8
Findings and Recommendations

INTRODUCTION

The Committee on Communication for Behavior Change in the 21st Century: Improving the Health of Diverse Populations accepted its charge in the context of three assumptions: Communication interventions to affect health behaviors are an increasingly important strategy for improving the health of the American people. Evidence shows that some of these communication interventions have affected health behavior. At the same time, there is evidence that disparities in some health outcomes are associated with identifiable characteristics of individuals, including race/ethnicity, socioeconomic status, gender, and age.

This charge led to the central question for this volume: What is the performance and the promise of health communication interventions in the context of diversity? This question includes the following subquestions: Have current communication interventions effectively served diverse populations? Is there added benefit for reducing disparities in using communication strategies that take account of diverse populations in one way or another? What do



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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations 8 Findings and Recommendations INTRODUCTION The Committee on Communication for Behavior Change in the 21st Century: Improving the Health of Diverse Populations accepted its charge in the context of three assumptions: Communication interventions to affect health behaviors are an increasingly important strategy for improving the health of the American people. Evidence shows that some of these communication interventions have affected health behavior. At the same time, there is evidence that disparities in some health outcomes are associated with identifiable characteristics of individuals, including race/ethnicity, socioeconomic status, gender, and age. This charge led to the central question for this volume: What is the performance and the promise of health communication interventions in the context of diversity? This question includes the following subquestions: Have current communication interventions effectively served diverse populations? Is there added benefit for reducing disparities in using communication strategies that take account of diverse populations in one way or another? What do

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations communication programs do now to serve the diverse audiences they must address? How might what they do be improved? In the process of examining this central question, the committee addressed a series of closely related questions: What is the role of theory in the construction of communication programs in the context of diversity? In particular, is there a need to modify theory for different subgroups of the population? Given concerns about diversity, do special ethical issues arise in health communication? Is the promise of communication and diversity different according to the health behavior(s) and disease process addressed? Is there evidence that targeting or tailoring messages for different cultural groups makes a difference in the effects of these messages on behavior change? The committee contrasted two important cases to help us consider this issue. Mammography was chosen to represent a discrete behavior that is recommended to occur every year or two for women age 40 and over; it is relevant to a large segment of the healthy population. Diabetes was selected as a contrast. Its treatment requires a complex set of continuing behaviors that is responsive to an evolving illness and relevant to those who have the illness and those around them. Large-scale communication campaigns are widely used as a mechanism for affecting the behaviors of broad populations when risk is widespread. Thus, as a third area of focus, the committee considered evidence from such large-scale campaigns. What is known about the best ways of constructing such programs in the context of diversity? The application of newer communication technologies to the problems of health promotion has an extraordinary dynamism. What are the implications of the rapid development of new technology-based health behavior interventions for the health of diverse audiences? How helpful are the conventional categories of diversity in constructing communication interventions? Are there other, more useful, approaches to thinking about diversity?

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations This chapter takes each of these questions in turn, summarizing the committee’s findings with regard to the question, then presenting the recommendations that come from those findings. OVERALL FINDINGS AND RECOMMENDATIONS The review makes it clear that researchers, program planners, and managers quite often take diversity into account when they construct their communication programs. This was true both for communication interventions addressing mammography and for those that were examined in the review of large-scale campaigns. The committee found few examples of communication programs that addressed diabetes. Three broad diversity-respecting strategies emerged from the rich variety of approaches described in the literature: They construct a unified communication program, but look for a common-denominator message that will be relevant across most populations. They construct a unified communication program, but systematically vary message executions to make them appeal to different segments, while retaining the same fundamental message strategy. They develop distinct message strategies and/or distinct interventions for each target segment. Despite the efforts to take diversity into account, the evidence base is quite thin about differential effects of interventions according to diversity subgroups. Some of those programs have been successful in changing behavior, including that of the diversity subgroups of particular interest in this volume. However, the available data do not effectively address the focus question for this volume: is there added benefit in addressing the behaviors associated with health disparities by using communication that takes diversity into account?

