Clear evidence from the Centers for Disease Control and Prevention, the National Institutes of Health, the Institute of Medicine, and other agencies that collect data on health behaviors and outcomes shows that significant health disparities continue to exist across diverse populations, despite efforts to reduce or eliminate those disparities. This problem is likely to grow if predictions of increasing social and cultural diversity in the United States over the next 50 years are correct. If effective actions are not taken, this increasing diversity could lead to a disproportionate rise in populations who have poorer health outcomes.
Given the likely growth in diversity, communication interventions to affect health behavior are an increasingly important strategy for improving the health of the American people. Constructing such interventions to effectively influence individuals in diverse populations to engage in healthy behavior, however, relies on an understanding of the social and cultural contexts that shape the behavior of individuals, families, and communities. Belief systems, religious and cultural values, and group identity are all powerful filters through which information is received and processed. Although many communication programs address diversity in their
development and implementation, there is little evidence of the differential effects of these programs according to diversity subgroups. As a result, money and time are spent without knowing when a common format would suffice, or when a variety of targeted or even tailored interventions would be more appropriate. Given the likely growth in diversity, there is an urgent need now to enhance our current understanding of the dynamics of health communication to achieve the greatest impact for the most people.
This volume is the product of the Committee on Communication for Behavior Change in the 21st Century: Improving the Health of Diverse Populations, established by the Institute of Medicine in 1999. It focuses on those programs that involve some use of communication technology and have incorporated the transmission or exchange of messages within interventions designed to influence behavior to improve health. Programs exclusively involving interpersonal communication, such as between physician and patient, were not the focus; interventions that include other elements along with communication technology are considered.
The charge to the committee was to (1) review existing theory and research applications in health communication and health behavior change, especially as they relate to culturally diverse populations, and define research areas that would benefit from expanded or new research efforts; (2) consider up to three specific examples of health communication interventions to evaluate whether and how those strategies affect culturally diverse groups; and (3) recommend how health communication strategies may be designed and implemented to help achieve sustained gains in public health across cultural groups. The committee included experts in anthropology, psychology, mental health, cancer prevention and control, health behavior change and theory, communication and the media, social marketing, and public health. In the context of this charge, the committee considered the following questions:
Is there evidence that targeting or tailoring messages for different cultural groups makes a difference in the effect of these messages on behavior change?
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?
Are there special ethical issues that arise in health communication because of diversity?
Is the promise of communication for diverse populations different according to the health behavior(s) and disease process addressed?
What are the implications of the rapid development of new technology-based health behavior interventions for health disparities?
What are the most useful categories of diversity to be used in designing communication interventions?
With the issue of differential disease burden in mind, the committee chose as its exemplars the following: promotion of primary and secondary prevention strategies conveyed through mass health communication campaigns; secondary prevention of breast cancer with screening mammography; and primary, secondary, and tertiary prevention of Type 2 diabetes. These exemplars offer different communication challenges for behavior change in diverse populations.
We chose large-scale communication campaigns because they are widely used as a mechanism for affecting the behaviors of broad populations when the risk is widespread. We chose mammography because it involves a discrete behavior that should occur every year or two in a large segment of the healthy population. Diabetes was selected as a contrast to mammography; its treatment requires a complex set of continuing behaviors responsive to an evolving illness by those who have the illness as well as those around them. As noted, the focus of the committee’s review and analysis of the exemplars was to examine the effects of health communication on the health behavior of diverse populations. To ensure completeness of coverage, the review included studies in which communication campaigns were combined with other interventions (such as
access to health care facilities) as well as studies that examined communication strategies exclusively.
The following section provides a brief overview of the concepts contained in this volume and the committee’s major recommendations. Chapter 8 presents a more detailed list of the overall findings and recommendations.
THE IMPORTANCE OF THEORY AND ETHICS IN DESIGNING HEALTH COMMUNICATION
Behavior and Communication Theory
A large body of literature exists on theories of behavior that focus on the structural, social, and psychological factors that influence behavior and on theories of communication that underlie approaches to influencing changes in these factors. Our perspective is restricted to those elements that appear to be most relevant to modifying a person’s health-directed activities through communication. Theory can increase the potential effectiveness of health communication by identifying critical beliefs to target, by structuring communication, and by guiding the selection of sources and channels of communication. Important determinants of whether a person does or does not perform a given behavior are the person’s beliefs about performing that behavior, the obstacles and facilitating factors in the environment, and the person’s feelings about his or her ability to perform the behavior. Recognizing that these determinants may vary significantly from one population to another illustrates the importance of considering diversity in developing effective health communication. Once one or more behaviors and target populations have been identified, behavior change theory can be used to demonstrate why some members of a target population change their behavior and others do not. The proper implementation of behavior change and communication theory requires that one goes to a sample of the population to identify the outcomes, referents, and barriers that are relevant for that population.
