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Immigrant health in context: a communication ecology approach to understanding health behavior

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Immigrant health in context: a communication ecology approach to understanding health behavior

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IMMIGRANT HEALTH IN CONTEXT: A COMMUNICATION ECOLOGY
APPROACH TO UNDERSTANDING HEALTH BEHAVIOR

by
Carmen Gonzalez

A Dissertation Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(COMMUNICATION)

December 2013

Copyright 2013 Carmen Gonzalez

ii
DEDICATION

This dissertation is dedicated to my parents, Rafael & Teresa Gonzalez, whose
perseverance as immigrants inspired my path in life.
Gracias por todo su sacrificio, su amor, y su apoyo – no sería quien soy hoy sin mi
familia!

iii
ACKNOWLEDGMENTS
The conclusion of my doctoral training, as symbolized by the completion of
this dissertation, has been a challenging and gratifying experience. One of the most
gratifying aspects is the opportunity to reflect on the tremendous amount of support I
have received over the years.
First and foremost I must thank my mentor, advisor and dissertation chair Dr.
Sandra J. Ball-Rokeach. I began working with Dr. Ball-Rokeach as an undergraduate
student, and since then she has graciously guided me through many years of personal
and professional development. I am incredibly fortunate to have established a close
relationship with someone whose work has inspired me from the moment I was
exposed to it. This dissertation is the culmination of many years of researching and
theorizing about the immigrant experience. Dr. Ball-Rokeach and the amazing work
of her Metamorphosis Project allowed me to combine my personal and academic
interests through grounded and applied research. Through her own practice, she
continues to teach me how to be an effective researcher, teacher, leader and a humble
individual. I will forever be grateful for Dr. Ball-Rokeach’s mentorship and
friendship, and will strive to make her proud in anything I do.
This dissertation has been dedicated to my parents, Rafael and Teresa,
because they, along with my sisters Gabriela and Teresa, have been my rocks
throughout my life. My parents truly understand the value of education, and worked
incredibly hard to make sure a quality education was always available to me. I
cannot thank them enough for providing me with the ingredients for success, and for

iv
instilling in me the confidence to pursue my dreams. My older sister Gabriela paved
the way as the first member of our family to go to college. Her courage and
determination to push the boundaries revealed to me a world of opportunities that I
had never imagined. My younger sister Teresa has been my guiding light; her
beautiful and infectious spirit has helped me stay on track during trying times. I hope
she understands how much her company, her food, and her laughter have contributed
to my academic success. I have also been blessed by the expansion of my nuclear
family, which brought my brother-in-law Gilberto into my life. He is undoubtedly
the person who has expressed the most interest in my work and my teaching—our
countless conversations and debates about life have put many things in perspective
for me. And I am most grateful for my nephew and godson Mateo, whose sparkling
personality and loving demeanor proved to be the ultimate motivation for the
completion of this project. I can only hope that I am a good role model for him and
that I help him believe that anything is possible.
I am blessed to also have a second family of friends and colleagues. I am
incredibly grateful for all of the current and past members of the Metamorphosis
Project. First, to my council of elders as I like to call them: Vikki Katz, Matthew
Matsaganis, Meghan Moran & Holley Wilkin, I would like to say thank you for
believing in me and supporting me even before I made the decision to enter graduate
school. I would not have survived a PhD program without your collective wisdom
and guidance. My dear friend Nikki Usher is an honorary member of my council of
elders, I am so proud of her accomplishments and I appreciate how she has looked

