Strona główna Speaking of Health: Assessing Health Communication Strategies for Diverse Populations

Speaking of Health: Assessing Health Communication Strategies for Diverse Populations

We are what we eat. That old expression seems particularly poignant every time we have our blood drawn for a routine physical to check our cholesterol levels. And, it's not just what we eat that affects our health. Whole ranges of behaviors ultimately make a difference in how we feel and how we maintain our health. Lifestyle choices have enormous impact on our health and well being. But, how do we communicate the language of good health so that it is uniformly received-and accepted-by people from different cultures and backgrounds? Take, for example, the case of a 66 year old Latina. She has been told by her doctor that she should have a mammogram. But her sense of fatalism tells her that it is better not to know if anything is wrong. To know that something is wrong will cause her distress and this may well lead to even more health problems. Before she leaves her doctor's office she has decided not to have a mammogram-that is until her doctor points out that having a mammogram is a way to take care of herself so that she can continue to take care of her family. In this way, the decision to have a mammogram feels like a positive step. Public health communicators and health professionals face dilemmas like this every day. "Speaking of Health" looks at the challenges of delivering important messages to different audiences. Using case studies in the areas of diabetes, mammography, and mass communication campaigns, it examines the ways in which messages must be adapted to the unique informational needs of their audiences if they are to have any real impact. "Speaking of Health" looks at basic theories of communication and behavior change and focuses on where they apply and where they don't. By suggesting creative strategies and guidelines for speaking to diverse audiences now and in the future, the Institute of Medicine seeks to take health communication into the 21st century. In an age where we are inundated by multiple messages every day, this book will be a critical tool for all who are interested in communicating with diverse communities about health issues.
Liczba stron:
356 / 377
ISBN 10:
ISBN 13:
PDF, 4.95 MB
Pobierz (pdf, 4.95 MB)

Most frequently terms


Models for Dynamic Macroeconomics

PDF, 1.95 MB

The European Renaissance in American Life

PDF, 1.55 MB
Committee on Communication for
Behavior Change in the 21st Century:
Improving the Health of Diverse Populations
Board on Neuroscience and Behavioral Health

Washington, D.C.


chosen for their special competences and with regard for appropriate balance.
Support for this project was provided by the Institute of Medicine. The views presented
in this report are those of the Institute of Medicine Committee on Communication for
and are not necessarily those of the funding agencies.
Library of Congress Cataloging-in-Publication Data
Institute of Medicine (U.S.). Committee on Communication for Behavior
Change in the 21st Century: Improving the Health of Diverse Populations.
Speaking of health : assessing health communication strategies for
diverse populations / Committee on Communication for Behavior Change in
the 21st Century: Improving the Health of Diverse Populations, Board on
Neuroscience and Behavioral Health, Institute of Medicine.
p. ; cm.
Includes bibliographical references and index.
ISBN 0-309-07271-9 (alk. paper)
1. Communication in medicine. 2. Health promotion.
[DNLM: 1. Health Promotion—methods. 2. Communication. 3. Cultural
Diversity. 4. Health Services Accessibility. WA 590 I59s 2002] I.
R118 .I575 2002
Press, 500 Fifth Street, N.W., Box 285, Washington, DC 20055. Call (800) 624-6242
www.nap; .edu.
Printed in the United States of America.
COVER: Cindy Friedman, Susan Bershad, Mary Ivory, and Leslie Sullivan, Volunteers:
The Stars of the House, 1997. 72′′ × 72′′. Textile. Philadelphia Ronald McDonald
by the Staatliche Museen in Berlin.

“Knowing is not enough; we must apply.
Willing is not enough; we must do.”

Shaping the Future for Health

society of distinguished scholars engaged in scientific and engineering research,
president of the National Academy of Sciences.
The National Academy of Engineering was established in 1964, under the
Engineering also sponsors engineering programs aimed at meeting national
The Institute of Medicine was established in 1970 by the National Academy
of Medicine.
The National Research Council was organized by the National Academy of
the scientific and engineering communities. The Council is administered
Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the
National Research Council.

SUSAN C. SCRIMSHAW (Chair), School of Public Health, University
of Illinois at Chicago
ALBERT BANDURA, Department of Psychology, Stanford
University, California
MARTIN FISHBEIN, The Annenberg School for Communication,
University of Pennsylvania, Philadelphia
LINDA GARRO, Department of Anthropology, University of
California, Los Angeles
ROBERT C. HORNIK, The Annenberg School for Communication,
University of Pennsylvania, Philadelphia
HOWARD LEVENTHAL, Center for Research on Health and
Behavior, Rutgers, The State University of New Jersey, New
STEVEN REGESER LOPEZ, Department of Psychology, University of
California, Los Angeles
YOLANDA PARTIDA, Tomas Rivera Policy Institute, Pitzer College,
Claremont, California
BARBARA K. RIMER, Cancer Control and Population Sciences,
National Cancer Institute, Bethesda, Maryland
EVERETT ROGERS, Department of Communication and Journalism,
University of New Mexico, Albuquerque
GLORIAN SORENSEN, Harvard School of Public Health and Center
for Community-Based Research, Dana-Farber Cancer
Institute, Boston
SHARYN SUTTON, Sutton Group, Washington, DC
LAWRENCE WALLACK, School of Community Health, Portland
State University, Oregon
A. EUGENE WASHINGTON, Medical Effectiveness Research Center
for Diverse Populations, University of California, San
KENNETH B. WELLS (liaison to the Board on Neuroscience and
Behavioral Health (NBH)), Neuropsychiatric Institute,
University of California, Los Angeles