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations In some cases, there are data about comparative trend lines for subgroups with regard to a health outcome or health behavior. (Most often the subgroups examined are defined by race/ethnicity, but sometimes they are reported by other conventional diversity categories.) These tend to show parallel trends among subgroups, although that varies. However, even if such comparative trend line data were available in more cases, it would not adequately address the question. Comparative trend lines do not deal with whether more or less diversity-respecting campaigns have differential effects. Few studies address the relative effectiveness of communication interventions across relevant diverse groups, and none were found that systematically compare the various approaches to addressing diversity, or compare those approaches with efforts that ignore diversity altogether. This does not mean there are no diversity-respecting programs. Rather, where such programs exist, they do not provide direct evidence about the interaction of communication programs and subgroup status. In general, the evidence does not indicate whether the efforts to take diversity into account were worthwhile, or which approaches were worthwhile and under what circumstances. Overall, the committee was surprised by the lack of published comparative effectiveness evidence. Overall Recommendation 1: There is a need to undertake comparative effectiveness research in each of the following ways: Secondary analysis of evidence already collected from existing communication programs. The committee assumes there is a substantial store of data that has already been collected, but not analyzed to examine diversity-related effectiveness issues. The committee encourages systematic analysis comparing subgroups with regard to trends in disparities in the target health outcomes, while simultaneously documenting specific diversity strategies that were employed at particular times. Ongoing effectiveness evaluations of new and ongoing programs. Evaluations of larger scale communication programs

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations should collect appropriate data so they can complement overall conclusions about effectiveness with conclusions about important subgroups of the population. These analyses should be reported in the context of systematic descriptions of diversity implementation strategies. Field tests of alternative diversity strategies. Where feasible, systematic comparative studies should be undertaken in which equivalent groups of the general population and of focus subgroups are assigned to different communication treatments reflecting alternative diversity strategies. These may be undertaken either in the context of ongoing communication programs, or as separately mounted field experiments. The National Institutes of Health (NIH) and other agencies that are funding communication interventions should provide special funding to evaluation staff or other researchers willing to pursue this research agenda. This recommendation is consistent with regulations that require researchers to include adequate numbers of men and women and diverse populations in funded research. Overall Recommendation 2: Until more convincing evidence is available pro or con, the committee believes it is sensible for many existing programs to continue to pay attention to diversity, particularly when diversity is associated with substantial disparities in health status and outcomes. However, this recommendation is subject to some limitations: The most important categories of diversity may not be the conventional ones. In this volume, there is some discussion of the tradeoff between relying on the conventional categories of diversity (e.g., race and ethnicity) and focusing on alternative characteristics that are closely tied to the focus health behavior and to susceptibility to communication interventions. It is appropriate to consider alternatives to conventional categories, including attending to the life experiences and contextual settings of the population. This issue is discussed further in this chapter.

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations Communication interventions should be targeted to specific subgroups only when evidence from program research suggests that important differences exist in health behavior or in the antecedents of health behavior or when there is a strong hypothesis that such differences exist. Otherwise, a reasonable approach will be to design communication interventions based on common features among groups/people. THEORIES OF COMMUNICATION AND HEALTH BEHAVIORS A substantial body of literature addresses many aspects of theory relevant to communication interventions. These include theories of behavior and behavior change focusing on the structural, social, and psychological factors that influence behavior, and theories of communication or persuasion that underlie approaches to influencing change in those factors. Substantial research underpins the theories of behavior, and there is substantial research on persuasive processes and some research on communication effects models. The committee considered the argument that current theories were inappropriately applied to some subgroups of the population—that is, theories of behavior change or theories of communication, for example, were developed with general population samples, and might not apply in important aspects to culturally distinct subpopulations. The committee found no evidence base for this claim, however. On the contrary, although subgroups may differ on the particular beliefs or social factors that affect their behaviors, this was not a challenge to existing theory. Relevant theory, in the committee’s assessment, does not assert causal preeminence for any particular belief or social influence or skill; it does not indicate which persuasion processes will be most effective for a particular audience; rather, theory suggests what the important categories of influence and important alternative influence processes might be. Therefore, most of the major theoretical frameworks are consistent with the possibility of variation across diver-

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations sity groups in the constructs that matter in a particular circumstance. Moreover, if theories are used appropriately, researchers and program planners alike will obtain population-specific data for planning purposes. Theory is highly relevant to the construction of communication programs in the context of diversity. Theory can drive the investigation of differences among diverse subgroups with regard to what influences on behavior are relevant and thus what factors should be addressed in a communication program. In its limited review of cases, the committee found great variation in the use of theory as an underpinning to implementation decisions. Some programs saw themselves as implementing certain theoretical principles and did so using theoretical constructs to guide intervention development; some made reference to theory as a justification for their implementation decisions, but outside observers found it difficult to match theory and implementation; and some programs made no theoretical claims at all. The committee recognizes that the research base for the translation of these theoretical notions into operational programs is less strong than the underlying theoretical research itself. Theory Recommendation 1: Theory has an important place in the construction of communication programs in general and for diverse populations. The committee encourages program developers and implementers to use theory in a more consistent and aggressive way in developing implementation plans. This implies each of the following: Whenever possible, program planners should use evidencebased programs that are grounded in theory. Implementing groups may want to develop formal training opportunities for their staffs to develop the skills in turning relevant theory into implementation when new programs are required. Agencies funding such programs should give strong priority to potential implementers who have a track record in applying

