UP FRONT

Volume 6,Number 4
October-December 2001

Vol. 6, Num. 4: Contents | Editorial | Up Front | Abstracts

From This Issue | Upcoming Conferences and Events | Internet Sources | Publications | Prescriptions

Vital Data

From This Issue

The difficulty of determining the factors that effectively change behavior are highlighted in this analysis of the effects of two mass media campaigns concerning reproductive health, broadcast in Bolivia from March, 1994 until June, 1996. The first article in this issue of the Journal of Health Communication examines the influence of this campaign and interpersonal communication as factors in contraceptive use in Bolivia. The authors tested four hypotheses regarding the adoption process for women in Bolivia. The study methods used proxy controls, theoretical explanations for behavior changes, and both cross-sectional and panel longitudinal data. Three waves of survey data were collected from a sample of randomly selected residents in the seven largest Bolivian cities. In each wave approximately 2,400 men and women were interviewed. Behavioral changes are thought to follow a knowledge (K), attitude (A), and practice (P) model. That is, individuals are expected to learn about a new idea, develop a positive attitude towards it and then try it. A campaign existed to inform the public of contraceptive methods, thus the authors hypothesized that contraceptive use in Bolivia would follow a knowledge, attitude and practice sequence. Results found that in actuality, positive attitudes, rather than knowledge, seemed to be the ®rst step in the behavior change sequence. However, awareness was positively associated with becoming a method user. Overall the analyses did not support the hypothesis. Interpersonal communication is a significant influence of behavior change, especially among peers. The authors second hypothesis was that interpersonal communication would influence contraceptive adoption most strongly when with a partner, secondly with friends and thirdly with anyone. Although the interpersonal communication variables were associated with outcomes, there was no statistical difference in the magnitude of the coefficients. In fact, spousal communication was negatively associated with contraceptive use. However, contraceptive use was associated with thinking that a high proportion of network members used contraception. Interpersonal communication is not directly amenable to programmatic manipulation at the population level. However, mass media campaigns can send a signal that a behavior is supported by current social and political structures. A mass media campaign that appeals to its audience and meets its needs with service provision and product supply can bring about changes in its audiences’ behavior. The third hypothesis asserted that mass media campaign exposure would be significantly associated with adoption of modern methods of contraception. There was modest support for the hypothesis in that campaign recognition was associated with awareness and contraceptive use, but not attitudes. The first three hypotheses did not address the interacti on of these factors with one another. The authors focused on the interaction of the mass media and the interpersonal communication by examining ``who says what to whom about the behavior.’ ’ The expectation was that the campaign would increase the perception that a behavior was used by a person’s social network thus affecting subjective norms regarding contraception which in turn influence behavior. The fourth hypothesis was that mass media campaign exposure would be positivel y associated with perceptions that an individual’s personal network uses contraception. The campaign was positively associated with perceptions that others use contraception. Thus, the Bolivia campaign may have contributed slightl y to shifting norms regarding the appropriateness of contraceptive use. Overall, the authors state that people who do not practice a behavior are more likely to think that their networks do not as well. While a campaign can change perceptions it can do so only incrementally and is more likely to do so for those who already have users in their network. A greater emphasis needs to be placed on interpersonal contexts and dimensions of decision-making needs when planning and evaluating mass media campaigns. Valente, T.W. and Saba, W.P. Campaign Exposure and Interpersonal Communication as Factors in Contraceptive Use in Bolivia. (p. 303).

Relational communication theory assumes that people co-construct their relations hips through their interactions. Although the balance of power in a medical situation has traditionally tipped in favor of the physician, a change in that balance can lead to medical interactions which are ineffective and dissatisfying to both participants. In the second article, authors found that when there is a disagreement over treatment methods, especially regarding the use of narcotics to control pain, it often results in a competition for control between physician and patient. A relational control analysis was applied to characterize the struggle for control in difficult interactions and to suggest solutions to the conflict. Relational theory follows from Bateson’s concept of schismogenesis, the process through which individual behavior results from the cumulative interaction between individuals. Bateson identified two types of schismogenesis: symmetrical, which is characterized by similar behaviors of the two participants, e.g. boasting followed by boasting, and complementary which is characterized by different behaviors such as assertiveness followed by submission. Complementary behaviors are classified as one-up if they exert control of the direction of the interacti on or one-down if they yield control. Control has been a central focus of research in doctor-patient communication. A coding system adapted from the Relational Communication Control Coding System has been used to apply relational communication theory. This study used the coding system to examine three challenging medical interactions that are characterized by a struggle for control between participants. The medical management of pain is unique in that the experience and degree of pain is subjective and varied across subjects. Additionally, narcotics are known to be potentially addictive, abused or sold illegally. Therefore, the doctor must determine both the severity of the pain and the likelihood that the patient will abuse or sell the medication with little or no objective criteria. The authors transcribed and coded videotaped interviews of three doctor-patient interactions regarding pain treatment. Results showed that nearly half of the control transactions were coded as competitive symmetrical , indicating both doctors and patients attempted, but failed, to gain control repeatedly throughout the interacti ons. The patients yielded control far more often than did the physicians. A similar study differed in that the most frequent transacti on control type was complementary. The authors suggest the reason for this difference was their focus on the difficult moments of the interaction rather than the interaction as a whole. However, taken together these two studies show that in a typical treatment negotiation the physicians and patient share control while in an interaction characterized by conflict, the physicians and patients competed for control. This study points out the need for physicians to reflect on their role in difficult encounters with patients. Communication skills training should train physicians to adopt strategies to improve the quality of their patient encounters by sharing control and adjusting their communication style in response to the needs of each encounter. Eggly, S., Tzelepis, A. Relational Control in Difficult Physician-Patient Encounters: Negotiating Treatment for Pain. (p. 323)

