2
Theory

This chapter synthesizes the main theories of communication and behavior change, including media advocacy and the diffusion of innovations, as they apply to health behavior change by diverse populations in the United States. Our perspective is restricted to those elements that appear to be most relevant to modifying a person’s health-directed activities through communication.

WHAT DOES THEORY DO?

Behavioral theories are defined by constructs, their relationships, and guidance for their implementation in applied settings. In health communication intervention programs, behavioral theories provide a framework for identifying the critical factors underlying the performance (or nonperformance) of specific health-related behaviors. The more one knows about the determinants of a given behavior, the more likely it is that one can develop an effective communication intervention to reinforce or change that behavior.



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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations 2 Theory This chapter synthesizes the main theories of communication and behavior change, including media advocacy and the diffusion of innovations, as they apply to health behavior change by diverse populations in the United States. Our perspective is restricted to those elements that appear to be most relevant to modifying a person’s health-directed activities through communication. WHAT DOES THEORY DO? Behavioral theories are defined by constructs, their relationships, and guidance for their implementation in applied settings. In health communication intervention programs, behavioral theories provide a framework for identifying the critical factors underlying the performance (or nonperformance) of specific health-related behaviors. The more one knows about the determinants of a given behavior, the more likely it is that one can develop an effective communication intervention to reinforce or change that behavior.

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations Perhaps the most critical determinant of whether a person does or does not perform a given behavior is the person’s beliefs about performing that behavior. Thus, behavioral theory, when properly applied, allows one to identify the beliefs that should be changed or reinforced to influence a given behavior change in a given population. Changing a person’s beliefs can be a precursor to changing a person’s behavior. Thus, behavior change can be said to be mediated by belief change. By recognizing that the critical beliefs in one population may be different from those in another population, behavioral theory helps in understanding the importance of diversity in developing effective health communications. However, knowing which beliefs to address does not tell us how to go about designing messages or interventions that can effectively reinforce or change those beliefs. Theories of communication and persuasion guide the selection of communication sources and channels and the preparation of the content of messages. For example, data about women’s beliefs regarding the value of mammography are important in creating interventions to enhance mammography use. However, finding out that many women in a given population do not believe that getting a mammogram will lead to early detection of breast cancer does not reveal how to design messages to convince them otherwise, or how to achieve social and environmental changes to influence this belief and therefore influence behavior change. By recognizing that different sources, channels, and message executions may be necessary for different populations, communication theories also point to the importance of considering diversity in developing effective health communication interventions. We also recognize that communication interventions influence beliefs (and behavior) in different ways. Sometimes people exposed to a message learn the information that it contains, and this knowledge has a “direct” effect on their beliefs. But the context in which one receives the message also may influence how the message is received. For example, if a person is exposed to a message in the company of friends, their reactions to the message may strongly influence whether the person learns or accepts the mes-

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations sage content. If one’s friends respond to an antismoking or a dental hygiene message with anger or derision, the context may be converted into one of resistance rather than careful processing and possible acceptance of the message content. Theories of media effects provide a framework for understanding how mass communication messages ultimately influence beliefs and behavior. In this chapter, we first consider behavioral theories and their implementation. We then consider theories of communication and persuasion, and theories of media effects. Rather than summarizing and describing the various theories in each of these areas, our focus is on identifying the critical concepts in these theories and on their theoretical integration. Many good reviews of theories have been conducted (e.g., Glanz, Lewis, and Rimer, 1997), but far fewer attempts have been made to synthesize constructs and achieve integration among behavioral theories or between behavioral and communication theories. Finally, we consider the implications of these theories for developing health messages for diverse audiences. “Good” theories not only recognize the role of diversity, but, when implemented properly, are specific to both the behavior of interest and to the population involved. FACTORS INFLUENCING BEHAVIORAL PERFORMANCE: KEY CONSTRUCTS FROM BEHAVIORAL THEORIES This volume shows that health disparities may reflect variations in biological risk factors, differences in access to diagnostic or treatment facilities, or behavioral differences. These latter differences (in health behaviors) are amenable to change via communication interventions. In order to develop health communication messages to eliminate or reduce the behavioral differences, it is essential to understand factors influencing the performance (or nonperformance) of a given health behavior. There are many theories of behavioral prediction, including: Theory of Planned Behavior (e.g., Ajzen, 1985, 1991; Ajzen and Madden, 1986);