ANNE S. MAVOR, Study Director (since September 2001),
Division of Behavioral and Social Sciences and Education
CAROLE A. CHRVALA, Senior Program Officer (until April 2001),
TERRY C. PELLMAR, Director, Board on Neuroscience and
Behavioral Health, IOM
ALLISON L. FRIEDMAN, Research Assistant (until August 2001),
SUSAN R. MCCUTCHEN, Research Associate (since September
2001) DBSSE, NRC
WENDY E. KEENAN, Senior Project Assistant (since September
2001), DBSSE, NRC
WENDY BLANPIED, Project Assistant (between September 2000
and May 2001), NBH, IOM
AMELIA MATHIS, Project Assistant (until May 2001), NBH, IOM
LINDA V. LEONARD, Administrative Assistant (until September
2000), NBH, IOM
LORA K. TAYLOR, Administrative Assistant (between October
2000 and June 2001), NBH, IOM
CATHERINE PAIGE, Administrative Assistant (since October 2001),


KENNETH B. WELLS (Chair), Neuropsychiatric Institute, University
of California, Los Angeles, California
NANCY E. ADLER, University of California, San Francisco,
PAUL S. APPELBAUM, University of Massachusetts Medical School,
Worcester, Massachusetts
WILLIAM E. BUNNEY, University of California, Irvine, California
HOWARD FIELDS, University of California, San Francisco
RICHARD G. FRANK, Harvard Medical School, Boston, Massachusetts
SID GILMAN, University of Michigan, Ann Arbor
HERBERT D. KLEBER, Columbia University and New York State
Psychiatric Institute, New York, New York
BEVERLY B. LONG, World Federation for Mental Health, Atlanta,
KAREN MATTHEWS, University of Pittsburgh School of Medicine
and Western Psychiatric Institute and Clinic, Pittsburgh,
BRUCE MCEWEN, The Rockefeller University, New York,
New York
KATHLEEN R. MERIKANGAS, Yale University, New Haven,
DAVID REISS, George Washington University Medical Center,
Washington, D.C.
RHONDA J. ROBINSON-BEALE, Blue Cross/Blue Shield, Detroit, Michigan
CHARLES F. ZORUMSKI, Washington University School of
Medicine, St. Louis, Missouri


MICHAEL ABRAMS, Program Officer
MILAP NOWRANGI, Research Assistant
BRIAN MCQUILLAN, Senior Project Assistant
ALLISON M. PANZER, Senior Project Assistant
CATHERINE A. PAIGE, Administrative Assistant




his report has been reviewed in draft form by
ensure that the report meets institutional standards for objectivity,
individuals for their review of this report:
Noreen M. Clark, University of Michigan
Karen Glanz, University of Hawaii
Russell E. Glasgow, AMC Cancer Research Center
Lawrence W. Green, Centers for Disease Control and
Helen P. Hazuda, University of Texas Health Science Center
at San Antonio
Matthew Kreuter, Saint Louis University



Thomas R. Prohaska, University of Illinois at Chicago
William A. Smith, Academy for Educational Development
was overseen by S. Leonard Syme, University of California, Berkeley. Appointed by the Institute of Medicine, he was responsible for
making certain that an independent examination of this report was
carried out in accordance with institutional procedures and that all
review comments were carefully considered. Responsibility for the

Chair’s Preface


n 1993, McGinnis and Foege published a landmark article that reviewed the causes of death in the United States
in 1990 in terms of both the listed causes (e.g., heart attack, homicide) and the “actual causes” or underlying factors (e.g., obesity,
violence). Behavioral factors were implicated in 50 percent of all
deaths for that year (McGinnis and Foege, 1993). The importance
of behavior for health has long been emphasized by behavioral
scientists, such as anthropologists, psychologists, and sociologists;
by public health researchers and practitioners; and by clinicians in
areas such as preventative medicine and maternal and child health.
Until recently, however, the importance of behavior for health was
minimized in favor of the dramatic impact of biomedical innovations, and perhaps their perceived ease of administration as well.
In fact, many in the health care delivery field deemed behavior
intractable, or at least very difficult to change, and thus they preferred to look for what Rene Dubos (1959) called the “magic bullets” of medicine.
Usually, it is less costly both financially and in human terms to
prevent than it is to treat. Type 2 diabetes provides an example.
Both primary (prevention of onset) and secondary (prevention of



complications) prevention are preferable to the costs of treatment
and the burden of the disease. Both types of prevention involve
behavior change around smoking, diet, and exercise, and secondary prevention involves complex monitoring and medication behaviors as well. In some cases, behavioral interventions are the
only option for prevention, with treatment very costly, and not
always successful. An example is HIV/AIDS, where vaccines are
still in the developmental stage, and the only prevention involves
sometimes complex and difficult behaviors. Even where vaccines
exist, such as for hepatitis B, behavioral interventions can be crucial in controlling the spread of the disease and in limiting the
consequences of an infection.
Technology alone is not enough. Despite the existence of a
measles vaccine for the last 40 years of the 20th century, U.S. cities
continued to experience occasional epidemics and some measles
deaths into the 1990s. Even if there were “magic bullets” for all
conditions, behavioral interventions would be needed to help motivate people to utilize them.
Unfortunately, knowledge is rarely sufficient to change behavior, although knowledge is important. The risks of smoking and
other tobacco use are well known, but that knowledge is seldom
enough to get people to stop smoking or to keep people from initiating the behavior. There is evidence that smoking prevention
and cessation programs work (Wasserman, 2001; Fiore et al.,
2000), but they must be funded and applied.
On one hand, human behavior is difficult to change, but on
the other hand, it is constantly changing. One has only to witness
the changing trends in food, clothing, and music in U.S. society, as
well as the rapid increase in Internet use, to see behavioral change.
Nor are those changes random. They are influenced by concerted
efforts on the part of advertisers—and their investment of billions
of dollars. During the past 20 years in particular, the health community began to work with the advertising community to develop
behavior change strategies. Some of these were mass media campaigns, which will be discussed in this volume. Behavioral scientists working in public health also developed effective health



