UP FRONT

Volume 6, Number 2
April-June  2001

Vital Data

From This Issue

Understanding the target audiences’ barriers to a specific action is crucial when creating and implementing an effective health communication program. Program planners cannot rely on estimated guesses of what they think these barriers are.  The first article in this issue of the Journal of Health Communication examines this issue, comparing and contrasting diabetes patients’ and educators’ perceptions of patient barriers to following a meal or exercise plan.  Shultz, Sprague, Branen, and Lambeth studied patients from three eastern Washington area hospitals (n=97) who have type 2 diabetes and had completed some amount of diabetes education prior to the study. Mailed questionnaires asked patients to describe their barriers to following meal and exercise plans, adherence to prescriptions, and compliance with recommendations of care.  Subsequently, diabetes educators who were members of the Washington State Association of Diabetes Educators (n=143) answered survey questions on program structure and evaluation, patient information, and perceived patient barriers to following a meal or exercise plan.  Study results revealed that diabetes patients and diabetes educators described different patient barriers. For example, patients were more likely to describe lack of food selection in their meal plan as a major barrier to following their prescribed plan, whereas educators perceived portion control as the biggest barrier for patients.  There was also a significant discrepancy between barriers perceived by educators and those perceived by patients in following an exercise plan.  In general, educators placed greater emphasis on all barriers, while patients did not perceive certain barriers as having a large effect.  These findings may demonstrate that educators may be discussing issues that do not resonate with their patients.  The authors suggest combating these communication problems by including more follow-up education sessions to identify and discuss specific issues and more open dialogue to explore patient barriers.  In the discussion section, the authors give several practical suggestions on alleviating barriers and increasing communication.  Both patients and educators need to press the diabetes health care community to provide more adequate follow-up so that educators can help patients with self-management over time. Shultz, J.A., Sprague, M.A., Branen, L.J., and Lambeth, S. A Comparison of Views of Individuals with Type 2 Diabetes Mellitus and Diabetes Educators about Barriers to Diet and Exercise. (p.99-115)
 

While the first article in this issue illustrated a real case scenario of why it is important to understand the target audiences’ needs, the authors of the second article provide a theoretical overview. Guttman and Ressler focus on how specific appeals may not be effective with certain audiences, describing how health communication campaigns that use personal responsibility appeals may not be ethical or effective. The authors identified several ethical issues that may arise in employing these types of appeals. For example, personal responsibility appeals presuppose causal links between people’s deeds and health outcomes. By saying that people need to be responsible for their health behaviors, we imply that they are culpable for adverse consequences when they do not adopt preventive measures, which could lead to additional “victim-blaming” in the health care industry.  This notion has potential to change the health care system so that insurance may be limited only to those who do not participate in risk-taking activities (i.e., smoking) that hinder good health.  In addition to ethical questions, the use of personal responsibility appeals may be ineffective. With messages that link a desired behavior with responsibility and an undesired, but pleasurable behavior with irresponsibility, individuals may not want to “sacrifice” their pleasure at society’s expense, particularly if others are still engaging the same negative behavior.  To place a more positive spin on these types of appeals, the authors suggest connecting personal responsibility appeals with potential positive outcomes and showing how an individual’s contribution to a problem can cause a sizable impact.  Other recommendations include emphasizing the feeling of obligation and promoting messages about being responsible for others.  For example, a National High Blood Pressure Education Program created a poster with a woman stating, “To take care of my three kids I need to take care of myself. So I take my blood pressure medicine every day.”   In addition, campaign strategies should promote a sense of agency, or the idea that the individual is self-aware and is free not to engage in actions deemed potentially hazardous.  Intended audiences need the opportunities and tools to make responsible health decisions and be able to interpret relevant information.   The authors assert that the consideration of these facets in personal responsibility appeals can serve to identify ethical concerns and strategic considerations in health campaign messages and consequently advance the development of responsible, effective appeals of personal responsibility. Guttman, N. and Ressler, W.H.  On Being Responsible: Ethical Issues in Appeals to Personal Responsibility. (p.117-136)
 

