that person. Our goal is not to judge that person. Our goal is to understand why they hold those beliefs, why they may be skeptical, what are those barriers, and identify ways to overcome those barriers that address the needs that those community members have and that are working with them. So it's really critically important throughout our strategic planning on an execution strategy at the very beginning that we have partners on board who represent the community and also who the community trusts and respect. If we engage thoughtfully, intentionally with those partners, we can be tremendously successful.

Lindsey Smith

Absolutely. Glad you mentioned partners in the community there. I think that's really important. And building trust is really long-term work and takes a lot of consistency, humility, and a lot of listening along the way. So today, we are seeing misinformation moving fast, and it's sticking. I'm curious to know the approaches you've seen that actually kind of cut through that noise and help people sort fact from fiction in combating misinformation.

Tesfa Alexander

The approaches that I've seen have been focused less on combating information directly and working with the communities and the people who are consuming that misinformation. And the reason why I say that, and some color or thoughts around what I just shared, is that we take into consideration the sheer volume of misinformation that is out there and we, as a field, led a valiant attempt to directly combat that information. So let's try to match volume with volume. 

We know that now, looking back, that that is a losing battle, that we cannot keep up with the sheer volume of misinformation, whether it be through social media, traditional media, or in interpersonal settings and sharing interpersonally. And so what we need to take into consideration in strategic planning is what are the available resources that we have and where can we be most effective? What I strongly recommend is shifting our focus from combating misinformation head on because I believe and through evidence what we see looking back, it's a losing battle. 

Instead, how do we focus our time in and with the communities who we are seeking to serve and those who are disproportionately impacted by misinformation and working with them again to develop a long-term relationship. It’s teaching a person how to fish rather than fishing for them at the end of the day. We have to work with communities to understand what their barriers are, their challenges are, the skepticism that they have around and for public health institutions, and work to acknowledge that and their lived experiences and the stories that they're telling themselves. 

We tell ourselves stories every day about who we are, that's what we believe, and not try to counter that story, but just understand it. It will go a long way in helping ourselves as a field of public health think less about us versus them or misinformation versus correct information and just develop a shared understanding. So at the end of the day, working with those communities so that they understand the benefits of the public health initiative, service or product that we're providing in ways that are meaningful to them and their lives. And that's how we combat misinformation effectively.

Lindsey Smith

I appreciate the way you frame that and think it's really helpful to hear what's working on the ground because so many people, including me, feel overwhelmed by the sheer volume of information coming at them on a regular basis.

Tesfa Alexander

I do as well. It's daunting to think about and we know that there's still hope and there's still an opportunity if we refocus and shift our focus to the folks who are actually being impacted as opposed to the people who are sharing the misinformation.

Lindsey Smith

Absolutely. So at Osmosis, we are a teaching company and we love to fill knowledge gaps. Is there a topic you think Osmosis should make a video about to fill a gap that is of particular concern or interest to you?

Tesfa Alexander

Thank you for that question. Obviously I'm biased here for the topic that we're talking about, and thank you for the opportunity to share my thoughts on health communication science and marketing and the power of marketing. Based on conversations that I've had with other professors, students, and public health practitioners we often think about marketing within the field of public health as something that happens at the end of the game. This is what we do. Let's promote it. Let's figure out how to message it. 

And we could benefit from an understanding of the value of marketing and what marketing is from a people-centered approach and the value of strategic marketing. So my recommendation and something I'm personally pushing for is that every health care professional and student has a core understanding of the principles of marketing, the value of marketing, and how it applies to the work that they do, and more importantly, helping to support the communities that they serve.

Lindsey Smith

That's a great idea and we will definitely share that with our team. So, you already gave a little bit of advice to students and early career health professionals in our audience. I wanted to come back and ask if you had a little bit more advice for them about meeting the challenges of this moment and building a career in medicine.

Tesfa Alexander

Yeah. My advice to them in meeting the challenges of this moment is that if we look back in history, we see trends and phases. I am a parent of three children, a 13 year old, 11 year old, and a seven year old. And the best advice that was given to me when I was early in my parenting journey, was that everything is in phases. So, where you may be tackling one challenge with a two-year-old and then be tackling a new challenge with a five-year-old, seven-year-old, 13-year-old, so on and so forth. Everything is in phases. 

I apply that to the challenges that we face right now as a field of public health and challenges that the members of the healthcare industry may be facing as well. This is not permanent. If we look back and take an historical view at the funding booms and busts or if you take an historical view of waves and challenges around trust with public health professionals as well as healthcare professionals, we see that there are again booms and busts and trends. 

So, the idea here is to play the long game, not get discouraged and continue to focus on who matters to you in terms of communities you serve and helping them address their needs because improvements in health and health quality is not gonna go away. There's gonna continually be a need, there's gonna continually be a demand for the great work that we. So I want to encourage folks not to get discouraged and continue to do the great work that you are doing despite the headwinds that we may face.

Lindsey Smith

That's wonderful advice. Thanks so much for sharing that and for this entire conversation. Before we wrap up today's episode, is there anything that we didn't cover that maybe we should have?

Tesfa Alexander

No, you covered it all, Lindsey. I really appreciate the questions that you asked and the work that you all are doing to share the expertise of folks like me and others with your community.

Lindsey Smith

Thank you so much for being with us today, Tesfa. We really appreciate it.

Tesfa Alexander

My pleasure.

Lindsey Smith

And that brings us to the end of this episode of Raise the Line. A huge thank you to Tesfa Alexander for sharing his insights and helping us better understand what it takes to communicate clearly, credibly, and compassionately in today's health landscape.

I'm Lindsey Smith. Thanks for checking out today's show. Remember to do your part to raise the line and strengthen the healthcare system. We're all in this together.