communication strategies that ranged from interventions for individuals to school- and work-based programs, to programs delivered through health care providers, to mass media and
community-based campaigns. Most often, programs that used
multiple interventions were found to have greatest effectiveness.
As new media such as the Internet and computer games emerged,
so did communication strategies that employed these media.
Public health workers began to recognize the need to look at
cultural factors when demographic and epidemiological data uncovered differences in risks of disease and death for various population subgroups. This came into sharper focus in the 1990s, as
more attention was brought to bear on the disparities in health and
illness among different ethnic, age, socioeconomic, gender, and
other groups. The existence of these disparities meant that prevention and treatment efforts needed to be focused on those populations in most need, and questions had to be asked about the
appropriateness and acceptability of these interventions.
The categories of “race” and ethnicity, which permitted the
identification of health disparities, are considered crude and inaccurate by anthropologists and others focusing on variations in
groups. This volume critically examines how culture and ethnicity
are defined and operationalized, and suggests more recent ways of
describing identity, such as cultural processes and life experiences
that shape both individuals and groups and lead to variations
within groups that may affect health behaviors. Modifications to
permit a more accurate understanding of the relationships among
cultural processes, life experiences, and health behaviors, especially
as these might relate to communication for health behavior change,
are also discussed.
Relevant behaviors vary from individual to individual, and are
influenced by factors such as age, gender, economic options, social
class, sexual orientation, life experiences, and cultural processes.
Given this, a key question that this volume asks is: Will the same
message content, medium, and format be received and understood
equally by all? If not, how, when, and in what format should
messages be focused for particular individuals or groups? To put



it another way, does it matter more for planning interventions that
two women have never had mammograms or that these women
are of two different ethnicities or ages?
The committee charged with preparing this volume grappled
with many related issues as well. From the start, the committee
recognized that ethical issues arise when behavior change is involved, especially when strategies are modified to be culturally attractive and when persuasion strategies are used. This led to a
consideration of ethical issues surrounding communication strategies. The committee struggled with theory. There are many behavior change theories, and no single theory explains all health
behaviors. Many communication programs are designed and
tested in the absence of theory. The challenge was to encourage
use of theory, discuss aspects of the existing theories that best inform behavior change interventions for diverse populations, and
identify gaps in theories. However, the committee did not produce
a summary of existing theories because there are already many
good sources for such reviews.
Three exemplars were chosen to illustrate the issues and approaches as they relate to communication and diverse populations.
Mammography was selected as an exemplar because having a
mammogram is an occasional behavior—yearly, at most, for
screening purposes—and one that has been the subject of hundreds
of communication interventions, including many for diverse populations. There is a strong foundation of evidence-based interventions. Diabetes was chosen because it involves primary and
secondary preventive behaviors that are complex and difficult and
must be practiced daily to achieve benefit. The evidence base is
much less robust than for mammography. For both mammography and diabetes, the committee assumed that attitudes and behaviors might vary both across and within populations. The third
exemplar, mass communication, was chosen because of its ubiquity as a public health strategy. As a result, the committee deemed
it important to examine the success of mass communication campaigns for diverse populations.



The committee also chose to examine the new and emerging
technologies that are dramatically changing the way we communicate about health and the way people obtain health information.
The breadth of the topic assigned to the committee for consideration is remarkable. Thus, conscious choices had to be made to
limit the scope of this volume. Time and space precluded further
attention to many important questions raised about each topic. At
the same time, many areas for future investigation are identified.
In particular, the lack of theory in the design of many communications and the lack of research and evaluation related to costly interventions were a surprise. The fact that shaping interventions to
conform to specific cultures is often done in the absence of evidence and with no evaluation is of concern. These findings
emerged in part because the committee included disciplines that
seldom converge on this topic. It was extremely valuable to have
the range of disciplines and experiences represented on the committee.
Many people contributed to this report. It was begun under
the leadership of Carole Chrvala as study director, and Allison
Friedman as research assistant. Wendy Keenan provided administrative support in the final project phase. Background papers by
Nurit Guttman, David Gustafson, Michael McDonald, Tim
Murphy, Charles Salmon, and Leslie Snyder provided very helpful
ideas and materials. Terry Pellmar provided steady oversight and
guidance, and key support at times when the task seemed overwhelming. Suzanne Stoiber believed in the importance of the topic,
and was supportive throughout. Anne Mavor provided extraordinary leadership, support and very hard work. She stepped in as
the second study director, and this report would not exist without
her efforts.
Finally, the committee members are grateful to the Institute of
Medicine, and to the leadership and support of outgoing IOM
President Ken Shine for the opportunity to begin the dialogue about
communication for health behavior change in diverse populations.
Susan C. Scrimshaw, Ph.D.





