THE HISTORY AND DEVELOPMENT OF THE FIELD OF HEALTH COMMUNICATION

Gary L. Kreps, Ph.D.
National Cancer Institute

Ellen W. Bonaguro, Ph.D.
Ithaca College

Jim L. Query, Jr., Ph.D.
Loyola University, Chicago

(IN: L.D. Jackson & B.K. Duffy (Eds.). (1998). Health Communication Research: Guide to Developments and Directions, Westport, CT: Greenwood Press, pp. 1-15.)

The Study of Health Communication

Health communication has developed over the last twenty-five years as a vibrant and important field of study concerned with the powerful roles performed by human and mediated communication in health care delivery and health promotion. Health communication inquiry has emerged as an exciting applied behavioral science research area. It is an applied area of research not only because it examines the pragmatic influences of human communication on the provision of health care and the promotion of public health, but also because the work in this area is often used to enhance the quality of health care delivery and health promotion. To this end, health communication inquiry is usually problem-based, focusing on identifying, examining, and solving health care and health promotion problems.

Communication and Health Information

Within the health communication field, communication is conceptualized as the central social process in the provision of health care delivery and the promotion of public health. The centrality of the process of communication is based upon the pervasive roles communication performs in creating, gathering, and sharing "health information." Health information is the most important resource in health care and health promotion because it essential in guiding strategic health behaviors, treatments, and decisions (Kreps, 1988).

Health information is the knowledge gleaned from patient interviews and laboratory tests that is used to diagnose health problems. It is the precedents developed from clinical research and practice used to determine the best available treatment strategies for a specific health threat. Health information is the data gathered in check-ups used to assess the efficacy of health care treatments. It is the input needed to evaluate bioethical issues and weigh consequences in making complex health care decisions. Health information is the recognition of warning signs needed to detect imminent health risks and direct health behaviors designed to avoid these risks. Health care providers and consumers use their abilities to communicate to generate, access, and exchange relevant health information for making important treatment decisions, for adjusting to changing health conditions, and for coordinating health preserving activities. The process of communication also enables health promotion specialists to develop persuasive messages for dissemination over salient channels to provide target audiences with relevant health information to influence their health knowledge, attitudes, and behaviors.

While communication is certainly a powerful process in health care, the dynamics of communication in health contexts are also very complex, the communication channels used are numerous, and the influences of communication on health outcomes are powerful. Health communication inquiry has developed to demystify the complexity of the multifaceted roles performed by communication in health care and health promotion. Such inquiry is conducted to increase knowledge about the influences of communication on health outcomes and direct the knowledge gained toward helping participants in the modern health care system use communication strategically to accomplish their health goals.

The Complexity of Health Communication Inquiry

Health communication is an extremely broad research area, examining many different levels and channels of communication in a wide range of social contexts. The primary levels for health communication analysis include intrapersonal, interpersonal, group, organizational, and societal communication. Intrapersonal health communication inquiry examines the internal mental and psychological processes that influence health care, such as the health beliefs, attitudes, and values that predispose health care behaviors and decisions. Interpersonal health communication inquiry examines the relational influences on health outcomes, focusing on the provider/consumer relationship, dyadic provision of health education and therapeutic interaction, and the exchange of relevant information in health care interviews. Group health communication inquiry examines the role communication performs in the interdependent coordination of members of collectives, such as health care teams, support groups, ethics committees, and families, as these group members share relevant health information for making important health care decisions. Organizational health communication inquiry examines the use of communication to coordinate interdependent groups, mobilize different specialists, and share relevant health information within complex health care delivery systems to enable effective multidisciplinary provision of health care and prevention of relevant health risks. Societal health communication examines the generation, dissemination,and utilization of relevant health information communicated via diverse media to a broad range professional and lay audiences to promote health education, health promotion, and enlightened health care practice.

Health communication inquiry involves examination of a broad range of communication channels. Face-to-face communication between providers and consumers, members of health care teams, and support group members are the focus of many health communication studies. A broad range of personal (telephone, mail, fax, e-mail) and mass (radio, television, film, billboards) communication media are also the focus of health communication inquiry. Increasingly, the use of new communication technologies are also examined as important health communication media.

The settings for health communication inquiry are also quite diverse. They include all of the settings where health information in generated and exchanged, such as homes, offices, schools, clinics, and hospitals. Health communication research has examined such diverse issues as the role of interpersonal communication in developing cooperative health care provider/consumer relationships, the role of comforting communication in providing social support to those who are troubled, the effects of various media and presentation strategies on the dissemination of health information to those who need such information, the use of communication to coordinate the activities of interdependent health care provides, and the use of communication for administering complex health care delivery systems.