v
out for me over the years. To my recent Metas, especially George Villanueva,
Garrett Broad, Minhee Son, Katya Ognyanova, Nan Zhao, Benjamin Stokes, and
Wenlin Liu—thank you for being amazing collaborators and inspiring me through
your work. And to the glue that keeps our team together, our project manager and
colleague Evelyn Moreno, words cannot express how much I appreciate your
unwavering support. You have become like a sister to me; your wisdom and
encouragement has kept me grounded while also reminding me to stop and smell the
roses. Thank you to you and your beautiful family, especially your daughter Maya,
whose genuine excitement and curiosity about the world around her continually
reminds me why I do this type of work. She has an amazing role model in her mom,
and I hope to be another example of the many opportunities and rewards available to
hardworking Latinas.
My tenure at the USC Annenberg School for Communication and Journalism
has been a long one, and I am proud to have three degrees from such a fine
institution. I would like to acknowledge the wonderful faculty and staff at the school,
especially Francois Bar, Larry Gross, Sheila Murphy, Anne Marie Campian, Stella
Lopez, Christine Lloreda, Margaret McLaughlin, Felix Gutierrez, and Bill Celis for
their intellectual, logistical and emotional support during my tenure at Annenberg.
And to the brilliant community of scholars that Annenberg has molded, I appreciate
each and every one of you, whether I worked with you on a project or simply chatted
with you in the hallways—thank you for your encouragement. Specifically, I must
thank Sheila Murphy and Sandra Ball-Rokeach for inviting me to participate in the

vi
Multilevel Study. This study not only provided the data for this dissertation, but it
also allowed me to formulate my research focus through invaluable hands-on
training. Thank you to all of the individuals involved in the Multilevel Study,
including Sindy Lomeli, Rosalba Sierra, Blanca Ovalle, Angie Mora, Paula Amezola
de Herrera, and all of the Latina women who shared their stories with me. And a
special thank you to Lourdes Baezconde-Garbanati for your insights into Latina
health and your willingness to support this Latina in any way possible—Gracias!
Last, but not least, I would like to acknowledge a few individuals that have
taken care of me and provided emotional support during this process. To Komathi
Ale, thank you for your insightful pep talks and for reinvigorating my confidence
when it was shaken. And finally, to Ricardo Luna, your steadfast encouragement
during the completion of this project means more to me than you will ever know.
You came into my life when I needed you the most—thank you from the bottom of
my heart!

This work was supported by the National Cancer Institute for Barriers to Cervical
Cancer Prevention in Hispanic Women: A Multilevel Approach, which was an award
to the University of Southern California (R01CA155326 - Murphy/Ball-Rokeach).
The content is solely the responsibility of the authors and does not represent official
views of the NCI or of the National Institutes of Health.

vii
TABLE OF CONTENTS

DEDICATION ii

ACKNOWLEDGMENTS iii

LIST OF TABLES ix

LIST OF FIGURES xi

ABSTRACT xiii

CHAPTER ONE: INTRODUCTION & BACKGROUND OF STUDY
Conceptual and Methodological Study Design 5
Dataset 1: Neo-traditional Multilevel Survey 5
Dataset 2: Health Communication Ecology Measure 6
Dataset 3: Health Communication Asset Mapping 8
Why Latino Health? 10
Sociocultural Approaches to Health Communication 16
Organization of the Dissertation 21

CHAPTER TWO: THEORETICAL FRAMEWORK
Communication Ecology 23
Media Systems Dependency Theory 27
Communication Infrastructure Theory 30
Transnational Health 34
Research Questions 44

CHAPTER THREE: METHODOLOGIES OF THE NEO-TRADITIONAL
MULTILEVEL SURVEY AND THE HEALTH COMMUNICATION ECOLOGY
MEASURE
Multilevel Survey: Sampling Procedure 46
Multilevel Survey: Measures 47
Multilevel Survey: Sample Characteristics 55
Health Communication Ecology Measure 59
HCE Measure: Dimensions 61
HCE Measure: Development 63
HCE Measure: Administration 74

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CHAPTER FOUR: A COMPARISON OF THE COMMUNICATION RESOURCE
PATTERNS IDENTIFIED IN THE MULTILEVEL SURVEY AND THE HCE
MEASURE
Health Communication Resource Patterns Identified by the Neo-traditional
Multilevel Survey 77
Health Communication Resource Patterns Identified by the HCE Measure 86
Transnational Connections Identified by the Multilevel Survey and the HCE
Measure 93
Comparing Variations in General Health, Behavioral Intention, and Self-Efficacy of
Screening Behaviors by Communication Resource Connections 96

CHAPTER FIVE: A CASE STUDY OF HEALTH COMMUNICATION ASSET
MAPPING
HCAM Workshop Development 109
HCAM Deployment 111