When faced with a perceived or real threat, an individual can choose to be defensive avoidant from fear or to confront the threat and take the recommended action(s) to avert the threat. In the third article, the authors state that understanding which path a person is more likely to take is critical for effective health message design. As fear appeals studies tend to involve individuals who originate from individualist cultures and not collectivist ones, most messages are written to be self-threatening (e.g., ``You will suffer if you get the AIDS virus’ ’ ), not group threatening (e.g., ``Your family would suffer . . .’’). Individualist culture members tend to place their self-needs above any group (i.e., family / friend) concerns, while collectivi st culture members tend to place group needs above their own. As a result, scholars must question if current health messages used to target self-needs are effective with populations in which the focus in on the group, not the individual. Using the threat of the AIDS virus as the fear appeals subject, two studies were conducted (Study 1: African American youth versus Mexican American youth; and Study 2: American college students versus Chinese/Taiwanese college students) to assess if manipulating the self-needs or the group needs in a message would affect individuals
personal ratings of fear, attitudes toward AIDS prevention, and intentions to prevent AIDS. In the first study, cultural orientation was ascribed to individualism/collectivism, in the second study it was measured as idiocentrism / allocentrism. In Study one, results indicated that individualist members (African American youth) were influenced by threats targeting the self than the family, and collectivist members (Mexican Immigrant youth) were influenced by threats targeting the family rather than the self. However, attitudes were more favorable for AIDS prevention in the self-targeting message over the family-targeted message for both groups. Intentions to prevent AIDS were also stronger for individualist members over collectivist members. In Study two, Taiwanese college students scored higher on the revised INDCOL scale than the American college students, thus, the Taiwanese students were identified as idiocentric and the American students were identified as allocentric. Idiocentric students preferred the self-targeting messages over the group-targeted (i.e., family) messages, while the reverse was true for the allocentric students. Idiocentric students also demonstrated stronger attitudes and intentions to prevent AIDS over the allocentric students. The results indicated that fear appeals should address cultural orientation (i.e., individualist vs. collectivist orientati on and idiocentrism versus allocentrism) to achieve maximum effectiveness for health message design. Addressing Cultural Orientations in Fear Appeals: Murray-Johnson, L., Witte, K., Liu, W., Hubbell, A., Sampson, J., Morrison, K. Promoting AIDS-Protective Behaviors among Mexican Immigrant and African-American Adolescents, and American and Taiwanese College Students. (p. 335)

Upcoming Conferences and Events

The 16th National Conference on Chronic Disease Prevention and Control, ``Cultivating Healthier Communities Through Research, Policy, and Practice’ ’ will be held at the Sheraton Atlanta Hotel, February 27 - March 1, 2002. The conference is sponsored by the Centers for Disease Control and Prevention (CDC), the Association of State and Territorial Chronic Disease Program Directors (Chronic Disease Directors-CDD), and the Prevention Research Centers (PRC) Program. Nearly 1,000 health professionals and others are expected to attend. The theme is ``Cultivating Healthier Communities Through Research, Policy and Practice.’’ http://www.cdc.gov/nccdphp/conference

The Society for Behavioral Medicine is sponsoring a conference April 3-6, 2002 in Washington, D.C. The theme is Beyond Adherence: Partnerships Among Individuals, Clinicians and Systems. Proposals were invited from a broad range of perspectives that focus on the unique contributions of behavioral medicine. http://www.sbmweb.org

The H. Lee Moffitt Cancer Center is sponsoring their third conference focusing on cancer control across the continuum of cancer care, from prevention to end-of-li fe care. ``Cancer, Culture and Literacy’ ’ Conference will be held in Clearwater, FL May 16-18, 2002. Healthcare professionals interested in developing effective culturally, linguistically and literacy relevant cancer communications, innovative materials/media, programs and interventions should attend. For more information contact: Ann Gordon, Continuing Education at (813) 903-4975, fax (813) 979-3874 or e-mail GordonAC@moffitt.usf.edu. http://moffitt.usf.edu/promotions/ccl/index.htm.

