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Diagnosing communication connections: Reaching underserved communities through existing communication ecologies
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Content
DIAGNOSING COMMUNICATION CONNECTIONS:
REACHING UNDERSERVED COMMUNITIES THROUGH
EXISTING COMMUNICATION ECOLOGIES
by
Holley A. Wilkin
A Dissertation Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirement for the Degree
DOCTOR OF PHILOSOPHY
(COMMUNICATION)
December 2005
Copyright 2005 Holley A. Wilkin
UMI Number: 3219849
3219849
2006
Copyright 2005 by
Wilkin, Holley A.
UMI Microform
Copyright
All rights reserved. This microform edition is protected against
unauthorized copying under Title 17, United States Code.
ProQuest Information and Learning Company
300 North Zeeb Road
P.O. Box 1346
Ann Arbor, MI 48106-1346
All rights reserved.
by ProQuest Information and Learning Company.
ii
ACKNOWLEDGEMENTS
I recently heard about a study that showed the benefits of a large social
network of family and friends. While the study did not specifically mention the
importance of social support in the completion of a dissertation, I can personally
attest to the immeasurable value of my family, friends, and mentors while tackling
this endeavor.
First, I’ d like to acknowledge the support, encouragement, and guidance of
my co-advisors Sandra Ball-Rokeach and Michael Cody. Both have been incredible
mentors, assisting in my academic and professional development. I am especially
indebted to Sandra— for the opportunity to work on the Metamorphosis Project,
which made this dissertation possible, and for her diligent and efficient reviews of
my work. I also wish to express my gratitude to my other dissertation committee
members, Tom Valente, for his analytical feedback and expertise in the public health
arena, and Doe Mayer, for her experience and insight in regard to health campaign
development. Also thanks go out to Sandra, Cody, Tom, Sheila Murphy, Lynn
Miller, and H, H, & S for the vast research and publication opportunities.
I’ d also like to recognize the role of the Metamorphosis Project, which
conducted the research used in this dissertation. Special thanks to Wan-Ying Lin for
her support and advice about how to survive the dissertation process and both Yong-
Chan Kim and Joo-Young Jung for being “on-call” dataset consultants.
And props to all the Ph.D. students in the cohorts ahead of me who served as
role models and those in my cohort and the one’ s behind me for their support and
iii
“cheerleading” along the way (especially LiYing, Matt, Namkee, and Anna for my
“defense support and celebration” and Arul, Matthew, Vikki, and Steve for insisting
on “progress reports”). Thanks to my many marvelous friends who offered me
mental breaks from dissertation writing this past year. I also want to acknowledge
my solid base of friends from my years living in the Midwest who have encouraged
me in my endeavors, despite my moving to the West Coast in order to do them.
Especially Grace, who not only helped get me through my M.A. thesis, but is the
only one of them who will probably read my entire dissertation.
Finally, I would not be here without the love, devotion, and encouragement
of my family. My love goes out to my parents, Harvey and Dominique Wilkin, who
have always encouraged me to aim high and provided me with the support needed to
do so; my sister Heather and her partner Janeen, who enforced my deadline, offered
a few Disney breaks, and encouraged me along the way; my sister Heidi, who
challenged me to always work harder as we were growing up; and my nephew
Harrison, for being such a cute distraction! And a special thanks to my mother who
has taken on the overwhelming task of helping me edit this dissertation (and my dad
for standing over her asking her if she’ s done it yet). And to my aunts, uncles, and
other relatives who have sent encouraging words along the way and have helped me
celebrate!
iv
TABLE OF CONTENTS
ACKNOWLEDGEMENTS ................................................................................. ii
LIST OF TABLES............................................................................................... vii
LIST OF FIGURES ............................................................................................ x
ABSTRACT ....................................................................................................... xi
CHAPTER 1: IT’ S NOT JUST THE MESSAGE: THE IMPORTANCE OF
STRATEGIC PLANNING TO BEST REACH INTENDED AUDIENCES
WITH HEALTH MESSAGES............................................................................ 1
Introduction........................................................................................................ 1
Overview of the Dissertation............................................................................... 3
Research Problem: Hispanic Health Disparities .................................................. 5
Research Problem: Lack of Theory-Driven Reach Strategy................................. 7
Low Reach/High Influence: Micro-Level Agents............................................. 10
Moderate Reach/Moderate Influence: Meso-Level Agents............................... 13
High Reach/Low Influence: Macro-Level Agents ............................................ 15
Communication Technology: Potential Multiple-Level Actors......................... 17
Ecological Approaches to Health Campaigns .................................................. 19
CHAPTER 2: GROUNDING CAMPAIGN STRATEGIES IN COMMUNICATION
INFRASTRUCTURE THEORY AND MEDIA SYSTEMS DEPENDENCY
THEORY .......................................................................................................... 21
Communication Infrastructure Theory ............................................................... 22
Importance of the Storytelling Network for Health Campaigns ........................ 26
Media Systems Dependency Theory .................................................................. 27
MSD Goals and Persuasive Message Strategies ................................................. 32
Understanding Goal and Health ....................................................................... 33
Behavior Change Models and the Understanding Goal................................. 34
Cognitive Persuasion Theories/Models and the Understanding Goal ............ 35
Orientation Goal and Health ............................................................................ 37
Behavior Change Models and the Orientation Goal...................................... 38
Cognitive Theories/Models and the Orientation Goal.................................... 39
Play Goal and Health....................................................................................... 42
Entertainment-Education and the Play Goal ................................................. 42
Health Goal ..................................................................................................... 46
v
CHAPTER 3: RESEARCH QUESTIONS & METHODS.................................. 48
Research Questions............................................................................................ 48
Telephone Survey Methods................................................................................ 50
Survey Samples ................................................................................................. 52
2001 Glendale Survey...................................................................................... 53
2002–2003: Pico Union and Southeast L.A. Surveys........................................ 54
Survey Measures ............................................................................................... 55
Communication Connection Patterns ............................................................... 55
MSD: Understanding Goal ........................................................................... 55
MSD: Orientation Goal................................................................................. 57
MSD: Play Goal ........................................................................................... 57
MSD: Health Goal........................................................................................ 58
MSD: Telephone ........................................................................................... 59
MSD: Internet............................................................................................... 60
Scope of Internet Connections for Health......................................................... 61
Health Access Measures .................................................................................. 62
Health Insurance .......................................................................................... 62
Difficulty Getting Medical Care.................................................................... 63
Regular Place for Health Care...................................................................... 63
Clinic Closures ............................................................................................. 63
CHAPTER 4: SURVEY RESULTS. PART I: COMMUNICATION
PROFILES ........................................................................................................ 65
RQ1: Communication Connections & Geo-ethnicity.......................................... 66
RQ1a: Understanding Goal.............................................................................. 66
RQ1b: Orientation Goal................................................................................... 69
RQ1c: Play Goal.............................................................................................. 71
RQ1d: Health Goal .......................................................................................... 73
RQ2: Telephone & Internet & Geo-ethnicity...................................................... 76
Internet MSD Connections............................................................................... 77
RQ3: Hispanic Communication Connection Patterns ......................................... 80
RQ3a: Health Goal Connection Patterns .......................................................... 80
RQ3b: Understanding Goal and Health Connection Patterns ............................ 82
RQ3c: Orientation Goal and Health Connection Patterns ................................. 85
RQ3d: Play Goal and Health Connection Patterns............................................ 87
RQ4: Health Communication Resources & Strength of Internet & Telephone
Connections....................................................................................................... 90
Internet MSD Connections within Health Goal Connections ............................ 98
vi
CHAPTER 5: RESULTS. PART II: HEALTH DISPARITIES AND
COMMUNICATION CONNECTIONS ........................................................... 105
Specific Communication Connections and Health Disparities ........................... 106
RQ5: No Regular Place for Health Care.......................................................... 107
RQ6: Difficulty Getting Medical Care ............................................................ 109
RQ7: Affected by Clinic Closures................................................................... 117
Communication Profiles and Health Disparities................................................ 125
RQ8: Communication Connection Combinations & Health Disparities ........... 125
CHAPTER 6: DISCUSSION AND IMPLICATIONS....................................... 131
Theoretical and Methodological Contribution ................................................... 131
Communication Infrastructure Theory and Health Campaign Reach Strategy . 132
Media Systems Dependency and Health Campaign Reach Strategy................. 134
Major findings and implications........................................................................ 139
Specify the Audience: Geo-ethnicity Makes a Difference................................ 139
Hispanics Immigrants Living in Diverse Areas............................................. 141
Newer Immigrant Hispanics Living in Ethnically Homogeneous Areas ........ 141
Combine Communication Formats.................................................................. 142
Spark Interpersonal Communication ............................................................... 143
Strategically Place Hotline and Web Address Information .............................. 145
Incorporate Communication Connections Related to Health Outcomes ........... 148
Regular Place for Health Care..................................................................... 148
Ease of Finding Medical Care..................................................................... 150
Affected by Local Clinic Closures ............................................................... 152
Limitations ....................................................................................................... 155
Intervention Implications .................................................................................. 157
Conclusion ....................................................................................................... 161
REFERENCES ................................................................................................. 162
vii
LIST OF TABLES
Table 2.1: Summary: How MSD goals and persuasion theories align................. 46
Table 3.1: Demographics of geo-ethnic sample .................................................. 53
Table 4.1: Top 4 connections for understanding goal by geo-ethnic study area... 67
Table 4.2: Top 4 connections for orientation goal by geo-ethnic study area........ 69
Table 4.3: Top 4 connections for play goal by geo-ethnic study area.................. 72
Table 4.4: Top 4 health information resources for each geo-ethnic study area .... 74
Table 4.5: Independent t-tests: Geo-ethnic telephone connection
intensity comparison.......................................................................................... 76
Table 4.6: Independent t-tests: Geo-ethnic Internet connections comparisons..... 77
Table 4.7: Frequencies and chi-squares: Geo-ethnic comparisons
of online health behavior.................................................................................... 79
Table 4.8: Top 4 communication channels combinations for
each health information resource........................................................................ 81
Table 4.9: Top 4 communication channels for understanding within
each health information resource........................................................................ 84
Table 4.10: Top 4 communication channels for orientation within
each health information resource........................................................................ 86
Table 4.11: Top 4 communication channels for play within each
health information resource................................................................................ 89
Table 4.12: Independent t-tests: Connections to family or friends
for health and telephone connection intensity comparison.................................. 90
Table 4.13: Independent t-tests: Connections to health professionals
for health and telephone connection intensity comparison.................................. 91
Table 4.14: Independent t-tests: Connections to Internet for health
and telephone connection intensity comparison.................................................. 92
viii
Table 4.15: Independent t-tests: Connections to mainstream TV for
health and telephone connection intensity comparison ....................................... 93
Table 4.16: Independent t-tests: Connections to geo-ethnic TV for
health and telephone connection intensity comparison ....................................... 93
Table 4.17: Independent t-tests: Connections to geo-ethnic radio for
health and telephone connection intensity comparison ....................................... 95
Table 4.18: Independent t-tests: Connections to geo-ethnic newspapers
for health and telephone connection intensity comparison.................................. 96
Table 4.19: Independent t-tests: Connections to books or magazines
for health and telephone connection intensity comparison.................................. 97
Table 4.20: Independent t-tests: Connections to “other print”
for health and telephone connection intensity comparison.................................. 97
Table 4.21: Independent t-tests: Connections to family or friends
for health and Internet connection comparison................................................... 99
Table 4.22: Independent t-tests: Connections to health professionals
for health and Internet connection comparison................................................... 99
Table 4.23: Independent t-tests: Connections to Internet for health
and Internet connection comparison.................................................................. 100
Table 4.24: Independent t-tests: Connections to mainstream TV for
health and Internet connection comparison........................................................ 102
Table 4.25: Independent t-tests: Connections to geo-ethnic TV for
health and Internet connection intensity comparison ......................................... 103
Table 4.26: Independent t-tests: Connections to books or magazines
for health and Internet connection comparison.................................................. 104
Table 5.1: Health outcome measures for the geo-ethnic and total sample .......... 106
Table 5.2: Multiple regression analysis for understanding goal connections
predicting to difficulty getting medical care ...................................................... 110
Table 5.3: Multiple regression analysis for orientation goal connections
predicting to difficulty getting medical care ...................................................... 112
ix
Table 5.4: Multiple regression analysis for play goal connections
predicting to difficulty getting medical care ...................................................... 113
Table 5.5: Multiple regression analysis for health goal connections
predicting to difficulty getting medical care ...................................................... 114
Table 5.6: Multiple regression analysis for general communication
connections predicting to difficulty getting medical care................................... 116
Table 5.7: Multiple regression analysis for understanding goal connections
predicting to affected by clinic closures ............................................................ 118
Table 5.8: Multiple regression analysis for orientation goal connections
predicting to difficulty affected by clinic closures ............................................. 119
Table 5.9: Multiple regression analysis for play goal connections predicting
to affected by clinic closures............................................................................. 121
Table 5.10: Multiple regression analysis for health goal connections
predicting to affected by clinic closures ............................................................ 122
Table 5.11: Multiple regression analysis for general communication
connections predicting to affected by clinic closures......................................... 123
Table 5.12: Summary of communication connection and health
outcome results.................................................................................................. 126
Table 6.1: Top 2 connections for each goal by geo-ethnicity............................. 138
x
LIST OF FIGURES
Figure 2.1. Health storytelling network model ................................................... 24
Figure 6.1. Neighborhood storytelling network................................................. 158
Figure 6.2. Becoming part of the neighborhood storytelling network ................ 159
xi
ABSTRACT
Health communication campaign theory and research has concentrated on
how to best design messages and use various media technologies to persuade an
audience. However, even the best-designed campaigns are ineffective if they fail to
reach the intended audience. The primary aim of this dissertation is to develop a
theoretically grounded communication reach strategy; in so doing, the present
research represents an original expansion of communication infrastructure theory
(Ball-Rokeach, Kim, & Matei, 2001) and media system dependency theory (Ball-
Rokeach, 1985; Ball-Rokeach & DeFleur, 1976) for this purpose.
The author argues that for more effective reach, intended audiences should be
narrowed to a specific geo-ethnic community— i.e., an ethnic group living in a
geographic area. Communication connection patterns (i.e., the most important
communication resources deployed for goal achievement) of Hispanic survey
respondents in three L.A. communities, and of Anglos and Armenians living in one
of those study areas, illustrate that geo-ethnicity makes a difference. Hispanics living
in an ethnically diverse area have unique communication connection patterns that
distinguish them from Hispanics living in other less diverse L.A. communities and
from other ethnic groups living in the same geographic location. Findings also
indicate the importance of interpersonal communication in goal attainment for all
geo-ethnic groups.
The author also suggests that communication campaigns that have relied
primarily upon mainstream media to reach these target populations most probably
xii
failed to reach them, thereby contributing to health disparities. Empirically, this was
investigated by exploring whether communication connections were associated with
Hispanic health access issues; specifically, having no regular place for health care,
having difficulty finding medical care, and being affected by local health clinic
closures. In general, findings indicate that connections to mainstream media
(television and newspapers) and the Internet were associated with fewer health
access problems, while connections to geo-ethnic media— those that target a specific
geographic location and/or ethnicity— were associated with more health access
problems. An intervention, increasing health storytelling through geo-ethnic media
designed for Hispanics who have health access problems, is suggested and an
increased effort by health communication campaign specialists to utilize these media
in their outreach is advised.
1
CHAPTER 1
It’ s Not Just the Message: The Importance of Strategic Planning
To Best Reach Intended Audiences with Health Messages
Introduction
“5-A-Day for Better Health”— a health promotion program started in 1991 as
a combined effort of the National Cancer Institute (NCI), the Produce for Better
Health Foundation, the American Cancer Society, the Centers for Disease Control
and Prevention (CDC), the United States Department of Agriculture, United Fresh
Fruit and Vegetable Association, Produce Marketing Association, and the National
Alliance for Nutrition and Activity— is currently one of the nation’ s largest nutrition
education campaigns. The program boasts encouraging results, e.g., a “nearly
fivefold— from eight to 36%” increase of Americans who know they should eat five
or more servings of fruits and vegetables a day since the program began in 1991
(http://www.5aday.gov/index-about.shtml). Yet when I make comments to friends
and family about getting their “5-A-Day,” I often still get blank stares— what is “5-
A-Day”? With all the success of the program, there are still segments of the
population that have not been exposed to (or at least do not recall) the “5-A-Day”
campaign. This problem is not unique to the “5-A-Day” campaign; many health
promotion efforts fail to reach large portions of the intended audience.
2
The failure of appropriate health messages to reach and persuade segments of
the population that are at high risk for health problems intensifies health disparities.
Health disparities occur when segments of the population are disproportionately
affected by health problems. For example, low socioeconomic status (SES) African
American and Hispanic women are at disproportionate risk for life-threatening
ailments such as cancer (Baezconde-Garbanati, Portillo, & Garbanati, 1999; Marcus,
1999; NCI, 2002). Baezconde-Garbanati et al. (1999) discovered that the number of
poor Hispanic women in their middle years (45–64) who display higher cardiac risk,
higher rates of diabetes, and cervical cancer is increasing. These numbers will only
grow if health campaigns fail to increase awareness about the diseases and how to
prevent them within the Hispanic community.
The percentage of Americans afflicted by health disparities is bound to grow
exponentially with Hispanic immigration. The number of Hispanic immigrants to the
United States has grown considerably over the past three decades (Harket, 2001;
Singh & Siahpush, 2002). Almost half of the U.S. Hispanic population (47%)
communicates primarily in Spanish; only four percent of first generation Hispanic
immigrants converse mostly in English, while 72% speak predominantly Spanish
(Brodie, Steffenson, Valdez, Levin, & Suro, 2002). Hispanics now account for
approximately 45% of the population in Los Angeles County (Census, 2000).
Approximately 32% of Los Angeles County households report speaking Spanish in
the home; 30% of these are considered linguistically isolated, meaning that all
members of the household over the age of 14 have difficulty speaking English
3
(Census, 2000). The combination of linguistic isolation and the Spanish-language
preference in the home suggests that many Hispanics in the Los Angeles area are not
exposed to the more traditional health campaigns that run through the mainstream
English-language media.
Overview of the Dissertation
This dissertation is the first to explicate a unique theory-based research
strategy that can be applied to better reach any population. How the strategy can be
used is illustrated by applying it to new immigrant Hispanic communities in Los
Angeles. First, the communication connections of three Hispanic study areas are
compared and contrasted to each other and to Anglos and Armenians living in one of
the Hispanic study areas. Then, individual communication connection profiles are
created and analyses performed to determine the best reach strategy for the portion of
the sample at highest risk for health disparities.
There are six chapters in this dissertation. In Chapter One (this chapter), the
two major problems that guide this research are discussed in more detail: 1)
Hispanics are at high-risk for certain health problems, but traditional health
campaigns often fail to reach them; and 2) There is currently no comprehensive
theoretically-grounded research strategy determining how to best reach audiences
guiding health campaign strategy.
Chapter Two presents a theoretical framework for maximizing the
effectiveness of health communication campaigns. Communication infrastructure
theory (CIT) and media system dependency theory (MSD) are discussed in the
4
development of a research strategy to better reach intended audiences. MSD goals
are then discussed with regard to complimentary persuasive theories, goals, and
strategies.
Chapter Three introduces the research questions and methodology used to
explore them. Sampling, survey data collection methods, and the items used in
measuring key variables are discussed.
Chapter Four presents the results for the first groups of research questions
pertaining to geo-ethnic differences in communication connections and individual
communication connection patterns. Frequencies are used to identify the top four
most important resource connections identified by study areas for each MSD goal
and by individual communication resource connections. Independent t-tests were
also utilized.
Chapter Five presents the results for the second part of the data analyses and
the research questions pertaining to how media connection patterns relate to health
disparities. Independent t-tests and logistic and multiple regression analysis
techniques are employed in the analyses.
Chapter Six draws conclusions from the theoretical and empirical
investigations of the health communication campaign research design strategy
developed in this dissertation. This chapter contains a general discussion of the
research findings in terms of policy implications.
5
Research Problem: Hispanic Health Disparities
Hispanics are at high risk for diabetes, obesity, and certain types of cancer
(e.g., breast, cervical, and prostate). In 2000, about two million, or 10.2% of the
United States Hispanic population had been diagnosed with diabetes. Hispanics are
about 1.9 times as likely as non-Hispanic Americans of a similar age to have diabetes
(National Diabetes Information Clearinghouse, 2002). According to the CDC,
obesity is rising in the Hispanic community as well, with 22–23% of Mexican-
American children and 38% of Mexican-American women being classified as
overweight (CDC, 2004). In the state of California, Hispanic women have the second
highest obesity rate of any ethnic group, with 28.8% being identified as obese
1
(Brett
& Hayes, 2004). This is exacerbated by the fact that Hispanic women are the least
likely of any ethnic group in California to have any sort of leisure-time physical
activity (Brett & Hayes, 2004).
Latina
2
women across the U.S. have the highest incidence rate of and second
highest death rate from cervical cancer (NCI, 2003). They are less likely to have the
regular gynecological visits and pap smears necessary for early detection of cervical
cancer. Latina’ s in the United States also fail to receive adequate breast cancer
screening (Oetzel, 2002). Along with the alarmingly low cancer screening rates
amongst this population, Latina’ s also fail to get proper health maintenance care. In
the state of California, Hispanic women have the second lowest rate of adequate
1
Asian/Pacific Islanders have the lowest rates with only 5% of women in the state being considered
obese.
2
Latino and Latina are used for describing the population in the U.S., which is more diverse generally
in country of origin than the Hispanic population in the Los Angeles communities.
6
prenatal care
3
(Brett & Hayes, 2004), contributing to the rise in low birth weight
related problems in this population.
Many health problems are aggravated in this population by the lack of health
care access. According to Brett and Hayes (2004), Hispanic women have the lowest
rate of health insurance in California (67% of women aged 18–64 have insurance as
compared to approximately 91% of both Asian and White non-Hispanic women).
Hispanic children are least likely of all ethnic groups in Los Angeles to have health
insurance (United Way, L.A., 2000). And despite being at risk for certain health
problems, Hispanic immigrants in Los Angeles have far less contact with medical
resources than Hispanics in other U.S. cities. Berk, Schur, Chavez, and Frankel
(2000) found that in 1996–1997 undocumented Latinos (non-citizen immigrants who
are lawful permanent residents) over the age of 15 in Los Angeles were hospitalized
at lower rates (6.8%) than those in El Paso (11.4%), Houston (12.8%), Fresno (12%),
and across the entire United States (8.5%) and also see a physician less often (27.2%
in L.A., as compared to 36.4% in El Paso, 35% in Houston, 49.9% in Fresno, and
65.8% nationwide).
A study of patients in five L.A. clinics revealed that 24% of the 215 who
provided information were illegal immigrants. Forty-four percent of the illegal and
27% of the legal immigrants had no other access to health care (Asch, Rulnick,
Todoroff, & Richwald, 1996). Yet over the past few years, L.A. County has been
forced to close several clinics due to budget constraints. About 50% of the residents
3
American Indians have the lowest rates. White (non-Hispanic), Asian/Pacific Islander, and Black
(non-Hispanic) were the other three racial/ethnic categories compared in the analysis.
7
with children aged 0 to 5 in four Hispanic communities in L.A. said that they were
greatly affected by these clinic closures (Cheong, Wilkin, & Ball-Rokeach, 2003;
2004). Since Hispanics in L.A. are less likely to have adequate access to health care
services, it is especially important for health communicators to find effective ways to
reach this population.
Research Problem: Lack of Theory-Driven Reach Strategy
Most health communication campaign research and literature has
concentrated on the persuasion theories that drive message design and on the
methods for evaluating the effectiveness of specific campaigns. In fact, there are
entire books written about how to design health messages (e.g., Maibach & Parrott,
1995), but none about how to ascertain which communication channels best reach
target audiences
4
. There are numerous persuasion theories about how to produce
health behavior change. For example, the health belief model (Becker, 1974), the
theory of reasoned action (Fishbein & Ajzen, 1975), social learning theory (Bandura,
1977), the elaboration likelihood model (Petty & Caccioppo, 1986), the
persuasion/communication matrix/hierarchy of effects (McGuire, 1990), stages of
change (DiClemente & Prochaska, 1985; Prochaska, DiClemente, & Norcross,
1992), diffusion of innovations (Rogers, 1995) are discussed in most campaign
design textbooks.
4
There is a book called Reaching Audiences (Yopp & McAdams, 1998), but it focuses on tailoring
media writing to different audiences; and a chapter in Maibach and Parrott’ s (1995) book entitled
“Reaching Young Audiences” concentrates on message design and only briefly mentions media
connections needed to reach different age groups.
8
The channel designs necessary to best reach the target audience, on the other
hand, are given short shrift. In discussions of campaign design, the topic is usually
briefly mentioned as a part of the formative research stage. For example, Atkin and
Friemuth (1989) dedicate about one page out of 20 in a chapter about formative
evaluation to “ascertaining channel use” (p. 133). The general approach taken is to
determine which media the target audience use— often through the use of media
ratings— and then determine a media strategy that would best fit the budget. Often
television and/or radio public service announcements (PSAs) are used; but while this
saves money, campaign specialists have no control over when or how often a PSA
actually runs. There is no guarantee that PSAs will air when the target audience is
tuned in. Researchers have started to question the effectiveness of health campaigns
conducted through traditional mainstream media channels for specific audiences; for
example, African Americans (McLaurin, 1995) and Hispanics (Cheong et al., 2003;
2004).
In recent years discussion about the usefulness of different communication
channels to reach target groups has increased. Paisley (2000) identifies new
communication technology— specifically Internet, personal computers, cable and
satellite television— as the “most dramatic developments” for public communication
campaigns (p.7). Excitement about using new media to reach audiences has resulted
in numerous applications of these technologies in health communication
interventions (e.g., Buller, Woodall, Hall, Borland, Ax, Brown, & Hines, 2000;
Rogers, 2003).
9
Investigations have identified the benefits and limitations of the Internet as a
medium for health information dissemination (Keller & Brown, 2002), social support
(White & Dorman, 2001), and health campaigns and interventions (Bernhardt,
Dalton, Sargent, & Stevens, 2000; Bull, McFarlan, & King, 2001; Buller et al., 2000;
Moreno, Mayer, Spires, & Lester, 2001; Rogers, 2004). While new technologies hold
a lot of promise for the future of health communication campaigns, questions about
how best to reach intended audiences remain. For example, Rogers (2004) reports on
the potential for the Internet to reach “hard-to-reach” Hispanics in the Southwest
United States. He claims that the Internet is cheaper and has the ability to reach a
much larger audience with a fotonovela campaign than paper versions of the
fotonovela. This argument assumes that adapting the technological medium for a
given audience means it will be effective. In reality, those that may be most at risk
for some diseases (e.g., low income, homeless and runaway youth, Hispanics, etc.)
may have no Internet access (Cheong & Wilkin, 2003; in press; Cheong et al., 2003;
2004; Keller & Brown, 2002). For those who have access, Internet connectedness—
the “scope and centrality of Internet incorporation into the everyday lives of diverse
social groups”— varies across social groups (Jung, Qiu, & Kim, 2001, p. 507). In
other words, Internet access and use amongst the target population does not imply
health information seeking via the Internet. Therefore there is no guarantee that
campaigns using this technology will reach their target audience.
The major problem facing health communication strategists is that there is no
specific theory guiding campaign message channel strategies. Campaign failure can
10
be due to choosing the wrong behavioral objective, designing a poor message, or
failing to have adequate exposure to the campaign (Hornik & Yanovistzky, 2003). In
other words, even the best-designed messages will be ineffective if they fail to reach
the target audience.