CHAPTER SIX: SUMMARY AND DISCUSSION OF FINDINGS 118

CHAPTER SEVEN: LIMITATIONS AND CONCLUSIONS 131

REFERENCES 138

APPENDIX: HCE Data Collection Instrument 149

ix
LIST OF TABLES
Table 4.1. What are the two most important ways that you get health information for
yourself or your family? 77

Table 4.2. Cross tabulation of top five resources mentioned in first and second
responses 79

Table 4.3. Time spent with mainstream media during the last week 81

Table 4.4. Time spent with geo-ethnic media during the last week 82

Table 4.5. Top three television stations that Latinas find most helpful when seeking
health information 83

Table 4.6. Top three radio stations that Latinas find most helpful when seeking
health information 83

Table 4.7. Geographic distribution of health-specific social networks 85

Table 4.8. Health communication ecologies for general health goal 87

Table 4.9. Health communication ecologies for women’s health goal 89

Table 4.10. Resource category representation in general health and women’s health
communication ecologies 91

Table 4.11. Frequencies for transnational communication practices 94

Table 4.12. Frequencies for transnational health practices 95

Table 4.13. Independent t-tests: Connection to television for health information and
cervical cancer-related determinants 97

Table 4.14 Independent t-tests: Connection to radio for health information and
cervical cancer-related determinants 99

Table 4.15. Independent t-tests: Connection to Internet for health information and
cervical cancer-related determinants 100

Table 4.16. Independent t-tests: Connection to television and talking with others for
health information and cervical cancer-related determinants 101

x
Table 4.17. Independent t-tests: Connection to television and radio for health
information and cervical cancer-related determinants 103

Table 4.18. Independent t-tests: Connection to talking with others about health
information and cervical cancer-related determinants 104

Table 4.19. Independent t-tests: Connection to local interpersonal social network and
individual health outcomes 105

Table 4.20. Independent t-tests: Talking on the phone with someone in the home
country and cervical cancer-related determinants 107

Table 4.21. Independent t-tests: Talking to someone in home country about health
and cervical cancer-related determinants 108

xi
LIST OF FIGURES
Figure 1.1. Conceptual and Methodological Study Design 5

Figure 3.1. Paper grid and flashcards for HCE measure development 65

Figure 3.2. Textual representations of health communication ecologies during HCE
measure development 67

Figure 3.3. Screenshots of introduction video for health communication ecology
measure 69

Figure 3.4. Screenshot of Qualtrics survey used to capture respondent’s elaboration
of their health communication ecology 71

Figure 3.5. Screenshots of iPad visual mapping application that depict two different
health communication ecologies as elaborated by the respondent 72

Figure 3.6. Poster identifying universe of communication resources for HCE
measure 73

Figure 3.7. Health Communication Ecology Measure Methodological Flow 76
Figure 4.1. Communication patterns for obtaining health information as identified by
initial MSD question (top two ways of obtaining health information) 80

Figure 4.2. Communication resource patterns for obtaining health information as
identified by the MSD items in the Multilevel Survey 84
Figure 4.3. Communication resource patterns for obtaining health information as
identified by the MSD items and the social network items in the Multilevel Survey
86

Figure 4.4. Communication resource patterns for general health and women’s health
goals as identified by the HCE Measure 92

Figure 5.1. PowerPoint slides used during HCAM workshop 111
Figure 5.2. Fieldwork instructions and mapping form used during HCAM workshop
112

