Communication Divides and Implications for Health Disparities

1. 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

2. Risk Communication and Maternal & Child Health

3. 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.

5. Trends in National Television News Coverage of Leading Health Issues

6. 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

7. 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

8. Estimated Prevalence of Diabetes in Adults (>20yrs.) by Race/Ethnicity2002 and 2005 Percent Year Source: American Diabetes Association available at http://www.diabetes.org/diabetes-statistics/prevalence.jsp

9. Obesity Prevalence by Education Level 1991-2001 Percent Year Source: CDC, BRFSS, 1991-2001

10. Estimated Prevalence of Diabetes in Adults (>20yrs.) by Race/Ethnicity2002 and 2005 Percent Year Source: American Diabetes Association available at http://www.diabetes.org/diabetes-statistics/prevalence.jsp

11. 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.

12. Why do these disparities exist? • Social determinants: • Social cohesion • Social stratification • Social Class • SES • SEP • Social networks • Neighborhood conditions • Social policies

13. Multilevel approach to epidemiology Figure: Adopted from Kaplan (2004).

14. What links social determinants with health outcomes? Communication is one potential thread linking proximal to distal factors and their outcomes to health.

15. Multilevel approach to epidemiology Figure: Adopted from Kaplan (2004).

16. Functions of Communication in Health • Informational: acquire knowledge • Instrumental: enables action • Social control: defines social norms • Communal: access to social capital

17. 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 Structural Influence Model of Communication (SIM) • 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

18. 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.

19. 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

20. 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

21. 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.

22. 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)

23. Days Read Newspaper in Last Week, by Race

24. Days Read Newspaper in Last Week, by Education

25. Days Read Newspaper in Last Week, by Income

26. 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.jsp

27. Inequality in access to and use of information channels: Language barriers: 3-40% non-English speakers in the United States

28. 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.

29. 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/infocomm.pdf

30. Media exposure and language of interview

31. Info sources credibility ratings and language of interview, weighted

32. 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

33. Percent paying “A lot/Some” attention to health information on various media, by education (HINTS)

34. Attention paid to health information on mass media by different groups (HINTS)

35. 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.jsp

36. 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 < high school education reported “too many recommendations” to follow for cancer prevention.

37. 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

38. 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).

39. 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

41. 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)

42. 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?

43. 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?

44. Implications for inequality research (cont.) • Does the increasing sophistication in using and operating the new technologies likely to leave certain groups at a disadvantage?

45. 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