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations Theory of Subjective Culture and Interpersonal Relations (e.g., Triandis, 1972); Transtheoretical Model of Behavior Change (Prochaska and DiClemente, 1983, 1986, 1992; Prochaska, DiClemente, and Norcross, 1992; Prochaska et al., 1994); Information/Motivation/Behavioral-Skills Model (Fisher and Fisher, 1992); Health Belief Model (Becker, 1974, 1988; Rosenstock, 1974; Rosenstock, Strecher, and Becker, 1994); Social Cognitive Theory (Bandura, 1977, 1986, 1991, 1994); Theory of Reasoned Action (Fishbein and Ajzen, 1975; Ajzen and Fishbein, 1980; Fishbein, Middlestadt, and Hitchcock, 1991). However, there is a growing academic consensus that only a limited number of variables need to be considered in predicting and understanding any given behavior (see, e.g., Petraitis, Flay, and Miller, 1995; Fishbein, 2000). The variables come primarily from three theories that have been widely used in, and have a major influence on, current behavioral health research: the Health Belief Model, Social Cognitive Theory, and the Theory of Reasoned Action. (See Annex A at the end of this chapter for a brief description of each of these theories.) One way to predict whether or not a given person will engage in a given health behavior is to ask. People are remarkably accurate predictors of their own behaviors, and appropriate measures of intention (one’s subjective probability that he or she will or will not engage in a given behavior) consistently have been shown to be the best single predictors of the likelihood that one will (or will not) perform the behavior in question (see, e.g., Sheppard, Hartwick, and Warshaw, 1988; Van den Putte, 1991). However, people do not always act on their intentions. One may intend to perform a given health behavior, but discover that he or she does not have the necessary skills and abilities to carry out the behavior. In addition, one may encounter unanticipated environmental con-

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations straints (or barriers) that impede or prevent behavioral performance. At the same time, it is important to recognize that environmental (or ecological) factors may also facilitate acting on one’s intentions as well as behavioral performance per se. Nevertheless, if a person has made a strong commitment (or formed a strong intention) to perform a given behavior, and if he or she has the necessary skills and abilities required to perform that behavior, and if there are no environmental constraints or barriers to prevent performance of that behavior (i.e., if a context of opportunity exists for performing the behavior), the probability is very high that he or she will perform that behavior. Thus, if one has formed a strong intention (or made a strong commitment) to perform a given behavior, but is unable to act on that intention, a communication intervention should be directed at “skills training,” or at removing or helping people to overcome barriers or environmental constraints. Such interventions often increase a person’s sense of personal agency or self-efficacy, a concept discussed later. On the other hand, if people are not engaging in a behavior because they have little or no intention to do so, the intervention should be directed at developing or strengthening intentions. Note that intention is viewed as a continuous, rather than as a dichotomous, variable. People do not simply “have” or “not have” an intention to perform a given behavior, but rather, people have stronger or weaker intentions to perform (or not perform) the health behavior in question. People may tell us that they “definitely will” versus “probably will” perform a given health behavior, such as obtaining a mammogram. Similarly, there is a difference between saying that it is “slightly probable,” “quite probable,” or “extremely probable” that one will engage (or not engage) in some health behavior. Although it could be argued that many health-related behaviors are performed automatically, without reflection on or awareness of intention, when asked, people can tell us whether they will or will not perform a given behavior, and these measures of intention (or self-prediction) are highly related to actual behavioral performance. Thus, from a communica-