Internet Sources

The ``Turning Research into Practice’ ’ (TRIP) Database searches over 70 sites of high-quality medical informat ion and gives direct, hyper-linked access to the largest collection of `evidence-based’ material on the web as well as on-line articles from premier journals
such as the British Medical Journal, JAMA, and the New England Journal of Medicine. http://www.tripdatabase.com
The Center for the Advancement of Health has a new web site The Center’s most recent news releases from articles of interest that appeared in a variety of journals is at http://www.cfah.org/newsreleases.htm ``The Provider’s Guide to Quality & Culture,’ ’ is a web site designed to assist US health care organizations in providing high quality, culturall y competent services to multi-ethnic
populations. The site is produced by Management Sciences for Health. http://erc.msh.org/

Publications

The newest issue of Journal of Computer-Mediated Communication (from Annenberg School of Communication) focuses on Health and New Media. http://www.ascusc.org/jcmc or http://www.ascusc.org/jcmc/vol6/issue4/

The Bill & Melinda Gates Foundation GAVI Immunization Advocacy Resource Kit, is a collection of documents, video clips, and computer presentations which have proven useful when explaining about, and advocating for, stronger immunization programs. Most of the documents in the Kit are available for download http://www.childrensvaccine.org/html/gavi-ark.htm.

Prescriptions

Valente and Saba studied the impact of a mass media campaign on contraceptive use in Bolivia.

The media campaign has significant but modest impacts on outcomes suggesting that designers should have modest expectations regarding impacts. Interpersonal communication had a significant association with outcomes, particularly thinking that most people in one’s personal network were contraceptive users. The mass media campaign influenced perceptions that people in one’s network use contraceptives suggesting that media campaigns can change subjective norms. This research also showed that most people associate with others like themselves, consequently, behavior change is slow, since, most people who do not practice a behavior are surrounded by others who also don’t practice it. -T . W . V alente and W . P. Saba

Eggly and Tzelepis applied a relational control analysis to three difficult physician-patient encounters, demonstrating the competition for control of the interacti on between the two participants. Their research leads to the following recommendations for physicians and for further research in relational control theory:

Physicians should acknowledge that difficult encounters are mutually constructed by both physician and patient rather than placing blame on patients for being difficult, manipulative or deceptive. Communication training for physicians should incorporate skills of self-awareness, so that physicians can learn to recognize that feelings of discomfort or loss of control in an interaction may indicate the need for an adjustment of their communication strategy to improve the quality of the encounter. Communication skills training for physicians should teach strategies for sharing control of the interaction and the outcome of the interactions, such as listening and responding to patient’s emotions and agenda and reframing the interaction away from the disagreement. Researchers should continue to apply relational communication theory to the study of physician-patient interactions because this theory places the emphasis on the relationship created by the interaction, rather than on either the physician or patient. This research should be applied to a variety of medical settings and contexts. -S. Eggly and A. T zelepis

Murray-Johnson, Witte, Hubbell, Liu, Sampson and Morrison studied the effect of fear appeals on cultural orientati on, both individualism-collectivisi m and idiocentrism and allocentrism. From their research, they developed the following recommendations for use of fear appeal messages on African-American and Mexican immigrant high school youth, and Taiwan and United States college students:

Researchers must recognize that individualism-collectivism is an orthogonal concept, similar to idiocentrism-allocentrism. To improve the effect of fear appeals in health messages, it is important to measure cross-cultural perspectives and not rely on research designed to affect United States citizens’ attitudes, intentions, and behaviors on a particular topic. To understand that Hofstede’s (1980, 1983) categorization of cultural orientation is changing as evidence of Taiwanese college students holding a greater individualistic/idiocentric orientation over the traditional collectivistic/allocentric orientation. -L . Murray-Johnso n, K. W itte, K. Morrison, A. P. Hubbell, W .-Y . L iu, and J. Sampson

If you would like to suggest materials for this section, please send your suggestions with your name, e-mail address, fax and phone numbers to:

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

Phone: 202-416-0426
Fax: 202-467-2290/202-994-0900