Executive summary IntroductionHealth communication is integral to the effective public health response to the continuing threat posed by communicable diseases in European Union (EU) and European Economic Area (EEA) Member States. Public health practitioners, programme managers and policymakers need to be aware of what is known about the strengths, weaknesses and costs of health communication interventions aimed at the prevention and control of communicable diseases so that impacts can be enhanced and opportunities maximised for strengthening evidence-informed action.The overall aim of the Translating Health Communication research project was to support the optimal use and development of health communication activities for the prevention and control of communicable diseases in EU and EEA countries. This project consisted initially of two main strands of work: primary information gathering and synthesis of evidence. The multiple outputs from these two strands were further analysed through a SWOC (strengths, weaknesses, opportunities, challenges) analysis. Subsequently the results were developed via an online expert consultation process. Finally, all key project findings were considered against a Public Health Capacity Development Framework . This final project component identifies the future strategic actions required for strengthening capacity in Europe to develop evidence-informed health communication for communicable diseases. Thus, a process of knowledge generation and translation was instigated such as that described in the Knowledge- to-Action Framework . This three-year research project funded by the European Centre for Disease Prevention and Control (ECDC) was undertaken by a Research Consortium of Universities1.Primary information gatheringOne of the initial research strands comprised of primary information gathering which included an e-survey and telephone interviews with 109 key stakeholders and achieved representation from each of the 30 EU and EEA countries . The data from these research activities informed a subsequent expert consultation aimed at identifying the perceived priorities for the efficacious use of health communication by public health bodies for communicable diseases .Evidence reviewsThe second research strand comprised a series of evidence reviews: three rapid reviews of reviews of evidence, four literature reviews, and two systematic literature reviews. The topic areas of these reviews were:A rapid evidence review of interventions for improving health literacy .A rapid evidence review of health advocacy for communicable diseases .Evidence review: social marketing for the prevention and control of communicable disease .A literature review on health information-seeking behaviour on the web: a health consumer and health professional perspective .A literature review of trust and reputation management in communicable disease public health .Health communication campaign evaluation with regard to the prevention and control of communicable diseases in Europe .A literature review on effective risk communication for the prevention and control of communicable diseases in Europe .Systematic literature review of the evidence for effective national immunisation schedule promotional communications .Systematic literature review to examine the evidence for the effectiveness of interventions that use theories and models of behaviour change: towards the prevention and control of communicable diseases . Health Promotion Research Centre, National University of Ireland Galway, Ireland.Institute for Social Marketing and Centre for Tobacco Control Research, University of Stirling, Scotland. University of Navarra Clinic, Pamplona, Spain.￼Research consolidation processA consolidation process of all project outputs was devised to bring together, distil and develop further the multiple findings from the two strands of research undertaken. This process comprised an adapted and developed SWOT (strengths, weaknesses, opportunities and threats) analysis, with challenges replacing threats – SWOC .Strengths and weaknessesThe strengths and weaknesses identified in the evidence reviews were assessed per review [5-13] against specific areas which were developed through an iterative process with participation from Research Consortium members and members of the projects Scientific Advisory Panel. This process resulted in the identification of areas, formulation of questions, against which each evidence review was assessed. The areas included: level of conceptualisation, any models or theories identified, tools to facilitate practical application, level and quality of supporting evidence, health and disease outcomes, and application into practice. The results of this analysis process are presented in the form of matrix tables.The analysis process enabled the identification of significant strengths as well as gaps in the European evidence base currently available for health communication in the prevention and control of communicable diseases. For example, it is apparent that there is a limited evidence base focusing on communicable diseases in a European context, as most of the evidence originated from North America, and draws substantially on evidence from non- communicable diseases and other health issues. It is also evident that there is a lack of knowledge on how to use health communication to effectively engage and improve health outcomes for hard-to-reach groups. Overall, while there is a limited European evidence base for health communication and communicable diseases, there is also evidence indicating some, albeit limited, capacity across EU and EEA countries to support such activities.Opportunities and challengesThe process undertaken to analyse opportunities and challenges from the information gathering research strand of the project replicated that of the analysis of strengths and weaknesses of the evidence