Figure 5.3. GIS map of health communication assets identified in HCAM fieldwork
113

xii
Figure 5.4. Final collaborative map (front and back) developed through HCAM
workshops 115

xiii
ABSTRACT
This dissertation responds to the call for culturally relevant health research by
presenting an exploratory methodological framework that investigates influences on
health behavior from a communication perspective. Through the combination of
traditional and exploratory research methods, this dissertation proposes and deploys
a research design that highlights the significance of communication practices in the
study of health behavior. Grounded in the theoretical framework of communication
ecology, the health decisions of Latina women are examined through three different
methodologies: a neo-traditional quantitative survey, a pilot health communication
ecology measure and the fieldwork approach of health communication asset mapping.
Within the context of cervical cancer prevention among Latina women, this is
an investigation into the communication connections of a specific ethnic group and
in the context of a specific goal in an attempt to understand how sociocultural
practices can impact health behaviors. Because culture is often a mechanism through
which health is understood, particularly during a health crisis, communication
practices become properties of that mechanism through which culture is performed.
A contextual and ecological approach to understanding immigrant health can inform
health interventions by capturing everyday intricacies that differ across cultures and
geographies. Thus, this dissertation considers how discursive practices may influence
health behavior, and how an ecological understanding of such practices can help
further contextualize immigrant health.

1
CHAPTER ONE:
INTRODUCTION & BACKGROUND OF STUDY

In the United States, as in many globalized countries across the world, there
is a growing need to better understand and serve immigrant populations. As
immigrants and their families settle into urban and rural communities, researchers,
policymakers and practitioners struggle to better understand their behaviors so that
immigrant influences can be leveraged and wellbeing ensured. This need to examine
the behavior of immigrants and ethnic minorities is especially pronounced in efforts
to promote healthy individuals and communities. A recent President’s Cancer Panel
brought to the forefront the need for culturally relevant health research and
interventions. The panel found that cancer incidence among minority groups in the
U.S. is expected to double by 2030 as minorities continue to be disproportionately
affected by preventable diseases and low survival rates (Leffall & Kripke, 2011).
The report describes how our understanding of diseases and prevention methods is
largely based on studies that only include non-Hispanic white populations, making
such findings largely irrelevant among minorities and immigrants. This was the first
panel series that focused explicitly on health disparities and cancer incidence among
minority groups. The panel considered implications for U.S. cancer trends based on a
growing ethnic population and reflected on the effectiveness and relevance of
existing cancer prevention guidelines. Interestingly, the panel addressed health
disparities from a multilevel perspective, acknowledging the potential role that

2
patients, providers, the environment, culture, etc. may have in perpetuating health
disparities. In their initial formulation of questions to explore, the panel made a
statement about the need to understand the health behaviors of ethnic population in
order to address the health disparities that plague them. The following questions for
exploration, which closely align with the focus of this dissertation, were posed by the
President’s Cancer Panel:
• “Do patients from ethnic sub-populations experience, understand, and
discuss illness differently than mainstream populations? Do patients from
ethnic sub-populations have different help-seeking behavior?”
• “Does the clinical encounter differ across ethnic groups? To what extent
do patients and providers contribute to health disparities? Are there
beliefs (or stereotypes) held by providers about the behavior or health of
ethnic sub-populations?” (Leffall & Kripke, 2011)
To address these concerns, one of the main recommendations of the
President’s Cancer Panel, and many others like it, is the production of research that
identifies the role of socioeconomic and sociocultural determinants of health among
native and foreign-born minority populations. Specifically, the panel announced the
following cancer research and education recommendations, which received much
attention among practitioners, researchers and the popular media:
• “The President should direct the Secretary of the Department of Health
and Human Services to convene an ongoing, multidisciplinary working
group of stakeholders and other interested parties to develop more

3
accurate, representative, and useful ways of characterizing populations
and collecting population data so as to improve the quality of research
and health care to reduce the cancer burden and ensure social justice.”
• “Cultural competency must become an integral part of medical school,
other medical, and research training curricula, and also should be
included in continuing education requirements for all health care
providers and administrative personnel.”
• “Basic, translational, clinical, population, and dissemination research on
cancer health disparities must be increased, with a focus on identifying
and developing evidence-based interventions to address sociocultural
and/or biologic factors underlying the disproportionate burden of cancer
experienced by medically underserved, socially disenfranchised, and
other identified populations at high risk for cancer incidence and poor
outcomes.”
• “Social science research as it pertains to cancer health disparities should
be increased.” (Leffall & Kripke, 2011)

Such recommendations challenge researchers to develop approaches that
acknowledge the intricate influence of culture on health behavior. These approaches
would expand on traditional strategies that simply include minorities in the study
population for comparative purposes. Because personalized care is not always a
feasible option, medical practitioners need research and intervention strategies that