Valente (2002) suggests that there is a tradeoff between reach and persuasive
influence, such that programs with the greatest impact on an audience (e.g., provider
training) tend to reach a lower percentage of the intended audience and programs that
reach a higher percentage of the audience (e.g., entertainment-education) tend to
have a more limited impact on the audience. For present purposes, this conceptual
continuum between low reach-high influence and high reach-low influence is
artificially broken down into three segments: low reach-high influence programs that
involve more micro-level/interpersonal influence tactics; high reach-low influence
programs that tend to be run through macro-level/mass mediated agents; and finally,
moderate reach-moderate influence programs that tend to involve more meso-
level/community actors.
Low Reach/High Influence: Micro-Level Agents
Micro-level health communication agents are individuals within interpersonal
networks— family, friends, neighbors, work colleagues, other parents in children’ s
school activities, religious leaders, members of social groups, and the like— who
have connections to specific change agents like health practitioners and opinion
leaders. Individuals are most influenced by interpersonal communication (Griffin &
Dunwoody, 2000; Valente & Saba, 1998; 2001), but health programs using micro-
11
level agents are more costly and do not directly reach a high percentage of the
intended audience.
Micro-level approaches to health promotion generally involve activating
change agents that might influence the target audience. Change agents are people
who are often in socially established roles, who come in contact with members of a
community and who provide specialized information that may not be available
through other sources, although useful to potential adopters (Griffin & Dunwoody,
2000). Interpersonal networks and change agents are highly influential in the
behavior change process. The most salient change agents in terms of health
behaviors include physicians, nurses, health department workers, and other health
professionals (Griffin & Dunwoody, 2000). For example, nurses were used to review
risk factors for disability, develop a health promotion campaign, and to introduce
exercise plans in private sessions with seniors to improve their quality of life
(Wallace, Buchner, Grothaus, Leveille, Tyll, LaCroix, & Wagner, 1998).
However, the influence of health professionals is limited due to the fact that
some high-risk groups are less likely to see health professionals on a regular basis
and/or have a mistrust of people in this profession. For example, low-income and
uninsured individuals may see health professionals on a less frequent basis and both
African Americans and Hispanics are less trusting of health professionals. This
mistrust is due to historical injustices such as African Americans being used as
uninformed medical experimental subjects in the Tuskegee experiments as well as by
other medical research institutions and, more recently, “free” medical services being
12
used by the United States Citizenship and Immigration Services (USCIS, formerly
known as the INS) as a way to round up predominantly Hispanic illegal immigrants.
Family members have also been identified as key micro-level agents in health
campaigns. For example, formative research indicated that a campaign designed to
change alcohol abuse in Hispanic communities had to target the entire family, not
just the individual (Lalonde, Rabinowitz, Shefsky, & Washienko, 1997). In a
different study, Austin, Pinkleton, and Fujioka, (2000) found that parent
reinforcement of messages that are contrary to the media portrayal of alcohol (i.e.,
parents portray alcohol use in a negative fashion) moderates the effect of alcohol
consumption stereotypes portrayed in entertainment media. And talking with parents
was shown to moderate teen’ s condom efficacy beliefs after seeing an episode of
Friends where a lead character told her ex-boyfriend that she is pregnant, despite
having used a condom when they had sex (Collins, Elliot, Berry, Kanouse, & Hunter,
2003).
Finally, social networks also play an important role in influencing health
behaviors. For example, Alexander, Piazza, Mekos, and Valente, (2001) found that
cigarette smoking amongst adolescents is influenced by the number of smokers in
one’ s peer network and the amount of smoking by the “popular crowd.” Grassroots
volunteers have been used to instigate education within their social networks in order
to increase Pap smear screening for cervical cancer amongst women (Ramirez,
Villarreal, McAllister, Gallion, Suarez, & Gomez, 1999). And charlas (i.e., group
13
discussions) were suggested as an interpersonal communication strategy for reaching
Hispanics (Alcalay, Alvardo, Balcazar, Newman, & Huerta, 1999).
Moderate Reach/Moderate Influence: Meso-Level Agents
Community-level campaigns have the ability to reach more people than a
campaign run just through interpersonal channels, with a moderate amount of
influence on the audience. These programs involve meso-level agents such as
organizations, schools, libraries, churches, work places, community health
organizations and clinics, etc. Community-based campaigns also include local media
such as fliers, bulletins, community newspapers, and ethnically targeted radio
stations.
Meso-level health campaigns have incorporated the mobilization of
community organizations (Guttman, 2000) and the formation of health coalitions
(Brownson, Baker, & Novick, 1999). Partnerships and coalitions can help sustain a
campaign past the official funding period (Rudd, Goldberg, & Dietz, 1999) when
mediated campaign messages no longer exist. Organizations can continue sharing
campaign messages with the intended public by word-of-mouth, distributing leftover
campaign materials, and/or their own outreach efforts.
A more common meso-level approach to health communication is to
influence youth through school systems. Educational programs have been employed
to promote healthy behaviors and discourage unhealthy behaviors in target
populations. School-based programs have been designed to do everything from
combating eating disorders (e.g., Neumark-Sztainer, Butler, & Palti, 1995; Paxton,
14
1993; Posavac, Posavac, & Posavac, 1998), increasing condom use and HIV/AIDS
prevention (e.g., Guttmacher, Lieberman, Ward, Freudenberg, Radosh, & Des Jalais,
1997), and discouraging smoking (e.g., Botvin, Dusenbury, Baker, James-Ortiz,
Botvin, & Kerner, 1992) to promoting milk consumption (Wechsler, Basch, Zybert,
& Shea, 1998) amongst school-aged participants. One limitation of school-based
programs is that the behavior learned in school is not always reinforced or supported
outside of the school (Lalonde et al., 1997). Churches have also been used to reach
hard-to-reach audiences; for example, a nutrition campaign aimed to reach African
Americans through churches (Resnicow, Jackson, Wang, De, McCarty, Dudley, &
Baranowski, 2001).
Along with organizations such as churches and schools, the local or “geo-
ethnic” (i.e., designed for a specific ethnicity living in a specific area) media can also
be extremely important meso-level agents. Local media include a range of
newspapers, magazines, newsletters, radio stations, cable television channels, and the
like that are targeted toward a specific ethnic group or geographic area. One benefit
of using these media over more mainstream channels is the ability to tailor the
persuasive messages to a more specific population. For example, health articles in a
local newspaper can identify the local resources available to aid in preventing,
detecting, or treating health problems
5
. Mainstream channels discuss health issues
and medical resources more broadly, thereby requiring the audience to investigate
local resources on their own if health behavior changes are to occur.
5
According to the Health Belief Model, “cues to action” are important to increase the likelihood of
behavior change.
15
Local radio stations have proved to be important for community-based
campaigns. Radio news storytelling was used to reduce aggressive driving by
reframing the way that traffic stories were told to make them more injury-sensitive in
Los Angeles (Ball-Rokeach, Hale, Schaffer, Porras, Harris, & Drayton, 1999). And a
local radio station was key to helping distribute and encourage other local media
sources to air radio and television novellas designed to reduce alcohol abuse in the
Hispanic community (Lalonde et al., 1997).
Campaigns also sometimes use less traditional community-level media, such
as movie theater slides, pamphlets, billboards, bumper stickers, posters, and
matchbooks (Atkin & Friemuth, 1989); videos, cookbooks, printed education
materials such as a quarterly newsletter, and promotional items (e.g., magnets, pens,
etc.) (Resnicow et al., 2001); recipe books, brochures, and training manuals (Alcalay
et al., 1999); dramatic performances (Valente & Bharath, 1999); participatory theater
(Singhal, 2004); folk media (Panford, Nyaney, Amoah, & Aidoo, 2001); and
cartoons and comic books (McKee, Aghi, & Shahzadi, 2004). Finally, anti-smoking
campaigns could learn from the tobacco industry’ s community-based approach as
research indicates that the tobacco industry has used billboards to target minority
communities in Los Angeles County (Stoddard, Johnson, Sussman, Dent, & Boley-
Cruz, 1998).
High Reach/Low Influence: Macro-Level Agents
Macro-level agents are those that reach or influence a large and
heterogeneous audience. Health storytellers on this level include government health
16
programs and organizations, HMO’ s, the surgeon general, cultural and societal
institutions, food/drug manufacturers, advertising companies, and celebrities. Media
channels include the mainstream media— e.g., national television news,
entertainment programs, newspapers, and radio. One of the ways that a group is
“hard-to-reach” is when it is not connected to the mainstream media, of course many
groups connect to these media at high rates. For example, the top two media
connections that upper middle class Whites on the West Side of Los Angeles rely on
for community information are mainstream television and mainstream newspapers,
suggesting that mainstream channels are the key storytelling agents for this
community (Ball-Rokeach, Cheong, Wilkin, & Matsaganis, 2004). In contrast, a
middle class Chinese-origin community identified community/ethnically oriented
newspaper and television as the media that they have strongest connections to for
information seeking, which makes meso-level channels more appropriate for health
campaigns trying to reach this particular group (Ball-Rokeach et al., 2004).
Macro-level actors tend to use macro-level media sources such as PSAs,
paid-advertisement slots, and press releases to the news national services (e.g., the
associated press). Media advocacy is a strategy used to shape health storytelling in
the mainstream media. It involves attempting to create news about health research,
build on related news stories, and reframe the health issues in order to get health
storytelling included in the mainstream media (Brown & Walsh-Childers, 1994;
Wallack, Woodruff, Dorman, & Diaz, 1999). Media presentations that include
unhealthy behaviors, incorrect medical information, and antisocial attitudes are a
17
concern for health advocates (Rice & Atkin, 1994). Advocates also try to encourage
accurate health storytelling through the entertainment media (Beck, 2004;
Greenberg, Salmon, Patel, Beck, & Cole, 2004).
Communication Technology: Potential Multiple-Level Actors
Some media technology— specifically the telephone and the Internet— can be
used to influence people on more than one level. Flannigan and Metzger (2001)
identify the telephone as a mediated interpersonal technology, while the Internet can
be either interpersonal or mass mediated. However, I would argue that in the case of
telephone hotlines, the technology also offers information retrieval and information-
giving features similar to the Internet and mass mediated technologies.
Telephones are most widely used for interpersonal communication. But large
health organizations, which usually operate on the macro-level, often provide
telephone information services as another means of health information distribution.
This medium provides a way to dispense information to a mass-audience, but in a
more interpersonal fashion (e.g., when an actual operator speaks to the caller). An
evaluation of the cancer information service (CIS) showed that about 56% of callers
said that calling the hotline elicited a positive action and 22% said the call had
“reassured them” of decisions previously made (Thomsen & Maat, 1998). Meso-
level actors may also incorporate telephone hotlines into health promotion activities.
For instance, First 5 LA Connect has operators who answer questions by L.A.
County parents about everything from breast-feeding to how to get their child
insured and how to find a medical or dental provider in their area. Other forms of
18
media are generally needed to raise awareness of the hotline numbers. Hotline
numbers are commonly provided in PSA’ s, on brochures, billboards, posters, and
even on public transportation. Health-related entertainment storylines that air
coinciding PSA’ s announcing hotlines to call for addition information tend to cause
spikes in the number of callers to these hotlines (Beck, 2004; Kennedy, O'Leary,
Beck, Pollard, & Simpson, 2004) and celebrity announcements of health problems
have increased calls to relevant hotline services (Brown & Fraser, 2004).
New media technology such as interactive media and the Internet are being
used increasingly in health promotion. Flannigan and Metzger (2001) suggest that
the Internet can act as an interpersonal channel— through the use of electronic mail,
instant messaging, and chat rooms— or as a mass mediated channel used for
information retrieval and information-giving. This suggests the potential for the
Internet to be a micro-level or a macro-level health storyteller. The Internet can act
as a meso-level storyteller, for example, in old immigrant areas (Matei & Ball-
Rokeach, 2003) where community media are online and community forums available
for discussions. The fact that this technology can act on different levels of influence
makes it important for health communicators to identify not only if the target
audience is connected to the medium, but also to determine the nature of their
connections. For example, children and adolescents who have grown up
incorporating the technology in their daily lives may be effectively reached through
the use of interactive technology (Lieberman, 2000), but interactive technology may
not be as useful for someone who just uses the Internet to check email.
19
Ecological Approaches to Health Campaigns
Baker and Brownson (1999) indicate that the best approach to a community-
based health promotion program is to employ an ecological framework that
incorporates multi-levels— the individual, interpersonal, community (including
social and economic factors), organizational, and governmental levels. In addition to
these levels, Guttman (2000) also identifies the family, marketplace, societal-
institutional, and cultural-normative levels that may be incorporated into health
promotion goals. The assumption of an ecological framework is that the different
factors and levels are interrelated and that programs that address one level are likely
to enhance outcomes at other levels (Baker & Brownson, 1999). In other words, the
ability to change an individual’ s behavior depends on how they are being impacted
by influences that operate at higher levels (e.g., interpersonal or economic).
Failures in health promotion and health communication can be attributed to
lack of attention to communication networks and the cultural and the environmental
contexts of the community (Johnson, 2001). The following chapter explains how the
communication infrastructure theory (CIT) can improve health communication
success. CIT is rooted in media systems dependency theory (MSD), which is also
substantially elaborated upon for the purposes of developing a health communication
research strategy design. The basic research strategy is designed to take advantage of
communication ecologies— the web of interpersonal and media (new and
old/mainstream and geo-ethnic) connections that people construct in the course of
everyday life— to reach intended audiences with health messages. So, in addition to
20
being ecological by virtue of levels, the strategy is also ecological by virtue of
examining each communication connection in context of all other communication
connections. Several researchers have stressed the value added of examining media
in context so as to be able to assess their relative importance (Altheide, 1997; Atkin,
Bradley, & Thomas, 1991; Dorr & Kunkel, 1990; Engelberg, Flora, & Nass, 1995;
Hermand, Mullet, & Rompteaux, 1999; Perse, Ferguson, & McLeod, 1994; Sacco,
1995; Snyder & Rouse, 1995; Trumbo, 1998).
21
CHAPTER 2
Grounding Campaign Strategies in Communication Infrastructure
Theory and Media Systems Dependency Theory
The ideal “reach” strategy is ecological in nature, incorporating elements of
campaigns that get high reach (e.g., macro-level campaigns) with those that have the
highest influence (e.g., micro-level campaigns). The communication infrastructure
theory (CIT) offers a theoretical grounding for how to best reach an audience with
health messages through the interaction of mass media and interpersonal channels.
This is the first application of the theory toward the construction of a health
communication research design strategy. CIT considers the “interplay between
interpersonal and mediated storytelling systems and their contexts” (Ball-Rokeach,
Kim, & Matei, 2001, p. 396). Based upon Ball-Rokeach’ s media systems
dependency theory (MSD), the communication infrastructure theory offers a new
way to conceptualize campaign reach strategies and optimize the likelihood of
producing behavior change through interpersonal networks. In this chapter, I will
first explain how the communication infrastructure theory (CIT) advances health
campaign reach strategies. Then, I will return to the original MSD theory to discuss
how key concepts of MSD can help guide more effective campaign reach strategies
by aligning persuasive message strategies with individual goal dependency
relationships.
22
Communication Infrastructure Theory
Communication infrastructure theory developed out of research conducted by
the Metamorphosis project
6
. The communication infrastructure is the basic
communication system relied upon by a community for the information needed in
residents’ everyday lives. It consists of two elements: 1) the storytelling system and
2) the communication action context (Ball-Rokeach et al., 2001). The storytelling
system is comprised of macro-, meso-, and micro-level actors. Past research has
shown that the neighborhood storytelling network— a triangulated multi-level
network of residents (micro), community organizations (meso), and geo-ethnic
media (meso) who act as storytellers and stimulate each other to talk about the
neighborhood— has an impact on civic engagement (Ball-Rokeach et al., 2001; Kim,
2003; Kim & Jung, 2002; 2003). In order for a community to thrive, it must have a
strong network of such storytellers utilizing mediated and interpersonal types of
communication to build a discursive community for the identification and resolution
of issues of concern to the residents. The stronger the neighborhood storytelling
network, the more likely residents will feel and act like they belong to a community,
participate in civic activities, and have collective efficacy (i.e., feel like they can
come together to solve neighborhood problems) (Ball-Rokeach et al., 2001; Kim,
2003; Kim & Jung, 2002; 2003). Neighborhood participation has been linked to
health behaviors. For example, Merlo, Lynch, Yang, Linström, Ö stergren, Ramusen,
6
Metamorphosis is an ongoing research project conducted as part of the Communication Technology
and Community Program at the Annenberg School for Communication. The communication
infrastructure approach was developed based upon the project’ s research of geo-ethnic communities
in Los Angeles.
23
& Råstom (2003) found the use of hormone replacement therapy was significantly
lower in areas that had low levels of social participation compared to areas high in
social participation.
The neighborhood storytelling network is just a part of the larger storytelling
system within the communication infrastructure. The multilevel storytelling system is
comprised of macro-, meso-, and micro-level agents who are central in storytelling
production and dissemination. According to Ball-Rokeach et al., (2001), macro-level
agents include all media, political, religious, and other large institutions and
organizations that have the capacity to tell stories about the whole city, the nation,
and the world for large audiences (e.g., city, county, region). Meso-level agents are
smaller, more community-based media and organizations that focus on a particular
area or group of people within the storytelling system (Ball-Rokeach et al., 2001).
Finally, micro-level agents are the interpersonal networks that perpetuate the stories
in the network (Ball-Rokeach et al., 2001). This larger storytelling system
incorporates the specific neighborhood storytellers, and also the multitude of micro-,
meso-, and macro-level agents that are used in health campaigns (as identified in the
previous chapter). Therefore, the potential health storytelling network (see Figure
2.1) is much broader in scope and potential storytelling agents than the neighborhood
storytelling network.
24
Figure 2.1. Health storytelling network model
* These items include campaign materials such as cookbooks, ribbons, pens, bracelets, magnets, bags,
etc. that are meant to raise awareness/ spark interpersonal communication/ show support for a cause/
remind people of campaign messages
The communication action context is all of the elements in a community that
enable or constrain neighborhood storytelling. For examples, street safety,
transportation, condition of local grocery stores, law enforcement, availability of
child and health care services in the areas, and the like. Used here, the
communication action context varies from open, or a context that encourages
communication amongst people, to closed, or a context that discourages
communication (Ball-Rokeach et al., 2001). All contexts have elements of both
openness and closedness and are most often dictated by physical, psychological,
sociological, economic, and technological features (Ball-Rokeach et al., 2001).
Individuals in Personal
and Social Networks
Media
• New & Old Technology
• Geo-ethnic & Mainstream
• PSA’ s & Advertisements
• Promotional items*
Non-Profit/ Community
Building Organizations
• Health focused
• Community focused
Health Professionals &
Health Campaign
Specialists
25
Physical features include elements of how an area is designed to incorporate places
for people to gather and communicate or discourage this behavior (Ball-Rokeach et
al., 2001). In the case of health, physical features would include access to health,
fitness and wellness facilities, family clinics, doctor’ s offices, pharmacies, health
food stores, and the like as well as community centers and any other area where
groups can gather to discuss health issues with others.
Psychological features include the conditions that enable people to feel free
to engage in conversations with those around them (Ball-Rokeach et al., 2001). In
the case of community storytelling these factors include feelings of fear or comfort
(Matei, Ball-Rokeach, & Qiu, 2001). For health, this could also include perceptions
of how open others are to talking about the topic. For example, admitting a family
member has an alcohol problem is so taboo in Hispanic communities that people
would not participate in focus groups or call into a radio talk show program about it
(Lalonde et al., 1997). Economic features include having the time and resources
available to engage in communication with others (Ball-Rokeach et al., 2001). In the
case of health care this could involve what type of health service one is able to afford
(i.e., free clinic versus a specialist in an area) and whether one can afford to take the
time off work to go visit a health professional during the hours one is available.
Finally, technological features include access to transportation systems as well as
Internet connections (Ball-Rokeach et al., 2001). While it is important to recognize
that the indigenous storytelling network of communities is influenced by the
26
communication action context, the proposed reach strategy is grounded within in the
indigenous storytelling network element of the communication infrastructure.
Importance of the Storytelling Network for Health Campaigns
Tichenor, Donohue, and Olien’ s (1970) knowledge gap hypothesis posits that
as information disseminates through the mass media, higher socioeconomic status
segments of the population receive and gain knowledge at a faster rate than those of
lower socioeconomic status, permitting the gap of knowledge between the groups to
increase. The knowledge gap hypothesis involves two predictions: 1) knowledge
acquisition will be faster for better educated people over time and 2) at any given
point in time, highly publicized topics will be acquired faster by higher educated
individuals than lower (Gaziano, 1983). The knowledge gap hypothesis has been
used to explain why some groups, such as Hispanics and the young, are more
affected by the spread of diseases such as HIV/AIDS (Salmon, Wooten, Gentry,
Cole, & Kroger, 1996). Research shows that persons of low education lag behind
other groups in true-transmission knowledge and false-transmission knowledge
about the way that HIV/AIDS is spread (Salmon et al., 1996).
Differences between groups normally attributed to a “knowledge gap” may
be the result of the information failing to reach these groups quickly— or at all— as it
is generally diffused through the mainstream news channels, rather than the
communication channels that are part of the group’ s storytelling network. Ball-
Rokeach, Gibbs, Guiterrez-Hoyt, Jung, Matei, Wilson, Yuan, & Zhang (2000) found
significant differences exist in the communication infrastructure utilized by members
27
of different communities. While faster knowledge gain amongst higher status
persons has been attributed to their social networks and contacts, reliance on public
affairs media (e.g., newspapers), and their higher educational levels (Griffin &
Dunwoody, 2000), this difference can be conceptualized in terms of differences in
group storytelling networks. Health information was being told through the
mainstream channels (e.g., newspapers) that higher status individuals are connected
to and through more knowledgeable members within their social networks, thus
allowing the information travel to them faster. Identifying the specific elements that
comprise the target audience’ s storytelling network is imperative in order to get in
touch with the audiences that have traditionally been “hard-to-reach” through
mainstream media.
The basic principals found in Ball-Rokeach’ s media systems dependency
theory (MSD) aid in identifying the most important storytellers to disseminate health
information through a group. In the following sections, the basics premises guiding
MSD are described and the potential to align persuasive message tactics with the
optimal reach strategy for a specific persuasive goal is discussed.
Media System Dependency Theory
Ball-Rokeach’ s MSD theory is a way of incorporating the role that the media
plays within an ecological framework. The MSD theory assumes that: 1) media
systems develop to handle organizational demands that are too large to be handled by
social actors (societies, organizations, groups or individuals); 2) media systems are
dependent upon other systems that control the resources they need to operate; 3) the
28
connections between media systems and other societal systems are carried out
through their respective organizations; 4) the survival of a media system that is
operating within an ambiguous or unstable environment depends on constant
monitoring of the environment and adaptation; 5) media production systems that are
experiencing environmental stress will be more receptive to suggestions of how to
adapt to the environment; 6) the strength of media effects will be strongest when the
environment is ambiguous, threatening, or unstable due to the media’ s role in
making sense of and surveying the environment (Ball-Rokeach et al., 1999).
The structure, strength, and scope of the interconnectedness between media
systems, society, groups and/or individuals will determine the nature of the media
effects on multiple levels (Ball-Rokeach et al., 1999) (i.e., how effective a health
campaign could be if carried out through certain communication channels). Structure
refers to the actual “pattern of the media’ s interdependent relations with political,
economic, and other systems” (Merskin, 1999, p. 81). This involves “the degree of
asymmetry in control over dependency-engendering resources” (Ball-Rokeach, 1998,
p. 19). Strength refers to the intensity or the “perceived exclusivity” of control over
the resources needed to attain goals (Ball-Rokeach, 1998, p. 19). And scope refers to
the range of goals, number of units, and range of resources involved in a dependency
relation (Ball-Rokeach, 1998). The media play a strong role in an individual’ s goal
attainment due to the “macro dependency relations between the media and other
organizations and systems” (Ball-Rokeach, 1998, p. 15). Dependency relations are
determined by the extent to which one party relies on the resources of another for
29
attainment of goals (Ball-Rokeach, 1998). Macro-level dependency relationships
MSD relationships have to be considered when advocating health or social issues in
the media or entertainment arena.
Media networks have dependency relationships with their parent companies.
The relationship between media conglomerate Viacom and the networks it owns
(e.g., CBS, UPN, MTV, VH1) resulted in storylines on HIV/AIDS in the 2002–2004
seasons. Executives at Viacom pressured UPN executives to enforce the inclusion of
HIV/AIDS storylines into the Monday night primetime comedies geared toward
African Americans. While initially feeling that mixing serious educational
information and comedy was a bad idea, Laurie Zaks, Senior Vice President of
Current Programming, UPN, passed the order down to the writers and producers. She
admits that she was pleased with the results— they did a good job of incorporating
the message without losing entertainment and comedic value (Murphy & Cody,
2003). In this case, the structure of the relationship was such that the influence was
unilateral— Viacom used its power relationship to influence the networks. Viacom
depends on the various networks for profit so the dependency relationships will
never be fully unilateral; but since Viacom is not highly dependent on any one
network for profit, the strength of Viacom’ s dependency relationship with each
individual network is fairly weak. So while Viacom has more power, the dependency
relationships are still interdependent.
The producers of news and entertainment programs have dependency
relationships with the networks that carry them. And the networks have dependency
30
relationships with advertisers that sometimes make health advocacy and airing health
messages more difficult. Networks that receive a large portion of total revenue from
specific companies may feel pressure to avoid airing messages that are not in the
various companies’ best interests. For example, Phillip-Morris is not only a major
cigarette manufacturer, but also owns several other companies. Even though they do
not advertise cigarettes on television, a network might receive advertising revenues
from one of its subsidiaries (e.g., Nabisco) and worry that anti-tobacco programming
will hurt the network’ s relationship with Phillip-Morris. Community and ethnic
newspapers are particularly vulnerable to these types of dependency relationships.
Some papers are partially owned by cigarette companies and/or get a lot of their
advertising dollars from these companies, making it extremely difficult to get anti-
tobacco messages into these papers. If a newspaper is dependent upon tobacco
monies to continue to operate, then the strength of their dependency relationship with
the tobacco industry might be so great that the tobacco industry can influence what is
printed.
While macro- and meso-level dependency relationship should be considered
when determining the best strategy to reach your target audience (e.g., it might not
be beneficial to spend a lot of time trying to get anti-smoking ads into community
newspapers that rely heavily on tobacco company funding), ultimately, micro-level
dependency relationships are the basis for creating the optimal communication reach
strategy. The stronger the individual’ s media dependency relationships, the greater
the chance that the media messages will lead to changes in the audience’ s cognitions,
31
feelings, and behaviors (Ball-Rokeach, 1998; Merskin, 1999). Cognitive changes
include “the creation and resolution of ambiguity, attitude formation, agenda setting,
expansion of people’ s systems of beliefs and the media’ s impact on values”
(Merskin, 1999, p. 82). Potential behavior changes include the activation or
deactivation of different behaviors that the audience would typically do or not do
respectively (Ball-Rokeach, 1998; Merskin, 1999), such as exercising or smoking.
Therefore, mobilizing health action on any level (individual, interpersonal,
family, community, organizational, marketplace, cultural, or governmental) is
dependant on the structure, scope, and intensity of dependency relationships that
exist between the media and the intended audience. For example, Ball-Rokeach et al.
(1999), utilized MSD relations in an intervention designed to make drivers less
aggressive on the roads. In order to make the behavioral change on the individual
level, the researchers determined that changes had to be made to the way that local
radio stations reported traffic problems and crashes (Ball-Rokeach et al., 1999). The
assumption is that while on the road, driver’ s are highly dependent on radio reports
to discover what routes are slowed by how long they might be stuck in traffic, and
the like. However, dependency relationships do not just exist between the individual
and the media (in this case the radio). The dependency relationship between radio
stations and advertisers was incorporated into the intervention. Part of the
intervention process involved convincing the radio stations that the proposed traffic
report format would make radio listeners also pay more attention to the advertising.
