Communication Divides and Implications for Health Disparities

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Communication Divides and Implications for Health
Disparities

• K. Vish Viswanath
• Department of Society, Human Development and
  Health, Harvard School of Public Health
• Department of Medical Oncology, Dana- Farber
  Cancer Institute

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Risk Communication and Maternal Child Health
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Trends in Print News Coverage of Leading Health
Issues
FIGURE U.S. print news coverage of health issues.
4
Health-related News Stories Increasing in Ethnic
Print Media
FIGURE Ethnic print coverage of leading health
issues.
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Trends in National Television News Coverage of
Leading Health Issues
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July 2007 Google Hits for Health Topics

• Health 935,000,000
• Cancer 255,000,000
• Smoking 128,000,000
• Weight Loss 112,000,000
• Pregnancy 82,300,000
• Diabetes 84,500,000
• Obesity 36,400,000

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Profound health disparities exist

• Higher incidence rates
• Black males more likely to develop any type of
  cancer than White males
• Higher death rates
• Black women are more likely to die from breast
  cancer than White women.
• Cardiovascular disease
• SES disparities in smoking

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Estimated Prevalence of Diabetes in Adults
(gt20yrs.) by Race/Ethnicity2002 and 2005
Percent
Year
Source American Diabetes Association available
at http//www.diabetes.org/diabetes-statistics/pre
valence.jsp
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Obesity Prevalence by Education Level 1991-2001
Percent
Year
Source CDC, BRFSS, 1991-2001
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Estimated Prevalence of Diabetes in Adults
(gt20yrs.) by Race/Ethnicity2002 and 2005
Percent
Year
Source American Diabetes Association available
at http//www.diabetes.org/diabetes-statistics/pre
valence.jsp
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Disparities in Maternal Child Health Outcomes

• The Weathering Hypothesis (Geronimus,1992)
• On average, the 20s and 30s represent prime
  childbearing years for low risk pregnancies.
  However, when stratified by race, studies show
  that maternal age patterns of neonatal mortality
  vary.
• Compared to White infants, babies born to
  African-American teen mothers experience a
  survival advantage relative to infants whose
  mothers are older that is, as African-American
  women enter their 20s and 30s, infant mortality
  rates increase.
• The Weathering Hypothesis suggests that the
  health of African-American women may begin to
  deteriorate in early adulthood as a physical
  consequence of cumulative socioeconomic
  disadvantage.

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Why do these disparities exist?

• Social determinants
• Social cohesion
• Social stratification
• Social Class
• SES
• SEP
• Social networks
• Neighborhood conditions
• Social policies

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Multilevel approach to epidemiology
Figure Adopted from Kaplan (2004).
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What links social determinants with health
outcomes?

• Communication is one potential thread linking
  proximal to distal factors and their outcomes to
  health.

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Multilevel approach to epidemiology
Figure Adopted from Kaplan (2004).
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Functions of Communication in Health

• Informational acquire knowledge
• Instrumental enables action
• Social control defines social norms
• Communal access to social capital

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Structural Influence Model of Communication (SIM)
4).                             Figure 4.
Structural Influence Model Health
Communication.
Social Determinants  
  Socioeconomic Position    Education   
Income    Employment    Occupation  
Place    Neighborhood   Urban versus rural
Mediating/ Moderating Conditions
 
Socio-Demographics    Age    Gender   
Race/Ethnicity  
Social Networks    Social Capital  
Social Networks   Resources  

• Social Determinants
• Socioeconomic Position
• Education
• Income
• Employment
• Occupation
• Place
• Neighborhood
• Urban versus rural

• Mediating/
• Moderating Conditions
• Socio-Demographics
• Age
• Gender
• Race/Ethnicity
• Social Networks
• Social Capital
• Social Networks
• Resources

• Health
• Communication
• Outcomes
• Health Media Use Exposure
• Information seeking
• Attention
• Information Processing

• Health
• Outcomes
• Knowledge
• Health Beliefs
• Comprehension
• Capacity for action
• Incidence
• Health Behaviors
• Prevention
• Screening
• Treatment
• Survivorship
• End-of-life care

       Health Media Use Exposure   
Information seeking    Attention    Information
Processing    
Communication may play a role in linking SES,
resources and health outcomes.
Health Outcomes  
       Knowledge    Health Beliefs   
Comprehension    Capacity for action   
Incidence    Health Behaviors    Prevention   
Screening    Treatment    Survivorship  
End-of-life care  
 
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Communication Inequality

• Differences among social classes in the
  generation, manipulation, and distribution of
  information at the group level and differences in
  access to and ability to take advantage of
  information at the individual level.