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations tion perspective, it is important to know whether and why people do or do not hold a given intention. Behavioral change theories suggest that only a limited number of variables directly influence the strength of intentions. Some theorists view these determinants of intention as also having a direct influence on behavior—an influence that goes beyond their indirect influence through intention. Although different theories use different terminology, three major factors appear to influence intention (and thus behavior): (1) one’s attitude toward performing the behavior; (2) one’s perception of the norms governing performance or nonperformance of the behavior; and (3) one’s sense of personal agency or self-efficacy regarding personally performing the behavior. Attitude The attitude concept refers to the extent to which one “likes” or “dislikes” a given object, institution, event, or behavior, and is often defined as an overall feeling of favorableness or unfavorableness toward that object, institution, event, or behavior (Eagley and Chaiken, 1993). For the purpose of behavioral prediction, the critical attitude is the attitude toward one’s own performance of the behavior in question. The more favorable one is to personally performing a given behavior, the more likely it is that one will intend to perform that behavior. The attitude toward performing a given behavior is assumed to be based on a person’s beliefs about performing that behavior (Fishbein and Ajzen, 1975; Ajzen and Fishbein, 1980). The more a person believes that performing a given behavior will lead to positive consequences (e.g., “My performing this behavior will make me feel better”; “will show my partner that I care”; “is the responsible thing to do”) and/or prevent negative consequences (e.g., “will protect me from disease Y”; “will reduce the probability of an amputation”), the more favorable the person’s attitude is toward performing that behavior. Similarly, the more a person believes that performing the behavior will lead to negative consequences (e.g., “My performing this be-

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations havior will be painful”; “will be expensive”; “will make my partner angry”) or prevent positive consequences (e.g., “will not make me feel better”; “will not make me healthy”), the more unfavorable the attitude. Although many theories do not use the attitude construct, nearly all agree that intention (or behavior) is a function of one’s beliefs that performing the behavior will lead to various outcomes and the evaluation of those outcomes. It is assumed that a person will not form an intention (or perform a behavior) if the costs of performing that behavior outweigh the benefits. These underlying beliefs are called “outcome expectancies” or “behavioral beliefs.” Perceived Norms Perceived norms are the degree to which a person perceives that a given behavior is viewed as appropriate or inappropriate by members of the person’s social network or society at large. Norms reflect the amount of social pressure one feels about performing or not performing a specific behavior. Generally speaking, there are two types of normative pressure. On one hand, a person may believe that particular individuals or groups that are important to the person think that he or she should (or should not) perform the behavior in question. On the other hand, a person may believe these important others are, or are not, performing that behavior. Although it is likely that we have all been told to “do what I say, not what I do,” it is clear that both types of normative pressure ultimately influence behavior and intention. Although the notion of normative pressure seeks to capture an overall perception about what most “important” others are saying or doing concerning the behavior, this overall judgment must somehow incorporate and integrate the desires and/or actions of specific others. Indeed, these underlying normative beliefs (about the expectations or behaviors of specific others) are assumed to influence (or determine) a person’s overall perception of social pressure.

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations Personal Agency Agency is a belief that one has the necessary skills and abilities to perform the behavior in question. Two types of considerations underlie a person’s sense of personal agency. First, there is the notion of self-efficacy, the belief that one can perform the behavior even under a number of difficult challenges. Second, there are beliefs that performance of the behavior is “up to me” and “under my control.” Both self-efficacy and perceived behavioral control are seen as a function of beliefs concerning specific barriers or impediments to behavioral performance. Influence of Attitudes, Norms, and Personal Agency on Behavior Although there seems to be general agreement among behavioral theorists that attitudes (or the outcome expectancies underlying attitude), perceived norms, and personal agency are critical to understanding why people do or do not engage in any given behavior, there is considerably less agreement concerning the ways in which these variables influence behavior. Some theorists view these variables as having only an indirect influence on behavior or behavior change through their influence on intentions, while others would argue that their influence is direct. This is particularly true with respect to personal agency, and considerable evidence shows that personal agency (or self-efficacy) directly influences the likelihood that one will or will not perform a given health behavior (for a comprehensive review, see Bandura, 2001). For example, the stronger one’s feeling of self-efficacy, the greater the probability that one will persist in attempts to perform a behavior, even after an initial failure (Bandura, 1997a). Another disagreement among theoreticians concerns the role of social norms. Some theorists argue that perceived normative pressure directly influences intentions (and/or behavior) (e.g., Ajzen and Fishbein, 1980); others argue that normative pressure influences intentions (and/or behavior) only indirectly, by influencing outcome expectancies (Bandura, 1997). For example, from this

