Eliminating health disparities is one of the most pressing global health issues. In the United States, health disparities have been examined primarily as differences in groups based on racial, class, and ethnic classifications. Globally, the issue focuses on the differences between developing and developed nations in health status and access to state of the art treatments. Harshly put, wherever in the world you live, if you are poor and a minority, you live sicker and die sooner.
The causal paths leading to these disparities have been more controversial. In the United States, Kawachi and colleagues (2005) identified three paths frequently described in the literature. The first views race as a biologically meaningful category and racial disparities in health as reflecting inherited susceptibility to disease. The second treats race as a proxy for social class and blames socio-economic stratification for disparities. The third approach, and the one the authors strongly support as the most useful, accounts for the independent and interactive effects of both class and race. According to this approach, race is neither a biologically meaningful category nor a proxy for class, but is a separate construct from class. This approach suggests that race should not be used as a proxy for class, neither should racial disparities be analyzed without also considering the contribution of class disparities, and finally, class-based health disparities should never be analyzed without also considering the contribution of race and ethnicity (Kawachi et al. 2005).
The Contribution Of Communication To Health Disparities
While communication cannot solve the social, economic, and political issues underlying these disparities, it can make important contributions to reducing health disparities. First, we must acknowledge that there are racial and class disparities in communication as well as in health. The way information is generated, manipulated, and distributed differs among social groups. Viswanath and Emmons (2006) propose the idea of “communication inequalities,” that is, there are differences in the way social groups access and use, attend to, retain, and act on relevant health information. Almost every study of health knowledge and health protective behaviors shows gaps based on social class. Those from lower social classes tend to know less about the health risk and are less likely to adopt behaviors to protect against the risk. This problem has been particularly frustrating because attempts to close these gaps have often actually increased them. Traditional health promotion programs are used more readily by those with more resources to act on the information. For example, rates of smoking fell far more quickly among the more educated following the US Surgeon General’s report on smoking, resulting in the current socio-economic status (SES) gradient in smoking (Adler & Newman 2002).
Second, communication research needs to identify in much more depth the relationships between race and class and the responses to health risks of various kinds, the value placed on knowing more about the risk, the sources turned to and trusted when weighing what to do about a risk, and the way information is processed about the risk. Disadvantaged groups have poorer information processing skills such as health literacy (Kutner et al. 2006), may be more likely to use English as a second language, and have less experience with such communication skills as negotiation. They may be locked in an information ghetto where the only trusted information is internally generated and more likely to be inaccurate.
These disadvantaged groups often are portrayed as fatalistic people with a pervasive sense of helplessness (Bosma et al. 1999). They may use information channels differently than other social classes. While the disadvantaged have access to both informal and formal sources of information, they prefer the informal sources to meet specific information needs. Television is always reported as the source most frequently used by disadvantaged groups. Much has been written about the way the Internet has affected disadvantaged groups. The lower social classes tend to have less access and less use, a phenomenon that is described as the “digital divide.” There also is some evidence that social class impacts the way health risk information is processed. Several studies using quite different methodology have found evidence that lower social classes are more likely to process risk information heuristically rather than systematically.
Third, health communication scholars should examine the different strategies commonly used to enhance the health of individuals and communities to see what contributions they have and could make toward reducing disparities. The following sections begin this examination for health provider/client communication, social support, everyday interpersonal interactions, mass mediated health campaigns, entertainment education, media advocacy, and interactive health communication.
Strategies To Enhance Health
Street (2003) argues that the medical consultation is a socially constructed event and the primary activity is talk, i.e., the interaction between the health provider and the client. This talk between physicians and minority clients frequently misses the mark because of contrasting perceptions of physicians and patients, linguistic asymmetry, and selffulfilling prophecy spirals (Perloff et al. 2006). Van Ryn and Fu (2003) suggest that providers may even contribute to health disparities by influencing clients’ views of themselves and their relation to the world, by differentially encouraging health promotion and disease prevention behaviors and services, and by withholding access to treatments or services and denying benefits and rights. They cite evidence of physician contributions to racial/ ethnic disparities in both kidney transplant rates and cardiac procedures, in pain assessment and control, and in mental health services (Van Ryn & Fu 2003). They argue for interventions to help providers avoid these biases as one way to reduce disparities.