Two Competing Perspectives in Health Communication Inquiry

There are two major interdependent branches of inquiry in the field of health communication. The first is the "health care delivery" branch. The health care delivery scholars examine how communication influences the delivery of health care. The second is the "health promotion" branch; the health promotion scholars study the persuasive use of communication messages and media to promote public health.

These two branches of the health communication field parallel a division found within the larger discipline of communication between academic interest in human and in mediated communication. The health care delivery branch of the field has attracted communication scholars who have primary interests in the ways interpersonal and group communication influence health care delivery, focusing on issues such as the provider/consumer relationship, therapeutic communication, health care teams, health care decision-making, and the provision of social support. The health promotion branch has attracted many mass communication scholars who are concerned with the development, implementation and evaluation of persuasive health communication campaigns to prevent major health risks and promote public health. For example, health communication scholars have developed campaigns for preventing public risks for contracting diseases such as HIV/AIDS, Heart Disease, and Cancer. Many health promotion scholars are also concerned with evaluating the use of mediated channels of communication to disseminate relevant health information, as well as in examining the ways that health and health care are portrayed by popular media.

Unfortunately, many of the scholars representing the two branches of the field of health communication (health care delivery and health promotion) have perceived themselves as being in direct competition with each other for institutional resources, numbers of conference programs, journal space, and research grants. Yet, this competition has begun to diminish as more health communication scholars have started working in both of these areas, as health care delivery systems have begun utilizing an increasingly broader range of human and mediated channels of communication (in areas such as telemedicine, health care marketing, and health education), and as health promotion specialists have enlisted more interpersonal (support groups, personal appeals, family involvement programs) and macrosocial (neighborhood, workplace, and government interventions) health promotion strategies in recent years. Over time these two branches of the health communication field should continue to grow closer together and eventually merge. The merging of these two areas will be most advantageous because health care delivery and health promotion are closely related activities. Health promotion must be recognized as a primary professional activity of health care practice, with doctors, nurses, and other providers devoting increasing energy towards health education, and health promotion efforts must be coordinated with the many related activities and programs of the health care delivery system (Kreps,1996a; 1990).

Development of the Field: Social Scientific Influences

There were many starting points in the development of the field of health communication. One influential starting point was rooted in the communication discipline_s emulation of other social sciences, such as psychology and sociology, which were actively studying the health care system. The communication discipline has a long-standing history of adopting theories and methods from these social sciences, and the move towards adopting the health care context as a topic of study was a natural disciplinary trend. Moreover, scholars in these social sciences were beginning themselves to examine communication variables in health care (Bandura, 1969; Feldman, 1966; Kosa, Antonovsky, & Zola, 1969; McGuire, 1969; 1984; Tichenor, Donohue, & Olien, 1970; Zola, 1966), which encouraged communication scholars to follow suit.

The field of psychology generated a large body of literature that was very influential in the development of health communication inquiry. The humanistic psychology movement of the 1950s and 1960s,for example, pioneered by scholars such as Carl Rogers (1951, 1957, 1961, 1962, 1967), Jurgen Ruesch (1957, 1959, 1961, 1963), and Gregory Bateson (Ruesch & Bateson, 1951), stressed the importance of therapeutic communication in promoting psychological health and was most influential in the development of the health care delivery perspective to health communication inquiry. This exciting body of psychological literature captured the imagination of many communication scholars. In fact, the Journal of Communication devoted an entire issue in 1963 to the topic of "Communication and Mental Health."

The powerful book The Pragmatics of Human Communication by Watzlawick, Beavin, and Jackson, published in 1967, builds upon the literature of humanistic psychology, indelibly tying together humanistic psychology and human communication. This book was very influential in the development of the fields of interpersonal communication and health communication. Written from an interactional family therapy perspective, the book examined the ways communication defines and influences interpersonal relations, clearly illustrating how the quality of relational communication can lead to therapeutic or pathological outcomes. This book, along with other humanistic psychology literature, provided a very influential springboard to the development of current interests in the field of health communication in provider/consumer relations, therapeutic communication, and the provision of social support.