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations perspective, knowledge that another person “X” thinks one should not perform a given behavior will only influence performance of that behavior if this normative belief leads to an outcome expectancy, such as “My performing this behavior will make person X angry.” Despite these differences, and regardless of the exact theoretical model one adopts, communication interventions to change health behavior should increase skills, remove or help individuals overcome environmental constraints, or change intention (by changing attitudes, norms, or a sense of personal agency; i.e., by changing the factors that directly or indirectly influence intention and behavior). The relative importance of these variables as determinants of behavior and behavior change will vary as a function of both the health behavior and the population being considered. Thus, a given health-protective behavior may not be performed because of a lack of skills, while another health-protective behavior may not be performed because people have no intention to do so. Similarly, the same behavior may not be performed in one population because of environmental constraints, while the failure of behavioral performance may be because of a lack of skills or abilities in another population. The relative importance of attitudes, norms, and personal agency as determinants of intention (and behavior) also varies from behavior to behavior and from population to population. For example, intentions to perform one behavior (or the actual performance of that behavior) may be primarily under attitudinal control, while the intention to perform another behavior may be largely under normative control or be primarily influenced by beliefs about personal agency. Similarly, members of one population may intend to not perform a given behavior because they have negative attitudes toward performing that behavior, while members of another population may have decided not to perform the behavior because their important others think they should not perform the behavior or because they do not believe they have the necessary skills and abilities required to perform that behavior (i.e., they do

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations not have a sense of personal agency or self-efficacy with respect to performing that behavior). One immediate implication is that health communication interventions should be directed at changing those variables that are important determinants of health behavior change in the population being considered. Communication interventions that address an “unimportant” variable are unlikely to be successful. Thus, prior to developing a communication intervention, it is important to determine whether people have or have not formed an appropriate intention, and, if not, to determine whether that intention is influenced primarily by attitudes, norms, and/or issues of personal agency. Once the critical determinants of a specific behavior change in a particular population have been identified, one should be able to develop health communication interventions to change those determinants. Ultimately, this process involves changing a person’s underlying beliefs about the consequences of performing the health behavior, about the expectations or behaviors of others, or about one’s ability to perform the behavior under a variety of challenging circumstances. For example, in order to change an attitude, it is often necessary to change outcome expectancies, that is, beliefs that performing the behavior will lead to certain positively or negatively valued outcomes. Clearly, the more that one believes that performing the behavior in question will lead to “good” outcomes and prevent “bad” outcomes, the more favorable the person’s attitude will be toward performing that behavior. Similarly, the more one believes that specific relevant others think he or she should perform the behavior and the more one believes these others are performing the behaviors themselves, the more one will experience social pressure to perform the behavior change. Finally, the more one believes he or she can perform the health behavior, even when specific impediments are present, the stronger that person’s sense of self-efficacy or personal agency will be. The substantive uniqueness of each behavior comes into play at this level of underlying beliefs. For example, the barriers to obtaining a mammogram and/or the outcomes (or consequences)

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations of getting a mammogram may be very different from those associated with taking a PSA test (a blood test for detecting prostate cancer), or getting genetic screening. These specific health beliefs must be addressed in a communication intervention if one wishes to change intentions and behavior. Although an investigator or a practitioner can sit in his or her office and develop measures of attitudes, perceived norms, and self-efficacy, he or she cannot know what a given population (or a given person) believes about performing a given behavior without interacting with that population. Thus, one must go to members of a target population to identify salient outcome, normative, and efficacy beliefs; one must understand the health behavior change from the population’s perspective. Although behavioral theory suggests that a common set of variables is relevant to all populations, it recognizes that the relative importance and substantive meaning of these variables depends on the specific population being considered. By appropriately implementing a theory, one can identify the behavioral, normative, and/or efficacy beliefs that discriminate between people, in any given population, who do and do not perform a specific behavior. Theories of communication and behavior change inherently recognize the role and importance of diversity. Program planners should act on this knowledge. The above discussion focuses attention on a limited set of variables that have consistently been found to be among the strongest predictors of any given behavior (see, e.g., Petraitis, Flay, and Miller, 1995). Although focusing on behavior-specific variables may provide the best prediction of any given behavior, this approach does little to explain the genesis of the beliefs that underlie attitudes, norms, and self-efficacy. Clearly, the beliefs that one holds concerning his or her performance of a given behavior are likely to be influenced by a large number of other variables. For example, one’s life experience will influence what one believes about performing a given behavior, and thus one often finds relations among demographic variables such as gender, ethnicity, age, education, socioeconomic status, and behavioral performance. Similarly, women who perceive they are at high risk for, and/or are