In the end, the intervention was successful in making traffic reports more personal
32
(e.g., incorporating references to the people involved in crashes, injuries, and
offering alternative routes).
Along with the structure, scope, and intensity of dependency relationships, a
second key component of micro-level dependency relationships involves the nature
or goal of the media connection. Ball-Rokeach (1998) identified three major goal
types that guide our dependency relationships: understanding, orientation, and play.
Identifying how individual’ s goals are related to health campaign goals can help
practitioners’ better align persuasive messages with the strongest goal-related
dependency relations (i.e., reach intended audiences with messages designed to
influence people who are connecting to a resource for a similar goal). As illustrated
later, the goals are not mutually exclusive and often a persuasive theory might
incorporate elements that involve multiple MSD goals. In the following sections, the
ways that individuals’ MSD goals are related to health and persuasive message
strategies are described and overlapping goals are noted.
MSD Goals and Persuasive Message Strategies
How does aligning the persuasive message with the proper goal increase the
effectiveness of the message? We are constantly bombarded by messages in
everyday life that are trying to convince us to change our options, our attitudes,
and/or our behaviors. Why do we stop and pay attention to some and not to others?
Even the most eye-catching, interesting messages go unnoticed when not properly
placed. Think about your own communication behaviors. Pretend that you want to
enjoy the beautiful Los Angeles weather, but do not want to just go sit by yourself in
33
a park. You may pick up your community paper to find out if there are any outdoor
activities going on in your local area. You run across an advertisement for beginning
beach volleyball lessons. The classes meet once a week on your day off so you
decide to take them. You paid attention to the advertisement because you were
looking for an outdoor activity in your local area. Now imagine that same morning
you read the LA Times while drinking your morning coffee with the intention of
finding out information about the mayoral race. What are the chances you would
have noticed or paid attention to an advertisement about beach volleyball when you
flipped through the LA Times pages? Strategically placing persuasive messages in the
communication resources that people are connecting to for related MSD goals will
increase the likelihood that the audience will receive and process the message.
Understanding Goal and Health
There are two types of understanding goals: self-understanding, or making
sense of one’ s own self or “internal world,” and social understanding, which is the
act of making sense out of the social environment, society, or the “external world”
(Ball-Rokeach, 1998, p. 20). The desire to express yourself and the desire to learn
more about what drives or motivates you to do different things in your life are both
examples of self-understanding goals. When it comes to health, trying to self-
diagnose health symptoms and/or trying to figure out what treatments work best for
you are examples of self-understanding. Understanding what events are happening in
your community and finding out what medical services are available in your
community are both examples of social understanding. Health-related social
34
understanding goals include trying to figure out where to get the health services,
products, and resources you need in your community and understanding social
stigmas are that associated with certain diseases and illnesses. Knowing what
communication resources an intended audience depends upon for understanding can
aid campaigns that are designed to increase self and social understanding health-
related information better reach the intended audience.
Behavior Change Models and the Understanding Goal
The communication campaign literature has identified several persuasion
theories that serve as important guidelines for message construction. These theories
can also be aligned with the MSD goals in order to maximize the effectiveness of the
campaign. For example, McGuire’ s (1990) hierarchy of effects (a.k.a., persuasion or
communication matrix), stages of change (DiClemente & Prochaska, 1985;
Prochaska et al., 1992), diffusion of innovations (Rogers, 1995), and steps to
behavior change (Piotrow, Kincaid, Rimon, & Rinehart, 1997) are all theories that
suggest that behavior change is a multi-step process. McGuire’ s (1990) hierarchy of
effects posits 12 steps that are often involved in the behavior change process, starting
with message exposure as the most basic step and ending with post-compliance
activity as the most advanced step. Prochaska et al. (1992) identified 5 stages of
change: pre-contemplation, contemplation, preparation, action, and maintenance.
Rogers (1995) included five phases: awareness, persuasion, decision,
implementation, and confirmation. And Piotrow et al., (1997) identified 16 different
steps to behavior change starting with message recall and ending with supporting the
35
practice in the community (i.e., their steps go beyond simply adopting the behavior
oneself to include stages where you encourage the behavior in others and support
community-level changes).
The MSD communication connections for both types of understanding—
social and self— are most relevant for reaching and persuading audiences’ who are in
the earlier stages of each of these behavior change models. Each model of behavior
change includes some sort of knowledge comprehension, understanding,
contemplation, or persuasion phase. It follows that messages aimed to influence
these initial “understanding” stages will be more effective when directed through the
communication resources which individual’ s in the intended audience have strong
self or social understanding dependency relationships. Social understanding may also
play a role in later stages as the person tries to negotiate the behavior change within
their social environment. For example, a person may be persuaded to get annual
medical exams, but still needs to find out where to get those services.
Cognitive Persuasion Theories/Models and the Understanding Goal
Cognitive persuasion theories, which articulate what happens mentally when
persuasive messages are received, can also be viewed in terms of how they relate to
understanding goal dependency relations. For example, Petty and Caccioppo’ s
(1986) elaboration likelihood model (ELM) and Eagly and Chaiken’ s (1993)
heuristic-systematic model (HSM) address how people process persuasive messages.
Both ELM and HSM suggest that there are two different routes to message
processing that can influence whether or not a persuasive message is effective in
36
changing beliefs, attitudes, and behaviors and the extent to which the changes are
stable over time. The ELM’ s peripheral route is similar to the HSM’ s heuristic route
and the ELM’ s central route is similar to the HSM’ s systematic route. Eagly and
Chaiken (1993) posit, “people will exert whatever effort is required to attain a
‘ sufficient’ degree of confidence that they have accomplished their processing goals”
(p. 330). The amount of information needed to reach one’ s processing goals will
influence which route— systematic (high amounts of information needed) or heuristic
(low amounts of information)— one will take.
The heuristic or peripheral route to message processing involves taking less
cognitive effort to think through a message, but rather bases the credibility of the
message and whether one is going to comply with it on simple decision rules (Eagly
& Chaiken, 1993). These simple decision rules are based on heuristic cues such as
the number of message arguments (i.e., the more arguments, the more credible). This
route is taken when a person is either lacking the ability and/or motivation to
elaborate or counterargue a message (Petty & Cacioppo, 1986). Attitudes formed
based on the peripheral or heuristic processing of messages tend to be more
susceptible to change, less persistent, and less predictive of behavior (Petty &
Cacioppo, 1986). The central or systematic route to information processing involves
elaborating message arguments, comparing the information to other knowledge and
counterarguments (Petty & Cacioppo, 1986), and analyzing and evaluating
information (Eagly & Chaiken, 1993). In order to take the central route in processing
an intervention video, the audience member needs to be both motivated and have the
37
ability to do so. Systematic processing leads to more long-lasting attitude changes
(Eagly & Chaiken, 1993). Both types of processing can occur concurrently (Eagly &
Chaiken, 1993).
How does the MSD understanding goal add depth to the use of ELM and
HSM in health campaigns? The ELM posits that people will take the
central/systematic route to processing messages when they are motivated and have
the ability to process the message. The MSD goal dependencies cannot influence
ability, but can help identify when people will be most likely to systematically
process a message. Individuals should systematically process information that aligns
with the goals of their connections to a communication resource. In other words, if a
person’ s goal for interacting with a communication channel is social or self
understanding, then he/she is more likely to process health information
systematically that appeals to those goals. If their goal is orientation or play, they are
less likely to process health information systematically related to the understanding
goal.
Orientation Goal and Health
Ball-Rokeach (1998) distinguishes two types of orientation goals—
interaction and action— that help guide our behaviors in everyday life. Interaction
orientation involves interacting with other people effectively, while action
orientation involves navigating or problem solving one’ s environment effectively.
Interaction orientation is involved when conversing with others is required to address
a health problem. For example, asking friends or doctors about how to treat an
38
illness, parents talking to their kids about drugs, STD’ s, etc. Campaigns that aim to
encourage talking about health conditions (e.g., “Talk to your kids about drugs”,
“Talk to your partner about safe sex”, etc.) should aim to get messages to the
intended audience through the communication resources they connect to for the
interaction goal. Action orientation goals include taking action to get health services,
to adopt preventative health behaviors, to treat illnesses, etc.
Behavior Change Models and the Orientation Goal
Orientation goal dependency relations come into play when the intended
audience of a health campaign message is ready to take action and make a behavior
change (action orientation) or interact with others’ to discover ways of adopting
behaviors or to encourage other people to adopt the behaviors (interaction
orientation). In this fashion, the persuasive strategies that require the knowledge of
orientation goal dependency relations are those aimed at encouraging people to
change behaviors. In Prochaska et al.’ s (1992) stages of change, interaction
orientation goals might be relevant during the contemplation and preparation stages,
whereas action orientation goals are relevant during the action and maintenance
stages. For diffusion of innovations, knowledge of orientation goal dependencies
would be most helpful when the audience is in the decision, implementation, and
confirmation stages of change. In McGuire’ s (1989) hierarchy of effects, knowing
orientation goal dependency relations is most important when targeting people who
are ready for the last few stages of change, such as changing and reinforcing
behaviors.
39
Cognitive Theories/Models and the Orientation Goal
Festinger’ s (1957) cognitive dissonance theory posits that individuals feel
uncomfortable (i.e., cognitive dissonance) when messages and/or behaviors do not
align with their current beliefs and will take steps to reduce those feelings of
dissonance. People will try to avoid exposure to dissonant stimuli. When this is not
possible, individuals will try to cope with dissonance in four ways: 1) adding or
subtracting cognitions so as to improve the ratio of consonant (similar) as compared
to dissonant (contrary) cognitions, 2) changing behavior to become consistent with
their beliefs, 3) reducing the importance of the dissonant cognitions, and 4) distorting
the information in an effort to reduce the dissonance. How does this relate to the
orientation goal? When the proposed behavior change aligns with most of the
person’ s cognitions, then they are most likely to act upon it. In these situations, the
campaign strategy should incorporate the communication resources he/she depends
upon for the orientation goal.
Fishbein and Ajzen’ s (1975) theory of reasoned action (TRA) proposes a
mathematical formula that predicts behavioral intentions, which are related to actual
behaviors. According to the TRA, the weighted summations of attitudes toward a
behavior and subjective norms influence behavioral intentions. Attitude toward a
behavior are comprised of a multitude of beliefs about the behavior; the strength of
each belief is multiplied by how one evaluates that belief and added to other beliefs
to form an overall attitude toward a behavior. Subjective norms are formed from the
normative beliefs a person has about particular beliefs and the motivation to comply
40
with these norms. Examples of normative belief include “my mom would disapprove
of my smoking” and “my friends think it is cool to smoke.” A person’ s motivation to
comply with what their mother or friends think will influence the weight that each of
these beliefs has within the subjective norm component.
How does the TRA relate to the orientation goal? Behavior intentions are
directly related to action orientation goals. Talking about a behavioral intent to
determine what other people around you think (i.e., social norms) is an example of
interaction orientation. If planning a message designed to influence behaviors, the
orientation goal dependency connections are the best way to reach the audience.
TRA strategies include trying to increase the strength and evaluation of relevant
health beliefs or trying to change normative beliefs or the motivation to comply with
normative beliefs. When the goal of the campaign is to change social norms, than it
is possible that those goals might align more closely with MSD social understanding
connections. For example, anti-drug advertisements that try to demonstrate that the
majority of “kids like you” do not take drugs are designed to change normative
beliefs, but are also related to understanding the social environment.
Another persuasion model that often guides the formation of health messages
is the health belief model (HBM) (Becker, 1974). The model identifies health beliefs
that can be manipulated in order to try to change health behaviors. These variables
include perceived threat, perceived benefits and costs, perceived barriers, and cues to
action. In more recent years, other variables such as self-efficacy and demographic,
psychological, and structural variables that affect an individual's perceptions were
41
also incorporated into the model (Rosenstock, Strecher, & Becker, 1994). Perceived
threat consists of two parts: perceived susceptibility (i.e., beliefs about one’ s
personal risk of contracting a health condition) and perceived severity of a health
condition (i.e., beliefs about how serious contracting an illness or leaving an illness
untreated is). Perceived benefits involve beliefs about how much better life will be if
the steps to reducing health risk or treating a health problem is taken. The perceived
benefits are often weighted against the potential costs of the behavior (e.g., side
effects of treatments or having to stop eating foods that are enjoyed). Perceived
barriers include the array of things that may get in the way of performing health
actions on a regular basis; these include physical, psychological, and financial
demands (Rosenstock et al., 1994). Cues to action are the events (e.g., physical
symptoms of a health condition or media publicity about a health problem) that
motivate people to take action. Finally, Bandura coined the term self-efficacy as the
belief in one’ s capability to organize and execute the course of action required to
engage in a certain behavior (Bandura, 1997).
The health belief model can be used when trying to change health behaviors.
The idea is to increase the odds that a person will change a behavior, it is important
that they feel like they are at risk, they are capable of overcoming barriers and taking
the steps necessary to change their behavior, and ultimately will benefit greatly by
changing their behavior. Since the health belief model is ultimately designed to
change behaviors, it too may be most successful when presented through
communication resources that the intended audience is tapping into for their
42
orientation goals. It is important to note that when using the HBM to change
behaviors, certain aspects of the campaign might actually be better aligned with
MSD understanding goal connections. Therefore, while some theories seem to fit
well within one of the MSD goals, in reality, persuasive goals may align with one or
more MSD goal at a time.
Play Goal and Health
Ball-Rokeach (1998) identifies two types of MSD play goals: solitary and
social. As the titles suggest, solitary play has to do with entertaining or amusing
oneself and social play involves having fun or socializing with others. With the
exception of people who are fascinated with the health field and find medical
research as a form of entertainment, most people would not consider play goals to
have much to do with health. However, there are indirect relationships between play
and health. For example, how people choose to “play”— e.g., sitting and watching
television or rollerblading around the neighborhood— impacts the amount of exercise
they get and their overall health. In addition, certain types of health campaigns are
designed to inform or persuade us while we play (e.g., entertainment-education).
Entertainment-Education and the Play Goal
The relationship between the play goal and health campaigns is most
apparent for entertainment-education (E-E) efforts. Knowing what communication
channels the intended audience is most dependent upon for play will greatly increase
the ability to reach the audience with E-E messages. E-E is “the process of purposely
designing and implementing a media message to both entertain and educate, in order
43
to increase audience members’ knowledge about an educational issue, create
favorable attitudes, shift social norms, and change overt behavior” (Singhal &
Rogers, 2004, p. 5). Entertainment-education programs are heavily driven by a
particular set of attitude and behavioral change theories and concepts such as social
learning theory (Bandura, 2004), self efficacy (Bandura, 1997), the elaboration
likelihood model and the processing of narrative dramas (Petty & Cacioppo, 1986;
Slater & Rouner, 2002), the Sabido methodology (Sabido, 2004), theory of reasoned
action (Fishbein & Ajzen, 1975), the health belief model (Becker, 1974), the stages
of change models (DiClemente & Prochaska, 1985; Rogers, 1995; Singhal & Rogers,
1999; Sood, Menard & Witte, 2004), and social comparison theory (Festinger,
1954). While E-E originated as a format used within television and radio dramas, E-
E efforts have expanded to incorporate the use of other media such as interactive
videos (e.g., Buller et al., 2000), participatory theater (e.g., Singhal, 2004), comic
books (e.g., McKee et al., 2004), folk media (e.g., Panford et al., 2001) and
fotonovelas (e.g., Rogers, 2003).
The E-E format has been used to increase knowledge and awareness about
health issues often with the goal of changing health behaviors (e.g., Beck, 2004;
Brodie, Rideout, Baer, Miller, Fournoy, & Altman, 2001; Glik et al., 1998; Kennedy
et al., 2004; Rideout, 2004; Piotrow et al., 1992; Rogers et al., 1999; Sharf &
Friemuth, 1993; Sharf, Freimuth, Greenspon, & Plotnick, 1996; Valente, Kim,
Lettenmaier, Glass, & Dibba, 1994; Valente, Poppe, Alva, DeBrinceno, & Cases,
44
1995; Westoff & Rodriguez, 1995; Whittier, Kennedy, Seeley, St. Lawrence, &
Beck, in press; Winsten & DeJong, 2001).
The basic idea is that when a person identifies with an entertainment
character, they can learn from the character. Identification occurs when one
empathizes with and perceives similarity between a person or fictional character and
oneself or people they know (Slater & Rouner, 2002). When identification with the
characters results in overtly reacting to media characters by “talking” to the
characters or other audience members, then behaviorally oriented parasocial
interactions are at play (Papa et al., 2000). This type of parasocial interaction is
similar to what Sood (2002) calls cognitive-critical involvement. Involvement occurs
when audience members reflect upon and form parasocial interactions with media
programs often resulting in overt behavior change (Sood et al., 2004). People can
learn behaviors by watching characters that they identify with utilizing the behaviors
in their lives (e.g., how they overcome barriers and work the behavior into their daily
life).
E-E programs can also stimulate interpersonal communication on health
topics (Boulay, Storey, & Sood, 2002; Collins, Elliot, Berry, Kanouse, & Hunter,
2003; Papa et al., 2000; Piotrow & de Fossard, 2004; Singhal & Rogers, 2004;
Valente & Saba, 1998). Audience members are persuaded or persuade others, and
can increase feelings of self-efficacy or collective efficacy through interpersonal
communication. People commonly share stories about how they reacted in similar
situations when they talk about entertainment programs (Papa et al., 2000). This
45
practice of storytelling is likely to encourage collective efficacy and bring about
desired behavior change. In the U.S., research showed that interpretations of a cancer
storyline on thirtysomething were influenced through interpersonal conversation
(Sharf et al., 1996). Likewise, teen’ s condom efficacy beliefs were influenced by
parental conversation following an episode of Friends on the topic (Collins et al.,
2003).
E-E efforts should be incorporated into the communication resources that an
intended audience is most strongly connected to for the play goal. This will ensure
the highest likelihood that the audience will become involved with the E-E story and
identify with and learn from the characters. However, it is important to note again
that the specific goal of the E-E program might elicit one or more of the other MSD
goals as well. For example, when the goal of the E-E program is to model talking to
a loved one about safe sex, then it may align better with interaction orientation MSD
connections. If the goal of an E-E program is to demonstrate how easy it is to get a
HIV blood test, then it may align better with action orientation goals.
Table 2.1 summarizes how traditional persuasion theories align with the three
original MSD goals.
46
Table 2.1: Summary: How MSD goals and persuasion theories align
Understanding Orientation Play
Behavior Change Models
Solitary or Social
-- Beginning stages of
awareness, knowledge
acquisition, etc.
Self or social Interaction
-- Behavior adoption stages
Action or interaction
Processing Models
Solitary or Social
-- Systematic/Central Route
Self or social
-- Heuristic/ Peripheral Route
Cognitive Dissonance Theory
Action or interaction
Theory of Reasoned Action
Solitary or Social
-- Behavioral intentions
Action or interaction
-- Attitude toward behavior
Self Action or interaction
-- Social norms
Social
Health Belief Model
Self or social Action or interaction Solitary or Social
Social learning theory
Solitary or Social
Self-efficacy
Self Solitary or Social
Social comparison theory
Self or social Solitary or Social
Health Goal
A specific health goal was not specified within the MSD theory, but health
practitioners and policy makers may feel the need to reach this level of detail in order
to more effectively reach their intended audience with health messages. As
illustrated above, the health goal can be related to self-understanding (e.g., figuring
out what symptoms you are experiencing mean) and social understanding (e.g.,
figuring out where to get the health services and resources you need in your
community). The health goal can also be captured within interaction orientation (e.g.,
getting advice from friends or doctors about how to treat an illness) and action
orientation (e.g., deciding what products to buy to treat illnesses or prevent health
problems). And while not directly related to either of the play goals, health is
47
affected by the type of play one engages in and may be affected by health campaigns
via the entertainment medium. Communication dependency connections for any of
the specific health-related goals can add to the effectiveness of a health campaign
reach strategy.
The next chapter will explain how using these MSD goals aid in the
construction of a communication reach strategy. The chapter will also lay out the
research questions that will be explored in this dissertation.
48
CHAPTER 3
RESEARCH QUESTIONS & METHODS
Research Questions
The first set of research questions were designed to highlight how reach
strategies should change depending on how the intended audience is defined. First,
geo-ethnic (indicating the interaction of ethnicity and geographic place) differences
in communication connections for the different MSD goals were explored. The
subsequent research questions were:
RQ1: Do communication connection patterns vary by geo-ethnicity?
RQ1a: Are there geo-ethnic differences with respect to understanding
goal connections?
RQ1b: Are there geo-ethnic differences with respect to orientation
goal connections?
RQ1c: Are there geo-ethnic differences with respect to play goal
connections?
RQ1d: Are there geo-ethnic differences with respect to health goal
connections?
In recent years, telephone information lines and Internet websites have been
used as supplemental resources in health campaigns. The second research question
was designed to look specifically at the telephone and the Internet to ask if these
health information resources are more likely to be used by some groups than others.
The research question was posed as follows:
49
RQ2: Do telephone or Internet connections vary by geo-ethnicity?
The third set of research questions were designed to address differences in
communication connection patterns or the combinations of the most commonly
selected media, interpersonal or expert resources.
RQ3: Are there any patterns in the types of communication resources
Hispanic individuals connect to in order to achieve their goals?
RQ3a: What resources are mentioned most often together for the
health goal?
RQ3b: What resources are mentioned most often for the
understanding goal in conjunction with each health communication
resource connection?
RQ3c: What resources are mentioned most often for the orientation
goal in conjunction with each health communication resource
connection?
RQ3d: What resources are mentioned most often for the play goal in
conjunction with each health communication resource connection?
The goal of the fourth research question was to determine when it is most
effective to link telephone information numbers and Internet web addresses to health
messages presented in other communication resources. This research question asked:
RQ4: For which communication resources identified as important for the
health goal do respondents have stronger connections to the telephone and
Internet?
50
Research questions 5–7 address the specific communication resources found
to be most heavily implicated in health access outcomes. Answers to these questions
will be used to make recommendations for how to best reach audiences who are at
greater risk for health problems due to their lack of adequate health care access. The
following research questions were posed:
RQ5: Which specific communication resources deemed as important for goal
attainment attract the highest concentration of Hispanics with limited health
care access?
RQ6: Which specific communication resources did Hispanics who indicated
greater difficulty getting medical care deem as most important for goal
attainment?
RQ7: Which specific communication resources did Hispanics who indicated
being highly affected by local health clinic closures deem as most important
for goal attainment?
The final research question was designed to determine if communication
connection patterns affect health outcomes. The research question was phrased:
RQ8: Do communication resource combinations affect health outcomes?
Telephone Survey Methods
The survey data were collected as part of the USC Metamorphosis Project’ s
multi-year, multi-method exploration of geo-ethnic communities located within 10
miles of the Los Angeles civic center. The data used for this dissertation come from
the two most recent data collections that included the richest health-related
51
information. The 2001 telephone survey focused on Anglos (N = 189), Armenians (N
= 211), and Hispanics (N = 151) living in Glendale. The data collected in late
2002/early 2003 included predominantly Central American-origin Hispanics (N =
301) living in Pico Union and mostly Mexican-origin Hispanics (N = 438) living in
the Southeast L.A. cities of Cudahy, Huntington Park, and South Gate.
Glendale, located 8 miles northeast of Los Angeles, is the third largest city (a
30.5 square-mile area) in Los Angeles County with three major freeways traversing
the city. It is ethnically diverse and about half of the population of 200,000 residents
are foreign born. According to the 2000 census reports, non-Hispanic White
residents (excluding Armenians) constitute 35% of the population, while 21% of the
population is Armenian, 20% is Hispanic, and 16% is Asian from different countries-
of-origin. Seventy-nine percent of the Glendale residents over the age of 25 have a
high school degree, nearly 40% own homes, and the median household income is
approximately $41,800. Pico Union is located very close to the Los Angeles Civic
Center (1.7 miles). According to the 2000 Census, almost 79% of the population is
Hispanic; of these, 69% are first generation immigrants. They are primarily from
Central American countries. This area is relatively poor; Hispanic median household
income is $19,408. And the Hispanic population is young and fairly uneducated;
only 12% of Hispanics in this area have a high school degree. The Southeast L.A.
study area, which includes the contiguous cities of Huntington Park, South Gate, and
Cudahy, cover an area of 11.6 square miles east of the Los Angeles River and Los
Angeles City limits. Although these areas were historically white suburban
52
communities, dramatic demographic and cultural shifts have occurred in the last
three decades. According to the 2000 Census, 96% of Huntington Park, 92% of
South Gate, 94% of the total population of Cudahy is now Hispanic and more than
half are first generation immigrants. Residents in these three cities are relatively
young and only 34% completed high school. The median household income is about
$32,500 and about 22% live below the poverty line.
Random digit dialing (first adult contacted) was used by a well-respected
commercial survey research organization to contact residents for the survey. The 40–
47 minute survey was administered in the language preferred by the respondent
(Armenian, English, and Spanish). It was introduced as a survey of residents ’
feelings toward their community. Up to eight callbacks were made. The survey
response rate, conservatively calculated by dividing the number of completed
interviews by the number of theoretically eligible phone numbers, was 51% for the
2001 survey and 47.7% for 2002–2003 survey. Given the nature of our geo-ethnic
urban new and old immigrant samples, it is hard to find comparable response rates in
the literature. Our rates, nonetheless, compare favorably with those of national
surveys conducted by major research organizations (Keeter, Kohut, Groves, &
Presser, 2000).
Survey Samples
Table 3.1 provides the survey sample characteristics.
53
Table 3.1: Demographics of geo-ethnic sample
GEO- Southeast L.A. Pico Union Glendale Glendale Glendale
ETHNICITY Hispanics Hispanics Hispanics Anglos Armenians
Year 2002–2003 2002–2003 2001 2001 2001
Sample Size N=438 N=301 N=151 N=189 N=211
1
st
& 2
nd
gen. 91.8% 94.3% 84.9% 24.6% 96.7%
Median Age 35 35 34 48 40
Female 52.5% 48.7% 59.6% 57.1% 58.8%
HH Income
(Median)
$27,500
$20,000
$40,000
$52,500
$27,500
<=$35,000 73.7% 83.1% 38.4% 22.8% 51.6%
>=$75,000 3.6% 3.3% 17.9% 33.3% 10.4%
Education
<=High
School
75% 80% 43% 16% 41%
>=College 8% 7% 27% 51% 40%
2001: Glendale Survey
Of the 551 respondents who participated in the telephone survey in Glendale,
there are 151 Hispanics, 189 Anglos, and 211 Armenians. Fifty-eight percent are
females. The Armenian and Hispanic samples tend to be newer generation
immigrants, while the Anglos were older immigrants. The Armenians are largely
first generation immigrants (69%); Hispanics mostly second generation (50%); and
Anglos predominantly third generation and above (75%). Approximately 35% of the
Hispanics are first generation and 15% third and above, making Glendale Hispanics
a little more likely than the other Hispanic study areas to be second or third
generation. Fifty-six percent of the Hispanics in Southeast L.A. and 62% of the
Hispanics in Pico Union are first generation.
Glendale respondents ranged in age from 18 to 88 with a median age of 40;
Anglos tend to be a little older (Mdn = 48) and Hispanics younger (Mdn = 34). The
majority is married (53%); Anglos more often are married, 56% as compared to 48%
54
of Hispanics and 54% of Armenians. Hispanics are more likely to be single/never
married, 31% as compared to 22% and 30% of Anglos and Armenians respectively.
Anglos in the sample are more likely to have a college degree or higher (51%) as
compared to Hispanics (27%) and Armenians (40%). The percentage of Glendale
Hispanics with a college degree and/or graduate/professional degrees is higher in the
Hispanic samples in Southeast L.A. (8%), Pico Union (6%), and East L.A. (8%). The
annual household income varies between ethnic groups in Glendale; 36% of
Armenians earn less then $20,000 a year as compared to 18% of the Hispanic and
10% of the Anglos. Anglos are more likely to earn $75,000 or more (33%) as
compared to 17% of Hispanics and 10% of the Armenians. Hispanics in Glendale
earn more than Hispanics in other L.A. communities; Glendale Hispanics report a
median income of $40,000, Southeast L.A. and East L.A. Hispanics report a median
income of $27,500, and Pico Union Hispanics only $20,000.