Social support is another communication behavior that has profound consequences for mental and physical well-being (Albrecht & Goldsmith 2003). Yet there is evidence that kinship support networks are deteriorating in low-income and minority communities due to unemployment, transience, and substance abuse. Virtual support networks are becoming increasingly important but access to the technology is an issue in underserved communities.
Cline’s (2003) argument for shifting the focus of interpersonal communication about health from formal to informal contexts such as everyday talk highlights a rich and untapped dimension of communication that could contribute to reducing disparities. These informal contexts occur much more frequently and these relationships may be much more significant to the individual. She focuses on HIV/AIDS to illustrate how the primary frameworks of meaning driving participants’ behaviors are social rather than health related. HIV prevention behaviors, for example, may be driven more by desire to avoid character judgments and relational discord than to promote health. These primary frameworks of meaning are embedded in culture and must be understood before effective interventions can be designed.
Segmenting audiences on the basis of race and ethnicity is one of the most common ways that mass media health campaigns address health disparities. Hornik and Ramirez (2006) concluded after examining the race or ethnicity segmentation in health communication campaigns that there was no evidence that this segmentation, in any of its forms, reduces disparities. Yet they still defended segmentation as the most politically viable way of getting resources to reach disadvantaged segments of society. Even though race and ethnicity do not completely define disadvantage in US society, they may be the most politically respectable correlates of social disadvantage in a society where class politics are considered divisive (Hornik & Ramirez 2006). They do caution, however, that segmentation can have disadvantages – segmentation can increase costs, can be difficult to implement, and can have negative effects such as stigmatization on the people who are meant to be the beneficiaries.
Once audiences are segmented, messages need to be tailored for these segments. Health communicators frequently equate culture in a simplistic fashion with race and ethnicity. The Institute of Medicine (2002) claims that culture has been poorly examined in the context of health communication, and asserts that to consider culture in health communication requires significant exploration beyond the typical variables of race, ethnicity, and SES. Resnicow and Braithwaite (2001) refer to this superficial approach as the surface structure of a culture. Addressing surface structure includes matching messages and channels to observable social and behavioral characteristics, including familiar people, foods, music, language, and places. They argue that it may be more important to address deep structure, which reflects the cultural, social, psychological, environmental, and historical factors that affect health for a minority community. Resnicow and Braithwaite (2001) argue that when health communication reflects appropriate surface structure, it increases the receptivity and acceptance of the campaign, but when it also addresses deep structure, it conveys true salience with the community it seeks to reach.
Entertainment programming on the media is a powerful way to communicate health information, especially for minority audiences, who are heavy consumers of this type of media. In developing countries, entertainment education frequently produces entertainment programming for the sole objective of influencing health behaviors. In the US, organizations exist that introduce important health topics to writers and producers and assist them in portraying these issues accurately to their viewers. Several research studies have demonstrated that even brief exposure to health information and behaviors can have strong effects. For example, in surveys conducted by Porter Novelli during 1999 and 2000, over half of regular prime-time and daytime drama viewers reported that they learned something about a disease or how to prevent it from a TV show. About one-third of regular viewers said they took some action after hearing about a health issue or disease on a TV show (Centers for Disease Control and Prevention 2006).
Media advocacy is the strategic use of mass media and its tools, in combination with community organizing, for the purpose of advancing healthy public policies (Institute of Medicine 2003, 338). It moves beyond the individual to address the social conditions that affect individual health. An early example of such a campaign is the Uptown Coalition in Philadelphia, which used the media and community organizing to defeat R. J. Reynolds’ proposed campaign to market Uptown cigarettes in African-American communities.
Interactive technology, “computer-based media that enable users to access information and services of interest, control how the information is presented, and respond to information and messages in the mediated environment” (Hawkins et al. 1997, 2), has created new opportunities for health communication. These applications can eliminate barriers such as low literacy and expand the opportunities to tailor and personalize information. One of the pioneer applications of this technology, the Comprehensive Health Enhancement Support System (CHESS), has impressive research evidence of its potential for reducing disparities. Fifteen years of research on CHESS have shown consistently positive effects on low-income African-American women’s health informational competence (Shaw et al. 2006). Yet access issues prevent an effective approach such as CHESS from achieving its full potential in reducing health disparities.
Health disparities are insidious global problems that communication scholars can and should address. Sensitivity to the race and class issues underlying these disparities is essential when studying or designing health communication interventions.
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