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations leadership groups, public health and social advocates, and public health researchers (Wallack et al., 1993; Wallack et al., 1999). From a theoretical perspective, media advocacy borrows from mass communication research, political science, sociology, and political psychology to develop strategy. Central to media advocacy are the concepts of agenda setting (McCoombs and Shaw, 1972; Dearing and Rogers, 1994) and framing (Iyengar, 1991; Gamson, 1989; Ryan, 1991). From a practical perspective, media advocacy borrows from community organizing, key elements of formative research (i.e., focus groups and polling), and political campaign strategy (e.g., application of selective pressure on key groups or individuals) (Wallack et al., 1993). Media advocacy differs from traditional public health campaigns. It is most marked by an emphasis on: Linking public health and social problems to inequities in social arrangements rather than to flaws in the individual. Changing public policy rather than personal health behavior. Focusing primarily on reaching opinion leaders and policy makers, rather than on those individuals who are directly affected (the traditional audience of public health communication campaigns). Working with groups to increase participation and amplify their voices rather than providing health behavior change messages. Having a primary goal of reducing the power gap, rather than filling the information gap. Media advocacy is generally seen as part of a broader strategy, rather than as a strategy per se. It focuses on four primary activities in support of community organizing, policy development, and advancing policy: Developing overall strategy. Media advocacy uses critical thinking to understand and respond to problems as social issues, rather than as personal problems. Following problem definition,

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations the focus is on elaborating policy options; identifying the person, group, or organization with the power to create the necessary change; and identifying organizations that can apply pressure to advance the policy and create change. (For example, in Oakland, California, various elements of the community were organized to apply pressure on the zoning commission, mayor’s office, city council, and state legislature, which were all targets at various points in the campaign.) Finally, various messages for the different targets of the campaign are developed. Setting the agenda. Getting an issue in the media can help set the agenda and provide legitimacy and credibility to the health issue. Media advocacy involves understanding how journalism works in order to increase access to the news media. This approach includes maintaining a media list, monitoring the news media, understanding the elements of newsworthiness, pitching stories, and holding news events and developing editorial page strategies for reaching key opinion leaders about a given health issue. Shaping the debate. The news media generally focus on the plight of the victim, while policy advocates emphasize social conditions that create victims. Media advocates frame policy issues using public health values that resonate with broad audiences. Some of the steps include “translate[ing] personal problems into public issues” (Mills, 1959); emphasizing social accountability as well as personal responsibility; identifying individuals and organizations who must assume a greater burden for addressing the problem; presenting a clear and concise policy solution; and packaging the story by combining key elements such as visuals, expert voices, authentic voices (those who have experience with the problem), media bites, social math (creating a context for large numbers that is interesting to the press and understandable to the public), research summaries, fact sheets, and policy papers. Advancing the policy. Policy battles are often long and contentious, and it is important to use the media effectively to keep the issue on the media agenda. The Oakland, California, effort took 4 years and now must focus media attention to ensure that the policy

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations is properly implemented. Thus, it is important to develop strategies to maintain the media spotlight on the policy issue on a continuing basis. This effort means identifying opportunities to reintroduce the issue to the media—informing them of key anniversaries of relevant dates, publication of new reports, and significant meetings or hearings—and linking the policy solution to breaking news. Diffusion of Innovations When a new idea or innovation is introduced, diffusion theory (see, e.g., Rogers, 1995) suggests that the innovation has five characteristics, as perceived by members of a social system, that determine its rate of adoption: (1) relative advantage—the degree to which an innovation is perceived as being better than the idea it supersedes; (2) compatibility—the degree to which an innovation is perceived as being consistent with the existing values, past experiences, and needs of potential adopters; (3) complexity—the degree to which an innovation is perceived as being difficult to understand and use; (4) trialability—the degree to which an innovation may be experimented with on a limited basis; and (5) observability—the degree to which the results of an innovation are visible to others. In summary, innovations that are perceived by individuals as having greater relative advantage, compatibility, trialability, and observability and less complexity will be adopted more rapidly than other innovations. In addition to the perceived characteristics of the innovation, people (or organizations and other units of adoption) vary in their innovativeness, the degree to which they are relatively earlier in adopting new ideas than other members of a social system. According to diffusion theory, there are five adopter categories: (1) innovators—the first 2.5 percent of the individuals in a system to adopt an innovation; (2) early adopters—the next 13.5 percent of the individuals in a system to adopt the innovation; (3) early majority—the next 34 percent to adopt; (4) late majority—the next

