Mechanisms behind effective public health education remain complex, and the best practices are seldom implemented. Consequently, too many health education programs, especially those that target high poverty, low literacy communities are unsustainable or unimpactful [1
]. Moreover, the excessive quantity of information from traditional and social media, coupled with the overwhelming volume of commercial advertising, has led to information overload and intense competition for the public’s attention [2
]. These factors are responsible for what has been called “the attention economy”, in which human attention is characterized as a commodity that is becoming increasingly scarce [3
]. Therefore, novel approaches to health education in this modern environment has become a public health imperative, especially among economically disadvantaged populations where existing disparities are the highest [4
A body of well-designed programs has been shown to improve health outcomes [5
]; however, the penetration of these programs into an economically disadvantaged population is often inadequate, and their sustainability is a major challenge. To date, an integrative approach to health education that considers both conventional and unconventional (those that incorporate new media, entertainment, and other art forms) methods has not been systematically explored, even though such an approach may hold promise, particularly for health education programs within diverse communities.
Current frameworks focus on constructs governing “why” a person engages in a certain behavior and consequently “what” needs to be a target of an intervention designed to address this behavior. They include (1) individual factors, such as attitudes, motivation, normative beliefs, and self-efficacy; (2) interpersonal factors, such as social norms and social support; and (3) constructs that target the different stages of behavioral change [9
]. For example, Health Belief Model [10
] and Theory of Planned Behavior [11
] address individual factors that affect one’s health, such as attitudes, motivation, or perceived behavioral control, just to name a few. Social Cognitive Theory [12
], Elaboration Likelihood Model [13
], or Social Support Theory [14
] build on individual models and consider social factors that influence one’s health including social support, modeling, and persuasion. The most recognized behavioral stage models—Transtheoretical Model [15
] and the Diffusion of Health Promotion Innovation Model [16
]—are predominantly concerned with stage-wise, step-by-step progression of adopting a healthy behavior. Finally, the Educational Entertainment concept [17
] focuses on utilizing different forms of art and entertainment as educational and communication tools. Although these frameworks represent valid and well-established approaches to health education, they tend to focus on constructs governing the “why/what” of human behavior, and lack specific strategies to help guide the design and implementation of effective health campaigns, which we refer to as the “how” of health education.
In addition to frameworks that address the “why/what” of human behavior, public health practitioners have recognized the importance of context in human health. Indeed, most successful programs consider the major social and environmental factors influencing behavior. We refer to these socio-ecological influencers as the “who/where” of health education. These levels of influence, which are expressed in the Socio-Ecological Model (SEM), [18
] include: (1) public policy, (2) organizations/institutions within the community, (3) community culture and social norms, (4) family and friends, and (5) factors that are intrinsic to the individual [19
]. However, while the Socio-Ecological Model (SEM) focuses on which level of the human environment (i.e., physical and social or “who/where”) needs targeting, it does not address the crucial question of “how” public health practitioners can best design effective health education strategies that permeate these levels. We attempt to answer the “how” question by presenting a functional framework outlining the dynamic relationship between the health education strategies and their levels of influence within individuals’ socio-ecological landscape. This framework—the Multisensory Multilevel Health Education Model (MMHEM)—represents an integrative health education model that provides practitioners with key constructs along with their operationalizable units for public health practice. Our model incorporates elements from both conventional and unconventional health education approaches. Indeed, by integrating unconventional strategies, such as leveraging culturally tailored artistic materials in the form of storytelling, music, animation, film, gamification, among others, our model moves beyond traditional approaches to health education.
The current article presents a Multisensory Multilevel Health Education Model (MMHEM) that encompasses the (1) “why/what”, (2) “who/where”, and (3) “how” of health education. The “why/what”, which reflects mechanisms governing human behavior, is often the target of existing health behavior models (e.g., attitudes, motivation, normative beliefs, self-efficacy, social norms, social support, etc.); the “who/where” reflects the levels of influence as outlined by the Socio-Ecological Model (e.g., family, community, organizations, public policies); and, the “how” considers methodological and innovative approaches to health education design, cultural adaptation, and implementation.