Theories of behavior change and communication have an important place in the construction of communication programs in general and for diverse populations. The committee encourages program developers and implementers to use these theories in a more consistent and aggressive way in developing implementation plans for health communication interventions. Additional research is needed about the translational process of moving from theory to implementation. The committee recommends that more attention be given to how theories are translated into effective practice and implemented in health communication interventions; that is, how the theoretical principles are applied in practice. One approach might employ case studies that document specific interventions and include discussions of the operational difficulties of translating theory into practice.
Respecting an individual’s autonomy to make choices, maximizing benefit, avoiding harm, and treating groups and individuals justly and equitably are core ethical principles. These principles are easily endorsed, but not always easily achieved. Implementing ethical principles can be complicated by the developers’ needs to consider tradeoffs among efficiency, cost, and improving the health of the most in need versus benefiting a broader range of persons. Sometimes these choices have to be made under conditions of uncertainty, either in terms of uncertainty about the scientific support for an intervention or uncertainty about the effect of the intervention. Some communication strategies come into conflict when trying to secure benefit for one segment of the population versus another. This risk may be heightened in the context of reaching heterogeneous audiences with a common message. There is always the opportunity for unintended consequences to occur (e.g., confusion, unwarranted anxiety), even with the most well-intentioned and well-executed health communication interventions. Some of these concerns can be minimized through close cooperation with the groups whose health care one hopes to improve. This
recommendation may be complex to implement in practice, given the need to choose among potential representatives and the possible tension between technical “expertise” and preferences of intended beneficiaries. However, the committee believes that health communication program managers should not only explicitly consider ethical guidelines in their decisions about implementation, but also should involve affected individuals and communities as active participants in decision making about each campaign.
COMMUNICATION INTERVENTIONS FOR DIVERSE POPULATIONS
The State of the Evidence
The committee’s review of the literature makes it clear that researchers, program planners, and managers quite often take diversity into account when they construct their communication programs. This is true both for communication interventions that addressed mammography and for those that were examined in the review of large-scale campaigns. However, we found few examples of communication programs that addressed diabetes. Nevertheless, three broad diversity-respecting strategies emerged from the rich variety of approaches described in the literature. They are:
The construction of a unified communication program with a common denominator message that will be relevant across most populations.
The construction of a unified communication program with systematic variations of message executions to make them appeal to different segments, while retaining the same fundamental message strategy.
The development of distinct message strategies and/or distinct interventions for each target segment.
However, 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 whether there is added benefit in addressing health disparities by using communication that takes diversity into account. That is, there are few studies that 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 that compare those approaches with efforts that ignore diversity altogether. This is not to say 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 consider diversity were worthwhile, or which approaches were worthwhile and under what circumstances. Based on these findings, the committee believes the following:
There is a need to undertake comparative effectiveness research in each of the following areas: secondary analysis of evidence already collected from existing communication programs, effectiveness evaluation of new and ongoing programs, and field testing of alternative diversity strategies.
Until more convincing evidence is available pro or con, 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. This recommendation is subject to the following limitations: (1) the most important categories of diversity may not be the conventional ones, and (2) communication interventions should be targeted to specific subgroups only when the evidence from program research suggests that important differences exist in health behavior or the antecedents of health behavior or when there is a strong hypothesis for such differences.
Components of a Successful Program
Many successful communication programs have been reported in the literature. A review of these can be found in Chapters 3 and 4. The committee finds that these programs have met certain conditions, and that these conditions should serve as a guide for future program development. These conditions 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.
The Promise of New Technology
New uses of current and widely accessible communication media, such as print and telephone, have been possible because of computer applications that have permitted content to be tailored to individuals, thus allowing people to use older tools in new ways. Among the most important of these innovative uses are tailored print communication and telephone-delivered interventions. The potential of these media for reaching people with and without Internet access, and people with highly diverse linguistic and cultural requirements, should not be underestimated, nor should the challenge of harnessing the new media for reaching diverse audiences.
Achieving the potential of new technologies for diverse populations requires attention to access, as well as to the acceptability, availability, appropriateness, and applicability of content. Without deliberate action, new computer technologies may exacerbate inequities in health and health care. To improve the health care of diverse populations, the committee believes that investments are needed in research, training, and delivery of technology-based communication interventions. In many cases, new technology should be combined with established communication strategies, such as
face-to-face contact and telephone counseling. Research methods are needed to estimate untapped potential and costs of communication technology used to improve health care for diverse populations.
TOWARD A NEW DEFINITION OF DIVERSITY
Diversity is frequently defined for policy and research purposes by broad social and demographic categories such as race, ethnicity, socioeconomic status, age, and gender. Although these categories may have important political relevance, there is usually as much heterogeneity with regard to behavior and its determinants within a specified group as between groups. The committee argues that communication programs need to focus on other, more meaningful ways of describing heterogeneity. Specifically, they should focus on cultural process, 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. There are multiple dimensions to be considered, 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.
The committee recommends that policy makers and program planners 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. 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 rarely will 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.
The field of public health communication relies on contributions of many disciplines. Skilled communicators and intervention developers 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 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 technologies and medical knowledge about health problems. Some programs also need the expertise of marketers, and others need informatics expertise. 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.
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 infrastructure for prioritizing and implementing such large-scale campaigns are needed.