Outline of Today’s Lecture

1. Epi 246 Social Cognitive Theory, Models of Patient-Provider Communication, and Culture-Centered Health Communication Margaret Handley, PhD MPHAssistant Professor DEB and DGIM-SFGHApril 8, 2010

2. Outline of Today’s Lecture • Discuss Social Cognitive Theory and applications of it 2. Describe models for Patient-Provider Communication and examples of different ways of developing theory-informed descriptive and intervention projects 3. Present alternative approaches to health-communication theory and practice that are particularly relevant to community engagement principles and working with marginalized populations

3. Learning Objectives 1 1. Understand components of Social Cognitive Theory 2. Understand models of Health Communication and how functions relevant to health communication relate to diverse theories 3. Be familiar with culture-centered approaches to health communication and their relevance to community engagement with diverse populations 4. Be able to apply components of the presented theories to health-related behaviors and health communication strategies

4. Theories and Models Related to Interpersonal Behavior and Behavior Change • Interpersonal health behavior theories such as Social Cognitive Theory fall within social influences on health, yet are delineated from social support and social networks. • Can be in family, friends, peers and informal settings or in more formal settings, such as clinical settings for patient-provider communication, communication among clinicians in clinics and hospitals, and for teachers and students in variety of settings • For patient-provider communication specifically, there are many theories that relate to specific functional components of communication – may be more complex to attribute to single theories

5. I. Social Cognitive Theory From Bandura

6. Social Cognitive Theory(formerly Social Learning Theory) • SCT is a learning theory used in many settings • Used to explain behavior: we learn from experience, observation, and symbolic communication >> we apply this learning to shape the environment we are in, as well as respond to it, and become adaptable to changes in it • Often used for health behavior change interventions: -- Patient-provider communication re cancer pain, school-based HIV prevention programs, self-management for distressed diabetes patients, adult education programs focused on community health problems

7. Social Cognitive Theory

8. Social Cognitive Theory Self-Efficacy Applications Glanz K, Rimer, B, Viswanath, Health Behavior and Health Education 2009

9. Application of Social Cognitive Theory to a Tailored Intervention Focusing on Patient Activation for Cancer Pain Control Conceptual Model – Ca-HELP - Began with interest in patient activation* for participatory decision making - Informed by SCT to frame the tailored education intervention Focus on communication competence skill development Kravitz RL et al, 2009 Cancer Health Empowerment for Living Without Pain. BMC Cancer *Kaplan S Greenfield S and others

10. CA-HELP Application of Social Cognitive Theory *Using the ACT-PREP Paradigm: ASSESS,CORRECT,TEACH,PLAN,REHEARSE,PORTRAY

11. Feasibility Study Using SCT Constructs inClassroom Discussions/Analysis of Hip-Hop Music • Challenge - Reaching NYC urban minority youth about HIV/AIDS prevention education and interventions • Response - What education-based practices could match the unique characteristics of this population? • Concept – Hip-Hop creates social env. where music is shared, and so are misconceptions, but this can be re-framed to shape messages. Hip-Hop/Rap music analysis and discussion at school as a means to explore content and feasibility. • SCT Focus Areas: • Are lyrics highlighting unrealistic positive outcomes of sexual • promiscuity? (behavioral expectations) • What observational learning occurs from watching videos? • How do images act as reinforcements (glamour/wealth) in • sustaining risky behavior? Table 1 Constructs of SCT incorporated in classroom discussions and in the analysis of music Boutin-Foster C et al J Urban Health, 2010

12. Feasibility Study cont… Table 1 Constructs of SCT incorporated in classroom discussions and in the analysis of music Boutin-Foster C et al J Urban Health, 2010

13. SCT-Conceptual Framework for the REDEEM PROJECT (Reduce Distress Enhance Effective Management) Fisher et al, personal comm. - NIDDK-funded R01