In the Journal of Health Communication 5(3), Vaughan and Rogers examine the effects of a Tanzanian entertainment-education radio soap opera, "Twende na Wakati" (Let’s Go with the Times) on listeners’ adoption of family planning practices.  This issue of the Journal includes a second article on the effects of this radio soap opera, discussing its effects on listeners’ personal communication networks (set of persons whom an individual links through mutual information exchange.)  Interpersonal communication is an integral factor in the diffusion of mass media messages about family planning and HIV prevention. The term “inter-media processes” has been developed to describe the set of processes by which mass media content is translated into personal behavior change through interpersonal discussion via networks.  In this study looking at the relationship of inter-media processes, Mohammed gathered data from 3,020 total people, representing both the treatment and control regions for the broadcasts of the entertainment-education radio soap opera.  In addition to respondents’ demographic information, the surveys also asked respondents information about their personal communication network partners and the frequency of discussion of “Twende na Wakati,” family planning, and HIV prevention. Results reveal that listeners to the entertainment-education radio soap opera were more likely than non-listeners to discuss family planning and HIV prevention issues in their social networks, with 81% of listeners discussing HIV prevention with network partners compared to 65% of non-listeners. Analyses also showed that respondents—both listeners and non-listeners—were more likely to discuss HIV prevention and family planning with network partners who are of similar tribal membership, religious affiliation, and gender, as well as with those who are equally or more highly educated than themselves.  In their discussion, the authors acknowledge that the radio program alone may not have explained the difference in findings.  The closeness of network partners may be more important than the media content alone in explaining the behavior of audience members.  The authors discuss the issue further with examples of previous studies showing this effect and this study’s implications for future research.  Mohammed, S. Personal Communication Networks & Effects of an Entertainment-Education Radio Soap Opera (p.137-154)
 

The fourth article in this issue reports on unique formative research findings that could help program planners guide campaigns aimed to prevent occupational noise-induced hearing loss. Despite the physiological, emotional, and psychological consequences of hearing loss, coal miners in the Appalachian Mountains continually fail to use available hearing protection devices.  As part of a formative evaluation study, four focus groups were conducted with coal miners from two different mines in Appalachia (n=32) to investigate the barriers miners encounter in using protection devices.  Findings from the sessions distinguish between environmental barriers that act as systemic constraints against behavioral change and individual barriers that serve as internal cues preventing healthful actions. Specific environmental barriers cited include economic issues (i.e., did not want to appear “weaker” than co-workers if asked for devices), medical issues (i.e., earplugs may cause infections), and a lack of laws that mandate the consistent use of proper hearing protection. The individual barriers to wearing hearing protection included perceived loss of hearing,  possible negative emotions such as fear or isolation from wearing devices, and the perceived social norms (i.e., they engaged in the same safety procedures as other miners; other miners did not typically wear devices.)  The session discussions also revealed a fundamental attribution error; miners tended to credit themselves for positive results involving safety, but tended to blame the problems associated with wearing hearing protection devices to outside sources. From this formative research, the authors conclude that health communication planners would want to emphasize the external/internal barriers perspective in future research or program planning with this audience.  While other frameworks such as the Health Belief Model or Stages of Change consider a number of factors influencing human behavior, they may not be able to provide the necessary information for these different stratified barriers.  The authors discuss the importance of understanding the differences in this audience’s perceived barriers and also conclude that secondary audiences may be an effective way to communicate with miners about changing attitudes and myths about barriers. Patel, D.S., Witte, K., Zucherman, C., Murray-Johnson, L., Orrego, V., Maxfield, A.M., Meadows-Hogan, S., Tisdale, J. and Thimons, E.D. Understanding Barriers to Preventive Health  Actions for Occupational Noise-Induced Hearing Loss. (p.155-168)
 

In the Forum section of this issue, the authors discuss that while physicians, public health experts, and social scientists now use the public health model to frame discussions of violence, newspapers still do not. In most media coverage, the reporting on crime over-represents the number of crimes actually committed, as well as ignores the contextual and casual processes related to crime patterns.  To test this phenomenon, Rodgers and Thorson conducted a content analysis of crime coverage in the Los Angeles Times. Analysis of the 416 crime stories coded illustrated that one of the nation’s largest newspapers did not incorporate a public health framework in their reporting of crime.  The frequency of crime stories was greater than the frequency of other topics in the newspaper, including business, education, and health. In addition, stories of homicides outnumbered reports on other types of crimes and also were over-represented relative to the actual number of homicides committed in Los Angeles.  More importantly, crime stories were most likely to report one-time events rather than discussion of crime as a larger issue. Violent crime articles were almost two times more likely than nonviolent crime articles to report the consequences of committing the crime. However, most often incarceration was the only consequential fact mentioned.  In addition, only 17% of articles discussed the psychological impact of crimes, while no articles discussed the economic impacts.  Rodgers and Thorson argue that this type of reporting does not portray an accurate picture of reality.  Readers are being inundated with crime and violence stories predominantly framed as isolated events, not patterns caused by factors that should be examined for their potential impact in prevention. The authors call for a change in media coverage of violence and discuss suggestions on what type of guidelines and investment in resources may be necessary for this change.  Rodgers, S. and Thorson, E. Reporting of Crime/Violence in the LA Times: Is there a Public Health Perspective? (p.169-182)
 