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Dimensions of communication inequality

• At the societal level, differences in
• The generation, manipulation and distribution of
  information among social groups.
• Capacity to act on information

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Dimensions of communication inequality

• At the individual level, differences in
• Access and use of information channels
• Attention to health content
• Recall, knowledge and comprehension
• Capacity to act on information

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Inequality in access to and use of information
channels

• Income, education and employment are positively
  associated with
• subscription to cable or satellite TV and the
  Internet
• daily readership of newspapers
• Difference in use among racial and ethnic groups
• Blacks spend more time with TV but less with
  newspapers, and have lower access to Internet,
  cable and satellite TV.

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Recent Work

• SES, Race and Ethnicity are associated with
• subscription to cable or satellite TV and the
  Internet
• daily readership of newspapers
• Attention to health content in different media
• Differential time with different media
• Knowledge gaps in health
• (Viswanath, 2005 Viswanath, 2006 Viswanath et
  al., 2006 Ramanadhan Viswanath, 2006)

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Days Read Newspaper in Last Week, by Race
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Days Read Newspaper in Last Week, by Education
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Days Read Newspaper in Last Week, by Income
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Percentage of respondents who went online to
look for health information in the United States
From the Health Information National Trends
Survey, National Cancer Institute
http//www.cancercontrol.cancer.gov/hints/index.js
p
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• Inequality in access to and use of information
  channels Language barriers
• 3-40 non-English speakers in the
• United States

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Access to Information Services among Different
SES and Racial Ethnic Groups
Note For all ethnicity assessments, multi-racial
persons were excluded from the analysis. Data
from HINTS.
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Major Media and their Audience Demographics in
the United States
United States Bureau of Census, Statistical
Abstract of the United States, 2004-5, available
at http//www.census.gov/prod/2004pubs/04statab/in
focomm.pdf
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Media exposure and language of interview
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Info sources credibility ratings and language of
interview, weighted
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Inequality in attention to health information

• Education and income positively influence degree
  of attention to media
• No difference in self-reported attention to media
  by race or ethnicity
• Differences in attention to media by language

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Percent paying A lot/Some attention to health
information on various media, by education (HINTS)
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Attention paid to health information on mass
media by different groups (HINTS)
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Cancer information seekers and non-seekers in the
United States
From the Health Information National Trends
Survey, National Cancer Institute
http//www.cancercontrol.cancer.gov/hints/index.js
p
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Inequality in comprehension and knowledge of
health information

• Confusion due to plethora of information at each
  stage
• Prevention
• Diagnosis
• Treatment
• Navigation of health system
• Change over life course
• 38 of HINTS respondents lt high school education
  reported too many recommendations to follow for
  cancer prevention.

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Inequality in comprehension and knowledge of
health information

• Issue of health literacy in the informed decision
  making environment
• 47-51 of U.S. adults lack basic literacy skills
  (1992 NALS)
• The Knowledge Gap Hypothesis

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The Knowledge Gap Hypothesis

• Increasing flow of information into a social
  system is more likely to benefit groups of higher
  socioeconomic status (SES) than those of lower
  SES
• thus widening the already existing gaps in
  information rather than narrowing them
• (Tichenor, Donohue Olien, 1980).

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Percent saying that their chances of cancer
increase by a lot or some with exposure, by
Education
40
Percent saying that their chances of cancer
increase by a lot or some with exposure, by
Income
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Inequality in capacity to act on health
information

• Action is subject to opportunity structure and
  built environment
• Examples from Energy Balance
• Access to green space (Sallis et al., 2002)
• Availability of grocery stores (Block et al.,
  2004, Moore et al., 2006)
• Neighborhood disorder (King et al., 2002, Perkins
  et al., 1993)

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Trajectories of communication inequality

• Will disparities disappear with technological
  advances?
• Will decrease in cost of technology lead to
  saturation?
• With improvement comes greater demand for more
  high-end equipment
• Not a one time expenditure
• Trend toward convergence of channels and content
  what are the implications?

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Implications for inequality research

• What does convergence of technologies mean to
  access to and use of different channels? Would it
  be cost efficient and more affordable if most
  information and entertainment be obtained from a
  small set of media delivery systems and services?
  
• Is the constant change and improvement in
  technologies of information delivery systems
  likely to be a deterrent for those who cannot
  afford to update their technologies?

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Implications for inequality research (cont.)

• Does the increasing sophistication in using and
  operating the new technologies likely to leave
  certain groups at a disadvantage?

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Members of the Lab

• Kelly Blake, MHS
• Katrina Bond, MPH
• Josephine Crisostomo, MPH
• Elizabeth Eichel, BA
• Jose Jorge
• Emily Zobel Kontos, SM
• Susan Koch-Weser, Dr.Ph.
• Sara Minsky, MPH
• Lisa Lowery, BS
• Kalahn Taylor-Clark, Ph.D.
• Shoba Ramanadhan, MPH
• Andy Reisenberg, MA
• Sherrie Wallington, Ph.D.
• http//www.hsph.harvard.edu/viswanathlab