2002–2003: Pico Union and Southeast L.A. Surveys
A total of 739 adults participated in the phone survey in Pico Union and the
Southeast L.A. cities. Fifty-seven percent of the respondents are female.
Respondents are largely new immigrants— 57% first generation and 31% second
generation. Nearly 84% completed the telephone interview in Spanish and 16% in
English. Fifty-three percent speak both English and Spanish in the home, 43% speak
Spanish-only, 3% speak only English. Respondents range in age from 18 to 91 with a
median age of 35; the majority is either married (53%) or never married/single
(25%). Less than half the sample population (47%) has a high school diploma and a
55
large portion of the sample (35%) only has an eighth grade education or less. The
annual household income is low; 44% earn less then $20,000 a year as a family, 26%
earn between $20,000 and $35,000, 11% earn between $35,000 and $45,000, and
11% earn more than $45,000.
Survey Measures
Communication Connection Patterns
A series of media system dependency questions were used to determine
residents’ communication connections as they pertain to the attainment of each of
Ball-Rokeach’ s MSD goals— understanding, orientation, and play— plus parallel
questions also pertaining to health goals. In addition, questions were asked to
determine the extent to which the telephone and Internet is used for the three MSD
goals.
MSD: Understanding Goal. The understanding goal question assesses
respondents’ connections to communication resources for the goal of “social
understanding.” The understanding goal question, which appears before the other
goal questions in the survey, is preceded by the prompt, “Thinking about all of the
different ways of communicating and getting information, using television, radio,
newspapers, books, magazines, movies, the Internet, talking with other people, or
any other way… ” The main understanding goal question asked, “What are the most
important ways for you to stay on top of what’ s happening in your community?” The
question is open-ended, allowing respondents to provide as many different answers
as they want. Trained interviewers coded answers into the following predetermined
56
categories: talking with other people/telephone; Internet; movies; books or
magazines; television/cable TV/satellite TV; radio; newspapers; organizations;
leaflets or folders (other media); and other (specify).
When respondents mentioned television, radio, and/or newspapers, follow-up
questions determined if they usually go to mainstream or geo-ethnic media. For
television, the follow-up was: “When you watch TV for community information, is it
more often … major English commercial channels; public television channels; other
television or cable channels that target your area or that are produced for your ethnic
group?” For radio, the follow-up question was: “When you listen to the radio for
community information, is it more often …mainstream English commercial radio;
public radio stations; other radio stations that target your area or that are produced
for your ethnic group?” For newspapers, the follow-up question was: “When you
read the newspaper for community information, is it more often … mainstream
English commercial newspapers; community newspapers that cover your area; other
newspapers that are produced for your ethnic group?” When necessary, interviewers
provided specific examples of each media type. Responses were recoded into two
different categories: “mainstream” and “geo-ethnic” (referring to a media geared at
either a specific ethnic group or local geographic area). Mainstream channel
connections are based upon answering “Mainstream English commercial.” The “geo-
ethnic” categorization included either public media and/or media geared toward the
respondent’ s area and/or ethnic group.
57
MSD: Orientation Goal. The orientation goal measure is designed to
ascertain “action orientation” and follows the understanding goal question in the
survey. It reads: “Thinking again about all of the different ways of communicating
and getting information— using television, radio, newspapers, books, magazines,
movies, the Internet, talking with other people, or any other way… .What are the
most important ways you get information to make decisions about the products you
buy?” The interviewer coded respondents’ open-ended responses into the following
categories: talking with other people/telephone; Internet; movies; books or
magazines; television/cable TV/satellite TV; radio; newspapers; personal
trial/personal use; reading label or packaging, brand recognition; brochures,
literature, mailings, advertising, prices, coupons, specials (other print); and other
(specify).
As with the understanding goal, if the respondent mentioned television, radio,
and/or newspapers, they were asked similarly phrased follow-up questions to
categorize responses as either mainstream or geo-ethnic.
MSD: Play Goal. The play goal question refers to both “solitary play” and
“social play.” It reads: “Again thinking about all of the different ways of
communicating… What are the ways that you usually relax and have fun?”
Respondents were free to mention as many different ways as they wanted and then
interviewers coded their responses into the following categories: get together with
family or friends; go on the Internet; go to a movie; rent a movie; read a book or
magazine; watch television/cable TV/satellite TV; listen to the radio; listen to CD’ s
58
or cassettes; read a newspaper; sports/exercise/travel/parks/outdoors;
hobbies/games/gardening; partying/dining/shopping/social activities; high brow
cultural activities/art shows/concerts/theatre; do nothing/sleep; talk on the telephone;
participate in church-related activities; and other (specify). For the purpose of this
analysis, the categories of “go to a movie” and “rent a movie” were later recoded
into one category identified as “movies.”
As with the other MSD goals, television, radio, and/or newspapers responses
were followed-up with a question designed to determine if the media were
mainstream or geo-ethnic in nature.
MSD: Health Goal. The health goal question came after the MSD
understanding, orientation, and play goal questions. Respondents are prompted,
“Thinking again about all of the different ways of communicating and getting
information— using television, radio, newspapers, books, magazines, movies, the
Internet, talking with other people, or any other way… ” and then asked, “What are
the most important ways that you get medical and health information for yourself or
for your family?” The question was asked in an open-ended fashion, allowing
respondents to identify as many different responses as they desired. The telephone
interviewer than recorded their answers within predetermined categories that we
identified: talk with family or friends; contact health providers including hospitals
and clinics; contact alternative medicine practitioners (e.g., acupuncture, etc.); use
the Internet; watch television/cable TV/satellite TV; listen to radio; read a
newspaper; watch movies; read a book or magazine; organizations (e.g., NCI, ADA,
59
etc.); leaflets or folders (other print media); from work; from church; and other
(specify). As with the original MSD questions, when respondents mentioned
television, radio, and/or newspapers, a follow-up question determined if they usually
go to mainstream and/or geo-ethnic media.
MSD: Telephone. A series of questions were used to ascertain respondents’
connections to the telephone to achieve the three main goals— understanding,
orientation, and play. The question phrasings were altered slightly between the 2001
and 2002–2003 survey to better capture the goals in relation to health and family
concerns
7
. As a result, only the 2002–2003 survey data were used in the present
analyses involving MSD connections to the telephone. The MSD telephone questions
can be broken down into six categories: social understanding, self understanding,
action orientation, interaction orientation, solitary play, and social play. Respondents
were asked to respond on a scale from 1 to 5, where “1” meant ‘ not at all important’
and “5” meant ‘ very important,’ how important the telephone is as a means to
achieve MSD goals.
In the 2002–2003 survey, the understanding goal questions were phrased,
“…keep up with events in your area that you and your family care about?” (social
understanding) and “…talk with others about the challenges in raising children?”
(self understanding). The orientation goal questions were phrased, “…get
information about products to buy for you and your family?” (action orientation);
“…get information about various social, medical, educational or childcare services
7
Questions were adjusted in 2002 to better serve the interests of the Metamorphosis Projects new
funding agency, First 5 L.A., Healthy Families and Children First, Commission of Los Angeles.
60
you and your family might be able to use?” (action orientation); and “…arrange and
get together with others to solve health, family or neighborhood problems?”
(interaction orientation). The play goal questions were: “…have something to do
when nobody else is around the house?” (solitary play) and “…just have good
conversations with your family and friends?” (social play). These seven items were
summed to form a telephone connection intensity scale. Tabachnick & Fidell’ s
(2001) procedure was used to correct for a moderate negative skew, which resulted
in a 5-point scale. This 5-point scale was once again reverse coded so that higher
values indicated higher intensity telephone connections
8
. Cronbach’ s alpha was used
to determine the reliability of this new measure (a = .79).
MSD: Internet. A series of questions also were used to ascertain respondents’
MSD goal precipitated Internet connections. Again, the question phrasings were
altered slightly between the 2001 and 2002–2003 survey to better capture health and
family goals. Accordingly, only the 2002–2003 survey data were used in analyses
involving MSD Internet connections. The MSD Internet questions also capture the
six goal categories. Respondents were asked to respond on a scale from 1 to 5, where
1 meant “not at all important” and 5 meant “very important,” how important the
Internet is as a means to achieve MSD goals: “… to stay on top of what is happening
in your community?” and “… how about to get information about social, medical,
educational or childcare services available in your area?” (social understanding); “to
8
The procedure to correct for a moderate negative skew is to take the square root of a constant
(largest score plus one) minus the current score. This corrects for the skew, but causes the resulting
index to be artificially transformed so that the highest values are now the lowest and vice versa.
61
stay on top of events that you care about” and “to express yourself”(self
understanding); “… to get your work done?” and “to gain skills for career
development?” (action orientation); “… to get in touch with people about your job or
to find a job?” and “… to get advice on how to deal with doctors or clinics that
provide services to families and/or children?” (interaction orientation); and “… to
play or amuse yourself” (solitary play) and “… how important is the Internet for
social reasons like making friends?” (social play).
Respondents’ answers to these ten items were added and averaged to form a
5-point Internet connection intensity scale
9
. Cronbach’ s alpha was used to determine
the reliability of this new measure (a = .87).
Scope of Internet Connections for Health
The 2002–2003 survey also added questions to find out the extent to which
people were connecting to the Internet for health goals. The telephone survey asks if
the respondent goes online for health information, and if so, whether they use the
Internet to: “… look for information about a particular illness or condition?”; “…look
for information about a particular doctor or hospital?”; “… look for information about
alternative or experimental treatments or medicines?”; “… look for information about
a sensitive health topic that is difficult to talk about?” “…look for information about
prescription drugs?”; “… look for information or advice about nutrition, exercise or
weight control?”; “…diagnose or treat a medical condition on your own, without
consulting your doctor?”; and “… gather information BEFORE visiting your doctor?”
9
Jung (2003) used a similar procedure to create an Internet intensity measure using the Glendale data
(i.e., before questions were added and adjusted for First 5 LA interests).
62
Factor reduction and inter-item reliability analyses suggested a six-item
Internet health scope measure, with Cronbach’ s a = .71, which included all items
except: “…look for information about a particular doctor or hospital?” and “… look
for information or advice about nutrition, exercise or weight control?”. These two
items were treated as independent items in the analysis; the other 6 items were added
together to form the scope variable.
Health Access Measures
Several indicators are used to measure health care access. With the exception
of adult health insurance, these questions were asked in just the 2002–2003 surveys.
Health Insurance. Two questions asked about health insurance: “Do you have
health insurance” and “Does the child we’ ve been discussing have health insurance?”
The second question was asked just of adults who take care of a child in the home
who is aged 0 to 5
10
. While adult health insurance is often contingent upon certain
work benefits, California has several programs to ensure that children have health
insurance. Therefore, it is possible for the child to be insured while the adult is not.
Despite the State’ s variety of health insurance programs available, not all children
have health insurance. For example, a study of Latino children living in the San
Francisco Bay area found that 28% of the children eligible to receive subsidized
health insurance were not enrolled (Manos, Leyden, Resendez, Klein, Wilson, &
Bauer, 2001). Lack of health insurance is related to not seeing a doctor in the past 12
months and not having a regular place for medical care (Manos et al., 2001).
10
The 2001 survey only includes the question about whether the adult has health insurance. Both the
adult and child’ s health insurance questions are asked in the 2002–2003 survey.
63
Difficulty of getting medical care. A single item measures how difficult it is
for respondents to get medical care and services: “Overall, how easy or difficult is it
for you to get medical care when you need it? Would you say it is very difficult,
somewhat difficult, somewhat easy, or very easy?”
Regular place to go for health care. Respondents were asked: “Is there a
place you usually go when you need health care for yourself?”
Clinic Closures. In the months before the 2002 telephone survey began, the
Los Angeles County Health Department announced several health clinic closures
around Los Angeles. Questions were added to the survey to determine the extent to
which residents’ paid attention to news about the closures and how much they
thought they would be affected by those closures. Two question versions were
created. The San Antonio Community Clinic located in Huntington Park and serving
the Southeast cities was closing and was provided as a specific example; the question
was asked more generically in Pico Union where residents may have been affected
by any number of clinic closures. Residents in Pico Union were asked to use a scale
of 1 to 10, where “1” means it would ‘ not affect you at all’ and “10” means it would
affect you ‘ a great deal’ and asked: “How much will the closures of these clinics
affect you and your family?” In the Southeast L.A. areas, the question read, “How
much will the closure of this clinic [referring to the San Antonio clinic in the
previous question] affect you and your family?”
64
The next chapter reports the results for the first four research questions.
These questions are designed to compare communication connections at both the
meso- and micro- level and help identify the channels to use in different types of
health campaigns.
65
CHAPTER 4
SURVEY RESULTS
PART I: COMMUNICATION PROFILES
The goal of the first part of the data analysis was to explore the ecological
nature of communication connections and create geo-ethnic-level and individual-
level communication profiles. For each MSD goal— health, understanding,
orientation, and play— frequencies of how often residents of the different geo-ethnic
communities mentioned each communication resource as one of the most important
for that goal were used to identify the geo-ethnic groups four most important
resources for the goal. To create individual level profiles, frequencies were run to
determine the most frequently occurring responses for each of the MSD goals within
the individual health goal answers. So, for example, if a person identified friends or
family as one of the most important ways to achieve the health goal, how often did
they mention interpersonal, mainstream television, geo-ethnic television, etc. for
other MSD goals? These frequencies were used to create profiles of how individuals
most often combine resources to attain goals, using their health goal answers as the
anchoring point. Research questions one through four all pertained to resource
connections with regard to creating these communication profiles. Given the large
number of communication resources and groups, only the most important similarities
and differences are abstracted out in the text and a closer inspection of the tables is
left to the reader.
66
RQ1: Do communication connection patterns vary by geo-ethnicity?
This research question was broken down into more specific research
questions for the purpose of distinguishing geo-ethnic variation among MSD goals.
RQ1a: Are there geo-ethnic differences with respect to understanding goal
connections?
The understanding goal was assessed by asking respondents to identify the
most important ways that they stay on top of what is happening in their community.
For the entire sample (N = 1290), geo-ethnic television is mentioned most frequently
(N = 569), followed by interpersonal (N = 361), mainstream TV (N = 314), geo-
ethnic newspapers (N = 290), mainstream newspapers (N = 201), geo-ethnic radio (N
= 184), Internet (N = 129), mainstream radio (N = 57), and books or magazines (N =
48). However, connection patterns vary when broken down to the geo-ethnic study
samples. Table 4.1 illustrates the geo-ethnic differences in connection patterns for
the understanding goal.
67
Table 4.1: Top 4 connections for understanding goal by geo-ethnic study area
Hispanics Hispanics Hispanics Anglos Armenians
Southeast L.A. Pico Union Glendale Glendale Glendale
N=438 N=301 N=151 N=189 N=211
1
Geo-Ethnic TV
Geo-Ethnic TV
Geo-Ethnic
TV
Mainstream
Newspapers
Geo-Ethnic
TV
57.1% 50.2% 31.8% 37.6% 38.9%
2
Interpersonal
Interpersonal
Mainstream
TV Interpersonal
Mainstream
TV
26.9% 32.9% 31.1% 32.3% 29.9%
3
Geo-Ethnic
Newspapers
Geo-Ethnic
Newspapers
Interpersonal*
Mainstream
Newspapers*
Geo-Ethnic
Newspapers Interpersonal
25.3% 22.9% 24.5% 28.6% 19%
4
Geo-Ethnic
Radio
Geo-Ethnic
Radio
Mainstream
TV
Geo-Ethnic
Newspapers
21.7% 20.6% 25.9% 12.8%
* Indicates tie.
The major similarities and differences between groups are as follows:
• Interpersonal communication is important for staying on top of community
events. Interpersonal channels are in the top four most frequently mentioned
for all geo-ethnic groups and ranks as high as second for Glendale Anglos
(32.3%) and Hispanics in Southeast L.A. (26.9%) and Pico Union (32.9%).
• All geo-ethnic groups except Glendale Anglos identified geo-ethnic
television as one of the most important ways to stay on top of community
events. The relative importance, however, varies. Geo-ethnic television is
identified as important by more than half the residents in both Southeast L.A.
(57.1%) and Pico Union (50.2%), but by less than a third (31.8%) of
Glendale Hispanics. Almost 40% of Armenians identified geo-ethnic
television as important for the understand goal.
68
• Mainstream television appears as important for staying on top of community
events for residents in Glendale; approximately 31% of Hispanics; 30% of
Armenians; and 26% of Anglos identified it. While Glendale Hispanics are
just about as likely to mention mainstream television as geo-ethnic television,
mainstream television did not rank in the four most frequent resources
identified by Hispanics in other areas.
• Newspapers are important for community events, but what type of newspaper
varies. While Hispanics in Southeast L.A. (25.3%) and Pico Union (22.9%)
are more likely to identify geo-ethnic newspapers as a resource, Glendale
Hispanics are more likely to rely on mainstream newspapers (24.5%).
Glendale Anglos identify both mainstream (37.6%) and geo-ethnic
newspapers (28.6%) as important. Armenians are least likely of the groups to
identify newspapers, but still geo-ethnic newspapers (12.8%) ranks in their
top four most frequently identified resources for the understanding goal.
• Geo-ethnic radio ranks fourth most frequently for Hispanics in Southeast
L.A. and Pico Union, was (21.7% and 20.6% respectively), but was not in the
top four resources identified by any other geo-ethnic group.
Taken together these findings illustrate geo-ethnic outcomes; that is, that
people in the same place can vary by ethnicity and the same ethnicity in different
places also produces variation.
69
RQ1b: Are there geo-ethnic differences with respect to orientation goal connections?
For the orientation goal, respondents identify the most important ways they
get information to make decisions about the products they buy. For the entire sample
(N = 1290), interpersonal channels are most frequently mentioned (N = 369),
followed by geo-ethnic TV (N = 263), mainstream TV (N = 236), Internet (N = 204),
books/magazines (N = 161), mainstream newspapers (N = 147), geo-ethnic
newspapers (N = 139), brochures/literature/mailings/advertising/prices/coupons/
specials (N = 111), and trial use (N = 102). Geo-ethnic radio (N = 64), mainstream
radio (N = 30), and product labels (N = 26) were less frequently mentioned. There
are geo-ethnic differences in the connection patterns for the orientation goal (Table
4.2).
Table 4.2: Top 4 connections for orientation goal by geo-ethnic study area
Hispanics Hispanics Hispanics Anglos Armenians
Southeast L.A. Pico Union Glendale Glendale Glendale
N=438 N=301 N=151 N=189 N=211
1
Geo-Ethnic TV
Geo-Ethnic TV Interpersonal Interpersonal Interpersonal
25.6% 31.9% 35.8% 37.6% 28%
2
Interpersonal
Geo-Ethnic
Newspapers
Mainstream
TV Internet
Mainstream
TV*
Internet*
25.3% 20.6% 23.8% 30.7% 18.5%
3
Mainstream TV Interpersonal Internet
Mainstream
Newspapers
15.3% 20.3% 21.9% 25.4%
4
Geo-Ethnic
Newspapers Mainstream TV
Books &
Magazines
Mainstream
TV
Geo-Ethnic
TV
12.8% 12.6% 19.9% 24.9% 10.9%
* Indicates tie.
The major similarities and differences between groups are as follows:
70
• Interpersonal channels are important in making decisions about what
products to purchase by all geo-ethnic groups. However, while Glendale
Anglos, Armenians, and Hispanics mention it most frequently, other
resources are identified more often for the orientation goal by Hispanics in
Southeast L.A. and Pico Union.
• Mainstream TV is important for all groups to determine what products to
buy, but the relative importance varies. Glendale Anglos (24.9%), Hispanics
(23.8%), and Armenians (18.5%) as well as Southeast L.A. (15.3%) and Pico
Union (12.6%) respondents identified mainstream TV as important for
orientation.
• Geo-ethnic TV is indicated for the orientation goal most frequently in
Southeast L.A. (25.6%) and Pico Union (31.9%) and within the top four for
Glendale Armenians (10.9%). It is not in the top four resources identified by
Glendale Hispanics and Anglos.
• Newspapers are mentioned as important resources for determining what
products to buy in only three geo-ethnic areas. Glendale Anglos identify
mainstream newspapers (25.4%), while Hispanics in Pico Union (20.6%) and
Southeast L.A. (12.8%) prefer geo-ethnic newspapers for the orientation goal.
• The Internet is identified as an important resource for orientation by Glendale
residents— 30.7% of Anglos, 21.9% of Hispanics, and 18.5% of
Armenians— but does not rank within the top four in either Southeast L.A. or
Pico Union.
71
• Books or magazines (19.9%) are identified as important by Glendale
Hispanics, but no other geo-ethnic group.
These findings taken together indicate geo-ethnic variations in connection
patterns for the orientation goal.
RQ1c: Are there geo-ethnic differences with respect to play goal connections?
For the play goal, respondents were asked to name the ways that they usually
“relax and have fun.” Communication resources are mixed with other recreational
activities within the answers to this category so that the phenomenological conditions
in which media and interpersonal channels co-exist with other ways of achieving
goals. Categorizations that are not traditionally considered “communication
resources” existed for the other goals, but were not identified frequently. For the
entire sample (N = 1290), sports/exercise/travel/parks/outdoors are mentioned most
frequently (N = 407). Spending time with family or friends (N=351), geo-ethnic TV
(N = 220), mainstream TV (N = 205), books/magazines (N = 204), movies (N = 169),
social activities (N = 131), hobbies/games (N = 116), and listening to music
(N = 111) are also mentioned relatively often. Geo-ethnic radio (N = 87), Internet
(N = 65), mainstream radio (N = 55), highbrow cultural activities/art shows/concerts/
theatre (N = 34), geo-ethnic newspapers (N = 18), and mainstream newspapers
(N = 15) are mentioned less frequently. Table 4.3 illustrates the differences in most
frequently mentioned sources of play for the five geo-ethnic groups.
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Table 4.3: Top 4 connections for play goal by geo-ethnic study area
Hispanics Hispanics Hispanics Anglos Armenians
Southeast L.A. Pico Union Glendale Glendale Glendale
N=438 N=301 N=151 N=189 N=211
1
Sports/
Outdoors
Sports/
Outdoors
Family/
Friends
Family/
Friends
Family/
Friends
33.1% 38.9% 35.8% 37.0% 31.3%
2 Family/
Friends Geo-Ethnic TV
Sports/
Outdoors
Mainstream
TV
Mainstream
TV
23.3% 21.3% 31.8% 30.2% 19.0%
3
Geo-Ethnic TV
Family/
Friends Movies
Sports/
Outdoors
Sports/
Outdoors
19.6% 17.9% 21.9% 27.5% 17.5%
4
Books &
Magazines
Books &
Magazines
Mainstream
TV
Books &
Magazines
Books &
Magazines
11.9% 12.6% 15.9% 25.4% 17.1%
The major similarities and differences between groups are as follows:
• Sports/exercise/travel/parks/outdoors are amongst the top most frequently
identified resources for the play goal. These activities are mentioned most
frequently amongst Hispanics in Pico Union (39%) and Southeast L.A.
(33%), but also appear in the top four most frequent responses for Glendale
Hispanics (32%), Anglos (28%), and Armenians (18%).
• All geo-ethnic groups identify family and/or friends in the top four most
frequent resources for relaxation and fun. However, Glendale Anglos (37%),
Hispanics (36%), and Armenians (31%) mention family or friends more often
than Hispanics in Southeast L.A. (23%) and Pico Union (18%).
• Television, mainstream or geo-ethnic? All geo-ethnic groups identified
television as a play goal resource. However, for Glendale Anglos (30%),
Armenians (19%), and Hispanics (16%) it was mainstream television, but for
73
Hispanics in Pico Union (21%) and Southeast L.A. (20%) it was geo-ethnic
television.
• All geo-ethnic groups except Glendale Hispanics identify books or magazines
as important for play. Glendale Anglos (25.4%) and Armenians (17.1%) as
well as Hispanics in Pico Union (12.6%) and Southeast L.A. (11.9%)
frequently mentioned books and magazines.
• Glendale Hispanics are the only group that frequently indicated movies
(21.9%) are important for the play goal.
While there are many similarities in the resources identified most frequently
for play goals, the relative importance of the different resources in relation to each
other indicate geo-ethnic differences. In addition, Glendale Hispanics prove to be a
unique case, varying from both Hispanics in other study areas and Glendale Anglos
and Armenians.
RQ1d: Are there geo-ethnic differences with respect to health goal connections?
For the health goal, respondents identified the most important ways they get
medical and health information. For the entire sample, the most frequently
mentioned connections for health information were health professionals (N = 346),
family or friends (N = 316), geo-ethnic TV (N = 285), books or magazines (N = 190),
Internet (N = 166), mainstream TV (N = 112), pamphlets/leaflets (N = 108),
geo-ethnic newspapers (N = 84), geo-ethnic radio (N = 68), mainstream newspapers
(N = 56), alternative health professionals (N = 44), and mainstream radio (N = 12).
74
Table 4.4 shows the top four most frequently identified health information resources
that each geo-ethnic group identifies connecting to for health information.
Table 4.4: Top 4 health information resources for each geo-ethnic study area
Hispanics Hispanics Hispanics Anglos Armenians
Southeast L.A. Pico Union Glendale Glendale Glendale
N=438 N=301 N=151 N=189 N=211
1
Geo-Ethnic
TV
Geo-Ethnic
TV
Health
Professionals
Health
Professionals
Health
Professionals
31.7% 33.2% 30.5% 45.5% 25.1%
2
Family/
Friends
Family/
Friends
Family/
Friends Internet
Geo-Ethnic
TV
27.4% 26.9% 19.9% 26.5% 17.1%
3
Health
Professionals
Health
Professionals Internet
Books &
Magazines
Family/
Friends
21.7% 18.3% 17.2% 23.3% 16.1%
4
Books &
Magazines
Geo-Ethnic
Newspapers
Books &
Magazines
Family/
Friends Internet
13.7% 11.6% 16.6% 20.6% 13.7%
The major similarities and differences between groups are as follows:
• Health professionals are mentioned frequently by all geo-ethnic groups, but
are most popular amongst Glendale residents. Glendale Anglos (46%),
Hispanics (31%) and Armenians (25%) all identify health professionals more
frequently than other health information resource. Health professionals are
mentioned third most frequently by Hispanics in Southeast L.A. (22%) and
Pico Union (18%).
• All the geo-ethnic groups frequently mention family or friends as a resource
of health information. For Hispanics, family or friends are identified second
most often for health goals— Southeast L.A. (27%); Pico Union (27%)
75
Glendale (20%)— while one or two other resources were identified more
often for Glendale Anglos (21% identified family or friends, fourth most
frequent response) and Armenians (16% identified family or friends, third
most common answer).
• Geo-ethnic differences in consulting television for health information. It is
identified by Southeast L.A. (32%) and Pico Union (33%) Hispanics most
frequently and by Glendale Armenians (17%) second most often for health;
Glendale Anglos and Hispanics do not mention any form of television as
important for finding out health information.
• Hispanics in the different study areas also differ in their connections to
printed health materials. Hispanics in both Southeast L.A. (14%) and
Glendale (17%) identify books or magazines as important, while Hispanics in
Pico Union are more likely to reference geo-ethnic newspapers (12%).
Glendale Anglos (23%) also identify books or magazines frequently, while
Glendale Armenians do not preference any form of print materials for health.
• Internet is again only mentioned frequently by Glendale Anglos (27%),
Hispanics (17%), and Armenians (14%).