 

From Other Sources

A new study published in Health Affairs reveals that watching the television show "ER" can increase viewer knowledge on certain health topics, but only in the short-term. The analysis is drawn from data gathered over several years in random surveys of 3,500 regular viewers of the show before or after the airing of programs that dealt with emergency contraception and human papillomavirus (HPV), among other issues. Interviews conducted in the week after the shows aired found dramatic increases in awareness and understanding of medical issues surrounding both topics. For example, those interviewed after the HPV program were twice as likely to report having heard of the virus as those interviewed beforehand, and they were three times as likely to be able to describe it. In addition, viewers’ awareness of emergency contraception increased 17% in the week after the episode aired.  Results from the analysis revealed that "ER" viewers—who differ significantly from the general population only in that they are more likely to be female—found the medical information presented on the show useful in a variety of ways. For example, about one-third of viewers said information they learned helped them make choices about their own or their family's health care.  However, after a two-month follow-up survey, general awareness of the same health issues—particularly in the case of emergency contraception—had decreased to pre-episode levels. The authors discuss the role of fictional television as an appropriate mode of information dissemination and the role of government in encouraging these types of storylines.  Brodie, M., Fohr, U., Rideout, V., Baer, N., Miller, C., Flournoy, R., and Altman, D.  (2001). Communicating Health Information Through the Entertainment Media. Health Affairs, 20(1), 192-199.
 

While the role of fictional television as a venue for behavior change has yet to be established, the role of mass media advertising is. Econometric studies, which model the effects of advertising expenditure on aggregate tobacco consumption, generally show that smoking prevalence increases as the amount of advertising increases and reduces when advertising is banned.  In this recent study, MacFadyen, Hastings, and MacKintosh examined young people's awareness of and involvement with a broad range of tobacco marketing activities.  A random sample of 1,062 15 year-olds in northern England were surveyed on their awareness of and involvement with different types of tobacco marketing (coupons schemes, product placement, package design, Internet sites, etc.), smoking status, and other variables known to be related to adolescent smoking (including intentions for future smoking and education, smoking by peers, siblings, and parents, gender, and social class).  In this sample, 20% of the respondents were regular smokers, 78% were not regular smokers, and 2% did not state their smoking status.  The majority of respondents had seen cigarette advertising on billboards, in the press, and at point of sale, as well as was aware of coupon schemes and special price offers for cigarettes.   However, other forms of promotion were less familiar, such as brand stretching  (clothing or other items with cigarette logos on), new pack designs or sizes, free gifts offered on packets, competitions, promotional mail, and famous people smoking in films and on television. Over half of current smokers had participated in tobacco marketing of one form or another, compared with around a quarter of non-smokers and those who had tried smoking. The findings demonstrated that young people aged 15-16 are aware of, and participating in, many forms of tobacco marketing, and this phenomenon is consistently associated with being a smoker. When other factors that are known to be linked with teenage smoking were held constant, awareness of coupon schemes and brand stretching, and tobacco marketing in general, were all independently associated with current smoking.  The authors conclude that young people, and especially young smokers, are getting some kind of benefit or reward from tobacco marketing which could encourage their risk-taking behavior.  MacFadyen, L. Hastings, G. and MacKintosh, A.M. (2001). Cross Sectional Study of Young People's Awareness of and Involvement with Tobacco Marketing. British Medical Journal, 322, 513-517.
 

A recent evaluation of a multimedia campaign on sexual responsibility revealed that lack of knowledge does not necessarily translate into lack of change in behavior.  In 1997, a youth campaign was launched in Zimbabwe focusing on self-respect and self-control. These were expressed in three slogans, which were repeated in all materials and activities, in both English and native languages: "Have self-control," "Value your body" and "Respect yourself."   The campaign employed a comprehensive approach including peer educators, a hotline, radio spots, and increasing access to reproductive health services. Baseline and follow-up surveys, each involving approximately 1,400 women and men aged 10-24, were conducted in five campaign and two comparison sites. Logistic regression analyses were conducted to assess exposure to the campaign and its impact on young people's reproductive health knowledge and discussion, safer sexual behaviors and use of services. The campaign reached 97% of the youth audience; awareness of specific contraceptive methods increased in campaign areas, but general reproductive health knowledge changed little. However, as a result of the campaign, 80% of respondents had discussions about reproductive health—with friends (72%), siblings (49%), parents (44%), teachers (34%) or partners (28%). In response to the campaign, young people in campaign areas were 2.5 times as likely as those in comparison sites to report saying no to sex, 4.7 times as likely to visit a health center and 14.0 times as likely to visit a youth center.  The campaign assessment revealed that launch events, leaflets and dramas were the most influential campaign components. The authors conclude that one of the campaign's greatest accomplishments was building support in the community and within the health care system. It achieved this by decentralizing management to local committees and by designing activities to reach secondary audiences including family, friends and teachers. In the article, the authors also discuss additional campaign accomplishments and recommendations for future programs. Kim, Y.M., Kols, A., Nyakauru, R., Marangwanda, C., and Chibatamoto, P.  (2001). Promoting Sexual Responsibility Among Young People in Zimbabwe. International Family Planning Perspectives, 27(1), 11-19.