Context, 14
Approach and Scope, 24
Organization of the Volume, 27



What Does Theory Do?, 28
Factors Influencing Behavioral Performance:
Key Constructs from Behavioral Theories, 30
Applying Behavior Change Theory, 43
Theories of Communication and Behavior Change:
Key Constructs, 45
Implications of Theory for Health Communication with
Diverse Populations, 68
Annex A: Overview of Key Concepts in Three Behavior
Change Theories, 70
Annex B: Self-Regulation Models, 73






Introduction, 76
What Are Campaigns?, 82
The Logic of Segmentation and Its Relation to Diversity, 85
Adaptation of Health Communication Campaigns for
Diverse Audiences, 96
Evidence That Different Approaches to Diversity in
Campaigns Have Differential Success, 109
Conclusions, 120
Recommendations, 122
Annex: Changing Health Behaviors: The Mammography
Case Study, 123


Why Mammography Is a Useful Exemplar, 127
The Effect of Breast Cancer on Diverse Populations, 130
The Role of Screening Mammography in the Early
Detection of Breast Cancer, 132
Predictors of Mammography Use in Mainstream and
Diverse Populations, 134
The Impact of Mammography-Enhancing Interventions on
Diverse Populations, 140
Conclusions, 151
Recommendations, 153


Introduction, 154
Why Diabetes?, 155
Diabetes and Diverse Populations, 157
Recommendations, 175


The Changing Health Communication Landscape, 179
Innovative Uses of Current Technologies, 181





New Health Communication Technologies, 193
Conclusions, 211
Communication: The Next Frontier, 215
Recommendations, 220

Dimensions of Diversity, 224
Cultural Competence and Health Communication, 239
Ethics of Health Communication Interventions for
Diverse Populations, 243
The Sociocultural Environment, 250
Summary and Conclusions, 252
Recommendations, 253



Introduction, 255
Overall Findings and Recommendations, 257
Theories of Communication and Health Behaviors, 260
Ethics, 262
Communication Campaigns, 264
New Communication Technology, 268
Diversity, 269
Infrastructure, 271



A Consultants
B Biographical Sketches






lear 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?

Executive Summary


• 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
• 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
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.
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.


Executive Summary

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.
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
• 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

Executive Summary


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
• 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

Executive Summary


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.
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
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
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 largescale campaigns are needed.




s the 21st century begins, the nation is facing
increasing concern about health problems, particularly chronic diseases such as diabetes, and escalating health care costs. Our society is becoming more diverse in every conceivable way, and
diversity is often, though not always, associated with health disparities. On the other hand, we have available increasingly robust
theories about health behavior and exciting new opportunities for
expanded health communication strategies through enhanced technologies. These offer the potential for interactive approaches that
can be tailored more precisely to individual and small group needs.
Many broad social, economic, and political forces affect the
health status of populations (e.g., Institute of Medicine, 2000), and
these forces ultimately must be addressed. Yet health communication, in its various applications, offers a potentially important approach to a better informed and presumably healthier population
by focusing on the behavioral aspects of risk factors, such as diet,
smoking, alcohol use, sedentary lifestyle, and sexual behavior
(McGinnis and Foege, 1993).
In 1999, the Institute of Medicine convened the Committee on
Communication for Behavior Change in the 21st Century: Im11



proving the Health of Diverse Populations, in response to requests
from the Board on Neuroscience and Behavioral Health and the
Board on Health Sciences Policy to examine the potential of health
communication strategies to improve public health behaviors, especially among demographically and socioculturally diverse populations. Health communication strategies, for purposes of this
volume, are defined as approaches that seek to persuade or motivate people to change their behavior in order to improve their
health. This volume is concerned primarily with communication
strategies that are designed for larger groups or the public, rather
than individual persuasion strategies such as doctor-patient communication. However, the committee recognized that health communication can be initiated by a variety of sources, including health
care providers, campaign developers, and individuals seeking
health information.
The salience and timeliness of examining how communication
strategies relate to diversity within the U.S. population are emphasized by recent federal initiatives on disparities in health. Examples
include the Eliminating Racial and Ethnic Disparities in Health
campaign, Healthy People 2010, and the Minority Health and
Health Disparities Research and Education Act of 2000. Although
informed by the concerns about disparities raised by these initiatives, this volume adopts a considerably broader view of social and
cultural differences that will be addressed briefly here and in detail
in Chapter 7.
Substantial evidence exists on the relationship of diversity—
mostly categorized by race/ethnicity, socioeconomic status, age,
and gender—and health status (Centers for Disease Control and
Prevention, 2001). The less socially or politically advantaged a
population group is, the more compromised its health status.
There is also reasonably good evidence that health communication
campaigns can influence health behavior (e.g., Hornik, 2002).
However, there is little evidence on the enhanced impact of health
campaigns that are planned with special attention to addressing
the needs of diverse audiences. This does not mean that health
communication campaigns have not taken diversity into account.



Most campaigns are concerned about diversity and shape their
message and placement based on age, gender, ethnicity, race, sexual
preference, or other relevant personal variables. However, there is
a striking lack of data available to answer essential questions about
diversity—for example, does a health communication effort that
takes extra care in understanding and responding to the needs of a
diverse audience show effects that are greater than if such efforts
are not made? In other words, it is not possible now to answer the
question of whether added value, defined as better health outcomes, results from incorporating a focus on diversity compared
to an intervention designed for a more general audience.
The challenge for those involved in the design, implementation, evaluation, and research concerning health communication is
to influence behaviors with the greatest potential to significantly
improve health outcomes across demographically and culturally
diverse population groups. This volume addresses the challenge of
improving health communication in a racially and culturally diverse society. Although targeting messages to specific audiences
should increase effectiveness, this volume describes the difficulty
and complexity of categorizing audiences in a meaningful way.
Many of the “markers” that are used to describe groups are of
little relevance and utility in crafting communication—or must be
considered in a subtle way. Belief systems, religious and cultural
values, life experiences, and group identity are all powerful filters
through which information is received and processed. We need to
know more about these in order to understand how to frame messages that will be understood and lead to action. A major goal of
this volume is to clarify and evaluate the potential of health communication strategies to meet this challenge.
The committee that was formed to explore this fundamental
question of the value of integrating diversity factors more scientifically into health communication approaches includes experts in
anthropology, psychology, mental health, cancer prevention and
control, health behavior change and theory, communication and
the media, social marketing, and public health. This expertise was