4
identify more effective approaches to promoting healthy lifestyles and proactive
prevention and treatment behaviors among underserved and hard-to-reach
populations. More specifically, such strategies can impact wellness across the
lifespan by informing screening guidelines, prevention methods and treatment
options for various diseases and conditions. Thus, understanding determinants of
health in more textured ways is vital to the sustainability of a rapidly growing
segment of the U.S. population.
This dissertation responds to the call for culturally relevant health research by
presenting an exploratory methodological framework that investigates socio-cultural
health determinants from a communication perspective. Through the combination of
traditional research methods and exploratory methods, this dissertation proposes and
deploys a research design that highlights the significance of communication practices
in the study of health behavior. Grounded in the theoretical framework of
communication ecology (Broad, 2013; Ball-Rokeach, Gonzalez, Son, & Kligler-
Vilenchik, 2012; Wilkin, 2007; Wilkin, Ball-Rokeach, Matsaganis, & Cheon, 2007),
the health decisions of Latina women are examined through three different methods.
Figure 1.1 depicts the design of the study and the different dimensions that can be
captured through the complementary methodologies.

5
Figure 1.1. Conceptual and Methodological Study Design

There are three different, but related databases for this dissertation research.
All of the data collection efforts were conducted as part of a much larger study titled
“Barriers to Cervical Cancer Prevention in Hispanic Women: A Multilevel
Approach,” (referred to as the Multilevel Study), a project supported by a grant from
the National Cancer Institute and led by Principal Investigators Dr. Sheila Murphy
and Dr. Sandra Ball-Rokeach. The Multilevel Study identifies the barriers and
conduits to cervical cancer prevention at the individual, interpersonal, and
community levels. In this current work, three components of the Multilevel Study
will be examined: a neo-traditional survey, a Health Communication Ecology
measure and Health Communication Asset Mapping.
Dataset 1: Neo-traditional Multilevel Survey
The first dataset is a subset of 500 respondents to what we call the Multilevel
Survey, the neo-traditional survey. The Multilevel Survey can be considered a neo-
Neo-‐Traditional

Survey

Health

Communication

Asset
Mapping
Health

Communication

Ecology

Measure

Local
Community
Connections
Transnational
Connections
Interpersonal &
Media Connections
Individual Health
Outcomes
Temporal
Decisionmaking
Neighborhood
Assets

6
traditional design due to its incorporation of both traditional survey measures such as
individual health outcomes, health knowledge and behaviors, and media exposure,
and innovative measures such as connections to local and ethnic media, community
connections and the differentiation between local and transnational communication
resources. Survey respondents are self-identified as Latinas and recruited primarily at
the partner site, Los Angeles County-USC Women’s Clinics, or at local sites
including small community clinics, laundromats, parks and health fairs. The survey
is designed to include women who are waiting to get Pap tests and women who are
non-compliant with screening guidelines and have not received a Pap test in over
three years.
Dataset 2: Health Communication Ecology Measure
The second database is a further subset of the 500 respondents to the
Multilevel Survey. It consists of 40 respondents who participated in a Health
Communication Ecology (HCE) measure after their completion of the Multilevel
Survey. While the Multilevel Survey and the HCE measure draw from the same pool
of respondents, they deploy different methods of data collection. An advantage of
this design is that a wealth of information collected in the Multilevel Survey can be
linked to the data collected in the HCE measure. I was a member of the Multilevel
Survey research team led by Professors Murphy and Ball-Rokeach and took
leadership in the development and implementation of the HCE measure.
While the Multilevel Survey informs us about the communication
connections that may play a role in influencing health decisions and behaviors, it