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations theory successfully, or who have provided proposals that establish their full understanding of relevant theory and of the practical implications of theory for implementation. Reports about communication research should specify clearly the theory that was used and indicate how the underlying theoretical constructs were applied and measured. Theory Recommendation 2: Additional research is needed about the translational process of moving from theory to implementation. The committee recommends that more attention be given to how behavior change theories are translated into effective practice and implemented in health communication interventions; that is, how the theoretical principles are applied in practice. This would include: Case studies. Documentation is needed on the theoretical basis for particular interventions, and the particular ways that theory was implemented in practice. These narratives might include discussion of the operational difficulties of translating theory into practice, and evidence that expected theoretical processes mediated observed changes in outcomes. Research on translational programs. There is a need to develop and test transfer and implementation models for health promotion using communication. ETHICS A number of ethical principles should be considered in the development and implementation of health communication for diverse populations. These include avoidance of harm, maximizing benefit, respecting an individual’s autonomy to make choices, and treating groups and individuals justly and equitably. Many ethicists argue that direct incorporation of representatives of affected groups in decision making increases the likelihood that the rights of and benefit to those groups will be respected.

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations Ethical principles are easily endorsed, but not always easily achieved. Implementing ethical principles can be complicated by developers’ needs to consider tradeoffs among efficiency, cost, and improving the health of those most in need versus benefiting a broader range of persons. A communication strategy may have to choose between maximizing benefit for one segment of the population versus another. Also, there is always the opportunity for unintended consequences, even with the most well-intentioned and well-executed health communication interventions. This risk may be heightened in the context of reaching heterogeneous audiences with a common message. Risks include confusion about the meaning of the message, unwarranted anxiety resulting from implying individual culpability, or the stigmatizing of certain cultural practices. The recommendation for the incorporation of relevant group representatives may be complex to implement in practice, given the need to choose among potential representatives and the possible tension between technical “expertise” and beneficiary preferences. Many intervention programs may not explicitly consider ethical issues and tensions as they make implementation decisions, and they may not avoid problematic ethical dilemmas. Approaches for translating ethical principles into practical recommendations are not well established in health communication. Ethics Recommendation 1: Health communication programs should explicitly consider ethical guidelines in their decisions about implementation. This process is likely to be helped if: NIH convenes a workshop to assist in the development of an ethical framework and operational guidelines for implementing the framework. Ethics Recommendation 2: Programs are encouraged to involve individuals and communities affected as active participants in decision making and not only as passive respondents. There is

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations now a growing literature on participatory research that may be helpful. NIH may wish to commission a review of the alternative mechanisms that programs have used to incorporate representatives of recipients in their decision making, including some evaluation of the success of those mechanisms. COMMUNICATION CAMPAIGNS The findings stated previously in the overall findings section apply specifically to communication campaigns: There are many such campaigns, and many address issues of diversity in their plans and their implementation; there is credible evidence for the overall positive effects of some of these programs; there is sometimes evidence available about differential trends with regard to target outcomes for different demographic groups, but there is little evidence available as to whether diversity strategies contribute to success, or as to which strategies are more and less effective. Sophisticated public health communication programs pay close attention to the heterogeneity of their audiences, recognizing that their audiences are different with regard to the behaviors they are currently undertaking; the psychological, social, and structural factors that influence those behaviors; the channels through which they can be reached; and the types of message executions to which they will respond. They follow the lead of commercial marketers who “segment” the audience into more homogeneous groups, choosing to focus attention on only some segments, or addressing multiple segments with different communication strategies. Sometimes these segments correspond to the conventional diversity categories based on demographic characteristics. Sometimes there is much less correspondence. In these situations, relying on the conventional categories to segment the audience can be unproductive. Recently, some programs have used tailored approaches designed to customize interventions for individuals. In this case, the factors relevant to an individual can be used as the basis for messages.