supplemented by consultants in communication technology and
ethics. The committee’s specific charges were as follows:
• 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;
• Consider up to three specific examples of health communication interventions to evaluate whether and how those strategies
affect culturally diverse groups; and
• Recommend how health communication strategies may be
designed and implemented to achieve sustained gains in public
health across cultural groups.
The results of this effort are intended to inform policy makers,
researchers, funders/sponsors, advocacy organizations, practitioners, and others in developing, implementing, evaluating, and conducting research on communication strategies to improve the
public’s health.
Health and Diversity
The importance of understanding diversity for public health is
clearly evident. Yet current categories, which use arbitrary groupings of “race” and ethnicity, are not useful enough and do not
contribute to necessary knowledge on the relationship between
diversity and health behavior. New ways of understanding diversity will be required to develop more appropriate, and presumably
more successful, approaches for health communication efforts. Yet
jettisoning current categories of diversity as a means for identifying need and targeting programs will likely be controversial. Many
political organizations, constituency groups, the U.S. Congress, and
major administrative agencies of the government are organized
around current definitions and categories. If the definition of di-



versity is changed, then the basis for funding decisions will change.
This uncertainty could result in considerable argument, which happened during efforts to change the census categories for racial/
ethnic identification. Making diversity scientifically and programmatically meaningful undoubtedly will cause political conflict.
Categories for Describing Diversity
Discussions of disparities and health outcome differences
across cultural groups contrast broad ethnic or racial categories
that, although they have some utility for simplifying and focusing
public discussion, relate little, if at all, to variation in socioculturally based beliefs and behaviors that have specific implications for
health outcomes. The widely used broad ethnic categories, in particular, are simply not valid indicators of meaningful variation in
health-related beliefs and behaviors. The most useful information
for framing this volume—data that provide a much deeper and
how health behavior is shaped by sociocultural processes—is not
available, and one of the committee’s recommendations is to develop this exact information. For example, how individuals come
to think about and make sense of the world is mediated, to a large
extent, by their social group identification and participation and
by their life experiences. The term “cultural processes” is used to
refer to these socially grounded ways of learning that contribute to
how an individual thinks, feels, and acts.
Part of the challenge in addressing health behavior change for
diverse populations is determining the circumstances under which
diversity matters. The categorical comparisons that are available,
and that are used throughout this volume, emphasize the importance of attending to cultural differences, even if presenting information in this way risks misguiding the reader into thinking these
categories are relevant to the committee’s charge.
Economic status and social class are considered dimensions of
diversity for this volume because there are differences in health



outcomes, and presumably in health risks, for these groupings
(Lynch and Kaplan 2000; House and Williams, 2000). Although
economic status and social class can be considered separately, they
are most often grouped. Socioeconomic status (SES) commonly
includes education, occupation, and income, but other factors such
as net worth may be considered. The measurement of socioeconomic status has been discussed at length in the literature, and is
clearly summarized in Lynch and Kaplan (2000). Similarly, the
relationship between socioeconomic status and health has been
discussed in detail in a recent Institute of Medicine report, Promoting Health (2000).
In discussing the relationship between SES and race/ethnicity,
House and Williams (2000:97) note: “Although not useful as biological markers, current racial/ethnic categories capture an important part of the inequality and injustice in American society. . . .
There are important power and status differences between groups.”
In fact, as they document, these power and status differences relate
directly to the health disparities through factors such as environmental conditions and access to preventative and curative health
care. They also note that SES alone does not explain health disparities. Furthermore, caution must be applied to the measurement of SES, and to assumptions about relationships between
poverty and culture. As just mentioned, poor health outcomes are
not confined to people with low SES, nor does low SES mean inevitably poorer outcomes.
Age and gender also show differences in health outcomes.
These are partly because of biological factors, but also because of
other kinds of factors underlying health disparities such as access
to care, education, and environmental contexts, as well as health
beliefs and behaviors. Both age and gender affect how people are
treated in U.S. society. The very old and the very young are likely
to have fewer rights and be subjected to more discrimination, as
are women, regardless of ethnicity.
The committee members acknowledge that sexual orientation
is a relevant and important parameter of diversity for the develop-



ment, implementation, and evaluation of effective health communication interventions. Indeed, significant differences have been
reported on various health measures for women and men, depending on sexual orientation (Institute of Medicine, 1999a; Dean et
al., 2000). Many of the differences in health outcomes are related
to differential risk behaviors, such as higher risk of sexually transmitted diseases and AIDS from unsafe sexual behavior in gay men,
higher rates of poor diet and being overweight among lesbian
women, and higher rates of smoking, alcohol use, and substance
abuse among lesbian, gay, and bisexual persons.
Unlike the other defining constructs of diversity in this volume, however, sexual orientation is not routinely used as a demographic grouping to assess or report differences in health behaviors
or health outcomes. In fact, the collection of reliable information
about gay and lesbian populations has been constrained by political obstacles and methodological challenges (Dean et al., 2000;
Institute of Medicine, 1999a).
Similarly, other dimensions of diversity are highly relevant to
communication, but we cannot focus on them in an examination
of existing studies. For example, the issue of an individual’s primary language is minimally addressed in this volume, although it
is clearly an important topic. For the decade starting in 1990, the
“most recent wave of immigration is composed largely of nonEuropean, non-English speaking ‘people of color’ arriving in unprecedented numbers from Asia, the Caribbean, and Latin
America” (Suárez-Orozco, 2000:5). Significant numbers of U.S.
residents also communicate primarily using languages other than
standard English. Literacy and education are additional dimensions of diversity that are not closely examined. The lack of attention to such factors should not be viewed as a measure of their
importance, but rather reflect constraints in terms of what reasonably could be examined within the scope of the committee’s time
frame and available data.