While the relative rankings of the resources differ, Anglos and Hispanics in
Glendale identify the same four resources most frequently for health. Armenians
differ from the other Glendale residents by identifying a higher connection to geo-
ethnic TV. Hispanics in Glendale again differ from Hispanics in Pico Union and
76
Southeast L.A. with regard to the relative importance of communication resources
for the health goal.
RQ2: Do telephone or Internet connections vary by geo-ethnicity?
The goal of this research question was to determine if providing telephone
and Internet information as part of campaigns might be more effective for some
target groups than others. Since the MSD telephone and Internet items were altered
between surveys only Southeast L.A. (N = 438) and Pico Union (N = 301) samples
are compared. Independent t-tests were used test for differences between geo-ethnic
areas for the specific health related items and the intensity measures. Geo-ethnic
differences for telephone connections are shown in Table 4.5.
Table 4.5: Independent t-tests: Geo-ethnic telephone connection intensity
comparison
Southeast
L.A
Mean (SD)
Pico Union
Mean (SD)
df t-value Sig.
Get social, medical,
education, child care
information
4.05 (1.44) 4.32 (1.26) 696.6^ -2.67 .008**
Solve health, family,
neighborhood problems
4.00 (1.40) 4.11 (1.39) 737 -1.04 .300
Telephone connection
intensity
3.11 (1.21) 3.34 (1.19) 737 -2.53 .012*
^Equal variances not assumed. *Significant at the p<.05 level. **Significant at the p<.01 level.
Levene’ s test of equal variances showed a significant difference in variances
for the item “Get social, medical, education, child care information”, F(1,737) =
17.16, p < .001; Pico Union residents (M = 4.32) indicated stronger connections to
the phone for getting social, medical, education, and child care information than
those in Southeast L.A. (M = 4.05), t(1,696.6) = -2.67, p < .01. There was no
77
significant difference between geo-ethnic study areas for the other health-related
goal item, “Solve health, family, and neighborhood problems”: t(1,737) = -1.04, p >
.05. Overall, those in Pico Union identified a significantly stronger telephone
connection intensity (M = 3.34), than those in Southeast L.A. (M = 3.11), t(1,737) =
-2.53, p < .05.
Internet MSD Connections
Internet connection rates are rather low, leaving only approximately 24% of
the Southeast L.A. respondents (N = 104) and 22% of the Pico Union respondents
(N = 67) for the geo-ethnic comparison. Independent t-tests were used to determine if
differences between Internet connectors in the two geo-ethnic study areas were
significant. Table 4.6 illustrates the geo-ethnic variances in Internet connections for
health-related goals, the Internet connection intensity measure, and the Internet
health scope measure.
Table 4.6: Independent t-tests: Geo-ethnic Internet connections comparisons
Southeast
L.A.
Mean (SD)
Pico Union
Mean (SD)
df t-value Sig.
Advice on how to deal
with doctors or clinics
3.21 (1.50) 3.50 (1.52) 169 -1.24 .22
Get information about
social, medical,
educational or childcare
services
3.39 (1.52) 3.61 (1.45) 169 -.93 .35
Internet intensity 2.94 (1.03) 3.32 (1.04) 169 -2.36 .02*
Health connection scope
!
3.28 (1.71) 2.94 (1.81) 79 .86 .39
!
Only those who indicate looking for health information online are included in this measure.
*Significant at the p<.05 level.
78
Hispanics living in Pico Union (M = 3.32) indicate significantly stronger Internet
connection intensity compared to those in Southeast L.A. (M = 2.94), t(1,169) =
-2.36, p < .05. There are no significant differences between the Hispanics living in
the two areas when it comes to using the Internet for health, both when it comes to
the specific health-related goal items and the scope of potential online health
behaviors.
The number of Internet connectors who indicated that they look for health
information online is low (N = 81); 44% of Southeast L.A. Internet connectors
(N = 46) and 52% of Pico Union Internet connectors (N = 35) seek health
information online. Pearson’ s chi-square was used to determine if geo-ethnic
differences with regard to online health behaviors were significant. Table 4.7 shows
area frequencies and results of the chi-square tests.
The chi-square tests indicated that Hispanics in these two study areas do not
differ significantly in the types of activities they engage in when they go online for
health. The only item that may have risen to significance if there were more Internet
connectors going online for health in these communities is “diagnosing or treating a
medical condition on your own, without consulting your doctor.” Thirty percent of
Pico Union Internet health connectors indicated going to the Internet to self-diagnose
as compared to 14% of Southeast L.A. Internet health connectors. For both areas, the
most common online health activity was looking for information about illnesses and
medical conditions; mentioned by 91% of the Pico Union connectors and 86% of
Southeast L.A. connectors. The second most frequent online health behavior in these
79
areas was looking for information or advice about nutrition, exercise or weight
control; identified by 80% of Southeast L.A. and 85% of Pico Union Internet for
health connectors. The third most frequent online health behavior is looking for
information about a sensitive health topic that is difficult to talk about; this is
mentioned by 61% of the connectors in Pico Union. This option is tied in frequency
with “looking for information about a particular doctor or hospital” in Southeast L.A.
“Looking for information about alternative or experimental treatments or medicines”
(59%) was the fourth most common online health activity in Pico Union.
Table 4.7: Frequencies and chi-squares: Geo-ethnic comparisons of online health
behavior
Southeast L.A
% YES.
Pico Union
% YES
X
2
p value
Look for information on
illness or medical condition
85.7% 91.3% .62 .43
Look for information about a
particular doctor or hospital
65.7% 56.5% .70 .40
Look for information about
alternative or experimental
treatments or medicines
48.6% 58.7% .82 .37
Look for information about a
sensitive health topic that is
difficult to talk about
65.7% 60.9% .2 .66
Look for information about
prescription drugs
37.1% 41.3% .14 .70
Look for information or
advice about nutrition,
exercise or weight control
80% 84.8% .32 .57
Diagnose or treat a medical
condition on your own,
without consulting your
doctor
14.3% 30.4% 2.89 .09
Gather information BEFORE
visiting your doctor
42.9% 45.7% .06 .80
80
RQ3: Are there any patterns in the types of communication resources
Hispanic individuals connect to in order to achieve their goals?
The goal of this series of analyses was to determine what types of
information sources individuals identified most frequently in conjunction with the
resources identified as important for the health goal
11
. In doing this, a more complete
picture of Hispanic individual communication connection patterns can be made. For
each potential resource identified for the health goal, frequencies were run to
determine what percentage of the population that selected a resource for health also
selected each of the other health resources. For example, if “family or friends” was
an important health resource, what other health goal resources did they tend to
identify? Similar analyses were run for each MSD goal
12
. Given the large quantity of
data, only the most notable trends will be discussed in the text; the reader is
encouraged to inspect the tables further.
RQ3a: What resources are mentioned most often together for the health goal?
Table 4.8 illustrates the top four communication resource combinations for
health identified most frequently by Hispanics.
11
Since alternative health professionals and mainstream radio were not frequently mentioned, they
were not included while reporting the results.
12
The analyses were also run for the entire sample. When the Anglos and Armenians were removed
from the sample, the relative importance of communication resources shifted so that the Internet and
mainstream channels became less important (except when identified as important for the health goal).
81
Table 4.8: T op 4 communication channels combinations for each health information resource
* Indicates tie
Family &
Friends
Health
Profs.
Internet Mainstream
TV
Geo-ethnic
TV
Geo-ethnic
Radio
Mainstream
Nwsp.
Geo-ethnic
Nwsp.
Books &
Magazines
Other
Print
N=231 N=199 N=79 N=75 N=245 N=65 N=33 N=80 N=120 N=79
1
Geo-ethnic
TV
Family/
Friends
Family/
Friends Geo-ethnic TV
Family/
Friends
Geo-ethnic
TV Mainstream TV Geo-ethnic TV
Family/
Friends
Geo-ethnic
TV
20.8% 10.1% 17.7% 24% 19.6% 66.2% 36.4% 52.5% 21.7% 25.3%
2
Book/Mags
Book/
Mags
Health
Profs.*
Book/
Mags* Family/ Friends
Geo-ethnic
Radio
Family/
Friends Book/Mags
Family &
Friends
Geo-ethnic
TV
Family/
Friends
11.3% 7% 16.5% 22.7% 17.6% 24.6% 21.2% 27.5% 20.8% 19%
3
Geo-ethnic
Nwsp.
Internet*
Geo-ethnic
TV*
Book/Mags
Geo-ethnic
Nwsp.
Geo-ethnic
Nwsp Internet
Geo-ethnic
Radio Health Profs
Book/
Mags
9.5% 6.5% 17.3% 17.1% 23.1% 15.2% 18.8% 11.7% 13.9%
4
Health Profs
Geo-ethnic
TV
Mainstream
Nwsp Book/Mags Book/Mags
Family &
Friends Book/ Mags
Geo-ethnic
Nwsp.*
Internet*
Mainstream
TV*
Health
Profs.
8.7% 8.9% 16% 10.2% 16.9% 12.1% 16.3% 10.8% 12.7%
82
Notable health communication resource combinations include:
• Interpersonal channels, especially family and friends, are important. Family
or friends are identified as a health resource frequently within all the other
health information resources. Health professionals, on the other hand, only
appear frequently with family or friends, books or magazines, the Internet,
and geo-ethnic television.
• Geo-ethnic resources tend to be mentioned together. For example, those who
identified geo-ethnic television frequently mentioned geo-ethnic radio and/or
geo-ethnic newspapers.
• Books or magazines are frequently mentioned with geo-ethnic resources,
primarily geo-ethnic television.
• Written materials (e.g., newspapers, books or magazines, Internet, “other
print”) are often mentioned together, while mediated resources (e.g., radio
and television) appear frequently together.
RQ3b: What resources are mentioned most often for the understanding goal
in conjunction with each health communication resource connection?
Similar analyses were used to determine what communication connections
were mentioned frequently for the understanding goal in combination with each of
the health goal resources that were identified. Understanding was measured by a
question that asked, “What are the most important ways for you to stay on top of
what’ s happening in your community?” Table 4.9 illustrates the top four
83
communication resource combinations for health and understanding that are
identified most frequently by Hispanics.
Notable health communication and understanding goal resource combinations
include:
• Interpersonal channels are mentioned as one of the top four most important
resources for the understanding goal with all the health communication
resources except for the Internet.
• Television is important understanding resource. Geo-ethnic television is
identified as an important resource for understanding in conjunction with
each health resource except mainstream newspaper. Mainstream television is
identified for understanding frequently when health professionals, the
Internet, mainstream television, mainstream newspapers, and books or
magazines are identified as important for the health goal.
• Geo-ethnic newspaper is often mentioned in combination with the health
resources. The notable exception is that when the Internet and mainstream
television are implicated for health, mainstream newspapers are more often
mentioned for the understanding goal.
• Geo-ethnic resources tend to be mentioned together. For example, those who
identified geo-ethnic television frequently mentioned geo-ethnic radio and/or
newspapers.
• The Internet is not mentioned frequently for understanding in conjunction
with any health resource except the Internet.
84
Table 4.9: T op 4 communication channels for understanding within each health information resource
Family &
Friends
Health
Profs.
Internet Mainstream
TV
Geo-
ethnic
TV
Geo-
ethnic
Radio
Mainstream
Nwsp.
Geo-ethnic
Nwsp.
Books &
Magazines
Other
Print
N=231 N=199 N=79 N=75 N=245 N=65 N=33 N=80 N=120 N=79
1
Geo-ethnic
TV
Geo-
ethnic TV Internet
Mainstream
TV
Geo-ethnic
TV
Geo-ethnic
TV Interpersonal Geo-ethnic TV
Geo-ethnic
TV
Geo-ethnic
TV
51.9% 46.7% 34.2% 56% 71.8% 66.2% 45.5% 70% 54.2% 58.2%
2
Interpersonal
Inter-
personal
Geo-
ethnic TV Geo-ethnic TV
Geo-ethnic
Nwsp.
Geo-ethnic
Radio
Geo-ethnic
Nwsp*
Mainstream
TV*
Geo-ethnic
Nwsp Interpersonal
Geo-ethnic
Nwsp
40.3% 30.2% 31.6% 32% 31.8% 60% 39.4% 47.5% 32.5% 36.7%
3
Geo-ethnic
Nwsp
Main-
stream TV
Main-
stream
Nwsp Interpersonal Interpersonal Interpersonal
Interpersonal*
Geo-ethnic
Radio*
Geo-ethnic
Nwsp
Geo-ethnic
Radio
21.6% 25.1% 30.4% 29.3% 31.4% 41.5% 30% 31.7% 27.8%
4
Geo-ethnic
Radio
Geo-
ethnic
Nwsp
Main-
stream TV
Mainstream
Nwsp
Geo-ethnic
Radio
Geo-ethnic
Nwsp
Mainstream
Nwsp
Mainstream
TV Interpersonal
18.2% 16.1% 27.8% 22.7% 27.3% 40% 36.4% 25% 24.1%
85
RQ3c: What resources are mentioned most often for the orientation goal
in conjunction with each health communication resource connection?
A series of analyses were used to determine what communication
connections were mentioned frequently for the orientation goal in combination with
each of the health goal resources that were identified. The orientation goal asked,
“What are the most important ways you get information to make decisions about the
products you buy?” Table 4.10 illustrates the top four communication resource
combinations for health and orientation that are identified most frequently by
Hispanics.
Notable health communication and orientation resource combinations
include:
• Interpersonal channels are mentioned as one of the top four most important
resources for the orientation goal in conjunction with all the health
communication resources except for the mainstream newspapers.
• Television is an important orientation resource. Geo-ethnic television is
identified as an important resource in conjunction with each health resource
except the Internet, mainstream television, and mainstream newspaper.
Instead, mainstream television appears frequently with those three health
resources as well as with family or friends, health professionals, and geo-
ethnic television.
86
Table 4.10: T op 4 communication channels for orientation within each health information resource
* Indicates Tie.
Family &
Friends
Health
Profs.
Internet Mainstream
TV
Geo-
ethnic
TV
Geo-
ethnic
Radio
Mainstream
Nwsp.
Geo-
ethnic
Nwsp.
Books &
Magazines
Other
Print
N=231 N=199 N=79 N=75 N=245 N=65 N=33 N=80 N=120 N=79
1
Interper-
sonal
Inter-
personal Internet
Mainstream
TV
Geo-ethnic
TV
Geo-ethnic
TV
Mainstream
Nwsp.
Geo-ethnic
TV Interpersonal
Geo-ethnic
TV
42.4% 27.1% 49.4% 42.7% 44.1% 53.8% 57.6% 53.8% 32.5% 34.2%
2
Geo-ethnic
TV
Geo-
ethnic TV
Inter-
personal Interpersonal
Interper-
sonal
Geo-ethnic
Radio
Mainstream
TV
Geo-ethnic
Nwsp Book/ Mags
Other Print*
Interper-
sonal*
26.8% 18.1% 30.4% 36% 22% 32.3% 54.5% 37.5% 26.7% 22.8%
3
Geo-ethnic
Nwsp *
Mainstream
TV* Trial Use
Main-
stream
TV
Mainstream
Nwsp
Geo-ethnic
Nwsp.
Interper-
sonal Internet
Interper-
sonal
Geo-ethnic
TV
15.2% 17.1% 22.8% 17.3% 21.2% 29.2% 24.2% 22.5% 23.3%
4
Main-
stream
TV
Books/
Mags Internet
Geo-ethnic
Radio*
Mainstream
TV*
Geo-ethnic
Nwsp Books/ Mags
Geo-ethnic
Radio
Mainstream
Nwsp
Geo-ethnic
Nwsp
15.1% 16.5% 16% 11% 23.1% 21.1% 16.3% 16.7% 21.5%
87
• Geo-ethnic newspaper is often mentioned in combination with the health
resources. The notable exception is that when the Internet and mainstream
television are implicated for health, mainstream newspapers are more often
mentioned for the understanding goal.
• Geo-ethnic resources are related to other geo-ethnic resource connections.
Mainstream connections tend to be mentioned with other mainstream
resources as well.
• The Internet is identified frequently for orientation only when the Internet
and mainstream channels are identified as important for the health goal.
• Books or magazines are only mentioned frequently for orientation when they
were also identified for the health goal. Interpersonal, geo-ethnic television,
and mainstream newspapers are often mentioned for orientation when books
or magazines were identified for the health goal.
RQ3d: What resources are mentioned most often for the play goal in
conjunction with each health communication resource connection?
A series of analyses were also used to determine what communication
connections were mentioned frequently for the play goal in combination with each of
the health goal resources that were identified. The play goal asked, “What are the
ways that you usually relax and have fun?” Table 4.11 illustrates the top four
communication resource combinations for health and play that were identified most
frequently by Hispanics.
88
Notable health communication and play resource combinations include:
• Sports/exercise/travel/parks/outdoors are amongst the top most frequently
identified resources for the play goal for each health information resource
identified.
• Family or friends are mentioned as one of the top four most important
resources for the play goal in conjunction with all the health communication
resources.
• Television is an important play resource. Either geo-ethnic television or
mainstream television is identified as an important play resource in
conjunction with each health resource except health professionals.
• Movies are identified as an important source of play when health
professionals, the Internet, and mainstream television are identified as
important for the health goal.
• Geo-ethnic resources are related to other geo-ethnic resource connections.
Mainstream connections tend to be mentioned with other mainstream
resources as well.
• Books or magazines are mentioned frequently for play when family or
friends, mainstream newspapers, geo-ethnic newspapers, books or magazines,
or “other print” are identified for the health goal.
• The Internet is not identified frequently for play in conjunction with any
health goal resource.
89
Table 4.11: T op 4 communication channels for play within each health information resource
* Indicates tie.
Family &
Friends
Health
Profs.
Internet Mainstream
TV
Geo-ethnic
TV
Geo-ethnic
Radio
Mainstream
Nwsp.
Geo-ethnic
Nwsp.
Books &
Magazines
Other
Print
N=231 N=199 N=79 N=75 N=245 N=65 N=33 N=80 N=120 N=79
1
Outdoor/
Sports
Outdoor/
Sports
Outdoor/
Sports Outdoor/ Sports
Outdoor/
Sports
Outdoor/
Sports Outdoor/ Sports
Geo-ethnic
TV
Outdoor/
Sports
Outdoor/
Sports
32.5% 42.7% 36.7% 42.7% 38% 43.1% 51.5% 38.8% 40.8% 41.8%
2
Family/
Friends
Family/
Friends
Family/
Friends Mainstream TV
Geo-ethnic
TV
Geo-ethnic
Radio Mainstream TV
Outdoor/
Sports
Family/
Friends Family/ Friends
31.2% 26.1% 31.6% 26.7% 26.9% 35.4% 39.4% 36.3% 26.7% 31.6%
3
Geo-ethnic
TV Movies Movies Family/ Friends
Family/
Friends
Family/
Friends Family/ Friends Books/ Mags Books/ Mags
Geo-ethnic
TV
24.2% 14.1% 20.3% 21.3% 18.8% 29.2% 27.3% 22.5% 25% 20.3%
4
Books/ Mags
Social Ac-
tivity
Main-
stream TV Movies
Geo-ethnic
Radio
Geo-ethnic
TV Books/ Mags
Family/
Friends
Mainstream
TV Books/ Mags
13.4% 13.6% 19% 20% 14.7% 27.7% 24.2% 21.3% 20% 17.7%
90
RQ4: For which communication resources identified as important for the
health goal do respondents have stronger connections to the telephone and Internet?
Independent t-tests were used to determine if the strength of connections to
the telephone for the health-related items and overall telephone connection intensity
was related to health resource connections. Tables 4.12-4.20 illustrate the
relationships between major health resource connections and the strength of
telephone connections. Due to changes in the survey questions that measured
telephone connections, only the Southeast L.A. and Pico Union samples are used in
these analyses (N = 739).
Two hundred and one people in this sample indicated that they go to family
or friends for health information. Table 4.12 shows telephone connection intensity
differences for those who identified friends and family as an important resource for
health compared to those who did not.
Table 4.12: Independent t-tests: Connections to family or friends for health and
telephone connection intensity comparison
Family or
Friends Not
Mentioned
Mean (SD)
Family or
Friends
Important
Mean (SD)
df t-value Sig.
Get social, medical,
education, child care
information
4.11 (1.39) 4.27 (1.34) 737 -1.42 .16
Solve health, family,
neighborhood problems
4.02 (1.41) 4.11 (1.36) 737 -.77 .44
Telephone connection
intensity
3.18 (1.21) 3.28 (1.20) 737 -1.04 .30
91
No significant differences in telephone connection health goals or telephone
connection intensity were found between those who identified family or friends as an
important health resource and those who did not.
One-hundred and fifty respondents indicated that health care professionals
are an important health information resource. Results of independent t-tests are
shown in Table 4.13.
Table 4.13: Independent t-tests: Connections to health professionals for health and
telephone connection intensity comparison
Health Profs
Not
Mentioned
Mean (SD)
Health Profs
Important
Mean (SD)
df t-value Sig.
Get social, medical,
education, child care
information
4.18 (1.36) 4.08 (1.44) 737 .79 .43
Solve health, family,
neighborhood problems
4.06 (1.38) 3.99 (1.48) 218.8^ .55 .59
Telephone connection
intensity
3.23 (1.21) 3.11 (1.20) 737 1.11 .27
^Equal variances not assumed.
Levene’ s test of equal variances showed a mildly significant difference in variance
for the item “solving health, family, and neighborhood problems” via the phone,
F(1,737) = 3.97, p < .05. However, those who identified health professionals as an
important health resource did not vary significantly from those who did not identify
health professionals on the telephone connection measures.
Fifty-two respondents in Pico Union and Southeast L.A. indicated that the
Internet is an important health information resource. Independent t-tests results are
shown in Table 4.14.
92
Table 4.14: Independent t-tests: Connections to Internet for health and telephone
connection intensity comparison
Internet Not
Mentioned
Mean (SD)
Internet
Important
Mean (SD)
df t-value Sig.
Get social, medical,
education, child care
information
4.12 (1.36) 3.65 (1.47) 737 2.75 .006**
Solve health, family,
neighborhood problems
4.09 (1.38) 3.40 (1.46) 737 3.45 .001**
Telephone connection
intensity
3.26 (1.20) 2.55 (1.09) 737 4.14 .000***
*Significant at the p<.05 level. **Significant at the p<.01 level. ***Significant at the p<.001 level.
Those who identified the Internet as one of the most important ways they get health
information find the phone less important for getting “social, medical, education,
child care information” (M = 3.65) than those who did not mention the Internet
(M = 4.12), t(1,737) = 2.75, p < .01. Respondents who revealed that the Internet was
an important health resource also found the phone less important to “solve health,
family, and neighborhood problems” (M = 3.40) than those who did not mention the
Internet (M = 4.09), t(1,737) = 3.45, p < .01. Finally, when it comes to the overall
intensity of connection to the telephone for several goals, including health, those
who identified going to the Internet for health placed a significantly lower
importance on the phone (M = 2.55) than respondents who did not identify the
Internet for the health goal (M = 3.26), t(1,737) = 4.14, p < .001.
Sixty-one respondents indicated that mainstream television is an important
health information resource. Results from independent t-tests are illustrated in Table
4.15.
93
Table 4.15: Independent t-tests: Connections to mainstream TV for health and
telephone connection intensity comparison
Mainstream
TV Not
Mentioned
Mean (SD)
Mainstream
TV
Important
Mean (SD)
df t-value Sig.
Get social, medical,
education, child care
information
4.17 (1.36) 4.02 (1.51) 737 .83 .41
Solve health, family,
neighborhood problems
4.07 (1.38) 3.75 (1.56) 737 1.70 .09
Telephone connection
intensity
3.23 (1.20) 2.97 (1.23) 737 1.57 .12
Those who identified mainstream TV as an important health resource did not vary
significantly from people who did not identify mainstream TV when it came to the
intensity of their telephone connections.
Two hundred and thirty-nine respondents indicated that geo-ethnic television
is an important health information resource. Independent t-tests are illustrated in
Table 4.16.
Table 4.16: Independent t-tests: Connections to geo-ethnic TV for health and
telephone connection intensity comparison
Geo-ethnic
TV Not
Mentioned
Mean (SD)
Geo-ethnic
TV
Important
Mean (SD)
df t-value Sig.
Get social, medical,
education, child care
information
4.02 (1.45) 4.44 (1.16) 572.7^ -4.15 .000***
Solve health, family,
neighborhood problems
3.90 (1.48) 4.34 (1.17) 579.5^ -4.41 .000***
Telephone connection
intensity
3.07 (1.22) 3.48 (1.12) 737 -4.39 .000***
^Equal variances not assumed. ***Significant at the p<.001 level.
94
Levene’s test of equal variances showed a significant difference in variances for the
two health-related items: “Get social, medical, education, child care information”,
F(1,737) = 31.08, p < .001, and “Solve health, family, and neighborhood problems”,
F(1,737) = 36.71, p < .001. Those who identified geo-ethnic television as one of the
most important ways they get health information found the phone more important for
getting “social, medical, education, child care information” (M = 4.44) than those
who did not mention geo-ethnic television (M = 4.02), t(1,573) = -4.15, p < .001.
Those who mentioned geo-ethnic television as an important health resource also
found the phone more important to “solve health, family, and neighborhood
problems” (M = 4.34) than those who did not identify geo-ethnic television
(M = 3.90), t(1,580) = -4.41, p < .001. Finally, when it comes to telephone
connection intensity, those who identified going to geo-ethnic television for health
placed a significantly higher importance on the phone (M = 3.48) than those not
identifying geo-ethnic television for health (M = 3.07), t(1,737) = -4.39, p < .001.
Sixty-two respondents indicated that geo-ethnic radio
13
is an important health
information resource. Independent t-test results are shown in Table 4.17.
13
Mainstream radio is not used in this analysis because only 8 people identified it as an important
health resource.
95
Table 4.17: Independent t-tests: Connections to geo-ethnic radio for health and
telephone connection intensity comparison
Geo-ethnic
Radio Not
Mentioned
Mean (SD)
Geo-ethnic
Radio
Important
Mean (SD)
df t-value Sig.
Get social, medical,
education, child care
information
4.13 (1.39) 4.42 (1.14) 78.73^ -1.86 .07
Solve health, family,
neighborhood problems
4.03 (1.40) 4.21 (1.32) 737 -.97 .33
Telephone connection
intensity
3.19 (1.21) 3.43 (1.20) 737 -1.53 .13
^Equal variances not assumed.
Levene’ s test of equal variances showed a significant difference in variances for the
item “Get social, medical, education, child care information”, F(1,737) = 8.52,
p < .01. Those who identified geo-ethnic radio as an important health resource did
not vary significantly from people who did not identify geo-ethnic radio with regard
to the telephone measures.
Seventy-eight respondents indicated that geo-ethnic newspaper
14
is an
important health information resource. The results of independent t-tests are
illustrated in Table 4.18.
14
Mainstream newspapers were also not included in this analysis due to a low number of people
(N=17) in these two Hispanic communities indicating it was important for health information.
96
Table 4.18: Independent t-tests: Connections to geo-ethnic newspapers for health and
telephone connection intensity comparison
Geo-ethnic
Nwsp. Not
Mentioned
Mean (SD)
Geo-ethnic
Nwsp.
Important
Mean (SD)
df t-value Sig.
Get social, medical,
education, child care
information
4.12 (1.41) 4.51 (1.00) 116.2^ -3.16 .002**
Solve health, family,
neighborhood problems
4.02 (1.41) 4.27 (1.25) 737 -1.51 .13
Telephone connection
intensity
3.18 (1.21) 3.41 (1.18) 737 -1.58 .12
^Equal variances not assumed. **Significant at the p<.01 level.