We deconstruct the MMHEM through the prism of an evidence-based intervention called Hip Hop Stroke (HHS)—a multisensory, culturally tailored, evidence-based intervention designed to increase stroke recognition and 911 calls (stroke preparedness) among urban minority children and their families [21
]. Due to the disproportionately high stroke case fatality rates among United States (U.S.) Blacks, and the correspondingly low acute stroke treatment rates, HHS was developed to increase the stroke treatment rates among this group. Acute stroke treatment is a time-dependent activity, because these life-saving treatments can only be administered to patients within 4.5 h from the onset of stroke symptoms. Unfortunately, among U.S. Blacks, stroke patients are often excluded from these treatments due to late hospital arrival, which, in-turn, has been linked to behavioral failure to act in an urgent manner when the symptoms begin (lack of “stroke preparedness”). HHS is designed for children (direct targets) because of the high proportion of children living with older high-risk parents/grandparents (indirect targets) in economically disadvantaged Black communities [26
]. These children, who may be the only witnesses present during a stroke event, are trained to act as first responders by immediately calling 911 upon witnessing a stroke in their home. They are also trained to serve as a vehicle through which stroke symptoms knowledge and their urgency are delivered to parents and grandparents at home. Hip Hop Stroke uses a novel multisensory, multimedia, and culturally tailored strategy to increase the appropriate behavioral action, which is to immediately call 911 in the event of a stroke, and thereby improve time-dependent acute stroke treatment rates. Importantly, HHS has been shown to be effective in a large randomized clinical trial (RCT) [25
HHS is an example of a public health education intervention that deploys art, culture, and science across multiple levels of an individuals’ physical and social environment. Our experience with HHS and evidence from its randomized trial [25
] suggests that the effectiveness of public health education campaigns can be optimized through innovative, culturally tailored, and evidence-based multisensory and multilevel approaches.
The MMHEM is built on well-established health education frameworks, predominantly the Socio-Ecological Model and Entertainment Education theory. However, several unique features distinguish MMHEM from the existing health education models: (1) it represents an integrative approach to health communication by combining conventional and unconventional methods of health education; (2) it outlines specific components of health communication and their targeted functions; (3) it provides an operational roadmap for the design, implementation, and evaluation of effective and multisensory health education programs; (4) it may help enhance the competitiveness of health education interventions in the “attention economy” of the modern world by mimicking persuasive and creative marketing approaches through its art domain; and, (5) it is a translational framework that enables researchers and practitioners to apply behavioral theory into practice by outlining the key steps involved.
In summary, the MMHEM integrates: (1) “why/what”, (2) “who/where”, and (3) “how” of an effective health education. It does this by highlighting specific and modifiable reasons for individual-level knowledge gaps, interpersonal barriers, and facilitators of health education (“why/what”); the socio-ecological levels of influence (“who/where”); and, the methodology of effective health education programming (“how”). When compared to existing health education models (see Table 2
), the MMHEM not only incorporates key constructs of several traditional frameworks, it goes a step further by deconstructing how its major domains—art, science, and culture—can be operationalized in a manner that synergizes with people’s social and physical environments and engages their individual health behaviors. We note that the concept of educational entertainment [17
] overlaps with the MMHEM in terms of its emphasis on different forms of art and entertainment as educational and communication tools. However, MMHEM expands on the educational entertainment framework by grounding these constructs within the socio-ecological context, culture, and science.
Although the Multisensory Multilevel Health Education Model is a promising framework to help guide the design and implementation of health education programs, several limitations of the model exist. First, the key constructs of the model have not been prospectively tested; rather, the MMHEM is the product of a retrospective analysis of a single, successful, widely adopted, evidence-based health education intervention, and literature review. Second, since the MMHEM is limited to a single stroke education campaign, it is important for public health practitioners to consider its applicability to their domains of interest, and the specific interventions designed to address them. Indeed, targeting multiple levels of socio-ecological influence is not always indicated or appropriate, and certain interventions may only require single level targeting. Finally, because we have not prospectively measured the specific constructs of the MMHEM, our deconstruction of HHS represents a qualitative illustration that requires validation. This may include the development of specific scales for measuring the key constructs of the MMHEM.