reviews. The areas identified, against which the opportunities and challenges were assessed, were developed into questions which reflected the focus of the original information gathering process . The areas identified included: structures for health communication, planning and finance, health communication for communicable versus non communicable diseases, types of health communication used, understanding of ‘evidence’, participation in development of health communication, channels used, examples, capacity for use, and evaluation activities. The results of this analysis process are presented in the form of matrix tables.The analysis process resulted in the identification of both opportunities and challenges for practice. For example, it was evident that there is great variability between countries in the range and level of health communication activities undertaken. There are also various levels of capacity, both within and between countries, for the effective application of health communication for the prevention and control of communicable diseases. Gaps identified included: a lack of education and training; under-use of evaluation; and limited resources to develop, effectively use, and evaluate health communication in the prevention and control of communicable diseases.Informing future directions through an online expertconsultationThe findings of the SWOC analysis formed the basis of a further level of stakeholder consultation . The aim of the consultation was to identify, from stakeholders’ perspectives, what would be useful and practical to enhance and support future capacity and strategic development of health communication in the prevention and control of communicable diseases. The consultation was undertaken via an online asynchronous, private email consultation/mailing list: the ECDC-Health Communication Forum (ECDC-HCF). The questions posed covered the following domains: challenges, opportunities, feasibility, desirability and viability for the future development of health communication activities in EU/EEA countries over the next five years.Overall, results validated previous research findings from the project , which indicated varying levels of capacity for health communication in the prevention and control of communicable diseases within and between countries. Insights concerning the potential for capacity development were identified which included: enhanced sharing, coordination, collaboration, communication with key target audiences and stakeholders, development of stronger partnerships, and future use of new media. In addition, the role of evidence as a foundation for effective health communication developments and as a basis for building public trust was recognised, highlighting the need for the evidence base in Europe to be strengthened.￼Capacity developmentFollowing the distillation process through the SWOC analysis and matrix development for all project outputs, including the online expert consultation, a capacity development framework was applied. This final phase of this research project used the dimensions of The Review of Public Health Capacity in the EU , a conceptual framework for mapping capacity development in public health against which the implications of the project findings were explicated. The dimensions are: organisational structures, partnerships, financial resources, leadership and governance, knowledge development, and workforce.Organisational structuresHealth communication activities will bring the most success if they are incorporated into health policies and strategies from the time at which they are being developed; this will require greater structure in planning health communication activities from policy to practice than currently exists. The role of trust and reputation management for communicable diseases health communication is increasingly being recognised as a strategic function requiring long-term planning and evaluation . Health communication for non-communicable diseases may be a more developed field than health communication for communicable diseases. Priority should be given to the exploration of the transferability of knowledge in relation to health communication for non-communicable diseases to communicable diseases. Health literacy must be embedded in all population-level health initiatives at both a national and European level. The capacity for health communication for communicable diseases would be significantly improved by enhanced collaborative working and greater coordination at a European level.PartnershipsCapacity-building partnerships are those that increase the capacity of the partnership members to work together . Advantages of partnership working include ‘sharing’ expertise and experiences of the application of health communication in the prevention and control of communicable diseases. This in turn has the potential to: limit costs, facilitate transnational approaches, and ensure a commonality of health communication messages and strategies across Europe [3, 4]. Sustainable communication and partnerships with organisations involved in health communication for non-communicable diseases could facilitate establishing networks to explore the transferability of expertise, capacity, information, best practice, and lessons learned in health communication for non- communicable diseases to communicable diseases. The importance of partnerships with community groups reflects the new paradigm of citizen-centred health communication with the identification of the inclusion of citizen stakeholders as active partners in health communication endeavours aimed at the prevention and control of communicable diseases. A strong, linked professional network of communicators and experts within countries and across Europe would provide a useful resource to drive the strategic and consistent development of health communication for communicable diseases. Nevertheless, there