Upcoming Conferences and Events

The Second International Conference on Traditional Medicine, entitled "Integrating Traditional Medicine Into Orthodox Medicine" will be held in Accra, Ghana July 20-21, 2001.  This conference is organized by Africa First LLC in association with the Ministry of Health of Ghana with the aim of advancing global health care through a continuing process of dialogue and education between practitioners of orthodox medicine and practitioners of traditional medicine.  There will be pre/post conference tours to hospitals and other interesting sites and medical institutions.  Doctors and nurses are encouraged to offer voluntary services and medical supplies to institutions where needed during the tour.  For more information contact J.William Danquah, Chief Executive Officer, Africa First, LLC or send e-mail to africafirst@yahoo.com

The Sixth Annual Future of Health Technology Summit (FHT2001), organized by the Future of Health Technology Institute in association with MIT Media Laboratory will convene September 24-26, 2001 at the MIT Media Laboratory, Cambridge, Massachusetts, USA.  FHT2001 is an interactive discussion forum for industry, government, and academic healthcare and technology leaders. FHT2001's goals are to define health technology areas with biggest impact on health in 1, 5, 10, and 50 years and to develop a vision of Future of Home TeleCare. Keynote -  "Importance of Technology in Public Health" by Professor Karen Emmons, Harvard School of Public Health. For more information call FHTI at (508) 497-2577, send e-mail to bushko@fhti.org or visit the URL http://www.fhti.org.

The 88th Annual Meeting of the National Communication Association (NCA) will be held in Atlanta, Georgia, USA at the Atlanta Marriott Marquis and Atlanta Hilton and Towers Hotels from November 1-4, 2001. The primary convention planner is Bill Balthrop, NCA’s First Vice President.  The theme for the 2001 convention is Radical(izing) Roots, exploring the possibility and desirability of effecting fundamental or even revolutionary changes in current practices, conditions, or institutions.  This theme is especially important since at no previous time in history has the communication discipline faced such enormous opportunities or significant challenges.  For more information, visit the NCA Web site at http://www.natcom.org or call the Association headquarters at (202) 464-4622.

The American Public Health Association (APHA) is now accepting solicited abstracts and session outlines for the 129th APHA Annual Meeting to be held in Atlanta, Georgia, USA October 21-25, 2001. The theme of the meeting is One World: Global Health.  For more information, visit their Web site at http://www.apha.org.

Internet Sources

UNAIDS and Health & Development Networks have started an e-mail discussion forum focused on HIV/AIDS and stigma, denial, shame, and discrimination in Africa.  It is being launched as part of a consultative strategy to facilitate development of an African research agenda on stigma.  If you would like to be part of this process, send an e-mail to: join-stigma-aids@hdnet.org

Publications

The U.S. Surgeon General has released a new report entitled "Women and Smoking" that provides a detailed study of smoking and health issues among women and girls in the United States.  For information visit http://www.cdc.gov.

WHO has issued a publication entitled “Studies of Drugs and Other Measures to Prevent and Treat Osteoporosis; A Guide for Non-Experts.”  This report addresses the rationale, performance, and interpretation of studies carried out to assess preventive or treatment strategies targeted at osteoporosis.  For information visit http://www.who.int/ageing/global_movement.

Prescriptions

Shultz, Sprague, Branen, and Lambeth compared diabetes patients’ and educators’ perceptions of patient barriers to following a meal or exercise plan.  Study results revealed that diabetes patients and diabetes educators described different patient barriers. In light of their findings, the authors give several practical suggestions on alleviating barriers and increasing communication:

• Diabetes educators need to ensure that their efforts to meet curriculum requirements in diabetes education also include the lifestyle needs and perspectives of patients.