The U.S. Population and Categorical Demographic Diversity
The U.S. population now has more than 281 million residents.
The number of persons in the United States has tripled over the
past century among persons under age 65, and increased by a factor of 11 among those age 65 and over (U.S. Census Bureau, 2000).
Ethnic diversity has increased among all age categories in the population, particularly among younger populations. By the year 2050,
the percentage of non-Hispanic whites in the United States is expected to decrease to 53 percent overall. As many as 56 percent of
adolescents are projected to represent ethnic minority groups; that
is, groups other than non-Hispanic whites or EuroAmericans (National Center for Health Statistics, 2000; Brown et al., 1996).
More people are completing formal education, poverty rates have
reached their lowest levels since 1979, and real median household
income has reached a record high, increasing for all types of households in all regions of the United States in 1998 (U.S. Census Bureau, 1998, 2000; Dalaker and Proctor, 2000).
All of these changes in demographics suggest that the cultural
landscape of the U.S. population is changing toward a larger, older,
more ethnically diverse, and more educated population. For example, Hispanics constitute a relatively younger population lagging in education and income, while whites are older and have
higher accumulated wealth. Among populations age 15 and older,
non-Hispanic whites (83 percent) were most likely to have at least
a high school education in 2000, followed by Asian Americans/
Pacific Islanders (78 percent), non-Hispanic African-Americans (72
percent), and Hispanics (53 percent) (Bennett and Martin, 1995).
The income gap between rich and poor remains considerable
(U.S. Census Bureau, 1998). In 2000, Asian Americans/ Pacific
Islanders had the highest median income ($55,500) and Hispanics
and African-Americans had the lowest ($33,400 and $30,400, respectively). The poverty rate across all groups is approximately 11
percent, with African-Americans and Hispanics well above the
mean and non-Hispanic whites well below the mean (U.S. Census
Bureau, 2001).



meeting basic needs, such as the inability to meet essential living
percent reported either not having enough food or the kind of food
to eat.
The burden of death and disease frequently falls most heavily
on some ethnic groups and on those with lower levels of education
among men and women in the three largest ethnic groups (nonHispanic whites, non-Hispanic Blacks, and Hispanics) are shown
are for heart disease and cancer. However, significant variations
the most part, Hispanics have significantly lower rates across all
difference in mortality rate between Black and white males is three
times greater at age 65 than at age 45.
1Age-adjusted data were not available for Asian Americans/Pacific Islanders and



TABLE 1-1 Age-Adjusted Rates for 10 Leading Causes of Death
by Ethnic Group—Males (rate per 100,000)


All cancer
Chronic obstructive
pulmonary disease
Unintentional accidents 50.6
Pneumonia and
Diabetes mellitus
Kidney infections
Chronic liver disease
and cirrhosis


















SOURCE: Centers for Disease Control and Prevention (2001).

TABLE 1-2 Age-Adjusted Rates for 10 Leading Causes of Death
by Ethnic Group—Females (rate per 100,000)


All cancer
Chronic obstructive
pulmonary disease
Diabetes mellitus
Unintentional accidents 22.7
Pneumonia and
Alzheimer’s disease
Kidney infections















SOURCE: Centers for Disease Control and Prevention (2001).



TABLE 1-3 Age-Adjusted Rates for Four Major Causes of
Death from Cancer by Ethnic Groupa (rate per 100,000)b

Lung and
Colon and
Prostate (males)
Breast (females)















aData are from the American Cancer Society, Surveillance Research (2001).
SOURCE: Surveillance, Epidemiology, and End Results Program, Division of Cancer
Control and Population Science, National Cancer Institute (2000). Mortality derived
from data originating from the National Center for Health Statistics, Centers for Disease Control and Prevention (2000).
bPer 100,000, age adjusted to the 1970 U.S. standard population.
cHispanic is not mutually exclusive from white, African-American, Asian American/
Pacific Islander, and Native American.

for both males and females based on data from the Surveillance,
Epidemiology, and End Results Program of the National Cancer
Institute (Centers for Disease Control and Prevention, 2000).
Black males have the highest death rates for lung, colon, and prostate cancer; Black women have the highest death rates for colon
and breast cancer. Asian Americans/Pacific Islanders have the lowest rates of breast and prostate cancer; Hispanics have the lowest
rates of lung cancer. Several factors may contribute to these disparities, including health behaviors, access to and availability of
prevention and treatment services, patterns of service utilization,
environmental and occupational risks, community support and
cohesion, differences in insurance coverage, and underlying biological risk factors.