Levene’ s test of equal variances showed a significant difference in variances for the
item “Get social, medical, education, child care information”, F(1,737) = 19.80,
p < .001. Those who identified geo-ethnic newspapers as one of the most important
ways they get health information find the phone more important for getting “social,
medical, education, child care information” (M = 4.51) than those who did not
mention geo-ethnic newspaper (M = 4.12), t(1,116.2) = -3.16, p < .01. There were no
significant differences in the importance of the telephone overall or for “solving
health, family, neighborhood problems”.
Ninety-one respondents indicated that books or magazines were an important
health information resource. Independent t-tests results are depicted in Table 4.19.
97
Table 4.19: Independent t-tests: Connections to books or magazines for health and
telephone connection intensity comparison
Books or
Magazines
Not
Mentioned
Mean (SD)
Books or
Magazines
Important
Mean (SD)
df t-value Sig.
Get social, medical,
education, child care
information
4.17 (1.36) 4.07 (1.50) 737 .67 .50
Solve health, family,
neighborhood problems
4.06 (1.39) 3.97 (1.44) 737 .56 .57
Telephone connection
intensity
3.22 (1.20) 3.08 (1.26) 737 1.08 .28
Those who identified books or magazines as an important health resource did not
vary significantly from people who did not identify books or magazines when it
came to the intensity of their telephone connections for health-related activities
specifically or for the telephone in general.
Sixty-six respondents indicated that leaflets or pamphlets (i.e., “other print”)
are an important health information resource. Results from independent t-tests are
shown in Table 4.20.
Table 4.20: Independent t-tests: Connections to “other print” for health and
telephone connection intensity comparison
Other Print
Not
Mentioned
Mean (SD)
Other Print
Important
Mean (SD)
df t-value Sig.
Get social, medical,
education, child care
information
4.16 (1.37) 4.15 (1.39) 737 .02 .98
Solve health, family,
neighborhood problems
4.03 (1.41) 4.18 (1.30) 737 -.83 .40
Telephone connection
intensity
3.22 (1.21) 3.09 (1.14) 737 .82 .40
^Equal variances not assumed. *Significant at the p<.05 level. **Significant at the p<.01 level.
98
Those who identified leaflets or pamphlets as an important health resource did not
vary significantly from people who did not identify leaflets or pamphlets.
Internet MSD Connections within Health Goal Connections
Internet connectors (N = 171) make up approximately 23% of the Pico Union
and Southeast L.A. sample. Independent t-tests were again used to determine if there
were significant differences in the intensity and scope of Internet activities when
different communication resources were identified as important for the health goal.
Since only nine Internet connectors identified geo-ethnic radio, only ten identified
geo-ethnic newspapers, and eight mentioned leaflets or pamphlets for the health goal,
none of these connections were included in the Internet analyses. Due to their low
frequency of identification for the health goal in the entire Southeast L.A. and Pico
Union sample, mainstream radio and mainstream newspapers were also not included
in these analyses. Tables 4.21-4.26 illustrate the relationships between major health
resource connections and the strength and scope of Internet connections.
Forty Internet connectors identified family or friends as important health
resources; 20 respondents who indicated using the Internet for health purposes
mentioned friends or family as important for the health goal. Tables 4.21 shows the
differences in Internet connection intensity for those who identified friends or family
as an important resource for health compared to those who did not.
99
Table 4.21: Independent t-tests: Connections to family or friends for health and
Internet connection comparison
Family or
Friends Not
Mentioned
Mean (SD)
Family or
Friends
Important
Mean (SD)
df t-value Sig.
Advice on how to deal
with doctors or clinics
3.34 (1.47) 3.26 (1.67) 169 .29 .77
Get information about
social, medical,
educational or childcare
services
3.44 (1.48) 3.60 (1.52) 169 -.58 .56
Internet intensity 3.10 (1.04) 3.04 (1.09) 169 .31 .76
Health connection scope
!
3.07 (1.74) 3.35 (1.81) 79 -.63 .53
!
Only those who indicate looking for health information online are included in this measure
Those who identified family or friends as an important health resource did not vary
significantly from people who did not identify family or friends when it came to
Internet connection measures.
Forty Internet connectors indicated that health care professionals are an
important health information resource; 19 of those who indicated using the Internet
for health purposes identified health professionals for the health goal. Results from
independent t-tests are shown in Table 4.22.
Table 4.22: Independent t-tests: Connections to health professionals for health and
Internet connection comparison
Health Profs
Not
Mentioned
Mean (SD)
Health Profs
Important
Mean (SD)
df t-value Sig.
Advice on how to deal
with doctors or clinics
3.41 (1.49) 3.01 (1.54) 169 1.40 .14
Get information about
social, medical, educ.
or childcare services
3.54 (1.47) 3.28 (1.55) 169 .99 .32
Internet intensity 3.21 (1.03) 2.71 (1.05) 179 2.69 .008**
Health connection scope
!
3.29 (1.79) 2.63 (1.57) 79 1.44 .15
!
Only those who look for health information online are included in this measure; **Significant at the p<.01 level.
100
Those who identified health professionals as an important health resource did not
vary significantly from people who did not identify health professionals when it
came to health-related goals online and the scope of online health activities. Those
who identified health professionals as one of the most important health information
resources placed a significantly lower importance on the Internet (M = 2.71) than
those not identifying health professionals as an important health resource (M = 3.21),
t(1,179) = 2.69, p < .01
Fifty Internet connectors indicated that the Internet was one of the most
important resources for health information. This includes 40 of the 81 people who
said that they go online for health information. Independent t-tests results are
illustrated in Table 4.23.
Table 4.23: Independent t-tests: Connections to Internet for health and Internet
connection comparison
Internet Not
Mentioned
Mean (SD)
Internet
Important
Mean (SD)
df t-value Sig.
Advice on how to deal
with doctors or clinics
3.24 (1.58) 3.50 (1.33) 107.7^ -1.08 .28
Get information about
social, medical,
educational or childcare
services
3.36 (1.54) 3.78 (1.33) 169 -1.71 .09
Internet intensity 2.95 (1.09) 3.43 (.85) 116.6^ -3.10 .002**
Health connection scope
!
2.59 (1.64) 3.70 (1.70) 169 -3.00 .004**
!
Only those who indicate looking for health information online are included in this measure
^ Equal variances not assumed. **Significant at the p<.01 level.
101
Levene’ s test of equal variances showed a significant difference in variance for the
item “Advice on how to deal with doctors or clinics” via the Internet, F(1,169) =
4.91, p < .05 and for the Internet connection intensity measure, F(1,169) = 5.85,
p < .05. No significant differences existed between people who identified the Internet
as an important health resource and those who did not mention the Internet as an
important health resource when it comes to the specific health-related Internet goal
items. However, those who identified the Internet as one of the most important ways
they get health information had a stronger connection to the Internet for all goals
(M = 3.43) than those who did not mention the Internet as one of the most important
sources of health (M = 2.95), t(1,116.6) = -3.10, p < .01. And those who identified
going to the Internet for health information identified performing a significantly
higher number of online health activities (M=3.70) than those who did not identify
the Internet for health (M = 2.59), t(1,169) = -3.00, p < .01.
Nineteen Internet connectors indicated that mainstream television is
important for the health goal. Eight of the 81 respondents who indicated they go
online for health information identified mainstream television for the health goal.
Independent t-tests results are shown in Table 4.24.
102
Table 4.24: Independent t-tests: Connections to mainstream TV for health and
Internet connection comparison
Mainstream
TV Not
Mentioned
Mean (SD)
Mainstream
TV
Important
Mean (SD)
df t-value Sig.
Advice on how to deal
with doctors or clinics
3.33 (1.53) 3.26 (1.41) 169 .17 .86
Get information about
social, medical,
educational or childcare
services
3.50 (1.49) 3.32 (1.49) 169 .51 .61
Internet intensity 3.08 (1.04) 3.15 (1.14) 169 -.29 .77
Health connection scope
!
3.08 (1.80) 3.63 (1.31) 169 -.83 .41
!
Only those who indicate looking for health information online are included in this measure
Those who identified mainstream TV as an important health resource did not vary
significantly from those who did not identify mainstream TV for any of the Internet
variables.
Thirty-five Internet connectors indicated that geo-ethnic television is an
important health information resource. Of those who said that they have sought
health information online, 12 identified geo-ethnic television as an important health
resource. Independent t-tests results appear in Table 4.25.
Those who identified geo-ethnic television as one of the most important ways
they get health information find the Internet more important for getting “advice on
how to deal with doctors or clinics” (M = 3.89) than those who do not mention geo-
ethnic television (M = 3.17), t(1,169) = -2.53, p < .01. Those who identified going to
geo-ethnic television for health indicated performing significantly less health
activities online (M = 1.83) than those who did not identify geo-ethnic television for
health (M = 3.36), t(1,79) = 2.92, p < .01. There were no significant differences when
103
it came to the second specific health-related goal “getting information about social,
medical, educational, or childcare services” or the overall MSD Internet connection
intensity measure.
Table 4.25: Independent t-tests: Connections to geo-ethnic TV for health and Internet
connection intensity comparison
Geo-ethnic
TV Not
Mentioned
Mean (SD)
Geo-ethnic
TV
Important
Mean (SD)
df t-value Sig.
Advice on how to deal
with doctors or clinics
3.17 (1.53) 3.89 (1.28) 169 -2.53 .01*
Get information about
social, medical,
educational or childcare
services
3.40 (1.50) 3.78 (1.42) 169 -1.30 .19
Internet intensity 3.06 (1.05) 3.21 (1.06) 169 -.78 .43
Health connection scope
!
3.36 (1.72) 1.83 (1.40) 79 2.92 .005**
!
Only those who indicate looking for health information online are included in this measure
* Significant at the p<.05 level. **Significant at the p<.01 level.
Twenty Internet connectors indicated that books or magazines are an
important health information resource. Twelve of the people who said they have
looked for health information online indicated that books or magazines are an
important health resource. Independent t-tests results are illustrated in Table 4.26.
104
Table 4.26: Independent t-tests: Connections to books or magazines for health and
Internet connection comparison
Books or
Magazines
Not
Mentioned
Mean (SD)
Books or
Magazines
Important
Mean (SD)
df t-value Sig.
Advice on how to deal
with doctors or clinics
3.40 (1.48) 2.70 (1.63) 169 1.97 .05*
Get information about
social, medical,
educational or childcare
services
3.54 (1.48) 3.00 (1.56) 169 1.54 .13
Internet intensity 3.12 (1.03) 2.89 (1.18) 169 .89 .37
Health connection scope
!
3.16 (1.78) 3.00 (1.65) 79 .29 .77
!
Only those who indicate looking for health information online are included in this measure
* Significant at p = .05.
Those who identified books or magazines as an important health resource did not
vary significantly from people who did not identify books or magazines when it
came to the intensity of their Internet connections for health-related activities
specifically or for the Internet in general.
105
CHAPTER 5
SURVEY RESULTS
PART II: HEALTH DISPARITIES AND COMMUNICATION
CONNECTIONS
The goal of the second part of the data analysis is to determine if Hispanics
who indicate that they are affected by health disparities (e.g., have no regular place
for health care, have a greater difficulty finding medical care, and are affected more
by clinic closures) have similar communication resource connection patterns. If so,
then health practitioners and promoters might be informed by learning the best ways
to reach this population in order to improve the situation. The data used in these
analyses were available only for the Southeast L.A. and Pico Union study samples.
Considering only about half of these groups reported having health insurance— 55%
of Southeast L.A. adult respondents and 45% of Pico Union adult respondents had
health insurance— the likelihood of health disparities existing in these populations is
fairly high. Due to the State’ s many health insurance options for children, the rate of
health insurance reported for children in the household who are five years old or
younger was a little more optimistic with 86% of the respondents indicating their
children were insured. Approximately 69% of the children had had their eyes
checked and 75% of them had had their ears checked by a doctor, indicating some
form of medical care for these young children.
106
The descriptive statistics pertaining to health-related items used in the
analysis of the Pico Union, Southeast L.A., and the combined sample are reported in
Table 5.1.
Table 5.1: Health outcome measures for the geo-ethnic and total sample
Southeast L.A Pico Union Total Sample
Adult has regular health care
place
84% 78% 82%
Difficulty getting medical
care*
M = 2.56
SD = 1.02
M = 2.40
SD = 1.06
M = 2.49
SD = 1.04
Affected by clinic closures** M = 6.45
SD = 3.72
M = 7.74
SD = 3.17
M = 6.99
SD = 3.55
* Measured on a scale where 1 = very difficult, 2 = somewhat difficult, 3 = somewhat easy, and
4 = very easy.
** Measured on a range from 1 (Not at all affected) to 10 (Affected a great deal)
While 82% of adults indicated having a regular place to receive medical care,
they also reported being quite affected by local clinic closures and having difficulty
getting medical care. Pico Union residents tended to indicate slightly more difficulty
getting medical care than Southeast L.A. residents. While all residents reported that
local clinic closures would affect them to some degree, this feeling was slightly
greater in Pico Union than in Southeast L.A..
Specific Communication Connections and Health Disparities
Research questions five through seven address the specific communication
resources most highly related to health access outcomes. These questions were
explored first by examining how communication connections for specific MSD goals
were related to health outcomes and, second, by examining how connections to
resources for any MSD goal were related to outcomes. The specific MSD goals are
understanding, orientation, play, and health.
107
RQ5: Which specific communication resources deemed as important for goal
attainment attract the highest concentration of Hispanics with no regular place for
health and medical care?
A series of logistic regressions were used to determine the most important
communication connection resources for each MSD goal related to having no regular
place for medical care. Having a regular place for health care was used as the
dependent variable. Since there was no theoretical reason to suspect some
communication resources would have a greater impact than others, the
communication resources were entered into the equations in a backward stepwise
fashion. Only the communication resources that were identified most frequently (i.e.,
the top four choices in any Hispanic study area
15
) were included for each goal. The
inclusion decision rule is practical in nature. Some resources were deemed important
by such a small percentage of the sample that the likelihood of coming up with a
cost-effective strategy for reaching the intended audience through those channels is
not great.
For the understanding goal, interpersonal, books or magazines, mainstream
television, geo-ethnic television, geo-ethnic radio, mainstream newspapers, and geo-
ethnic newspapers were entered into the first logistic regression equation as
independent variables using a backwards-stepwise (Wald) procedure (the degree to
15
Even though the outcome measures were not available for the Glendale sample, the top four media
choices for each goal were included in the regression equation. The rationale is that their connection
patterns are unique enough from the overall patterns in the other study areas, but there might be some
common tie between their preferences and the Hispanics connecting to these resources within the
Southeast L.A. and Pico Union study areas.
108
which each independent variable predicts to the dependent variable is determined;
independent variables that are strong predictors are then included with other
independent variables to determine the effects when other independent variables are
included). None of the communication resources predicted having a regular place for
health care (p > .05).
Hispanics in the study areas identified interpersonal, Internet, books or
magazines, mainstream television, geo-ethnic television, and geo-ethnic newspapers
most frequently for the orientation goal. These items were entered into a second
logistic regression equation. None of the communication resources identified as
important for orientation predicted having a regular place for health care (p > .05).
For the play goal, friends or family, movies, books or magazines, mainstream
television, geo-ethnic television, and sports/exercise/travel/parks/outdoors were
entered into a third logistic regression equation as independent variables.
Sports/exercise/travel/parks/outdoors was the only variable that significantly
predicted having a regular place for health care, ß = .43, Wald (1) = 4.13, p = .04. Of
the people who do not have a regular place for health care, 27.8% identified
sports/exercise/travel/parks/outdoors as an important source of fun or relaxation. Of
those who have a regular place to go for health care, 37.2% identified
sports/exercise/travel/parks/outdoors as a source of fun or relaxation.
For the health goal, family or friends, health professionals, Internet, books or
magazines, geo-ethnic television, and geo-ethnic newspapers were mentioned most
frequently. Therefore, these communication resource connections were entered into
109
the regression equation as independent variables. Health professionals was the only
health goal communication resource that predicted having a regular place for medical
care, ß = .58, Wald (1) = 4.48, p = .03. Only 13.5% of people who do not have a
regular place for health care, as compared to 21.8% of people who have a regular
place for health care, identified health care providers as an important health resource.
As a final step in exploring this research question, response options that
appeared frequently across the goals— interpersonal (which includes both family and
friends and health professionals for the health goal), Internet, geo-ethnic television,
geo-ethnic radio, geo-ethnic newspapers, mainstream television, mainstream
newspapers, and books or magazines— were utilized in a logistic regression
equation. New variables were created to indicate when respondents’ connected to
each of these communication channels for any of the four goals. Interpersonal
channels were the only communication resource that predicted to having a regular
place for medical care, ß = .48, Wald (1) = 5.85, p = 016. While 60.2% of people
who do not have a regular place for health care identified interpersonal channels as
important for at least one of the MSD goals, 70.9% of people who have a regular
place for health care identified interpersonal channels are an important resource.
RQ6: Which specific communication resources did Hispanics who indicated
greater difficulty getting medical care deem as most important for goal attainment?
A series of backward stepwise multiple regressions (a procedure where
weaker independent variables are systematically removed from the equation until a
model with the strongest predictors remains) were run to determine if any of the
110
most important communication connection resources for each MSD goal were
related to having a greater difficulty getting medical care. The item assessing ease or
difficulty of getting health care was used as the dependent variable and the most
frequently identified individual communication resources
16
for each goal were
entered as independent variables.
For the understanding goal, interpersonal, books or magazines, mainstream
television, geo-ethnic television, geo-ethnic radio, mainstream newspaper, and geo-
ethnic newspapers were entered into the regression equation as independent
variables. The analyses resulted in six models. Table 5.2 shows the original model
that included all the communication resources entered and the final model in which
all communication resources except geo-ethnic television and mainstream
newspapers had been removed.
Table 5.2: Multiple regression analysis for understanding goal connections
predicting to difficulty getting medical care
Model 1 (ß) Final Model (ß)
Interpersonal -.03
Books or Magazines -.01
Mainstream TV .02
Geo-ethnic TV -.12** -.13***
Geo-ethnic Radio -.06
Mainstream Newspapers .10** .10**
Geo-ethnic Newspapers .02
Adjusted R
2
.03*** .03***
* p < .05; ** p < .01; *** p < .001.
16
As with the last research question, only the communication resource identified in the top four most
frequently mentioned by Hispanics in any of the three Hispanic study areas were included.
111
The original model significantly predicted ease of getting medical care,
F(7,714) = 3.97, p = .000. The complete regression model indicated that geo-ethnic
television, ß = -0.12, t(7,714) = -2.91, p = .004, and mainstream newspapers,
ß = 0.10, t(7,714) = 2.63, p = .009, had an impact on the ease or difficulty of getting
medical care. After systematically removing the other communication resources, the
final model significantly predicted ease of medical care, F(2,719) = 12.29, p = .000.
Geo-ethnic television, ß = -0.13, t(2,719) = -3.55, p =. 000, and mainstream
newspapers, ß = 0.10, t(2,719) = 2.73, p = .007, both had a significant impact on ease
of getting medical care. The relationships exist such that those who identified a
strong connection to geo-ethnic television had less ease (i.e., greater difficulty)
getting medical care (M = 2.35) than those who did not identify geo-ethnic television
as important for the understanding goal (M = 2.67). And in contrast, the people who
identified mainstream newspapers as important for the understanding goal reported
greater ease (i.e., less difficulty) getting medical care (M = 2.96) than those who did
not identify mainstream newspapers (M = 2.46).
Interpersonal, Internet, books or magazines, mainstream television, geo-
ethnic television, and geo-ethnic newspapers were mentioned most frequently by
Hispanics for the orientation goal. Therefore, these communication resources were
entered into the regression equation as independent variables. The analyses resulted
in four models. Table 5.3 shows the original model that included all the
communication resources entered and the final model in which all communication
112
resources except Internet, mainstream television, and geo-ethnic television were
removed.
Table 5.3: Multiple regression analysis for orientation goal connections predicting to
difficulty getting medical care
Model 1 (ß) Final Model (ß)
Interpersonal -.02
Internet .10** .10**
Books or Magazines -.03
Mainstream Television .09* .09*
Geo-ethnic Television -.12** -.11**
Geo-ethnic Newspapers .04
Adjusted R
2
.03*** .03***
* p < .05; ** p < .01; *** p < .001.
The original model significantly predicted ease of medical care, F(6,715) =
4.97, p = .000. The complete regression model showed that only Internet, ß = 0.10,
t(6,715) = 2.80, p = .005, mainstream television, ß = 0.09, t(6,715) = 2.42, p = .016,
and geo-ethnic television, ß = -0.12, t(6,715) = -3.08, p = .002, had an impact on the
ease or difficulty of getting medical care. After systematically removing the non-
significant communication resources, the final model was significant, F(3,718) =
9.17, p = .000. The Internet, ß = 0.10, t(3,718) = 2.82, p =. 005, mainstream
television, ß = 0.09, t(3,718) = 2.43, p = .016, and geo-ethnic television, ß = -0.11,
t(3,718) = -2.91, p =. 004, all significantly affected the ease of getting medical care.
Those who identified a strong connection to geo-ethnic television had less ease (i.e.,
greater difficulty) getting medical care (M = 2.27) than those who did not identify
geo-ethnic television as important for the orientation goal (M = 2.58). And in
contrast, the people who identified mainstream television as important resource for
the orientation goal reported greater ease (i.e., less difficulty) getting medical care
113
(M = 2.78) than those who did not identify mainstream television (M = 2.45).
Likewise, those who indicted the Internet was important reported greater ease (i.e.,
less difficulty) getting medical care (M = 2.90) than those who did not identify the
Internet (M = 2.46).
For the play goal, friends or family, movies, books or magazines, mainstream
television, geo-ethnic television, and sports/exercise/travel/parks/outdoors were
entered into the regression equation as independent variables. The analyses resulted
in six models. Table 5.4 shows the original model that included all the
communication resources entered and the final model in which all communication
resources except books or magazines were removed.
Table 5.4: Multiple regression analysis for play goal connections predicting to
difficulty getting medical care
Model 1 (ß) Final Model (ß)
Family or friends .02
Movies .02
Books or Magazines .08* .07*
Mainstream Television .06
Geo-ethnic Television -.03
Sports/Exercise/Travel/Parks/Outdoors .02
Adjusted R
2
.004 .004*
* p < .05; ** p < .01; *** p < .001.
The original model did not predict ease of medical care, F(6,715) = 1.45,
p = .194. The complete regression model showed only books or magazines, ß = 0.08,
t(6,715) = 2.07, p = .039, had an impact on the ease or difficulty of getting medical
care item. After systematically removing communication resources, the final model
was significant, F(1,720) = 3.97, p = .047. This final model had only one
independent variable, books or magazines, ß = 0.07, t(1,720) = 1.99, p = .047. Those
114
with a strong connection to books or magazines for play reported greater ease (i.e.,
less difficulty) getting medical care (M = 2.70) than those who did not identify books
or magazines (M = 2.46).
For the health goal, family or friends, health professionals, Internet, books or
magazines, geo-ethnic television, and geo-ethnic newspapers were mentioned most
frequently. Therefore, these communication resource connections were entered into
the regression equation as independent variables. The analyses resulted in four
models. Table 5.5 shows the original model that included all the communication
resources entered and the final model in which all communication resources except
Internet, geo-ethnic television, and geo-ethnic newspapers were removed.
Table 5.5: Multiple regression analysis for health goal connections predicting to
difficulty getting medical care
Model 1 (ß) Final Model (ß)
Family or Friends -.02
Health Professionals .03
Internet .18*** .18***
Geo-ethnic Television -.09* -.10*
Geo-ethnic Newspapers -.10* -.10**
Books or Magazines .04
Adjusted R
2
.05*** .06***
* p < .05; ** p < .01; *** p < .001.
The original model was shown to significantly predict ease of medical care,
F(6,715) = 7.81, p = .000. Only Internet, ß = 0.18, t(6,715) = 4.81, p = .000, geo-
ethnic television, ß = -0.09, t(6,715) = -2.26, p = .024, and geo-ethnic newspapers,
ß = -0.10, t(6,715) = -2.60, p = .01, had a significant impact. The final model also
significantly predicted ease of medical care, F(3,718) = 14.85, p = .000. After
systematically removing the other communication resources, the final model
115
indicated a significant impact of the Internet, ß = 0.18, t(3,718) = 4.86, p = .000, geo-
ethnic television, ß = -0.10, t(3,718) = -2.59, p = .01, and geo-ethnic newspapers,
ß = -0.10, t(3,718) = -2.69, p = .007, on the ease of getting medical care scores.
Those who identified a strong connection to geo-ethnic television had less ease (i.e.,
greater difficulty) getting medical care (M = 2.30) than those who did not identify
geo-ethnic television as important for the health goal (M = 2.59). Likewise, those
who connected to geo-ethnic newspapers had less ease (i.e., greater difficulty)
getting medical care (M = 2.13) than those who did not identify geo-ethnic television
as important for the health goal (M = 2.54). And in contrast, the people who
identified Internet was important reported greater ease (i.e., less difficulty) getting
medical care (M = 3.21) than those who did not identify the Internet (M = 2.44).
As a final step in exploring this research question, communication resource
connections identified frequently across the goals— interpersonal (which includes
both family and friends and health professionals for the health goal), Internet, geo-
ethnic television, geo-ethnic radio, geo-ethnic newspapers, mainstream television,
mainstream newspapers, and books or magazines— were utilized in a multiple
regression equation. New variables were created to indicate when respondents’
connected to each of these communication channels for any of the four goals. The
analyses resulted in six models. Table 5.6 shows the original model that included all
the communication resources entered and the final model in which all
communication resources except Internet, geo-ethnic television, and mainstream
newspapers were removed.
116
Table 5.6: Multiple regression analysis for general communication connections
predicting to difficulty getting medical care
Model 1 (ß) Final Model (ß)
Interpersonal .01
Internet .14*** .14***
Geo-ethnic Television -.12** -.14***
Geo-ethnic Radio -.05
Geo-ethnic Newspapers .002
Mainstream Television .04
Mainstream Newspapers .09* .10**
Books or Magazines -.003
Adjusted R
2
.06*** .06***
* p < .05; ** p < .01; *** p < .001.
While the original model significantly predicted ease of medical care,
F(8,713) = 6.85, p = .000, only Internet, ß = 0.14, t(8,713) = 3.65, p = .000, geo-
ethnic television, ß = -0.12, t(8,713) = -3.06, p = .002, and mainstream newspapers,
ß = 0.10, t(8,713) = 2.45, p = .014, had an impact on the ease or difficulty of getting
medical care. The final model also significantly predicted ease of medical care,
F(3,718) = 17.28, p = .000. After systematically removing the other communication
resources, the final model indicated a significant affect of the Internet, ß = 0.14,
t(3,718) = 3.70, p = .000, geo-ethnic television, ß = -0.14, t(3,718) = -3.69, p = .000,
and mainstream newspapers, ß = 0.10, t(3,718) = 2.70, p = .007, on the ease of
getting medical care. Those who identified a strong connection to geo-ethnic
television had less ease (i.e., greater difficulty) getting medical care (M = 2.36) than
those who did not identify geo-ethnic television as important for any of the MSD
goals (M = 2.82). And in contrast, the people with strong Internet connections
reported greater ease (i.e., less difficulty) getting medical care (M = 2.94) than those
who did not identify the Internet (M = 2.41). And the people who indicated that
117
mainstream newspapers were important for one or more of the goals reported greater
ease (i.e., less difficulty) getting medical care (M = 2.90) than those who did not
identify mainstream newspapers (M = 2.43).
RQ7: Which specific communication resources did Hispanics who indicated
being highly affected by local health clinic closures deem as most important for goal
attainment?
A series of backward stepwise multiple regressions were run to determine if
any of the most important communication connection resources for each MSD goal
were related to being more affected by the closure of local health clinics. The item
assessing how much respondents were affected by the local clinic closures was used
as the dependent variable and the most frequently identified individual
communication resources for each goal
17
were entered as independent variables.