The psychological literature about persuasion and social influence (Bandura, 1969; 1971; Festinger, 1957; Fishbein & Ajzen, 1975; Hoviland, Janis, & Kelley, 1953; Katz & Lazarsfield, 1955; Rokeach, 1973) also provided a broad theoretic foundation for the field of health communication, influencing the development of the health promotion approach to health communication inquiry. The persuasion literature, in combination with the complementary sociologically-based diffusion of innovations literature (Rogers & Shoemaker, 1971; Rogers, 1973), social scientific theories about mass media influence(McCombs & Shaw, 1972-1973; Tichenor, Donohue, & Olien, 1970; Klapper, 1960; Wade & Shramm, 1969) and emerging literature about social marketing (Kotler, 1972; Kotler & Zaltman, 1971) encouraged communication scholars to study the role of communication in health promotion and develop persuasive communication campaigns to promote public health. A notable example of an early health communication campaign based upon a combination of social scientific theories is the Stanford Heart Disease Prevention Program. This landmark study illustrated the role of communication in health promotion with a longitudinal field experimental evaluation of a multi-city health promotion intervention program. This study, initiated in the early 1970_s as a collaboration between cardiologist Jack Farquhar and communication scholar Nathan Maccoby, clearly demonstrated the powerful influences of communication campaigns on public health promotion.

The medical sociology literature (Freeman, 1963; Jaco, 1972; Mechanic, 1968) was also influential in the development of the field of health communication. Medical sociologists have long been interested in the doctor-patient relationship and the social structure of health care delivery systems. Zola (1966) for example, in a now famous study, examined the ways that culture influences patients_ presentations of health problems to health care providers, illustrating the need for practitioners to understand the backgrounds and orientations of their client and develop situationally specific strategies for communicating with individual patients. Kleinman_s (1980) moving book, Patients and healers in the context of culture, further reinforced this lesson about cultural influences on doctor-patient interactions and has encouraged current work on culture and health communication (see for example, Kreps & Kunimoto, 1994).

There were also important literature from the field of medicine that increased interest is health communication. Korsch and Negrete_s (1972) influential article "Doctor-Patient Communication," published in the prestigious international journal, Scientific American, made communication in health care delivery an important academic and public issue that communication scholars raced to address. Several important books about doctor-patient communication, such as Bird_s (1955) Talking With Patients, Blum_s (1972) Reading Between the Lines: Doctor-Patient Communication, Bowers (1960) Interpersonal Relations in the Hospital, Browne and Freeling_s (1967) The Doctor-Patient Relationship, Ley and Spelman_s (1967) Communicating With Patients, Starr_s (1982) The social transformation of American medicine, Verwoerdt_s (1966) Communication With the Fatally Ill, and Vorhaus_s (1957) The Changing Doctor-Patient Relationship, also set the stage for development of the field of health communication.

Institutionalization of the Field of Health Communication

A field of study is largely defined by the body of literature it generates, and the field of health communication has a rich and varied literature. The first books concerning health communication written by communication scholars began appearing in the 1980_s with Kreps and Thornton_s (1984) introductory survey text written for an interdisciplinary audience of health care providers and consumers, Health Communication: Theory and Practice, Sharf_s (1984) succinct text for medical students and practicing physicians, The Physician_s Guide to Better Communication, and Northouse and Northouse_s (1985) survey text geared towards nursing students and other health care professionals, Health Communication: A Handbook for Professionals. These first three texts were followed by a rapid succession of important health communication books, edited volumes, and a burgeoning literature of journal articles (too numerous to list here), solidifying and enriching the field of health communication.

As literature concerning the role of communication in health care and health promotion began to increase, there was a growing need for academic legitimization for communication scholars studying the role of communication in health. In response to this growing need, communication scholars interested in health care and health promotion banded together in 1972 to form the Therapeutic Communication interest group of the International Communication Association (ICA). The formation of this professional group is one of the most influential moments in the genesis of the modern field of health communication because it provided an academic home for an eclectic group of scholars, communicated to the rest of the communication discipline that health was a legitimate topic for communication research, and encouraged scholars in the discipline to consider health-related applications of their work.

The annual ICA conventions were very important sites for an emerging group of health communication scholars to meet, present their research, and generate new ideas and new directions for this new field of study. At the 1975 ICA convention, held at the LaSalle Hotel in Chicago, another important milestone in the development of this field of study transpired. The members of the Therapeutic Communication Division voted at this conference to change the name of the group to the broader title of "Health Communication," recognizing the many ways that communication influences health and health care. This was an important change because the new name represented a much larger group of communication scholars than the title therapeutic communication did. The therapeutic communication title was most attractive to interpersonally-oriented communication scholars, while the name health communication appealed broadly to scholars interested in persuasion, mass communication, communication campaigns, and the organization of health care services, as well as those interested in interpersonal communication.