7
stops short of elaborating an individual’s agentic decision-making process. This
process is what uncovers a Health Communication Ecology, defined as a network of
communication resources constructed by an individual in a pursuit of a goal and in
context of their communication environment (Ball-Rokeach et al., 2012). To capture
this network of communication resources that Latinas would construct when faced
with a general health and women’s health problem, an HCE measure was deployed.
The exploratory HCE measure was developed in an attempt to qualitatively capture
the ways in which individuals obtain information while quantitatively
operationalizing the network of communication resources that are activated during
goal fulfillment or problem solving. The HCE measure has been in development as a
methodological expansion of research conducted under the auspices of the USC
Metamorphosis Project (Broad, 2013; Wilkin, 2013; Ball-Rokeach al., 2012; Wilkin,
Moran, Ball-Rokeach, Gonzalez, & Kim, 2010; Matsaganis, 2008; Katz, 2007;
Wilkin et al., 2007; Wilkin & Ball-Rokeach, 2006; Wilkin, 2005).
The incorporation of the HCE measure in the Multilevel Study is an attempt
at both refining the conceptual definition of communication ecology and developing
a methodological tool for the empirical deployment of the concept. The HCE
measure helps uncover information gathering and problem solving through a visual
activity where respondents are asked to describe the resources they connect with
when they experience a health problem. By having the respondent visually depict the
steps that they take to solve health problems, we can capture a more holistic
perspective of the communication resources that are actually utilized in health-

8
specific contexts. This approach allows for the temporal elaboration of
communication connections, including the processes through which one
communication resource leads to another. For this dissertation, the communication
resource patterns identified in Latinas’ health information-gathering through the
HCE measure will be compared to those identified in the neo-traditional Multilevel
Survey. Health communication ecologies are also contextualized in a way that
identifies the presence of local and/or transnational resources in an effort to expand
on traditional understandings of immigrant health. In both the Multilevel Survey and
the HCE measure, the role that transnational health behaviors or socio-cultural
legacies play in the health behaviors of Latinas will be identified.
Thus, this dissertation presents a communication ecology concept, an
operationalization of the concept, and a pilot test of its feasibility as a data collection
tool.
Dataset 3: Health Communication Asset Mapping
The third methodology employed as part of the Multilevel Study and
presented here as a case study is called Health Communication Asset Mapping
(HCAM). HCAM differs greatly from both the Multilevel Survey and the HCE
measure because it consists of participatory fieldwork and the collaborative
production of a neighborhood map. In keeping with a multilevel approach that
considers community as well as individual and interpersonal health determinants,
HCAM is deployed and discussed as a third component of an ecological research
design. HCAM is a methodological tool also grounded in a communication ecology

9
framework that attempts to identify physical spaces in a community where health
storytelling and prevention can occur. It consists of the training of residents and
promotores (community health workers) to identify health communication assets by
walking the neighborhood and capturing these assets through photographs and
written notes. Using the identified health communication assets, participants then
collaboratively develop a print and digital neighborhood map that highlights the
spaces with the most potential for health promotion. HCAM is also an exploratory
method that seeks to further inform strategies to reach immigrant groups by
identifying neighborhood spaces that can serve as health communication resources,
and ultimately influence health behavior.
HCAM is an adaptation of Communication Asset Mapping (Villanueva &
Broad, 2012), which is an expansion of traditional community asset mapping
methods. The HCAM methodology is also a conceptual and methodological tool
currently being developed as part of the Multilevel Study and under the auspices of
the Metamorphosis Project (Ball-Rokeach, Gonzalez, Moreno, Villanueva, & Wilkin,
2013; Zhao, Gonzalez, Ball-Rokeach, Murphy, Son, & Amezola, 2013; Gonzalez,
Murphy, Ball-Rokeach, Son, Mira, Amezola, & Zhao, 2012; Villanueva & Broad,
2012). In this dissertation, HCAM is presented as a pilot investigation into how
participatory fieldwork can inform the findings in both the Multilevel Survey and the
HCE measure by exploring community resources from the perspective of residents
and community health workers.