For the understanding goal, interpersonal, books or magazines, mainstream
television, geo-ethnic television, geo-ethnic radio, mainstream newspapers, and geo-
ethnic newspapers were entered into the regression equation as independent
variables. The analyses resulted in four models. Table 5.7 shows the original model
that included all the communication resources entered and the final model in which
all communication resources except mainstream television, geo-ethnic television,
geo-ethnic radio, and mainstream newspapers had been removed.
17
Again, the communication resources identified in the top four most frequently mentioned by
Hispanics in any of the three Hispanic study areas were included in the analyses.
118
Table 5.7: Multiple regression analysis for understanding goal connections
predicting to affected by clinic closures
Model 1 (ß) Final Model (ß)
Interpersonal .05
Books or Magazines .03
Mainstream Television -.06 -.07
Geo-ethnic Television .11* .09*
Geo-ethnic Radio .08* .08*
Mainstream Newspapers -.11** -.11**
Geo-ethnic Newspapers -.01
Adjusted R
2
.04*** .04***
* p < .05; ** p < .01; *** p < .001.
The original model significantly predicted amount affected by clinic closures,
F(7,682) = 4.92, p = .000. The complete regression model showed only geo-ethnic
television, ß = 0.11, t(7,682) = 2.48, p = .014, geo-ethnic radio, ß = 0.08, t(7,682) =
2.12, p = .034, and mainstream newspapers, ß = -0.11, t(7, 682) = -2.78, p = .006,
significantly predicted the amount affected by clinic closures. After systematically
removing some of the communication resources, the final model was also significant,
F(4,685) = 8.06, p = .000. Geo-ethnic television, ß = 0.09, t(4,685) = 2.21, p =. 027,
geo-ethnic radio, ß = 0.08, t(4,685) = 2.17, p =. 031, and mainstream newspapers,
ß = -0.11, t(4,685) = -2.93, p = .003, significantly predicted amount affected by
clinic closures. Mainstream television, which also appeared in the model, had only a
marginal impact on the affected by the clinic closures measure, ß = -0.07, t(4,685) =
-1.72, p = .086. Those who identified a strong connection to geo-ethnic television
reported being more affected by the clinic closures (M = 7.47) than those who did
not identify geo-ethnic television as important for the understanding goal (M = 6.39).
Likewise, those who indicated that geo-ethnic radio was important were more
119
affected by the clinic closures (M = 7.67) than those who did not mention geo-ethnic
radio (M = 6.80). Those who indicated mainstream television was important for the
understanding goal, however, reported being less affected by clinic closures
(M = 6.22) than those who did not identify mainstream television (M = 7.17). And
finally, those who connect to mainstream newspapers reported being less affected by
clinic closures (M = 5.24) than those who did not identify mainstream newspapers
(M = 7.13) for the understanding goal.
Interpersonal, Internet, books or magazines, mainstream television, geo-
ethnic television, and geo-ethnic newspapers were mentioned most frequently by
Hispanics for the orientation goal. Therefore, these communication resources were
entered into the regression equation as independent variables. The analyses resulted
in four models. Table 5.8 shows the original model that included all the
communication resources entered and the final model in which all communication
resources except Internet, books or magazines, and geo-ethnic television were
removed.
Table 5.8: Multiple regression analysis for orientation goal connections predicting to
difficulty affected by clinic closures
Model 1 (ß) Final Model (ß)
Interpersonal .06
Internet -.14*** -.14***
Books or Magazines .07 .06
Mainstream Television -.06
Geo-ethnic Television .14*** .15***
Geo-ethnic Newspapers .03
Adjusted R
2
.05*** .05***
* p < .05; ** p < .01; *** p < .001.
120
While the original model significantly predicted to amount affected by clinic
closures, F(6,683) = 7.22, p = .000, only Internet, ß = -.14, t(6,683) = -3.68, p = .000,
and geo-ethnic television, ß = 0.14, t(6,683) = 3.69, p = .000, significantly predicted
amount affected by clinic closures. After systematically removing communication
resources, the final model was significant, F(3,686) = 12.61, p = .000. The Internet,
ß = -0.14, t(3,686) = -3.81, p =. 000, and geo-ethnic television, ß = 0.15, t(3,686) =
4.03, p =. 000, both significantly predicted how much respondents were affected by
the clinic closures. Books or magazines, which also appeared in the final model, was
marginally predictive, ß = 0.06, t(3,686) = 1.72, p = .086. Those who identified a
strong connection to geo-ethnic television reported being more affected by the clinic
closures (M = 7.91) than those who did not identify geo-ethnic television as
important (M = 6.61) for the orientation goal. Those who connect to books or
magazines were slightly more affected by clinic closures (M = 7.71) than those who
did not identify books or magazines (M = 6.90). And in contrast, those who
identified the Internet were less affected by the clinic closures (M = 5.14) than those
who did not identify the Internet (M = 7.16) as an important orientation resource.
For the play goal, friends or family, movies, books or magazines, mainstream
television, geo-ethnic television, and sports/exercise/travel/parks/outdoors were
entered into the regression equation as independent variables. The analyses resulted
in five models. The original model that included all the communication resources
entered and the final model in which all communication resources except movies and
geo-ethnic television were removed are shown in Table 5.9.
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Table 5.9: Multiple regression analysis for play goal connections predicting to
affected by clinic closures
Model 1 (ß) Final Model (ß)
Family or friends -.03
Movies -.09* -.09*
Books or Magazines -.01
Mainstream Television -.01
Geo-ethnic Television .09* .09*
Sports/Exercise/Travel/Parks/Outdoors -.02
Adjusted R
2
.01* .01**
* p < .05; ** p < .01; *** p < .001.
The original model significantly predicted the amount affected by clinic
closures, F(6,683) = 2.12, p = .050; it showed movies, ß = -0.09, t(6, 683) = -2.33,
p = .020, and geo-ethnic television, ß = 0.09, t(6, 683) = 2.29, p = .022, significantly
predicted amount affected by clinic closures. After systematically removing
communication resources, the final model was significant, F(2,687) = 6.02, p = .003;
movies, ß = -0.09, t(2,687) = -2.29, p = .022, and geo-ethnic television, ß = 0.09,
t(2,687) = 2.44, p = .015, both predicted how much the respondents were affected by
the clinic closures. Those who identified a strong connection to geo-ethnic television
indicated being more affected by the clinic closures (M = 7.68) than those who did
not identify geo-ethnic television as important for the play goal (M = 6.81). And in
contrast, those who identified movies were less affected by the clinic closures
(M = 5.99) than those who did not identify the movies (M = 7.10) as an important
play resource.
For the health goal, family or friends, health professionals, Internet, books or
magazines, geo-ethnic television, and geo-ethnic newspapers were mentioned most
frequently. Therefore, these communication resource connections were entered into
122
the regression equation as independent variables. The analyses resulted in four
models. Table 5.10 shows the original model that included all the communication
resources entered and the final model in which all communication resources except
Internet, geo-ethnic television, and geo-ethnic newspapers were removed.
Table 5.10: Multiple regression analysis for health goal connections predicting to
affected by clinic closures
Model 1 (ß) Final Model (ß)
Family or Friends .05
Health Professionals -.04
Internet -.11** -.11**
Geo-ethnic Television .18*** .18***
Geo-ethnic Newspapers .09* .09*
Books or Magazines .01
Adjusted R
2
.06*** .06***
* p < .05; ** p < .01; *** p < .001.
While the original model was shown to significantly predict amount affected
by clinic closures, F(6,683) = 8.42, p = .000, only the Internet, ß = -0.11, t(6,683) =
-2.87, p = .004, geo-ethnic television, ß = 0.18, t(6,683) = 4.56, p = .000, and geo-
ethnic newspapers, ß = 0.09, t(6,683) = 2.30, p = .022, significantly predicted the
amount affected by clinic closures. The final model also significantly predicted how
much respondents were affected by the clinic closures, F(3,686) = 15.78, p = .000.
After systematically removing the other communication resources, the final model
indicated a significant impact of the Internet, ß = -0.11, t(3,718) = -2.88, p =. 004,
geo-ethnic television, ß = 0.18, t(3,718) = 4.90, p = .000, and geo-ethnic newspapers,
ß = 0.09, t(3,718) = 2.53, p =. 012, on how much people were affected by the clinic
closures. Those who identified a strong connection to geo-ethnic television indicated
being more affected by the clinic closures (M = 8.04) than those who did not identify
123
geo-ethnic television as important for the health goal (M = 6.46). Likewise, those
who connected to geo-ethnic newspapers were more affected by the clinic closures
(M = 8.25) than those who did not connect to geo-ethnic newspapers (M = 6.83).
And finally, the people who identified Internet was important reported being less
affected by the clinic closures (M = 5.31) than those who did not identify the Internet
(M = 7.12) for the health goal.
As a final step in exploring this research question, communication resource
connections identified frequently across the goals— interpersonal (which includes
both family and friends and health professionals for the health goal), Internet, geo-
ethnic television, geo-ethnic radio, geo-ethnic newspapers, mainstream television,
mainstream newspapers, and books or magazines— were utilized in a multiple
regression equation. The analyses resulted in five models. Table 5.11 shows the
original model that included all the communication resources entered and the final
model in which all communication resources except Internet, geo-ethnic television,
geo-ethnic radio, and mainstream television were removed.
Table 5.11: Multiple regression analysis for general communication connections
predicting to affected by clinic closures
Model 1 (ß) Final Model (ß)
Interpersonal -.02
Internet -.11** -.11**
Geo-ethnic Television .19*** .20***
Geo-ethnic Radio .07 .08*
Geo-ethnic Newspapers -.01
Mainstream Television -.08* -.08*
Mainstream Newspapers -.05
Books or Magazines -.05
Adjusted R
2
.08*** .08***
* p < .05; ** p < .01; *** p < .001.
124
The original model significantly predicted the amount affected by clinic
closures, F(8,681) = 8.80, p = .000; the Internet, ß = -0.11, t(8,681) = -2.97, p = .003,
geo-ethnic television, ß = 0.18, t(8,681) = 4.56, p = .000, and mainstream television,
ß = -0.08, t(8,681) = -1.97, p = .050, significantly predicted the amount affected by
clinic closures item. Geo-ethnic radio, ß = 0.07, t(8,681) = 1.93, p = .054, was also
marginally significant in this model. The final model also significantly predicted
how much respondents were affected by the clinic closures, F(4,685) = 16.84,
p = .000. After systematically removing the other communication resources, the
Internet, ß = -0.11, t(4,685) = -3.00, p =. 003, geo-ethnic television, ß = 0.20,
t(4,685) = 5.03, p = .000, geo-ethnic radio, ß = 0.08, t(4,685) = 2.10, p = .036, and
mainstream television, ß = -0.08, t(4,685) = -2.12, p =. 034, significantly predicted
the amount affected by the clinic closures. Those who identified a strong connection
to geo-ethnic television indicated being more affected by the clinic closures
(M = 7.55) than those who did not identify geo-ethnic television as important for any
of the MSD goals (M = 5.53). Likewise, those who connected to geo-ethnic radio
were more affected by the clinic closures (M = 7.66) than those who did not identify
geo-ethnic radio as important (M = 6.68). The people who indicated that the Internet
was important for one or more of the MSD goals were less affected by the clinic
closures (M = 5.59) than those who did not identify the Internet (M = 7.24). And
finally, those who indicated mainstream television was important were less affected
by the clinic closures (M = 6.34) than those who did not identify mainstream
125
television (M = 7.32). Table 5.12 presents a summary of the results for research
questions 5 through 7.
Communication Profiles and Health Disparities
Individual level communication profiles were created from the patterns of
communication connections found during Part I of the analysis. Tables 4.8 – 4.11
were inspected to determine what communication resources tend to be identified
most frequently with other communication resources. Four communication resource
combinations were identified and used in the analysis— interpersonal and geo-ethnic
television, interpersonal and mainstream television, interpersonal and books or
magazines, and geo-ethnic television and books or magazines.
RQ8: Do communication resource combinations affect health outcomes?
First, independent t-tests were used to see if the communication combination
variables had a significant impact on either of the two continuous outcome measures:
difficulty/ease of getting medical care and amount affected by the health clinic
closures
18
.
18
Since results from RQ5 analyses indicated only “sports/outdoor/etc.” (play goal), “health
professionals” (health goal) and interpersonal (over all the goals) predicted “regular place for health
care,” it was not used as a dependent variable for the communication resource interaction analyses.
126
Table 5.12: Summary of communication connection and health outcome results
Connection
Regular place
for medical care
Ease of getting
medical care
Health clinic
closures
Interpersonal: Understanding
Orientation
Play (Family or friends)
Health (Family or friends)
Health (Health professionals) +
Any goal +
Internet: Understanding
Orientation + +
Play
Health + +
Any Goal + +
Mainstream TV: Understanding
Orientation +
Play
Health
Any Goal +
Geo-ethnic TV: Understanding – –
Orientation – –
Play –
Health – –
Any Goal – –
Geo-ethnic Radio: Understanding –
Orientation
Play
Health
Any Goal –
Mainstream Nwsp.: Understanding + +
Orientation
Health
Any Goal +
Geo-ethnic Nwsp.: Understanding
Orientation
Health – –
Any Goal
Books or Magazines: Understanding
Orientation
Play +
Health
Any Goal
Sports/Outdoors: Play +
Movies: Play +
+ = More likely to have a regular place for health care; More ease finding medical care; Less affected
by clinic closures
– = Less likely to have a regular place for medical care; More difficulty/less ease finding medical
care; More affected by clinic closures
127
When both interpersonal and geo-ethnic television were mentioned as
important resources for at least one of the goals there was a significant impact on
ease of getting health care, t(720) = 2.67, p = .008. Those who connect to both
resources reported less ease (i.e., greater difficulty) getting medical care (M = 2.38)
than those who did not indicate both resources were important. In addition, they
reported being more affected by clinic closures (M = 7.44) than those who did not
report both interpersonal and geo-ethnic television as important for any of the goals
(M = 6.58), t(688) = -3.20, p = .001.
Those who mentioned both mainstream television and interpersonal
communication reported a significantly greater ease at finding medical care
(M = 2.63) than those who did not identify both resources (M = 2.45) as important,
t(720) = -1.98, p = .048. Those who connect to both mainstream television and
interpersonal channels were also significantly less affected by the clinic closures
(M = 6.33) than those who do not connect to both of the resources (M = 7.18),
t(688) = 2.66, p = .008.
The combination of interpersonal and books or magazines did not have a
significant impact on difficulty or ease of getting medical care, t(720) = -0.13,
p = .89, or on amount affected by clinic closures, t(688) = -0.18, p = .86. Identifying
both books or magazines and geo-ethnic television, however, had more of an effect
on ease of getting medical care
19
, t(246.39) = 1.68, p = .09, and significantly
19
Equal variances were not assumed for this test because Levene’ s test for equal variances showed a
significant difference, F(720) = 5.06, p = .025.
128
influenced the amount affected by clinic closures
20
, t(250.62) = -3.12, p = .002. The
differences existed such that people who connected to both books or magazines and
geo-ethnic television were more affected by the clinic closures (M = 7.75) than those
who did not identify both resources as important (M = 6.78).
To explore this question further, multivariate regressions were used to
determine if connections to the individual channels made more of a difference than
the combination of communication channels
21
. The individual communication
resources (identified as important for any of the goals) were entered first into the
equations as covariates. The interaction term (i.e., connecting to both resources) was
entered into the equation in the second step. The two health access variables were
used as dependent variables.
First, the combination of interpersonal and geo-ethnic television was
incorporated into regression equations. When it comes to ease of getting medical
care, the resulting model was significant, F(3,718) = 10.12, p = .000, but geo-ethnic
television accounts for the majority of the variance, ß = -0.27, t(3,718) = -3.83,
p = .000, rendering the combination of interpersonal and geo-ethnic television
insignificant, ß = 0.12, t(3,718) = 1.27, p = .204. Interpersonal connections by itself
had little impact, ß = 0.20, t(3,718) = -1.13, p = .260. A second regression analysis
showed connections to geo-ethnic television also accounted for the majority of the
variance in the amount affected by clinic closures, ß = 0.36, t(3,686) = 4.92,
20
Levene’ s test for equal variances showed a significant difference, F(688) = 11.60, p = .001, so
equal variances were not assumed for this test.
21
The books or magazines and interpersonal combination was not used in these further analyses since
the combination did not have a significant impact on either health outcome variable.
129
p = .000; the combination of interpersonal and geo-ethnic television was no longer
significant, ß = -0.15, t(3,686) = -1.62, p = .106 and interpersonal was not a
significant predictor, ß = 0.10, t(3,686) = 1.29, p = .196.
Second, interpersonal and mainstream television was incorporated into
regression equations. When it comes to ease of getting medical care, the model
without the interpersonal/mainstream television variable was significant, F(2,719) =
3.72, p = .025, and the model incorporating the combination variable was marginally
significant, F(3,718) = 2.56, p = .054. The first model indicated that mainstream
television significant predicted ease of getting medical care, ß = 0.10, t(2,719) =
2.68, p = .007; interpersonal did not, ß = 0.02, t(2,719) = 0.52, p = .60. The second
model indicated that there was a marginally significant main effect for geo-ethnic
television, ß = 0.13, t(3,718) = 1.93, p = .055, but no main effect for interpersonal,
ß = 0.03, t(3,718) = 0.72, p = .472, and no interaction effect for the combination of
interpersonal and mainstream television, ß = -0.04, t(3,718) = -0.36, p = .614. A
second regression analysis showed that the model incorporating the combination
variable significantly predicted amount affected by the clinic closures, F(3,686) =
4.33, p = .005. There was a main effect for mainstream television, ß = -0.16, t(3,686)
= -2.42, p = .016, but not for interpersonal, ß = -0.05, t(3,686) = -1.13, p = .261.
There also was no interaction effect for the combination variable, ß = 0.04, t(3,686)
= 0.59, p = .559.
Finally, the books or magazines/geo-ethnic television combination variable
was entered into regression equations. Only geo-ethnic television had an impact on
130
ease of getting medical care, ß = -0.19, t(3,718) = -4.48, p = .000. There was no main
effect for books or magazines, ß = 0.02, t(3,718) = 0.30, p = .761, and no interaction
effect for the combination, ß = -0.02, t(3,718) = -0.21, p = .837. A second regression
analysis showed that only geo-ethnic television impacted the amount affected by
health clinic closures, ß = 0.26, t(3,686) = 6.01, p = .000. There was no main effect
for books or magazines, ß = 0.05, t(3,686) = 0.74, p = .457, or interaction effect for
the combination variable, ß = -0.02, t(3,686) = -0.22, p = .827.
131
CHAPTER 6:
DISCUSSION AND IMPLICATIONS
EFFECTIVE HEALTH STORYTELLING NETWORKS
The aim of this dissertation was to introduce and explore a research strategy
to maximize communication campaign reach and effectiveness. This was the first
application of media system dependency theory and communication infrastructure
theory for the purposes of developing a health communication reach strategy. Three
Hispanic, one Anglo, and one Armenian community samples were compared to
determine if geo-ethnicity— the interaction of ethnicity and geographic location—
makes a difference in how people connect to communication channels (both
interpersonal and mediated). Since Hispanics are at high risk for health problems, the
second part of the analyses concentrated on determining the best ways to reach
Hispanic audiences. Communication connection patterns— communication resources
that are frequently identified together as important for goal attainment— were
identified for Hispanics and the relationship between their communication
connections and health access factors was explored. The theoretical and
methodological contributions of this work, its major findings, implications,
limitations, and policy guidelines are discussed in this final chapter.
Theoretical & Methodological Contributions
The first goal of this dissertation was to develop a theoretically grounded
research strategy to improve campaign reach. Communication infrastructure theory
132
and media system dependency theory were offered as ways to conceptualize
campaign strategies within an ecological framework. Then, the interaction of media
and persuasion theories was discussed as a means to develop a campaign strategy
that is more effective in both reaching and persuading an intended audience.
Communication Infrastructure Theory and Health Campaign Reach Strategy
Communication infrastructure theory developed out of research conducted by
the Metamorphosis project and has been applied primarily with respect to civic
engagement. The communication infrastructure, which consists of a storytelling
network that is enabled or constrained by the communication action context, is the
basic communication system relied upon by a community for the knowledge
residents’ need to conduct their everyday lives (Ball-Rokeach et al., 2001). A strong
neighborhood storytelling network— comprised of residents, community
organizations, and geo-ethnic media
22
who talk about the neighborhood— leads to
higher levels of belonging, collective efficacy, and political participation (Ball-
Rokeach et al., 2001; Kim, 2003; Kim & Jung, 2002; 2003).
While residents, community organizations, and geo-ethnic media have the
greatest vested interest in telling neighborhood stories (thereby increasing civic
engagement), the potential health storytelling network has a broader range of
potential storytelling agents (See Figure 2.1). In Chapter 2, a health storytelling
network model comprised of individuals in personal and social networks, health
practitioners and health campaign specialists, media (including geo-ethnic and
22
Geo-ethnic media refers to all media that target a specific ethnic group and/or geographic location.
133
mainstream, new and old communication technology, and campaign promotional
items), and non-profit/community-based organizations was proposed. The
storytelling network model is comprised of all potential health storytellers. However,
in practice, there are variations in the connections people make to, and in the
importance they place on, the various storytellers. This leads to variations in the
composition of actual health storytelling networks. Campaign strategists have often
labeled groups who do not connect to mainstream media outlets as “hard-to-reach.”
From the ecological perspective of the present research, this usually means that the
health storytelling networks of these various groups do not include the mainstream
media. It was proposed that health disparities— disproportionately higher incidence
or mortality rates of a health problem as compared to other groups— are partially
attributable to failing to reach certain audiences with health information through their
health storytelling network.
As will be discussed in more depth in the findings and implications section,
data analyses indicated that not everyone connects to the same health storytellers.
For the present discussion, suffice it to say that, those that connect to mainstream
channels and the Internet are more likely to have positive health outcomes (i.e.,
fewer health access problems) and those connected to geo-ethnic media have more
negative health outcomes (i.e., greater health access issues). An effective health
communication campaign reach strategy needs to include the identification of the
health storytellers most prominent in the health storytelling network of the group(s)
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most at risk for a health problem and a commitment to working within this network
to reach the intended audience.
Media System Dependency and Health Campaign Reach Strategy
A second theoretical and methodological contribution of this dissertation is
an expansion of Ball-Rokeach’ s media system dependency theory (MSD) to issues of
campaign reach. Ball-Rokeach and Loges (2000) first expounded on the implications
of MSD for public health crises. They explain the importance of aligning public
health messages with the goals of media systems when planning public outreach for
each stage of a public health crisis. Their work focuses on negotiating the
dependency relations between public health agencies and media systems. In order to
create the best reach strategy, I instead focused on the dependency relations that exist
between the intended audience and both media systems and interpersonal networks
for goal attainment. It was suggested that aligning the persuasive goal of a campaign
with MSD goals could increase both the reach and persuasiveness of campaigns.
Campaign strategy too often takes the form of how to best utilize a particular
medium/communication technology to present a persuasive message to an audience.
This methodology neglects the question about how to best reach the intended
audience— even the best-designed message will fail if it does not reach the intended
audience. By concentrating on how to use a particular medium/communication
technology effectively, health campaign strategists often overlook the role that media
play within a larger ecological framework.
135
Incorporating MSD theory into campaign development forces campaign
strategists to consider the media ecology. An ecological approach to health
campaigns recognizes the interrelationship between multiple levels of influence—
e.g., the individual, interpersonal, community (including social and economic
factors), organizational, and governmental levels— that impact health outcomes
(Baker & Brownson, 1999). Media are part of this ecological system. MSD theory
suggests that dependency relationships— determined by the extent to which one party
relies on the resources of another for attainment of goals— exist between individuals,
media, and other organizations and systems (Ball-Rokeach, 1998). Health campaign
strategists often depend upon media to reach a mass audience with health messages
and individuals in that audience depend upon media for goal attainment. It is
important to strategically align campaign dependency relationships to those of the
audience. The communication infrastructure theory as discussed above places media
into an ecological framework— the health storytelling network— in which the media
function to both instigate health storytelling within the network and to receive and
react to health storytelling instigated by other health storytellers. In other words,
campaign designers should research health issues affecting the population, tell stories
provided by residents and community and non-profit organizations on health issues
affecting the population, and frame health stories to encourage health storytelling by
the other parts of the storytelling network.
136
The idea is to recognize and utilize the dependency relationships that exist
between health storytellers. Ideally, (1) health practitioners and campaign strategists
should instigate health storytelling through the media their intended audience
depends upon for goal attainment and (2) the media would frame health stories in
such a way that they instigate storytelling through individuals’ personal and social
networks and simultaneously connect people to health practitioners, community or
non-profit organizations, and to other media that provide additional health
information and/or health services.
The second major contribution of MSD theory to campaign development is
the premise that communication connections (i.e., dependency relations) vary by
goal. Ball-Rokeach (1998) identified three major goal types that spawn our
dependency relationships: understanding, orientation, and play. The understanding
goal involves making sense of one’ s own self or “internal world” (self-
understanding) and/or making sense out of the social environment, society, or the
“external world” (social understanding) (Ball-Rokeach, 1998, p. 20). The orientation
goal implies interacting with other people effectively (interaction orientation) and/or
navigating or problem solving one’ s environment effectively (action orientation)
(Ball-Rokeach, 1998). The play goal has to do with entertaining or amusing oneself
(solitary play) and/or having fun with or socializing with others (social play) (Ball-
Rokeach, 1998). Specific health goals can fall within these original dependency-
engendering goals. For example, finding out about medical services available to you
or about a health condition you may have is related to understanding; talking to
137
others to solve health problems, or trying to get health services, to adopt preventative
health behaviors, to treat illnesses, etc. is part of orientation; and certain play
behaviors can provide health benefits. For the purpose of this study, a fourth MSD
goal was added to be more specific to health; it pertained to connections for finding
health and medical information. It was argued in Chapter 2 that campaign
effectiveness is maximized when an effort is made to align the persuasive goal of the
campaign with the most relevant MSD goal. After identifying which MSD goal is
most closely related to the desired persuasive outcome, then the communication
connections deemed as most important for that MSD goal should be utilized in
campaign efforts. In other words, send the message through the channels where the
audience is most likely to pay attention for health goals, increasing the likelihood
that it will be persuasive.
Table 6.1 shows the two most frequently identified communication
connections important for attainment of each goal across the five geo-ethnic groups
examined in this study.
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Table 6.1: Top 2 Communication Connections for Each Goal by Geo-Ethnicity
Hispanics
Southeast
L.A.
Hispanics
Pico Union
Hispanics
Glendale
Anglos
Glendale
Armenians
Glendale
N = 438 N = 301 N = 151 N = 189 N = 211
Health
Goal
1
Geo-ethnic
TV
Geo-ethnic
TV
Health
Professional
Health
Professional
Health
Professional
2
Family/
Friends
Family/
Friends
Family/
Friends
Internet
Geo-ethnic
TV
Under-
standing
Goal
1
Geo-ethnic
TV
Geo-ethnic
TV
Geo-ethnic
TV
Mainstream
Newspapers
Geo-ethnic
TV
2 Interpersonal Interpersonal
Mainstream
TV
Interpersonal
Mainstream
TV
Orien-
tation
Goal
1
Geo-ethnic
TV
Geo-ethnic
TV
Interpersonal Interpersonal Interpersonal
2 Interpersonal
Geo-ethnic
Newspapers
Mainstream
TV
Internet
Mainstream
TV*/Internet*
Play
Goal
1
Sports/
Outdoors
Sports/
Outdoors
Family/
Friends
Family/
Friends
Family/
Friends
2
Family/
Friends
Geo-ethnic
TV
Sports/
Outdoors
Mainstream
TV
Mainstream
TV
* Indicates tie.