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations Successful public communication programs have met certain conditions. These include a strong science base for recommended behaviors, a realistic possibility that recommendations can be implemented by the population, coordination with other programs addressing related issues, enough resources available for the development and particularly the transmission of messages so that the intended audience sees them at needed frequency, and often the resources to maintain the campaign over time if the pace of change is slow. Communication programs may be particularly effective if they are an integral part of a multicomponent intervention. Examples include interventions that complement or facilitate access to services—such as improved local mammography availability— with a variety of communication strategies such as television advertisements, telephone reminders, and personal letters. Similarly, a television series focused on smoking cessation can offer a toll-free telephone number that viewers can call for referral to quit-smoking programs. Communication campaigns operate at a distance from their audiences. Therefore, they require extensive and virtually continuous gathering of “tracking” data about their target population’s awareness of messages, changes in relevant beliefs, social expectations and self-efficacy with regard to recommended behaviors, as well as measures of those behaviors themselves. This need is magnified in the context of programs that address heterogeneous audiences, when tracking research has to allow estimation of differential trends across important population subgroups. Communication campaign effects can be magnified if the exposure to messages achieved by the direct buying of media time (e.g., through purchases of broadcast time for TV ads) is complemented by other diffusion of messages. This may involve stimulating coverage of a particular health issue by newspapers or by broadcast news or talk shows, or inclusion of supportive messages in entertainment programming (or discouragement of modeling of problematic behaviors in entertainment programming). From the opposite perspective, some campaigns have been successful in the

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations context of media coverage of related events (e.g., Rock Hudson’s death from AIDS). Prohealth messages transmitted by programs may receive a better hearing in the context of such coverage. Also, programs may be able to encourage journalists to write about events to reinforce prohealth messages. In general, the presence of social environmental changes, such as policy initiatives supporting healthy behaviors, can provide fertile ground for communication campaigns. The committee addressed the urgent need for research about diversity and communication program effects in Overall Recommendation 1. The judicious use of existing subgroups was the focus of Overall Recommendation 2. Both of those are specifically relevant to communication campaigns. In addition, each of the following recommendations addresses the additional findings presented here. Communication Campaign Recommendation 1: Underresourced campaigns are unlikely to be effective and may deflect researchers from employing the most appropriate strategies. Campaigns are appropriately an attractive strategy to a health agency anxious to influence population behavior change. However, if the minimum conditions for successful public communication programs are not met—and often they are not, particularly with regard to resources needed to obtain high levels of exposure to messages—then the campaign is not an appropriate strategy. This concern is magnified in the context of a campaign that intends to address multiple diverse segments, when resource demands are even higher. Agencies should not initiate communication campaigns unless they are able to satisfy these conditions. Communication Campaign Recommendation 2: The committee recommends that practitioners employ evidence-based multicomponent programs that integrate communication with access to services, where feasible, and especially where the appropriateness

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations for diverse populations has been demonstrated. The Centers for Disease Control and Prevention’s Guide to Community Preventative Services is an important source of information about evidence-based programs (http:/www.thecommunityguide.org). Communication Campaign Recommendation 3: NIH Institutes that are considering mounting communication programs in high-priority public health areas, such as diabetes, that have not been systematically addressed by communications in the past should fund additional exploratory research to examine the suitability of communication approaches before developing full-scale campaigns. Communication Campaign Recommendation 4: The committee recommends that agencies undertaking campaigns incorporate ongoing tracking studies. These should be conducted in a timely manner to monitor the process and effects of the campaign (intended and unintended) and to refine and adjust campaign strategies and executions. They should be sensitive to potential differences among important subgroups of the population. The Office of Management and Budget (OMB) Paper Reduction Act and its complex and extended research approval process makes the undertaking of such tracking studies more difficult because, by their nature, tracking studies, like the campaigns they follow, are constantly evolving and need to respond to changing circumstances. There is a need to negotiate with OMB for an appropriate exception or an expedited process for such monitoring research. The results of these studies, which are likely to be relevant to other implementation planning, should be made available to the scientific and practitioner communities.

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations NEW COMMUNICATION TECHNOLOGY The application of new communication technology in health programs is occurring at a rapid pace. These include programs to individualize messages as well as those that permit interactive involvement by users. Moreover, Internet-based programs offer opportunities not only to tailor content to diversity issues, but to provide social support and create communities of interest. The committee found good evidence that a variety of communication technologies, including those based on older (e.g., telephone) and newer (e.g., wireless computer devices) technologies, have been used effectively to influence behavior. The impressive growth of new communication technologies offers significant opportunities to integrate mass and micro communication strategies, allowing more effective and efficient population reach while permitting segmentation and even tailoring to diverse populations. Some of these technologies depend on active engagement by individuals, such as searching for information on the Internet. Although there has been a dramatic increase in the reach of the Internet, little is known about how diverse populations use the Internet for behavior change. Some people will be interested in the Internet, some will lose interest, others will be interested but lack access, and still others will have interest and access, but lack the skills to obtain the information they need. Nevertheless, the menu of communication choices is expanding rapidly, and we must be prepared to use those options, where appropriate, for health communication. Technology Recommendation 1: Investments are needed in research, training, and delivery of technology-based communication interventions to improve the health of diverse populations. In many cases, new technology should be combined with established communication strategies, such as face-to-face contact and telephone counseling. New applications such as “live help” may be useful in this regard. Research methods are needed to estimate untapped potential and costs of communication technology used to improve health care for diverse populations.