• Diabetes educators may need to emphasize familiar or favorite foods on the meal plan initially so that the patient tries the plan, while emphasizing social coping skills to support long term adherence.

• Supervised exercise as a part of diabetes education may help patients who experience pain or discomfort with exercise, or who feel anxious about the consequences of exertion.

• Patients may not hold exercise in high priority as part of diabetes management; it may be helpful for educators to develop an “exercise inventory” to identify specific barriers to exercise, and to emphasize the benefits of exercise beyond weight management.

-J.A. Shultz, M.A. Sprague, L.J. Branen, and S.A. Lambeth

Guttman and Ressler focus on how specific appeals may not be effective with certain audiences, describing how health communication campaigns that use personal responsibility appeals may not be ethical or effective. To place a more positive spin on these types of appeals, the authors offer the following recommendations:
 

• Health campaigns that center on appeals to personal responsibility raise ethical concerns surrounding the issues of attribution of causality, obligation, and agency.

• Campaign planners should ask themselves if their messages can be interpreted as blaming "others" and thus inadvertently bolstering people's rationalizations for their own undesirable behavior.

• Ethical considerations could lead campaign planners to appeal to collective social benefits as well as to encourage feelings of self-efficacy by showing that individual positive behaviors can make a difference and by breaking large problems into smaller, more manageable components.

• Focusing on individual responsibility to dependent others may be an effective and ethical intervention strategy, but care must be taken to present specific actions that individuals can take in helping others and to focus on individuals' ability to empower those dependent on them.

• Responsibility appeals can promote agency by presenting messages that discuss different choices, by engaging audience members in thoughtful dialogues and by demonstrating ways in which people can influence that environment.

 

-N. Guttman and W. H. Ressler

Mohammed examined the personal networks of listeners and non-listeners to an entertainment-education radio soap opera in Tanzania to determine the effects of interpersonal discussion of the soap opera’s educational themes (family planning and HIV prevention). From the investigation the following recommendations are made:

• The interplay of interpersonal and mass media influences should be considered more closely in design and evaluation of entertainment-education and other health campaign interventions.

• The mechanisms by which interpersonal network discussions promote greater effects of mass media stimuli should be further investigated, in particular by focusing on the communicative habits and preferences of audience members.

• Future investigations of peer network discussion of entertainment-education and other health media stimuli may be conceptualized primarily in network terms and should use both ego-centric and sociometric methods for investigation.

-S. Mohammed

Patel, Witte, Zuckerman, Murray-Johnson, Orrego, Maxfield, Meadows-Hogan, Tisdale and Thimons conducted a formative evaluation to study why coal miners in Appalachia do not wear protective devices to prevent occupational noise-induced hearing loss.  From their research, they developed the following recommendations for public health campaigns:

•  Using the external/internal framework may be an effective method to identify specific types of barriers.

• Researchers should consider both internal and external barriers to preventive actions when designing persuasive health campaign messages.

• Applied health communication scholars need to be aware of the existence of a fundamental attribution error whereby individuals do not take personal responsibility of preventive action but blame external sources.

• Secondary audiences can be used to communicate with miners about changing attitudes, beliefs, and myths about barriers.

-D. S. Patel, K. Witte, C. Zuckerman, L. Murray-Johnson, V. Orrego, A.M.
Maxfield, S. Meadows-Hogan, J. Tisdale, and E.D. Thimons

Rodgers and Thorson conducted a content analysis of crime news coverage in the Los Angeles Times—a paper that has recently committed itself to improving the content of its news pages.  The authors present a public health framework for making such improvements, and findings suggest the following:

• Crime stories outnumbered all other stories coded, including business and education, which is consistent with news values of proximity and unusual, if not the horrific.

• The majority of crime news stories were reported as one-time, isolated events, which has been criticized as providing only enough information to increase the fear of violence and promoting a fatalistic attitude toward preventing crime and violence.

• Homicides were covered more frequently than any other criminal act, even though thefts are the most common crime committed in greater Los Angeles.

• Crime stories contained only one public health fact, and this fact often focused on punishment (e.g., incarceration) and not prevention.

-S. Rodgers and E. Thorson

Call for Information

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Journal of Health Communication  The GW Center for International Health Department of International Public Health, School of Public Health and Health Services, The George Washington University 2175 K Street, NW, Suite 820 Washington, DC 20037 Telephone (202) 416-0426 Fax (202) 467-2290/ (202) 994-0900

 The UpFront section is edited by Lisa Shusterman, Health Communication Program Officer at the Academy for Educational Development in Washington, DC and Marita Schlesser, Technical Research Staff at the GW Center for International Health in Washington, DC.