are many challenges to the establishment and maintenance of productive partnerships for health communication for the prevention and control of communicable diseases in Europe, including the diversity of culture, health service systems, and language. However, the review of social marketing for the prevention and control of communicable diseases cited data that identified a promising trend in partnership working .Financial resourcesThe stakeholder consultation identified that none of the countries that they represented has a specific budget for health communication . Funding for health communication is allocated from national health budgets and/or government programmes and the extent of funding from the private and commercial sectors varied between countries. A greater use of economic evaluation will equip policymakers, health communication planners and analysts with the evidence to determine how best to distribute their budgets among the various health communication activities .Leadership and governanceThe consultations identified that there was a lack of clarity about where responsibility for health communication rested both nationally and at a European level. During the consultations, the stakeholders reported their opinions that the development of formal structures within public health authorities or Ministries of Health would enhance and support the future development of health communication in the prevention and control of communicable diseases over the next five years. Except in relation to health advocacy , there was little evidence across the reviews of health communication interventions targeting disadvantaged or hard-to-reach groups [5, 7, 12] and thereby working to reduce health inequalities. It is clearly imperative for leaders, governments and organisations to be mindful of the impact of future health communication activities on minority and disadvantaged groups and implement strategies designed to reduce health inequalities. Stakeholders suggested a need for an international or European agency, such as ECDC, to provide leadership for health communication including by assisting countries todevelop their own national health communication strategies and plans .Knowledge developmentThere is generally a lack of evidence relating to health communication for communicable diseases within the European context. Nine evidence reviews were undertaken for this research project and these found that while there was a degree of conceptual agreement evolving about the concepts of health literacy , health advocacy , the promotion of immunisation uptake , and behaviour change , there was a more limited consensus and/or understanding about the concepts relating to social marketing , health information seeking , risk communication , campaign evaluations , and trust and reputation management .Comprehensive knowledge exists in the form of toolkits and guides to developing, implementing and evaluating health communication activities [for example, 17-19]. Resources such as these could usefully inform the development of a strategy for health communication activities for communicable diseases and provide a template for the development of initiatives. Evaluation is particularly underdeveloped in the broader context of health communication and is scant in relation to health communication for the prevention and control of communicable diseases. Integral to the development of more formal evaluation is progress in identifying the indicators of success for health communication activities. The current status of health communication campaign evaluation demonstrates the need for capacity building within and across EU/EEA countries .WorkforceHealth communication competencies may be defined as the combination of the essential knowledge, abilities, skills and values necessary for the practice of health communication (adapted from ). It is clear that the complexities and the multidisciplinary nature of health communication involve a vast range of skills drawing from a number of disciplines including health, education, public health, health promotion, social marketing and information technology. Overall, stakeholders considered that education and training focused on health communication in the prevention and control of communicable diseases is currently underdeveloped across Member States . Stakeholders identified that structured health communication training was required and suggested that European-level organisations should coordinate and facilitate such training.ConclusionsHealth communication for the prevention and control of communicable diseases is underdeveloped in EU and EEA countries. The research activity for health communication in communicable diseases in the European context is in a nascent stage of development. The lack of systematic evaluation of health communication for communicable diseases has resulted in a limited evidence base which could give rise to inefficient use of resources.Nevertheless, a body of evidence is emerging in relation to health communication, and some of it pertains to health communication for communicable diseases but much relates to non-communicable diseases. This evidence represents a resource that can be mined to establish its relevance and transferability to health communication for communicable diseases in the European context.The potential for capacity development for health communication in communicable diseases in Europe is manifest. European and international agencies and organisations such as ECDC and the WHO were identified in the stakeholder consultations as having a critical role to play in supporting the future development of health communication in the field of communicable diseases prevention and control. Such organisations could provide the leadership and coordination required to advance the field of health communication for communicable diseases in a coordinated and strategic way.