Speaking of Health Assessing Health Communication Strategies for Diverse Populations (2002) / Chapter Skim
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224 7 Toward a New Definition of Diversity DIMENSIONS OF DIVERSITY One part of the committee's charge was to review existing theory and research applications in health communication and behavior change, especially as they related to socioculturally and demographically diverse populations. Throughout this volume we have used traditional epidemiological categories to describe disparities in health risks and health outcomes for diverse populations and to characterize the research literature on communication interventions for those populations.
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Toward a New Definition of Diversity 225 mensions of demographic differences -- than may be commonly assumed. The second purpose of this chapter is to offer an alternative concept of cultural processes that affords a more relevant base from which to understand sociocultural diversity and its implications for health communication.
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226 SPEAKING OF HEALTH cultural differences even though positing a causal relationship is not warranted by the data. • There is also a tension resulting from the focus on "groups" and the tendency to reify culture as a static experience for members of so-called "ethnic groups" versus looking at cultural and social experiences or processes as they affect people's lives and behavior.
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Toward a New Definition of Diversity 227 Contradictions and inconsistencies exist in official use of terms for ethnic groups in the United States (Ahdieh and Hahn, 1996; Hahn, 1992, 1999; Hahn and Stroup, 1994)
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228 SPEAKING OF HEALTH Federal agencies [http://www.whitehouse.gov/omb/inforeg/stat97. html#classdata]
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Toward a New Definition of Diversity 229 of diabetes in Native Americans, but the causal link is unknown. In other cases, the gene is not expressed without some environmental context, and it may interact with environments and other genes in nonadditive and unpredictable ways (Goodman 2000:700)
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230 SPEAKING OF HEALTH exhibits it "[consists] of some Greeks, Italians, Turks, Arabs, Africans, and Indians" (Livingstone, 1962:280)
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Toward a New Definition of Diversity 231 find it acceptable to be grouped together under an umbrella term, even while advocating the need for tribe-specific data. Nobles (2000:1745)
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232 SPEAKING OF HEALTH must be cited in order to make any statements about the distribution of populations across the country and about health disparities; however, it is important to work toward more sophisticated and accurate ways of understanding and describing the American people (Office of Management and Budget, 1997a, 1997b)
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Toward a New Definition of Diversity 233 and the use of space, also assume cultural form without entering conscious apprehension. Culture has many definitions, but most include the following basic concepts: • Culture includes shared ideas, meanings, and values; • Culture is socially learned, not genetically transmitted; • Culture includes patterns of behavior that are guided by these shared ideas, meanings and values; • Culture is constantly being modified through "life experiences"; and • Culture often exists at an unconscious or implicit level.
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234 SPEAKING OF HEALTH ten resented as stereotyping. Imposed typologies that operationalize "ethnicity" in terms of checkboxes may, at times, be cast too broadly to relate to any meaningful discussion of cultural and social processes.
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Toward a New Definition of Diversity 235 vidual lives are embedded in a variety of cultural processes that shape the individual, although not in a deterministic fashion. For example, children who grow up in different parts of the United States, but who watch the same television programs and play similar children's games, come to share cultural understandings through their exposure to and participation in similar activities.
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236 SPEAKING OF HEALTH The concepts of life experiences and cultural processes need to be put into operation so that they can be used effectively in understanding and changing health behavior through communication. One way to describe these is the concept of experiential identity.
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Toward a New Definition of Diversity 237 Human illness is fundamentally semantic or meaningful. (It may have a biological base, but it is a human experience.)
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238 SPEAKING OF HEALTH previously had been suggested as reasons why community members consulted infrequently with physicians. However, it was found that community members generally believed that biomedical treatment was compatible with their own understanding about illness.
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Toward a New Definition of Diversity 239 Also, as noted earlier, there is a tendency for the onus for health problems to be put on the individual, to "blame the victim." Some ethnic groups or cultural groups are more likely to be impoverished, which affects their health status. The committee concluded that none of the current terms, including "race," ethnicity, and culture (interpreted as cultural group)
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240 SPEAKING OF HEALTH signed to help practitioners provide cross-cultural services and care, point to the importance of attending to the social context of health behaviors when providing health services and when designing health communications. Models of cultural competency offer a variety of definitions that attempt to capture or expand on five elements considered essential to providing culturally competent health care across cultures.
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Toward a New Definition of Diversity 241 Cultural competency implies more than beliefs, attitudes, and tolerance. It includes the ability to act appropriately in the context of daily interactions with individuals who are culturally unlike the health care providers.
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242 SPEAKING OF HEALTH sonal needs and interests; cultural, social, and philosophical values; personal tendencies; the environment in which communication takes place or the medium through which it is communicated; past experiences as they relate to message content; knowledge of the subject and basic beliefs or understandings; and how the message is understood. For example, a Vietnamese individual may smile in response to a message to avoid confrontation or to show respect for the speaker.
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Toward a New Definition of Diversity 243 ETHICS OF HEALTH COMMUNICATION INTERVENTIONS FOR DIVERSE POPULATIONS Principles of ethics are important in developing and implementing health communication interventions. Although there are competing ways to consider ethical principles, we focus our attention on four core values that are central to effective ethical analysis for health care: respecting an individual's autonomy, providing benefit (beneficence)
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244 SPEAKING OF HEALTH TABLE 7-1 Ethical Aspects of the Design and Conduct of Health Promotions Facets Examples of guiding questions and ethical issues The right and • Who has the moral right to intervene on this obligation to health issue? (respect for autonomy; utility/public sponsor the good)
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Toward a New Definition of Diversity 245 • To what extent should messages and strategies be tailored? To whom should they be tailored?
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246 SPEAKING OF HEALTH • Does the intervention proffer alternatives for practices that fulfill an important function for the population? (avoidance of harm, equity)
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Toward a New Definition of Diversity 247 Because health communication initiatives often encourage individuals to take responsibility for their own well-being (Kirkwood and Brown, 1995; Knowles, 1977; Guttman, 2000) , it is important for developers to assess environmental constraints, access to health care resources and facilities, and the values and beliefs of the group.
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248 SPEAKING OF HEALTH sponsiveness to others with special needs, fidelity, compassion, kindness, and keeping promises (Baier, 1993; Pellegrino, 1993)
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Toward a New Definition of Diversity 249 propriation may offend groups that may not want their cultural symbols used in a particular way, even in health communication efforts, out of concern that such use will have a stereotyping effect (López, 1997)
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250 SPEAKING OF HEALTH THE SOCIOCULTURAL ENVIRONMENT The fields of social epidemiology, psychology, anthropology, sociology, and economics are converging in the development of theories and methodologies, helping us to understand factors underlying health disparities. Levine and his colleagues set the stage for this convergence, especially with the Handbook of Medical Sociology (Freeman and Levine, 1989)
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251 F IG U R E 7 -1 G ui de t o co m m un it y pr ev en ti ve s er vi ce s: So ci oc ul tu ra l en vi ro nm en t lo gi c fr am ew or k.
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252 SPEAKING OF HEALTH sociocultural environment looks at underlying contextual issues related to health status. The framework includes six areas of potential interventions, with the outcomes being healthier communities and a healthier population.
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Toward a New Definition of Diversity 253 This view of culture deflects attention from a richer understanding of the diverse social and cultural processes that are meaningful for the development of effective health communication strategies. Cultural processes are dynamic, embedded in social context, and therefore influenced by social factors such as immigration or discrimination as well as by interactive social processes and cultural products like music, food, and language.
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254 SPEAKING OF HEALTH be important to monitor trends in gap opening and closing according to these categories.
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