The ICA Health Communication Division not only provided academic legitimization for a growing body of college faculty and graduate students, but the conference programs encouraged other communication scholars to conduct health communication research and submit it for presentation at ICA conferences. The ICA Health Communication Division began publishing the ICA Newsletter in 1973, communicating relevant information about health communication research, education, and outreach opportunities to a growing body of scholars. In 1977 the ICA began publishing the influential Communication Yearbook annual series, which included very important chapters about the emerging field of health communication.

In the first four volumes of the Communication Yearbook annual series each of the divisional interest groups (including the Health Communication Division) was allotted dedicated sections of the book to present research overviews and exemplar studies. In each of the first four volumes, Health Communication Division officers wrote important definitional overview chapters about the nature, purposes, and scope of health communication inquiry (see Cassata, 1978; 1980; Costello, 1977; Costello & Pettegrew, 1979). These overview chapters along with the accompanying research reports provided an excellent showcase for the developing field of health communication. Later issues of Communication Yearbook moved to a revised format of showcasing major review chapters along with accompanying responses from accomplished scholars representing the different ICA Divisions. The major review chapters concerning health communication were instrumental in defining this field of inquiry and the chapter responses helped to frame the major issues in the field for a large audience of scholars (see Kreps, 1987; Reardon, 1987; Pettegrew, 1987 for an example of a series of important health communication chapters in Communication Yearbook 11).

In 1985 the number of communication scholars interested in the field of health communication had grown enough that a groundswell of interested scholars formed the Commission for Health Communication within the Speech Communication Association (SCA), the largest of the communication discipline_s professional societies. Many of the members of the ICA Health Communication Division also became members of the SCA Commission on Health Communication and a large body of communication scholars who had limited exposure to health communication because they did not participate in the ICA, now learned more about this field of inquiry. In an uncommon example of cooperation between ICA and SCA, the two groups decided to share the publication of the Health Communication Newsletter, now renamed as Health Communication Issues. Within a few years the Commission for Health Communication had grown so rapidly that it surpassed the size of the ICA Health Communication Division and qualified to become the SCA Health Communication Division. Since 1992 the ICA and the SCA Health Communication Divisons have joined forces to present annual outstanding health communication dissertation and thesis awards to bothe the graduate student candidate and to the student_s graduate advisor, rewarding and encouraging outstanding health communication scholarship.

Health Communication Conferences and Mini-Conferences

The health communication conference programs at ICA and SCA became increasingly popular within the field, and in the mid eighties several health communication mini-conferences were founded to meet the burgeoning scholarly interest in this area. One of the first of these conferences was the "Medical Communication Conference" held at James Madison University in Virginia and hosted by Anne Gabbard-Alley. This mini-conference was quickly followed by a "Summer Conference on Health Communication" held at Northwestern University in July of 1985, hosted by Paul Arntson and Barbara Sharf. This very successful conference, which included a proceedings volume of contributed conference papers, began a popular trend of small research conferences focusing on health communication inquiry.

The Northwestern conference was followed by the first of several very effective annual "Communicating With Patients" conferences sponsored by the Communication Department of the University of South Florida and hosted by David Smith, Loyd Pettegrew, and others. Two important international conferences were organized in 1986, the "Oxford University/ICA Conference on Health Education in Primary Care," held at Oxford University (UK) and hosted by David Pendleton and Paul Arntson, as well as the "International Conference on Doctor-Patient Communication," held at the University of Western Ontario (Canada) and hosted by Moira Stewart. Since then there have been several additional international health communication conferences, which has expanded international interest in health communication inquiry.

In 1989 a series of "ICA Mid-Year Conferences on Health Communication" held at Monterey, California and hosted by Marlene Friederichs-Fitzwater was started. Under the leadership of Jim Applegate, Eileen Berlin Ray, and Lew Donohew, the University of Kentucky began a series of successful health communication conferences held in Lexington, Kentucky. In 1994 a "Conference on Health Communication, Skills, Issues, and Insights" was held at the State University of new York at New Paltz and SCA recently held a Summer Conference on Health Communication in Washington, D.C. Emerson College, under the direction of Scott Ratzan, also has initiated a series of conferences on health communication. These health communication mini-conferences spurred the growth of health communication inquiry both by serving as channels for disseminating health communication research information to a very large and often diverse audience of scholars and also by providing health communication scholars with attractive outlets for presenting their work.