14. SCT-Conceptual Framework for the REDEEM PROJECT (Reduce Distress Enhance Effective Management) DD=Diabetes Distress Fisher et al, personal comm. - NIDDK-funded R01 “The model suggests a variety of potential biological, environmental, disease-related and health care burdens and supports that define the personal and social context in which diabetes is managed and D/D is experienced ( ‘layers of potential chronic adversity’). Likewise, the beliefs, role behaviors and disease practices associated with ethnicity, gender, and social class (education, income) serve as filters through which burdens and supports are interpreted and experienced. The major constructs are dynamically interconnected, such that, for example, biological markers can be viewed both as a cause of emotional burden (patient receives a poor lab value after struggling with disease management) and a result of emotional burden (patient’s increased D/D leads to reduced self-management and, eventually, to poor lab values). This framework includes many of the factors known to affect D/D and self-management: social and environmental contributors, how personal, cultural and family based beliefs and roles affect these processes, and how the demands for care posed by diabetes sometimes creates seemingly unending circularities that can lead to both D/D and poor self-management.”

15. “Our ESL classroom [provides] students with an opportunity to share their personal difficulties, evaluate them against the experiences of others, and begin to recognize them as socially constructed and potentially transformed through social action. We might see this process, and its active facilitation in our classes, as a primary means by which new solidarities and ‘traditions’ are developed within immigrant communities.”Morgan, B. (1998). The ESL classroom: Teaching, critical practice, and community. Toronto, Canada: University of Toronto Press. Social Learning Theory in ESL-Health Partnerships

16. Social Learning Theory in ESL-Health Partnerships Learners Lives As Curriculum>>> ‘Re-Storying’ Health Info./Messages • 1. Build on What learners know • 2. Balance Skills and Structures with • Meaning-Making and Knowledge • Creation • Autonomy in Language and Content • 4. Shared responsibility for learning • among students and teachers • 5. Build communities of learner • -practitioners • EXAMPLES • Cancer – Women in SF Asian Communities • Diabetes Prevention- Statewide • Obesity Prevention – Fruitvale, Oakland • Lead Poisoning Prevention - Monterey Weinstein G. (1999). Learners' Lives as Curriculum. McHenry, IL: Delta Systems. Handley MA, Santos MG, McClelland J. Reports from the Field.Global Health Prom, 2009 Santos MG, Handley MA, McCleland J, Richards A. Under Review J CATESOL

17. II. Health Communication in the Context of Patient-Provider Communication • ‘Good communication’ improves health outcomes, but there is no single theory to what good communication looks like • Focus on the functions/pathways that could improve health via improved health communication, with particular focus on patient-providers communication • ‘Patient-centered’ approach/paradigm

18. Health Communication in the Context of Patient-Provider Communication Proximal Outcomes Understanding Satisfaction Clinician-patient agreement Trust Feeling ‘known’ Patient feels involved Rapport Intermediate Outcomes Access to Care Quality Medical decision Commitment to treatment Trust in System Social Support Self-care skills Emotional Management Indirect path Communications Functions 1. Information Exchange 2. Respond to Emotions 3. Manage Uncertainty 4. Foster Relationships 5. Make Decisions 6. Enable Self-Management Health Outcomes Survival Cure/Improvement Less suffering Emotional well-being Pain control Functional ability Vitality Direct path Direct and indirect pathways from communication to health outcomes. Figure 11.1 from Glanz, Rimmer, Viswanath, 2008

19. Health Communication in the Context of Patient-Provider Communicationfor Diabetes SMS Proximal Outcomes Understanding Satisfaction Clinician-patient agreement Trust Feeling ‘known’ Patient feels involved Rapport Intermediate Outcomes Access to care Quality medical decision Commitment to treatment Trust in system Social support Self-care skills Emotional Management Indirect path Communications Functions Information Exchange Respond to Emotions Manage Uncertainty Foster Relationships Make Decisions Enable Self-Management Health Outcomes Survival Cure/Improvement Less suffering Emotional well-being Pain control Functional ability Vitality Direct path Possible direct and indirect pathways from communication to health outcomes using IDEALL/ATSM Diabetes Self-Management Program. Schillinger et al. 2007, 2009

20. Health Communication in the Context of Interpersonal Communication in the ICU cont. • Decision-making in ICU when no surrogates- Unexplored area, began with descriptive epidemiology linked to descriptive communication and behavioral processes of decision-making • Included elements of HBM, TPB, SCT self-efficacy to make decisions, influence of peers/others in the hospital, relationship to guidelines and cues to action re legal concerns • Led to larger studies, ethical review project, current policy work on task force for the Am Thoracic Society White D, et al 2006. White D et al, 2007. Annals Int Med 2007.147:34-40.