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations DIVERSITY Diversity frequently is defined for policy and research purposes by broad social demographic categories such as race, ethnicity, and socioeconomic status as well as gender and age. This has some advantages. These characteristics are apparent and are often easily measured, and thus comparisons between groups are facilitated. Also, for many health behaviors and health outcomes, researchers using these categories have located important disparities. This evidence has allowed groups with poor health outcomes and their advocates to make a strong moral claim for redress and reallocation of resources. Also, groups organized around these identities have forged political bonds, and that has given them some power and ability to make additional claims on resources. At the same time, these diversity categories may have more political relevance than substantive relevance in the construction of communication programs. There is often as much heterogeneity with regard to a behavior and its determinants within a specified group as between groups. Also, the use of such categories to report disparities may reinforce stigma, a sense that a disadvantaged group is incapable of helping itself. This may be a particular concern when race and ethnicity are used as the criterion for diversity. There are alternative ways to describe heterogeneity in the population that do not rely on these categories. It is argued in Chapter 7 that programs need to focus on cultural processes, on understanding the life experiences of the communities and individuals being served, and on the sociocultural environment of individuals within the populations to be reached. This includes multiple dimensions ranging from economic contexts and community resources such as access to health services to commonly held attitudes, norms, efficacy beliefs, and practices pertinent to the health issue in question. Researchers and practitioners should identify and operationalize the particulars associated with a given group’s life experiences in designing and assessing health communication strategies.

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations This concern reflects much current research by anthropologists, sociologists, and psychologists. At the same time, it reflects the applied wisdom of sophisticated social marketers and communication campaign planners, who are making the same argument. As already described, their research is designed to segment audiences according to behavior and factors related to behavior. They suggest partitioning the audience on characteristics relevant to their behavior, not on irrelevant characteristics. This also applies to tailored programs. Diversity Recommendation 1: Policy makers and program planners should continue to use demographic factors to understand whether health benefits are equally distributed and to identify intergroup differences. Where there are existing disparities, it will be important to monitor trends in gap opening and closing according to these categories. Diversity Recommendation 2: At the same time, program planners need to recognize that other measures such as life experiences and cultural processes are needed to understand within-group variations and to understand their association with health behaviors. Actual planning of health communication programs will rarely be well served by an assumption of homogeneity within any of these categories. This may also require efforts to more systematically educate policy makers about the relevant domains of diversity for purposes of communication interventions. Diversity Recommendation 3: We recommend that greater support be provided for qualitative, ethnographic research that examines the historical, social, and cultural contexts of diverse communities’ health behavior.

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations INFRASTRUCTURE The field of public health communication relies on the contribution of many disciplines. Skilled communicators and interventionists are central to successful communication programs, but they depend on expertise from many other fields. Public health communication requires theories about behavior and behavior change; deep understanding of its audiences, their cultural experience, and their social and structural circumstances; and understanding of the health infrastructure around the health concern and its medical nature. Increasingly, public health communication requires technical expertise with new communication technologies. Some programs need the expertise of marketers and others need informatics expertise. Too often, resource constraints and routine work processes mean that practitioners are not able to bring these other skills and insights to their work; they are isolated from the public health and medical expertise; the social science expertise of psychologists, sociologists, and anthropologists; and the marketers and informatics experts who might help. Communication programs often are proposed, and sometimes even developed, when there is no likelihood that the resources will be available to operate a full-scale program. Research and resources are often lacking to permit the appropriate scale-up required to take evidence-based communication strategies from research or demonstration settings to larger scale implementation with assessment of impact. More attention to and resources for dissemination of evidence-based communication programs are essential. Infrastructure Recommendation 1: If advances are to be made in communication for diverse populations, the field of public health communication should be strengthened. This requires not only investment in research and training, but the active participation and collaboration of people from many disciplines. Interdisciplinary teams to design and implement communication strategies in diverse populations should be encouraged by funding agencies.

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations Infrastructure Recommendation 2: National campaigns to address major health priorities require the mustering of substantial resources and, often, coordinated efforts of multiple agencies if national audiences are to be reached and effects are to be sustained over time. They cannot be undertaken successfully without such commitment. A national strategy and the infrastructure for prioritizing and implementing such large-scale campaigns are needed.