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations 34 percent; and (5) laggards—the last 16 percent of the individuals in a system to adopt an innovation. Generally speaking, the early adopter category, more than any other, has the greatest degree of opinion leadership in most systems, and potential adopters often look to early adopters for advice and information about the innovation. Several health communication interventions identified opinion leaders in a given community (e.g., among medical practitioners or members of the public), and then introduced innovations through these opinion leaders, in order to speed up the rate of diffusion of a health innovation (Kelly et al., 1992; Kelly, 1994). IMPLICATIONS OF THEORY FOR HEALTH COMMUNICATION WITH DIVERSE POPULATIONS It should be clear that theories of communication and behavior change, and theories of media effects, all recognize the importance of considering diversity in developing effective health communication interventions to produce behavior change. More specifically, behavior change theories recognize that the relative importance of the theoretical determinants of any given behavior may vary across populations. For example, a given health behavior change may be attitudinally driven in one population, normatively driven in another, and primarily under the influence of personal agency in a third population. Moreover, even if the same determinant is of primary importance for two diverse populations, the substantive content of the beliefs underlying that determinant may differ. For example, although attitude may be the most important determinant of a given health behavior in both Asian-American and African-American communities, members of one community may hold very different beliefs from members of the other community about the consequences of performing that health behavior. Similarly, theories of communication and behavior change recognize that sources and channels that are perceived as credible by one population (i.e., for one audience) may be distrusted or not

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations utilized by another. Moreover, production values and formats in communication messages that positively appeal to one population may be viewed as unpleasant or boring by another. Finally, a message may lead directly to immediate or delayed health behavior change in one population, but will only affect beliefs if it leads to institutional diffusion in another. Although these considerations make it clear that one should develop health communication interventions with a specific target audience in mind, it is important to recognize that in many cases, the same belief or set of beliefs may be identified as a critical target for a number of diverse populations. The same message may be equally effective for diverse audiences. Moreover, when there is a “strong” message, the source may be less important than the message per se. Indeed, there is growing evidence that the source of a message is most important with a “weak” message, but has little or no effect with a “strong” message. Does theory matter? Theory can increase the potential effectiveness of communication interventions by identifying critical beliefs to target, by structuring the communication message, and by guiding the selection of sources and channels of communication. Does diversity matter in developing health communication interventions? To maximize communication effectiveness, one should adapt message formats, sources, channels, and frequency of exposure for different audiences. Factors such as age, gender, race/ ethnicity, and sexual orientation all draw on different interactions with the world and lead to different understandings regarding what is important and what is appropriate. Theory provides us with a roadmap to incorporate cultural differences into health communication interventions. Do we need new behavior change theories? Existing behavioral theories need to be more fully applied in implementing health communication interventions. The main need is not for new theory, but for better application of the communication and behavior change theories that we already have. Individuals developing communication interventions need to fully understand the behavior they are trying to change or to reinforce from the per-

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations spective of the particular population with whom they are dealing. That is, they need to know whether, in that population, a given health behavior is controlled by attitudes, perceived norms, or issues of personal agency. More important, they need to identify these behavioral, normative, and/or control beliefs that most strongly discriminate between those who do and do not perform a given health behavior. Once target beliefs have been identified, one must identify the communicator, medium, and type of message that will have the greatest chance of influencing the beliefs either directly or indirectly. Although theory is quite clear about the need to consider population differences in developing effective communication interventions, is there evidence that the appropriate use of theory helps to change health behaviors in diverse audiences? In the following chapters we examine the existing evidence and determine whether there are research gaps that need to be addressed. In sum, communication and behavior change theories provide a powerful tool for organizing our thoughts, the existing evidence, and cultural realities so that health communication interventions can be more comprehensive, more sophisticated, and more likely to have desired effects on health behavior change. The following annex (Annex A) describes three of the behavioral theories that have had the strongest impact on health behavior interventions. Annex B describes self-regulation models. ANNEX A: OVERVIEW OF KEY CONCEPTS IN THREE BEHAVIOR CHANGE THEORIES The Health Belief Model According to the original Health Belief Model, two major factors influence the likelihood that a person will adopt a recommended health-protective behavior change. First, the person must feel susceptible to a disease with serious or severe consequences. Second, the person must believe that the benefits of taking the rec-