The Role of Communication
Recognizing the potential of verbal and nonverbal messages to
modify beliefs and behavior, the public health community has been
working with communication and media experts for more than 30
years to develop mass media campaigns to change health behavior.
At the same time, behavioral scientists working in public health
have developed communication strategies, including materials for
individuals, programs at school and at work, programs delivered
through health care providers, and large-scale campaigns.
The design and development of effective health communication strategies has become increasingly important with the development of new, but untested, technologies that could have
potential for disseminating health communication across diverse
cultural groups. This potential power to affect public health
through communication, however, is attended by concerns that
not all groups benefit equally from communication or social innovation, as exemplified by the “digital divide” in access to and use
of the Internet (Rogers, 1995). Communication technologies may
fundamentally change who has access to health information, and
therefore shift the distribution of health-behavioral risk factors and
health status. Would this shift increase or reduce health disparities
as defined by conventional cultural categories? Would groups that
differ in health-related beliefs and behaviors respond differently to
health communication strategies? Are there options for optimizing health improvement from health communication programs?
The answers to these questions may depend on whether disparities
are malleable to communication strategies, and whether these strategies can be designed adequately to be effective for persons with
different culturally based beliefs and behaviors.
Many of the basic benefits of communication strategies may
be obtained across diverse cultural groups through a generic strategy that capitalizes on their similarities in beliefs and behaviors.
Alternatively, it may be that the communication intervention or
delivery strategy must be targeted to particular groups to have similar effects across groups, or tailored to the beliefs and values of the



group members to optimize the impacts. In this regard, it is of
particular policy interest to know whether targeting and tailoring
communication interventions is especially useful in improving the
health of populations with historical or current health or health
care disadvantages. Thus, the question of the marginal benefit of
special attention in communication interventions to subgroups may
depend on the goals of interventions and, specifically, how much
attention should be focused on vulnerable populations—a societal
ethical question. Furthermore, whether communication strategies
or their implementation must be modified to be effective for different cultural groups will be a function of the particular health problem and subpopulation.
In setting the scope, we purposely attempted to include public
health strategies, such as campaigns, and medical practice strategies, such as pamphlets or Internet-based communication by providers to larger groups of patients.
Ethical Considerations
A number of ethical principles need to be considered in the
development and implementation of health communication for
diverse populations, including avoidance of harm, providing benefit, respecting an individual’s autonomy to make a rational choice,
and treating groups and individuals justly and equitably. These
principles are not always easy to achieve. First, implementing ethical principles can be complicated by the developers’ need to consider tradeoffs among efficiency, cost, and improving the health of
the most in need versus a broader range of persons. Second, a
communication strategy that incorporates ethical principles may
function effectively and appropriately for one segment of the population, but not for another. Third, unintended consequences may
occur even with the most well-intentioned and well-executed health
communication interventions. Such outcomes for diverse populations include confusion about the meaning of a message, unwarranted anxiety resulting from implying individual culpability, or
the stigmatizing of certain cultural practices.



One method for dealing with these kinds of concerns is to
seek and maintain mutual collaboration with the community during all phases of the communication intervention process. This
method will increase the likelihood that the messages and strategies of the intervention will unfold in a manner that is appropriate
for the intended audience.
Given the important role that communication campaigns are
likely to play in the coming years, the field of public health communication should be strengthened and become more science
based. This means supporting research that improves our understanding of the values and context that determine how information will be received, supporting evaluation of campaigns to
measure their effectiveness, and paying more attention to the ethical and social concerns that must be appreciated and respected in
the design of communication campaigns.
In our review and analysis, we draw on several disciplines.
First, we rely on communication sciences and fields such as social
marketing to define the essential components and issues in communication strategies and to review the contributions of technological advances to those strategies in the near future.
Second, we rely on theories of culture and cultural process to
help define the scope of inquiry into culturally based beliefs and
behaviors and cultural comparisons. We begin with a broad view
of sociocultural and demographic diversity, considering ethnic
groups, gender differences, and differences in factors such as socioeconomic status and sexual orientation. Awareness of culture and
the concepts of culture as shared understanding within a community is essential to improving our understanding of the dynamic
factors that influence the process of health communication. Many
potential sources of shared understanding, such as ethnicity, training for a specific occupation, education, age, religion, language,
gender, and generation, may provide a basis for social groupings
within which cultural processes unfold and contribute to intra-



cultural variation because individuals participate in or are exposed
to different cultural processes.
Third, we focus on key social science theoretical contributions
to communication interventions and their dissemination. Social
cognitive and behavioral theories have brought an important conceptual and structural integrity to communication intervention
design and evaluation. Rather than reviewing individual theories,
we describe how health behavior is determined by underlying beliefs and how these beliefs are shaped by communication. We discuss the contributions of behavioral and communication theories
to conceptualize the relevant beliefs and behaviors and to hypothesize which interventions will affect them. In addition, we call on
theories of diffusion of innovations (1) to understand which communication-based interventions might be disseminated and what
might happen to those interventions and their impacts in the process of dissemination, and (2) to understand better the process of
dissemination itself.
Fourth, we broaden the context for our main questions by considering the equity of benefits of communication interventions
across diverse groups and the role of communication in reducing
the disparities among these groups. Furthermore, because communication interventions often use persuasive techniques, we must
examine the ethical issues involved in attempting to persuade diverse populations that include vulnerable groups to change their
behaviors in the interest of public health goals.
We believe exciting new opportunities are present to achieve
the goal of maximizing health benefits of communication strategies for a wide range of socioculturally diverse groups. Pursuing
this goal involves understanding basic principles of communication interventions, such as how messages are constructed for targeted audiences and how they are effectively conveyed. Messages
can be made more coherent and powerful and can be evaluated
more effectively by organizing communication interventions
around well-constructed, extensively studied social science theories. However, doing so requires consideration of what the specific beliefs and behaviors are for populations of interest and how