Dedicated Health Communication Journals

In 1989 a momentous occasion occurred in the life of the field of health communication. The first refereed scientific quarterly journal, Health Communication, dedicated exclusively to health communication inquiry, was introduced by its Founding Editor, Teresa Thompson. The publication of this journal marked the coming of age of this young field of study and encouraged scholars from around the globe to take this field of study seriously.

The first issue of Health Communication showcased five important invited essays by noted health communication experts evaluating the current status of the field of health communication and recommending directions for future development of the field. The lead article, by Barbara Korsch (1989), reviewed current knowledge about doctor-patient communication and identified fruitful directions for future inquiry. The next article, by Gary Kreps, describes the theory-building, theory-testing, discipline building, and pragmatic health care delivery system benefits of rigorous and relevant health communication inquiry. The third article, by David Smith, examines the ways health communication research has debunked the traditional medical model of doctor control and patient compliance, and advocates a sophisticated view of communication in future communication inquiry. The next invited essay, by Paul Arntson, argues for a focus on developing citizens_ health competencies in future health communication research, empowering citizens to make active and enlightened health care decisions. The final invited essay in this inaugural issue of Health Communication, written by Jon Nussbaum, provides a charge to scholars to conduct important, sophisticated, and influential health communication research. This first issue of Health Communication marked an important point in the academic maturation of the field of health communication inquiry, and over the years the journal has provided the field with a respected outlet for health communication research.

In 1996 a second dedicated refereed quarterly health communication journal, the Journal of Health Communication, was introduced, under the Founding Editorship of Scott Ratzan. This journal differs from the established journal Health Communication, by taking a more international orientation and health care practice perspective to health communication. While the important journal Health Communication is a rigorous research journal, the new journal, the Journal of Health Communication, is more of a research and practice journal. The two journals complement each other and provide important scholarly outlets for health communication scholarship, indicative of the growth and maturation of this field of study.

Curricular Growth in Health Communication

Along with the growth of health communication literature and professional organizations came the introduction of both undergraduate and graduate health communication courses. Some of the earliest health communication courses were housed in Departments of Speech Communication at large research universities such as the University of Minnesota (taught by Don Cassata), Pennsylvania State University (taught by Gerald M. Phillips), and the University of Southern California (taught by Gary Kreps). Several medical schools also began offering health communication courses focusing on interviewing skills for physicians at the University of Illinois (taught by Barbara Sharf), Southern Illinois University (taught by Susan Ackerman-Ross), University of North Carolina (taught by Don Cassata), and the University of Calgary (taught by Suzanne Kurtz). These courses were precursors to the development of many more undergraduate and graduate health communication courses in colleges both nationally and internationally.

Several undergraduate and graduate health communication majors are now offered at colleges (such as the University of Maryland, Emerson College, the University of Toledo, Bowling Green State University, the University of South Florida, the University of Florida, Northwestern University, Indiana University-Purdue University at Indianapolis, Rutgers University, Ohio University, the University of Georgia, Michigan State University, Stanford University, the University of Pennsylvania, and the University of Oklahoma). The Emerson College health communication graduate program is unique. It is a collaboration between Emerson_s communication program and Tufts University_s School of Medicine, enrolls students from both Emerson and Tufts, and offers courses taught by faculty from both institutions. This level of innovative interdisciplinary (and for that matter, interprofessional and inter-institutional) collaboration is unique and offers the students in this program an opportunity for a health communication education that emphasizes the intricacies of both the communication process and the health care delivery system.

Recently several Internet web-pages concerning health communication have been introduced that support curriculum development in the field. The American Communication Association sponsors one of the web-pages, which has links to many sources of information about communication and health care. Stuart Ainsworth, currently a graduate student at the University of Georgia, has also established a health communication web-page with information about the field of study, programs of health communication study, relevant health communication literature, and links to other health communication pages. The Emerson College Department of Communication has also developed a health communication web-page where they provide information about their innovative health communication graduate program, the new Journal of Health Communication that is edited by Emerson College faculty member Scott Ratzan, and about current news, conferences, and research opportunites in health communication. Important curricular information gathered by Kim Witte of Michigan State University and Scott Ratzan of Emerson College describing the many different health communication educational programs available at colleges and universities is also available on these web-pages. Clearly, these electronic information sources provide many people with access to the field of health communication, and serve important public relations, academic community building, and information dissemination functions for the health communication field.