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations ommended action outweigh the perceived barriers to (and/or costs of) performing the preventive action. In addition, the model recognized that a number of events (e.g., knowing someone who is ill, exposure to media campaigns, or other information) can serve as “cues to action.” These cues sometimes have been viewed as influencing “threat” (Janz and Becker, 1984) and sometimes as influencing behavior directly (Rosenstock, Strecher, and Becker, 1994). Most recently, the concept of self-efficacy has been added to the Health Belief Model (Rosenstock, Strecher, and Becker, 1994). Finally, the Health Belief Model also recognized that a number of demographic and individual difference variables could influence health beliefs (i.e., susceptibility, severity, costs, benefits, and self-efficacy). Social Cognitive Theory According to Social Cognitive Theory (Bandura, 1977b, 1986, 1997a), three primary factors determine the likelihood that someone will adopt a health behavior change: (1) self-efficacy, (2) goals, and (3) outcome expectancies. To adopt a given behavior change, individuals must have a sense of personal agency or self-efficacy that they can perform the desired behavior change, even in the face of various circumstances or barriers that make the change difficult to adopt and implement. Unless people believe they can exercise some control over their health behavior, they have little incentive to act or to persevere in the face of difficulties. Health behavior also is affected by the outcomes that people expect their actions to produce. These expected outcomes include physical effects, social costs and benefits, and positive and negative self-evaluative reactions to one’s health behavior. Personal goals, rooted in a value system, provide further self-incentives and guides for health habits. Personal health behavior change would be easy if there were no impediments to surmount. The facilitators and obstacles that people perceive in changing their behavior is another determinant of health behavior change.

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations In effecting large-scale change, communication systems operate through two pathways (Bandura, 2002a). In the direct pathway, communication media promote change by informing, modeling, motivating, and guiding people. In the socially mediated pathway, media influences are used to link people in social networks and community settings. These places provide continued personalized guidance, as well as natural incentives and social supports for desired changes. The Theory of Reasoned Action According to the Theory of Reasoned Action (Fishbein and Ajzen, 1975; Ajzen and Fishbein, 1980), performance of a given behavior change is determined primarily by the strength of a person’s intention to perform that behavior. The intention to perform a given behavior is, in turn, viewed as a function of two factors, namely the person’s attitude toward performing the behavior (i.e., one’s overall positive or negative feeling about personally performing the behavior) and/or the person’s subjective norm concerning the behavior (i.e., the person’s perception that his or her important others think he or she should or should not perform the behavior). Attitudes are a function of behavioral beliefs (i.e., beliefs that performing the behavior will lead to certain outcomes) and their evaluative aspects (i.e., the evaluation of these outcomes); subjective norms are viewed as a function of normative beliefs (i.e., beliefs that a specific individual or population thinks one should or should not perform the behavior in question) and motivations to comply (i.e., the degree to which, in general, one wants to do what the referent thinks one should do). It is worth noting that an extension of the Theory of Reasoned Action, the Theory of Planned Behavior (Ajzen, 1988, 1991), includes the concept of personal agency or perceived behavioral control. More specifically, according to the Theory of Planned Behavior, perceived behavioral control is viewed as a factor that directly influences both intention and behavior. *****