sociocultural groups that differ in their beliefs and behaviors may
respond to or be affected differently by communication interventions.
The committee’s strategy in preparing this volume was to use
an interdisciplinary approach to examine the current state of health
communication to diverse populations and to suggest fruitful approaches for developing improved interventions in the future.
More specifically, by drawing on the relevant disciplines, we explore two questions: (1) Can we improve our ability to optimize
public health in the context of diversity through communication?
(2) Can we improve the science base in this area?
Conducting a comprehensive evaluation of health communication is a challenging task given the size and complexity of the activities in this area. To make the task more manageable, we
developed an approach to analyze the field through a broad
examination of three exemplars. One exemplar is national or
large-scale regional public health campaigns. The second is communication to improve mammography or breast cancer screening
rates. The third area is the management of and outcomes for diabetes mellitus. These three exemplars offer our analysis a focus on
a communication method (public health campaign), a public health
problem (mammography screening), and disease management that
spans public health and medical practice concerns (diabetes mellitus). For all three cases, a prime object of intervention is changing
beliefs, intentions to act, or behaviors themselves, such as modifying personal health practices, accessing health care, or adhering to
treatment recommendations.
All three involve areas of public health and medicine. For national campaigns and screening mammography, there has been
extensive development of health communication strategies for large
groups of people; for diabetes mellitus, few systematic communication efforts have been implemented. This area offers an important opportunity for the future development and testing of
communication interventions to change behavior. There are surely
other health conditions or types of communication intervention
strategies in which the benefits of communication strategies for



improving health across diverse groups differ from what we observe for these three areas. However, our selected cases represent
major areas of national attention and provide the opportunity to
examine different methodological, theoretical, and research approaches to the design and conduct of communication strategies to
change health behavior. We note that communication strategies
are sometimes only one part of multicomponent interventions (e.g.,
to improve health) that combine communication and resources or
that intervene both at group and individual levels. In reviewing
the literature, we attended to interventions that use communication strategies exclusively as well as to those that include such strategies as a major component.
The volume is intended to inform policy makers, researchers,
funders/sponsors, advocacy organizations, practitioners, and others in providing and evaluating communication interventions to
improve public health. It is organized into eight chapters. Chapter
2 provides a framework for the committee’s review and analysis by
examining the contributions of behavior and communication
theory to the design, development, implementation, and evaluation of health communication to diverse populations. Chapters 3
through 5 present the three exemplars—national campaigns, mammography, and diabetes mellitus. As noted, our review of the diabetes literature resulted in the conclusion that little systematic work
has been done on communication campaigns to change behavior
in this area. As a result, the committee presents a discussion of
diabetes as a challenge for health communication developers in the
future. Chapter 6 reviews the state of technology and assesses its
potential. Chapter 7 discusses the problems associated with developing appropriate definitions of diversity and provides guidance
for a new direction. Chapter 8 presents the committee’s findings
and recommendations.




his 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.
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 healthrelated behaviors. The more one knows about the determinants of
effective communication intervention to reinforce or change that




Perhaps the most critical determinant of whether a person does
or does not perform a given behavior is the person’s beliefs about
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
value of mammography are important in creating interventions to
enhance mammography use. However, finding out that many
to achieve social and environmental changes to influence this belief
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
in which one receives the message also may influence how the
strongly influence whether the person learns or accepts the mes-



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.
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);



• 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,
• Theory of Reasoned Action (Fishbein and Ajzen, 1975;
Ajzen and Fishbein, 1980; Fishbein, Middlestadt, and Hitchcock,
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-



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-



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 selfefficacy regarding personally performing the behavior.
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-



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.



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



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
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



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
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)



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



afraid that they may have, breast cancer, may have beliefs about
“My getting a mammogram” that are very different from women
who do not believe they are at risk. Thus, factors that may influence one’s beliefs include perceived risk; moods and emotions as
well as personality, culture, knowledge, and attitudes toward objects or institutions; and stigma. In addition, ecological and social
factors such as availability of health services, types of interpersonal networks, and media exposure and/or exposure to various
interventions may all serve to shape and influence one’s behavioral, normative, and efficacy beliefs.
Although these are all important variables, and although they
may help us to understand why people hold a given belief, they are
perhaps best seen as “distal” variables that exert their influence
over specific behaviors by affecting the more “proximal” determinants of those behaviors. However, there is no necessary relationship between any of these variables and behavior-specific beliefs.
That is, these distal variables may or may not affect people’s underlying behavioral, normative, or control beliefs about a given
behavior. For example, rich and poor, old and young, those who
do or do not perceive they are at risk for a given illness, those who
do or do not have knowledge of a disease and how it is transmitted, and those who do or do not feel stigmatized may have different behavioral, normative, and control beliefs with respect to one
behavior, but may have similar beliefs with respect to another.
When one or more of these distal variables leads to different
beliefs, it is possible that the variable also will be related to behavior change. However, even though a given distal variable may
influence outcome expectancies, that variable may still be unrelated to behavior if attitudinal considerations are not important
determinants of that behavior change. Thus, rather than focusing
on distal variables, to be most effective, health communication interventions should focus on the behavioral, normative, or control
beliefs that underlie attitudes, perceived norms, and/or a person’s
sense of personal agency.
For example, let us assume that a behavioral analysis indicated
that whether or not one intended to (or actually did) get a flu



vaccination is determined primarily by the outcome expectancy (or
behavioral belief) that “My getting a flu shot will protect me from
getting the flu.” Assume that those who intended to get (or who
actually got) a flu vaccination believed that getting the flu shot
would protect them from the flu, while those who did not intend
to get (or who did not get) the vaccination believed that “My getting a flu shot will not protect me from getting the flu.” If this
scenario were the case, an appropriate communication to increase
the likelihood that people will intend to and will actually get a flu
vaccination would be one that tried to change this latter belief.
The more we understand about why some people do or do not
hold this belief, the more likely we are to be able to develop an
effective communication intervention to change that belief.
However, there are ma