21. Health Communication in the Context of Interpersonal Communication in ICU Proximal Outcomes Understanding Satisfaction Clinician-patient agreement Trust Feeling ‘known’ Patient feels involved Rapport Intermediate Outcomes Access to Care Quality Medical decision Commitment to treatment Trust in System Social Support Self-care skills Emotional Management Indirect path Communications Functions Information Exchange Respond to Emotions MD Managing Uncertainty Foster Relationships Team Decision-Making Enable Self-Management Health Outcomes Survival Cure/Improvement Less suffering Emotional well-being Pain control Functional ability Vitality Direct path Direct and indirect pathways from communication to health outcomes. White D et al 2006, 2007

22. Models and Measures of Patient Centered Communication P 241-49 Glanz, Rimmer, Viswanath, 2008

23. ‘Moderators’ of Clinician-Patient Communication Outcomes

24. III. Culture-Based Theory of Health Communication “Hierarchies of biomedical knowledge do not lend themselves to identifying who is most capable of deciphering the complex pragmatics of public discourse about health…..why not include people who are ‘experts’ in reading how information is interpellated within their own communities? In doing so, we might learn a lot more about the full range of publics that emerge as discourse about health circulates.” Briggs C Med Anthro Quartlerly p 313- 2003

25. Culture-Centered Approach to Health Communication A culture-centered approach is an alternative entry point for theorizing about health communication with marginalized populations Focuses on understanding health meanings and experiences within the space of marginalized settings Based in critical theories, cultural studies, post-colonial theory Critiques a biomedical approach to theories of health communication that can reflect ‘individualistic’ views that are not relevant to many marginalized populations Dutta MJ. Communicating Health 2008

26. Culture-Centered Approach to Health Communication Contextualized health communication as combining: structural forces, which refer to the constellation of institutional and organizational networks that constrain the availability of resources in marginalized settings local culture and agency, which refers to the capacity individuals and communities to be active participants and determining health priorities and solutions Dutta MJ. Communicating Health 2008

27. Culture-Centered Approach to Health Communication Goals of Culture-Centered Approaches: 1. To centralize context and bring to forefront awareness of the socio-structural contexts underlying many health behaviors. 2. To create culture-based health solutions. 3. To explore questions of power, ideology, hegemony and control in the discourses and practices of healthcare. 4. To correct, through health policies, approaches directed at ‘fixing’ marginalized populations’ behaviors. -- Is an application of community engagement principles.

28. A Culture-Centered Approach Example- Rural Bengal Q. How is health problematized and how are health solutions articulated? Q. What does the interdependence of context, access, and communication in health meaning look like in rural areas? Findings: Structural in-access from cost (to healthy foods), are aligned with ways health is seen globally, not a matter if individual knowledge or beliefs about the behavior Trust is more important than expertise in health providers Responsibility to ‘self-treat’ at family and community level Gaps between policy and the execution of policy Dutta MJ and Basu A. Health Communication 2008 http://web.ics.purdue.edu/~mdutta/

29. A Culture-Centered Approach Example- Rural Oaxaca Q. What comprises health? What is valued? What has changed across generations and with migration? How do illnesses get treated? How does health information get communicated? Who is trusted and why? Q. What does the interdependence of globalized migration, health beliefs and communication about health look like? Preliminary Findings – Nutrition promises health but is being lost with shift away from agrarian life, migration is unhealthy, and others’ land is not trusted to produce healthy food. Trust is more important than expertise in health providers Pride to ‘self-treat’ at family and community level, including value of companies that give health ‘milagros’ Handley M, Rodrigues M, Perez R, Grieshop J et al in preparation

30. Homework – Week 2 1. Apply the social cognitive theory to your work and create a conceptual model as presented in the readings and examples from class. Why or why not, would you use this in your current or planned work? 2. Which aspects of the health communication models/theories can be adapted to your area of interest? Be specific. Provide a detailed example that includes model constructs that incorporate both an individualistic view, and one that takes more into account structural and environmental factors. 3. How might you include a culture-centered perspective in your areas of interest? How do you anticipate it could inform your work?