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations Taken together, these three theories identify a limited number of variables that serve as determinants of any given health behavior change. All or some of these variables are found in nearly all other behavioral theories (e.g., the Information, Motivation, Behavioral Skills Model, Prochaska’s Stages of Change Model). Although there is considerable empirical evidence for the role of attitude, perceived norms, and self-efficacy as proximal determinants of intention and behavior (e.g., Shepphard, Hartwick, and Warshaw, 1988; Sheeran, Abraham, and Orbell, 1999), there is only limited support for the role of perceived risk (e.g., Gerrard, Gibbons, and Bushman, 1996). Thus, most behavior change theories suggest three critical determinants of a person’s intentions and behaviors: (1) the person’s attitude toward performing the behavior, which is based on one’s beliefs about the positive and negative consequences (i.e., costs and benefits) of performing that behavior; (2) perceived norms, which include the perception that those with whom the individual interacts most closely support the person’s adoption of the behavior and that others in the community are performing the behavior; and (3) self-efficacy, which involves the person’s perception that he or she can perform the behavior under a variety of challenging circumstances. ANNEX B: SELF-REGULATION MODELS The Common Sense Model (Skelton and Croyle, 1991; Leventhal, Meyer, and Nerenz, 1980; Petrie and Weinman, 1997; Cameron and Leventhal, 2002), is a specific example of a self-regulation that adds a detailed set of constructs specific to health behaviors presented in cognitive behavioral models. The model is based on findings from studies of health communication (Leventhal, 1970), showing that health actions are a product of a cognitive system representing the individual’s subjective or perceptual experience of health threats, and a system representing emotional reactions to these threats. The cognitive system is composed of 4 components: (1) the representation of the threat (e.g., the

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations name of the disease and the symptoms identifying its presence, likely duration and time of onset, cause, consequences (physical, social, economic), and controllability); (2) procedures for avoiding and/or controlling it and how these procedures are represented (medication is necessary; medication is addictive and dangerous; see Horne, 1997); (3) action plans (Leventhal, 1970) or implementation intentions (Gollwitzer and Oettingen, 1998), which specify time and place to perform specific procedures; and (4) the appraisal of action outcomes. Appraisal or efficacy assessments are made in relation to the goals set by the representation of both the threat and the procedure. For example, an analgesic medication will be appraised for its efficacy in eliminating pain and the time it takes to do so. The temporal expectations will be longer for more severe injuries and shorter for strong than for mild analgesics, e.g., ibuprofen versus aspirin. A key proposition of the Common Sense Model is that representations of both health dangers and procedures are abstract (e.g., labels such as diabetes, coronary disease) and concrete and/or experiential (symptoms of diabetes, effects of insulin, etc.). Fear of a disease threat, i.e., the emotional response, can stimulate avoidance responses (minimization of the threat, avoidance of information), though these interfering effects are usually short lived and visible among individuals lacking a sense of self-efficacy. Evidence from multiple studies suggests that fear focuses attention on the danger (Lieberman and Chaiken, 1992) and encourages protective action among message recipients with high self-efficacy (Leventhal, 1970; Witte and Allen, 2000). Even individuals inclined to avoid exposure to threat information return to learn about and confront threats once their fear subsides (Wiebe, in press). Unlike planned behavior where social influences are conceptualized as norms (Ajzen and Fishbein, 1980), social influence takes multiple forms in the Common Sense Model. Observation of others, including observation of strangers, can provide information on cause, proximity and symptoms of health threats, efficacy and side effects of treatment, modeling of skills, assistance and barriers for both changing and maintaining health behaviors, and

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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations amplify or reduce fear associated with health threats and treatment procedures (Leventhal, Robitaille and Hudson, 1997). Most of the studies guided by the “self-regulation” framework have focused on actions for primary, secondary, and/or tertiary prevention that occur repeatedly over relatively long time frames for chronic illnesses such as diabetes, cardiovascular disease and cancer (the majority of the 1,800 plus items using the keyword “self-regulation” that were entered in the PsychINFO data base since 1990 are focused on health issues (see Leventhal, Brissette, and Leventhal, in press; Petrie and Weinman, 1997). The focus on chronic illness is consistent with hypothesis and data showing that representations of health threats and the procedures for control evolve over time as a function of changes in the individual’s concrete experience with illness and its symptoms and information from other persons and various media messages. Data supporting the Common Sense Model indicate that the great majority of behaviors initiated for health reasons are motivated by symptoms or functional deficits in the self or by observations of such changes in other persons. Symptoms and functional change are indicators of the state of the system, whether one is ill, stressed, or simply feeling the effects of aging, and changes in these perceptions over experienced (rather than clock) time are typically used as criteria for evaluating the efficacy of self selected and medically recommended interventions for avoiding and controlling illness threats. Although the Common Sense Model and the Social Learning Models (e.g., Bandura, 1977) were developed in parallel, they hold common assumptions about the determinants of health action.