As illustrated, Hispanics in Pico Union have a particularly strong connection to geo-
ethnic television, which is identified for each of the four goals. The more common
case, however, is for a geo-ethnic group to select different resources for different
goals— e.g., Glendale Hispanics identified completely different resources as
important for the attainment of almost every goal. It is proposed that when
communication connections vary by goal, the connections associated with the
particular goal most closely aligned with the persuasive message goal will be the
most effective avenue to persuade the audience.
139
Major Findings and Implications
A series of research questions were posed with the goal of identifying
communication connection patterns and exploring the relationship between
communication connections and health outcomes. Specifically, this involved looking
for communication connection patterns, comparing patterns across geo-ethnic
23
communities, and exploring how Hispanics’ communication connections were
related to health access. In this section, I describe the major findings and
implications of the data analyses: 1) specify your audience: geo-ethnicity makes a
difference; 2) combine communication formats; 3) spark interpersonal
communication; 4) strategically place hotline and web address information; and 5)
incorporate communication connections that are related to health outcomes.
Specify the Audience: Geo-ethnicity Makes a Difference
The first set of research questions had to do with whether or not
communication connections varied by geo-ethnicity. The results of this study
demonstrate that geo-ethnicity makes a difference. Hispanics living in several
different communities identified different communication resources as most
important for goal attainment; the communication resources identified by Glendale
Hispanics were also different from those of other ethnic groups living in the same
area.
A ‘ one size fits all’ strategy would not be effective in reaching Hispanics in
Los Angeles. Hispanics account for only about 20% of the population in Glendale
23
Geo-ethnic refers to a particular ethnicity residing within a geographic location.
140
and come from several different origins— including those of Mexican, Central
American, South American, and Caribbean origin. Other ethnic groups in Glendale
include non-Hispanic White (excluding Armenians) residents (35%), Armenian
(21%), and Asian (16%). The other study areas are much less ethnically diverse—
Pico Union is 79% Hispanic and the Southeast L.A. cities are between 92% and 96%
Hispanic— and have less diversity in national origins. Southeast L.A. is primarily
Mexican-origin and Pico Union is predominantly Central American-origin. The
ethnic diversity in Glendale leads to a greater chance that Hispanics living there will
interact with people from different cultures and newer immigrants may acquire
English-language skills faster as a means to achieve goals in their daily lives. This is
how geographic location can interact with ethnicity. There is not as great of a need to
adapt in Pico Union and Southeast L.A., where people are surrounded by others who
are familiar with the culture from their home countries. In addition, Glendale
Hispanics tend to earn more money than Hispanics in either Pico Union or Southeast
L.A. and are also more likely to be of later immigration generations (i.e., more 3
rd
and 4
th
generation Hispanics than in the other areas). All of these differences
contribute to the variations in communication connections, and therefore the best
ways to reach these groups.
Looking across the communication connection goals, disregarding for a
moment the importance of aligning the persuasive goal with the communication
connection goals, the general communication patterns across goals suggest different
approaches for Hispanics living in diverse communities as compared to those who
141
live in ethnically homogeneous areas. There are two distinct storytelling networks at
play for these groups.
Hispanic Immigrants Living in Diverse Areas
When trying to reach Hispanics who are more acculturated or at least
exposed to more diverse cultures on a daily basis as in Glendale, a multimedia
strategy that incorporates mainstream television and newspapers, the Internet, and
interpersonal channels is most appropriate. Based upon play goal connections,
campaign messages can also be distributed through local movie theater
advertisements and events in local parks. Messages run through geo-ethnic television
may reach some of the Hispanics in the area, but not to the same degree as the other
alternatives. Geo-ethnic television only ranks as important for one goal
(understanding) by Glendale Hispanics and is identified as important by less than
one-third of the sample.
Newer Immigrant Hispanics Living in Ethnically Homogeneous Areas
The general approach to reach the newer immigrants living in ethnic enclaves
such as the Hispanics in Southeast L.A. and Pico Union should involve instigating
health storytelling through geo-ethnic television and interpersonal channels. These
two resources are repeatedly observed as important for goal attainment. Campaigns
might incorporate other forms of geo-ethnic media— newspapers and radio— to
increase campaign message exposure. The Internet is not yet a cost-effective way to
reach Hispanics living in areas with a high concentration of newer immigrants from
similar origins; only about a quarter of the Pico Union and Southeast L.A. Hispanics
142
in this study connect to the Internet in any location (home, work, library, etc.). Since
‘ sports/exercise/outdoors/etc.’ are frequently identified for the play goal in these
areas, health campaigns could also utilize local parks to distribute messages and hold
health awareness events.
Combine Communication Formats
Another set of research questions were designed to determine what clusters of
communication resources are frequently identified as important for goal attainment.
The data analyses showed that subgroups of Hispanics tended toward similar forms
of communication channels for goal attainment. First, this is illustrated by a
preference for either mainstream or geo-ethnic media. Those who connected to one
form of geo-ethnic media for goal attainment, tended to connect to other forms of
geo-ethnic media as well. Likewise, those who connected to one form of mainstream
media also tended to connect to other forms of mainstream media for goal
attainment. Second, there is a tendency for Hispanic subgroups to connect to similar
forms of communication (e.g., electronic, print, interpersonal). This is illustrated by
people who connect to one form of electronic communication channel (e.g.,
television or radio) also tending to connect to other forms of electronic
communication channels. Similarly, those who connect to one form of written
material (e.g., newspapers, books or magazines, pamphlets, etc.) have a tendency to
connect to other print media for goal attainment. Finally, those who connect to
interpersonal channels for one goal are inclined to connect to interpersonal channels
for other goals as well.
143
These communication patterns suggest multimedia channel combinations that
can be used to increase campaign exposure and health storytelling. For example,
since those who connect to one form of electronic media tend to connect to other
forms of electronic media, a health campaign run through the television can be
supplemented by similar messages run through the radio. Messages run through print
media can be supplemented by messages through other forms of print media and can
point to additional print resources on the topic. Health professionals can point to
other interpersonal health resources or encourage them to talk to their family and
friends about health information or services.
Spark Interpersonal Communication
The data analyses also demonstrated the overall importance of interpersonal
communication for reaching Hispanics across the board. Hispanics identified
interpersonal communication as important in combination with other resources for
every goal. This finding is significant for several reasons. First, it shows that
interpersonal channels— the individuals in their personal and social networks— play
a central role in the health storytelling network. This suggests that this mode is
important in every configuration of the health storytelling network. While the
specific media and/or organizations may differ, interpersonal channels are always
central to health storytelling.
Second, it suggests that promotora models— where a group of community
members are taught about a health topic and trained to disseminate the information
through their social networks and to other people living in their community— is a
144
very worthwhile approach for reaching Hispanics in Los Angeles. Third, the
importance of interpersonal channels lends support for incorporating social network
analysis into health communication research. Individuals need to be conceived of as
members of networks, not as individuals per se. People do not exist in isolation, but
rather are dependent upon interpersonal networks for goal attainment.
And finally, it suggests that mediated campaigns should incorporate elements
designed to increase interpersonal discussion on a health topic. Katz & Lazarsfeld
(1955) coined the phrase two-step flow to describe the situation in which media does
not influence the audience directly, but rather through the interpersonal
communication that is generated as a result of the media. The dominance of
interpersonal channels appearing as an important resource for goal attainment
highlights the need to spark discussion through media programs. Campaigns need to
be conceived of as conversation starters. Simply presenting health information, or
presenting health information in a way designed to influence an individual’ s
behaviors, is not enough. People should be encouraged to talk to their friends,
family, neighbors, etc. about the health problems (i.e., activate conversations/stories
in their networks).
The entertainment-education (E-E) format can be used to model how these
conversations might take place. Unlike messages that simply tell you to talk to
others, E-E dramas can illustrate how those conversations take place. They can
provide dialogue that people may try using themselves when bringing the health
topic up with people in their own lives. For example, rather than just telling people to
145
talk to their children, partner, or friends about safe sex, an E-E program demonstrates
safe sex discussions as naturally occurring amongst the characters in certain
situations. So on many U.S. programs you will see one character stop and ask the
other if they have a condom to use when they are about to engage in sex. Some
programs have shown discussions amongst friends about getting HIV/AIDS tests,
usually prompted after a potential sexual partner demands that one of the friends get
tested, or discussions about the importance of condoms after a character contracts a
sexually transmitted disease or has a pregnancy scare. Other programs have featured
concerned parents sitting down to have discussions about safe sex with teenage
children who have started going on dates or after a teenager has gotten pregnant.
These shows can prompt interpersonal discussion and provide an example for how
conversations about health problems can occur (Boulay et al., 2002; Collins et al.,
2003; Papa et al., 2000; Piotrow & de Fossard, 2004; Singhal & Rogers, 2004;
Valente & Saba, 1998).
Strategically Place Hotline and Web Address Information
Telephone hotlines and Internet websites offer health practitioners, campaign
strategists, and community/non-profit organizations a way to provide more in-depth
and tailored information to their intended audience. Media are often used to raise
awareness of these information services. Research questions were formulated to
determine when individuals are most likely to connect to telephone and Internet
resources. First, analyses examined whether telephone or Internet connections vary
by geo-ethnicity. The intensity of Hispanics in Pico Union and Southeast L.A.
146
Internet connections in general and for health goals were compared. Internet
connectors in Pico Union had a stronger connection to the Internet in general, but not
specifically for health goals. Keep in mind that since Internet connection rates are
low in these ethnically homogeneous newer immigrant Hispanic communities (e.g.,
Southeast L.A. and Pico Union), providing telephone hotline information is still
more advantageous than Internet information. With regard to telephone connections,
Pico Union Hispanics were found to be more reliant on the telephone in general and
specifically for the goal of finding “social, medical, education, and child care
information” than Southeast L.A. Hispanics. These findings suggest that Pico Union
Hispanics might be slightly more inclined to take advantage of telephone information
services than Southeast L.A. Hispanics. Los Angeles Hispanics who participated in
focus group discussions also indicate that telephone information numbers need to air
longer during television programs to allow for time to write them down (Wilkin et
al., in progress).
A second set of data analyses was conducted to determine how to best reach
Hispanics with Internet and telephone hotline information. The goal was to
determine what communication connections are most important for those who
indicate a strong connection to the Internet or the telephone. Analysis showed that
people who connect to the Internet for the health goal were less likely to rely on the
telephone in general and for specific health-related goals. Those connecting to geo-
ethnic television, on the other hand, were more strongly attached to the telephone in
general and for specific health-related goals. Those connecting to geo-ethnic
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newspapers for health information also find the telephone as a valuable resource for
getting social, medical, educational, and child care information as compared to those
who do not connect to geo-ethnic newspapers for health. These findings indicate that
efforts should be made to get telephone hotline information numbers related to health
topics into geo-ethnic television and geo-ethnic newspapers health storytelling.
With regard to incorporating web address information into campaigns, the
analyses were based upon just the small percentage of Hispanics in Pico Union
(22%) and Southeast L.A. (24%) who indicated that they connect to the Internet.
Internet connectors who said that health professionals are an important medical
information resource have a stronger connection to the Internet than those who do
not rely upon health professionals. This suggests that health professionals and
facilities should provide medical and service information on websites and include
website references in materials handed out to Hispanics in clinics, doctors’ offices,
and hospitals. In addition, Internet connectors who identify books or magazines as an
important health information resource are more likely to go to the Internet for
“advice on how to deal with doctors or clinics” than those who do not rely on books
or magazines for health. This suggests that magazine articles about health topics
should provide web address information indicating where additional information
about the health problem can be found. Finally, Internet connectors who indicated
that the Internet is one of the most important sources of health information, have a
stronger connection to the Internet, overall, and report performing a number of
online health activities. This means that when people incorporate the Internet into
148
their everyday lives, they are more likely to seek health information online.
However, caution is still warranted regarding not relying on websites for Hispanic
populations since connection rates are low amongst newer immigrants.
Incorporate Communication Connections Related to Health Outcomes
Finally, a series of research questions were formulated to explore the
relationships between the nature of people’ s communication connections and their
level of health access. The analyses suggest that different communication
connections impact health access outcomes and that there is more than one health
storytelling network in effect for Hispanics in L.A..
Regular Place for Medical Care
The first series of analyses illustrated that having a regular place for medical
care is not greatly influenced by communication connections. Only three
communication connections— health professionals (health goal), interpersonal
channels (any goal), and sports/exercise/travel/parks/outdoors (play goal)—
significantly predicted having a regular place for medical care. Not surprisingly,
those with a regular place for health care were more likely to connect to health
professionals when trying to find health information than those who do not have a
regular place for medical care (approximately 22% compared to 14%). In addition,
people who have a regular place for medical care are more likely to connect to
interpersonal channels in general. Approximately 71% of those who had a regular
place for medical care, as compared to 60% of those who do not, identified
interpersonal channels as important for at least one of the MSD goals.
149
Putting this in terms of the health storytelling network, the people with a
regular place for medical care can be said to have a strong connection to a health
organization (whether this be a private doctor’ s office, a clinic, a hospital, etc.). They
also are more likely to have a stronger connection to health professionals and to
personal and social networks to achieve their everyday goals. Media connections, on
the other hand, were not associated with whether or not people have a regular place
for health care. This implies that there is a missing or weak link between the health
care providers and organizations and the media that are most important in the daily
lives of their potential clientele.
Other analyses indicate that health insurance plays an important role in
whether or not one has a regular place for health care— approximately 91% of the
people with health insurance indicated having a regular place for health care, while
only 72% of people without health insurance have a regular place they go for health
care
24
. Health insurance providers should utilize the indigenous storytelling network
to raise awareness of programs available to Hispanics.
Those who have a regular place for health care are also more likely to
connect to sports/exercise/travel/parks/outdoors for a source of fun and relaxation—
approximately 37% as compared to 28% of those without a regular place for health
care. The causal link is difficult to determine here. Is it that people who are more
active for the play goal find more of a need to make sure that they have a regular
place to go for medical visits (i.e., just in case they get injured while doing the
24
Peason’ s chi-square indicated a significant difference between groups, ?
2
(1) = 47.86, p = .000.
150
activities)? Or perhaps that people who are more physically active in their play time
also value their overall health more, thereby making them more likely to have a
regular place for medical care. Or maybe it is having regular medical care that makes
a difference. Perhaps those who have a regular place for medical care are more likely
to be encouraged by the medical professionals to spend more time exercising,
playing sports, going outdoors, traveling, etc. This is something that should be
explored in future research.
Ease of Finding Medical Care
Those who connect to a health storytelling network that features mainstream
media and the Internet are more likely to have positive health outcomes (i.e., greater
ease of finding medical care), while those connecting primarily to geo-ethnic media
as part of their storytelling network have a greater difficulty getting medical care.
Health campaign and medical professionals need to become part of the STN of those
who are having difficulty finding medical care by connecting to geo-ethnic media.
Likewise, the geo-ethnic media need to perform a more adequate role as health
storytellers for this population; they need to provide information that links the
individuals in their personal and social networks to health professionals and
organizations that can assist them in their medical needs.
Geo-ethnic television connections significantly predicted a greater difficulty
getting medical care when identified as important for attaining understanding,
orientation, and health goals, but not for the play goal. These findings suggest that
those with greater difficulties getting medical care incorporate geo-ethnic television
151
into their everyday lives for goal attainment much more often than those who have a
greater ease of finding medical care. Geo-ethnic newspapers connections also had a
negative impact on ease of finding medical care when identified as important for the
health goal, but not when identified for other goals. This means that people who seek
health information in geo-ethnic newspapers are having more difficulty finding
medical care.
The Internet, when identified as an important resource for orientation (i.e.,
purchasing products) and health goals, had a positive impact on ease of getting
medical care. Likewise, those who indicated that they went to mainstream television
for the orientation goal reported a significantly greater ease in getting medical care.
This potentially indicates that the Internet and mainstream television are advertising
medical care products more frequently. Further analysis of advertising content via
these media is needed to determine if this is indeed the case. Mainstream newspaper
connections for the understanding goal were also associated with a greater ease
getting medical care. This potentially indicates that the mainstream newspapers are
doing a better job advertising where medical services are available and/or where
local health events are taking place in specific communities than other resources.
Finally, when books or magazines are a primary source of play, there was also a
greater ease getting medical care. It is difficult to know the reason why this
relationship exists without knowing more about the type of recreational reading that
is taking place. Future research can explore the relationship between book and
magazine reading and ease finding medical care.
152
Affected by Local Health Clinic Closures
People who are most affected by the local health clinic closures have greater
health access problems. As with the previous health access measures, differences in
the composition of the health storytelling network for Hispanics is related to the
amount people are affected by health clinic closures. Those who connect to a health
storytelling network that features mainstream media and the Internet are more likely
to have positive outcomes (i.e., less affected by local health clinic closures), while
those who connect primarily to geo-ethnic media were more affected by the clinic
closures. These findings suggest that the geo-ethnic media did not do enough to help
their audience cope with health clinic closures. There is a need for geo-ethnic media
to take on the responsibility of trying to connect individuals to available health care
resources (professionals and organizations) and provide the audience with
information about what to do if they have been dependent upon one of the clinics
that has closed for health care. Health professionals need to reach out to this
population by becoming part of the health storytelling network with regard to health
clinic closures. They need to connect to the geo-ethnic media and provide
information about how to get health care after clinics are closed.
Geo-ethnic television connections for each goal— understanding, orientation,
play, and health— were found to significantly impact the amount that local health
clinic closures would affect the audience. Those who were connecting to geo-ethnic
television perceived a greater effect of the clinic closures than those who were not.
This relationship could be due to a higher coverage or more attention paid to the
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coverage of local clinic closures on geo-ethnic television. The survey also asked the
amount of attention respondents had been paid to news about the local health clinic
closures, enabling follow-up analyses using this variable as a covariate. A
multivariate regression analysis showed that even with the amount of attention paid
to the clinic closures accounting for a significant portion of the variance in amount
affected by the closures, ß = 0.27, t(2,687) = 7.50, p = .000, geo-ethnic television
connections continued to significantly predict amount affected by the clinic closures,
ß = 0.22, t(2,687) = 5.99, p = .000.
The same is true for geo-ethnic radio, which significantly predicted the
amount affected by clinic closures when identified as important for the
understanding goal. The understanding goal has to do with how people stay on top of
what is happening in their community. The significant relationship indicates that
those who were affected most by the clinic closures were relying on geo-ethnic radio
for community information. Geo-ethnic newspapers, when identified as important for
the health goal, also significantly predicted the amount affected by clinic closures.
The Internet, when identified as an important resource for orientation (i.e.,
purchasing products) and health goals, had a positive impact on amount affected by
local health clinic closures. People who go to the Internet for health were less
affected by the local health clinic closures. Since the Internet connection rates are so
low within this population, it is likely that the conditions of everyday life that enable
Internet use are associated with the conditions that make people less likely to rely
primarily on county health clinics for health care. For instance, people with health
154
insurance often have a primary physician who meets most of their medical needs and
only need to go to clinics when there is an emergency. As a matter of fact, 78% of
those in Pico Union and Southeast L.A. who have health insurance indicated going to
a doctor’ s office (i.e., they do not rely on health clinics) most often for health care.
Office jobs are more likely to both provide health insurance and provide a work
environment with Internet access. Compare this situation to that of day laborers who
get neither Internet access nor health insurance as part of the job. Follow-up tests
indicated that Internet connectors (68%) are significantly more likely to have health
insurance than non-Internet connectors (46%) in Southeast L.A. and Pico Union,
?
2
(1) = 27.63, p = .000.
Mainstream newspaper connections for the understanding goal were also
associated with being less affected by local clinic closures. This trend could mean
that either the mainstream newspapers were covering the clinic closures in such a
way that made those connecting to them feel comfortable that there were other
options and the closures would not affect them much or that mainstream newspapers
attract an audience that is less reliant upon health clinics for medical needs. Follow-
up tests showed that 31% of those who connected to mainstream newspaper for any
goal indicated that clinics were their primary source of medical care. This means that
while almost 1/3
rd
of people connecting to mainstream newspapers were potentially
affected by clinic closures, most mainstream newspaper connectors did not feel as
affected. This could mean that the coverage in mainstream newspapers made readers
feel less worried about the closures.
155
Limitations
There are several limitations to this research that are based upon the
measurements and the data available for analysis. First, the study was limited to
exploring the effects of communication connections upon health access variables.
There are several sociodemographic factors that may mediate the relationship
between media connections and the health access outcomes. However for this study,
I was interested primarily in determining whether media connections as they exist
are related to health access outcomes. These direct relationships demonstrate that
differences in the composition of a health storytelling network can make a difference
in health outcomes. Knowing the communication connections of those with the
greatest health access problems, regardless of the sociodemographic factors that
might affect both access and communication connections, would help health
practitioners better reach these populations to improve health access. Future research
will also explore other health outcome measures— health knowledge, attitudes, and
behaviors— that should have a direct relationship to the health storytelling network
and specific communication channels. With this knowledge, campaigns can be better
designed to reach those who are at highest risk for health problems who have the
least amount of accurate knowledge about their health issues.
A second limitation is the level of detail about media connections. While this
research advances knowledge by examining both mainstream and geo-ethnic media,
future research needs to go one step further and identify the specific media venues. It
is possible, for instance, that while both Pico Union and Southeast L.A. identify geo-
156
ethnic television as important, the specific channels preferred may vary due to
program content appealing more to people from one country of origin over another.
These data will be collected through future surveys and focus groups.
A third limitation is that the way health access issues are covered in the
various media has not been evaluated. It is difficult to determine if communication
connections are directly causing health access problems (e.g., by not providing the
information consumers need to get medical attention) or if people who have the most
access problems are attracted to similar forms of communication for other reasons
(e.g., health access problems are related to a need for Spanish-speaking health
professionals, which is related to preferring geo-ethnic television). A content
analysis of health information provided on the major Spanish-language television
networks and in the geo-ethnic newspapers available in these study areas is currently
being conducted to explore this issue.
A fourth limitation is that this study concentrated on the main health
storytellers that residents connect to for health information. While this approach
enabled the development of a comprehensive approach to reaching residents through
their health storytelling network, some specific storytelling agents were not
identified as important. Health campaign professionals and organizations often
utilize health campaign materials (e.g., cookbooks, pamphlets/fliers, ribbons, pens,
bracelets) to stimulate health storytelling. These items may not be considered
amongst the most important resources for health information, but may play a pivotal
157
role in instigating health storytelling. Future research needs to explore the role that
these items play within the health storytelling network.
Finally, some of the media connection categories are too “all encompassing”
that it is difficult to determine the precise connection that is related to a health
outcome. For example, sports/exercise/travel/parks/outdoors is a play goal option
that is frequently identified by people across areas. While sports and exercise both
imply physical activity, travel, parks, and outdoors may or may not involve an
increase of physical activity. This makes it difficult to determine if people in this
category are performing healthy or non-healthy behaviors in their leisure time.
Intervention Implications
There are many issues that limit health access (e.g., lack of health insurance,
issues with immigration, low income, etc.) that are not addressed here. Many of these
things are difficult to change, but improvements can be made by addressing changes
in the health storytelling networks of those most affected by health access problems.
The significant relationship between certain communication connections and health
access suggests tactics for improving health access outcomes among Hispanics in
Southeast L.A. and Pico Union. The strong connection to geo-ethnic media amongst
those with health care access problems suggests that they are a part of a storytelling
network that resembles the neighborhood storytelling network (See Figure 6.1)— a
triangulated network of residents, community organizations, and geo-ethnic media
who tell stories about the neighborhood (Ball-Rokeach et al., 2001; Kim, 2003; Kim
& Jung, 2002; 2003).
158
Figure 6.1. Neighborhood Storytelling Network
A content analysis showed that geo-ethnic newspapers available to residents
in areas with lower levels of civic engagement were less likely to tell stories about
the local area and more likely to concentrate on information about the home country
of newer immigrants (Lin, Song, & Mercado, 2004). This too is likely to be the case
with health storytelling in these areas. The findings of this dissertation suggest that
the geo-ethnic media are failing to put health storytelling into a local context and
connect residents to local resources that will help them overcome health access
problems.
In order to maximize reach and efficiency, the goal of the health care
provider or health campaign strategist is to become part of that neighborhood
storytelling network and turn it to become more responsive to health storytelling
(See Figure 6.2).
Geo-
ethnic
Media
Residents/
Families
Community/
Non-profit
Organizations
159
Figure 6.2. Becoming Part of the Neighborhood Storytelling Network
Past research has shown that a strong connection between the three key
neighborhood storytellers in which they stimulate each other to tell neighborhood
stories promotes civic engagement (Ball-Rokeach et al., 2001; Kim, 2003; Kim &
Jung, 2002; 2003). However, in Pico Union and Southeast L.A., as in many new
immigrant areas, the storytelling network is not as strong as it could be. There is a
missing link between two key storytellers— the geo-ethnic media to which residents
are most strongly connected and the non-profit/community organizations that are
most important in their lives (Ball-Rokeach, Baezconde-Garbanati, & Mayer, 2004).
The Metamorphosis Project is currently developing a community-based strategy that
will both strengthen the neighborhood storytelling network and turn it so that it
becomes a viable health storytelling network. These changes are most likely to occur
if it happens from within the community with the residents leading the way. The first
Geo-ethnic Media Non-profit/ Community
Organizations
Residents/Families in
their Social Networks
Health Professionals &
Health Campaign
Specialists
160
step would be to partner with active residents and/or existing promotoras in the
areas. It is important that the residents take the lead in community change so that it
will be sustainable and take the form that is desired by the community. The residents
create a link between the media and the community organizations that are most
important to the residents in their community. Once these connections are made, a
series of workshops would bring the most important storytellers together to build
shared commitment to neighborhood storytelling and productive relationships with
each other. The goal is to change the storytelling network practices. Community
organizations often try to get mainstream media coverage, which is more difficult to
obtain and fails to reach the residents who are more connected to geo-ethnic media.
If active community organizations and residents provide geo-ethnic media with
neighborhood stories, then they will be more likely to reach the residents they serve;
and in turn, they will make neighborhood storytelling more feasible for the geo-
ethnic media, which might not have the budget to cover neighborhood stories on
their own.
Once a storytelling network is strong, then it can be deployed for health
purposes; that is, the storytelling can be turned to matters of health that are most
relevant to a specific population. Since the Hispanic populations in Pico Union and
Southeast L.A. were affected by local clinic closures and often have difficulty
getting medical care, health stories need to include information to point them to local
resources that can aid in health behavior adoption. For example, identifying
community organizations that can help get children enrolled in health insurance
161
programs, community centers that offer classes that teach how to make healthier
foods or affordable exercise programs, or how to get to clinics that serve people with
and without health insurance after the clinics closed. Essentially, geo-ethnic media
need to provide information in health stories that tells people who have health access
problems “how to” adopt proposed health behaviors by putting them in touch with
other key health storytellers.
Conclusion
My goal was to develop a theoretically grounded research strategy to improve
health communication campaign reach and ultimately help reduce health disparities.
It is time that health practitioners and campaign producers move beyond media
strategies that focus on either mainstream or new technology. Hispanics who are at
highest risk for health access problems are not connecting to these resources. My
hope is that as a result of this research, health practitioners and campaign strategists
will make efforts to become part of the storytelling networks of those at highest risk
for health problems. They will form relationships with the local organizations and
media that are important in the lives of their intended audience and help instigate
interpersonal health storytelling. Campaign strategists should recognize the
importance of utilizing geo-ethnic media and interpersonal channels when trying to
reach audiences they have missed in the past. After all, even the best-planned, most
persuasive messages will fail if they do not reach the intended audience.
162
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Asset Metadata
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Wilkin, Holley A.
(author)
Core Title
Diagnosing communication connections: Reaching underserved communities through existing communication ecologies
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Graduate School
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Doctor of Philosophy
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Communication
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education, health,health sciences, public health,mass communications,OAI-PMH Harvest,sociology, ethnic and racial studies
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Ball-Rokeach, Sandra (
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), Cody, Michael J. (
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), Mayer, Doe (
committee member
)
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