Future Directions in Health Communication Inquiry

Health communication inquiry has come a long way and is moving in a very positive direction. Current research on health communication clearly illustrates the powerful influences of communication on health (see for example Kreps & O_Hair, 1995). Health communication inquiry has become increasingly sophisticated and directed towards addressing significant social issues. With the growing sophistication of health communication has come increasing interdisciplinary and institutional credibility for health communication scholars.

Health communication scholars are more likely now than in any time in the past to attract federal research funding. Federal agencies, such as the Centers for Disease Control, the National Cancer Institute, and the National Institute for Drug Abuse have become increasingly more familiar with the field of health communication and receptive to health communication research. The Centers for Disease Control, for example, has established an Office of Communications with a Division of Health Communication dedicated toward emphasizing the development of rigorous message-based communication interventions across the CDC_s many important health risk prevention initiatives. Similarly, the Federal Agency for Health Care Policy and Research has increasingly emphasized the importance of health communication research and interventions in their many publications, conferences, and outreach programs.

Health communication scholars are increasingly in demand by communication programs at universities and colleges. More faculty job advertisements than ever before list expertise in health communication as one of the preferred qualifications of applicants. Communication scholars are receiving increasingly more respect from more established social sciences, with communication scholars invited to participate in interdisciplinary research teams and edit interdisciplinary social scientific journals, such as the American Behavioral Scientist. See, for example, the November, 1994 issue of the American Behavioral Scientist edited by Scott Ratzan that is devoted to "Health Communication: Challenges for the 21st Century" and the July/August 1991 issue devoted to "Communicating to Promote Health," co-edited by Gary Kreps and Charles Atkin. Similarly, a recent issue of the Journal of Health Psychology (Volume 1(3), 1996) devoted to "Messages and Meanings: Health Communication and Health Psychology" was edited by Gary Kreps and showcased state-of-the-art health communication research by respected communication scholars. This type of interdisciplinary respect and credibility marks the growing maturation of the field of health communication.

There is a growing emphasis on public advocacy, consumerism, and empowerment in health communication research that will help revolutionize the modern health care system by equalizing power between providers and consumers and relieving a great deal of strain on the modern health care system by encouraging disease prevention, self-care, and making consumers equal partners in the health care enterprise (see Arntson, 1989; Kreps, 1993; 1996a; 1996b). We believe that communication research will increasingly be used to identify the information needs of consumers and suggest strategies for encouraging consumers to take control of their health and health care. Ideally, health communication research should help identify appropriate sources of relevant health information that are available to consumers, gather data from consumers about the kinds of challenges and constraints they face within the modern health care system, as well as develop and field test educational and media programs for enhancing consumers' medical literacy. Such research will help consumers negotiate their ways through health care bureaucracies and develop communication skills for interacting effectively with health care providers.

Current and future health communication research will increasingly focus on the effective dissemination of relevant health information to promote public health. Modern health promotion efforts will recognize the multidimensional nature of health communication, identify communication strategies that incorporate multiple levels and channels of human communication, and implement a wide range of different prevention messages and campaign strategies targeted at relevant and specific (well-segmented) audiences (Maibach, Kreps, & Bonaguro, 1993). Modern campaigns will become increasingly dependent upon integrating interpersonal, group, organizational, and mediated communication to effectively disseminate relevant health information to specific at-risk populations.

Health communication inquiry is becoming increasingly concerned with the role of culture on health and health care. We believe that communication scholars will work to end the prejudicial treatment of marginalized cultural groups within the modern health care system, such as prejudicial treatment of people with AIDS, the poor, minorities, women, and the elderly (Kreps, 1996a). Future research will examine the health communication needs of marginalized cultural groups and identify strategies for enhancing health communication with members of these groups.

We believe the field of health communication is moving toward a sophisticated multidimensional agenda for applied health communication research that will examine the role of communication in health care at multiple communication levels, in multiple communication contexts, evaluate the use of multiple communication channels, and assess the influences of communication on multiple health outcomes. We are hopeful that future health communication inquiry and education will provide relevant information about the development of cooperative relationships between interdependent participants in the modern health care system, encourage the use of sensitive and appropriate interpersonal communication in health care, empower consumers to take charge of their own health care, enhance the dissemination of relevant health information and the use of strategic communication campaigns to promote public health, facilitate the development of pluralistic ideologies for effective multicultural relations in health care, and suggest adaptive strategies for using health communication to accomplish desired health outcomes.

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