10
As depicted in Figure 1.1, the deployment of a neo-traditional health survey,
the Health Communication Ecology Measure and the Health Communication Asset
Mapping combine to form a multilevel and multi-method approach to understanding
health behaviors and uncovering the potential influence of sociocultural health
determinants among an immigrant population facing health disparities. Thus the
overarching goal of this dissertation is to introduce a grounded research design that
provides deeper insight into the ways that individuals make health decisions and the
barriers that may inhibit healthy behaviors, specifically those relating to cervical
cancer prevention.
As will be discussed in the following sections, the current state of public
health and health communication research is shifting toward a focus on immigrant
populations and a consideration for the sociocultural determinants of health. The
theoretical and methodological approaches presented in this dissertation focus on one
specific ethnic group in an attempt to develop a communication-based strategy for
understanding and targeting hard-to-reach populations. The focus on Latinos at this
stage of the exploratory research responds to both the growing influence of Latino
immigrants and their families and the growing health disparities that Latinos face.
Why Latino Health?
On March 13, 2013 white smoke emerged from the Sistine Chapel as the
Catholic Church announced the election of a new pope, Cardinal Jorge Mario
Bergoglio from Argentina. In one of the briefest conclaves of recent years, Cardinal
Bergoglio’s appointment marked what many consider a symbolic move by the

11
Church. The election of the first pope from a Latin American country (and the first
from a non-European country) spurred headlines such as “New pope signals Latino
shift for Catholic Church” (Avila & Marshall, 2013); “Pope pick highlights Latin
America’s growing role in Catholicism” (Llorente & O’Reilly, 2013); “New pope:
Latinos overjoyed with selection of Argentine” (Becerra et al., 2013). The global
reaction to a new pope from Argentina seemed to be dominated by excitement about
the pope’s Latino-ness. A pope from Latin America meant that the Catholic Church,
an institution with more than one billion members, had recognized the growing
influence of its Latino constituency on a worldwide scale. In the United States
specifically, cities with large Latino populations expressed a sense pride as this new
pope symbolized the Church’s awareness of a Latino presence. This excitement was
particularly felt in Los Angeles, depicted through headlines such as “L.A. Latinos
praise Spanish-speaking, Latin American pope” (Mai-Duc, Chang, Becerra, Gerber
& Mather, 2013) and “Local Latino business owners feel ‘blessed’ by new pope”
(Raymond, 2013). While the official motivations behind Cardinal Bergoglio’s
appointment may never be revealed, the Pope’s country of origin has in itself made a
statement about the need to cater to a growing Latino demographic. In the United
States this need is even more pronounced, as the influx of immigrants and their
children have changed the cultural dynamics of both urban and rural cities across the
country.
A similar symbolic statement was made during the 2012 U.S. presidential
election. Arguably, the storyline that received the most buzz in media outlets and

12
social networking sites during the election was about the Latino vote. Both the
Democratic and Republican parties had worked hard to woo Latino voters, much
more, it seemed, than in previous elections. And Latinos indeed made their mark in
the election, helping re-elect President Obama after the Obama campaign drastically
outspent the Romney campaign in Spanish-language media advertisements and
outreach to Latino community groups. Journalists and political pundits were quick to
credit Latino voters with Obama’s re-election through stories such as “Latino voters
in Election 2012 help sweep Obama to reelection” (Foley, 2012) and “Obama’s re-
election sets record support from Latino voters” (Rodriguez, 2012). CNN ran a story
titled “Five things we learned on election night,” and the number one lesson was that
the Republican party would have difficult regaining control of the White House until
they figured out how to cater to Latino voters. This had become painfully evident as
Latino voters helped Obama win battleground states and even turned former swing
states into Democratic strongholds (Steinhauser, 2012). The significance of the
Latino vote was not a new conversation, but it was definitely heightened by post-
election analyses that demonstrated the value in understanding what issues are
important to the Latino community and how potential Latino voters can be more
effectively engaged.
The significance of a Latino constituency has become a hot topic in various
political and social spheres. At the local level, neighborhoods are experiencing a
shift in demographics and changes in the cultural landscape. At the national level,
powerful institutions such as the Catholic Church and the federal government have

13
made bold moves to acknowledge the presence and influence of Latino immigrants
and their families. Policymakers are now shifting their attention to this specific
population in order to effectively build an understanding and relationship with a
constituency whose numbers will continue to grow even as immigration from Latin
American countries decreases.
The growing Latino population and their integration into American society
poses a particularly demanding challenge in health prevention. According to the
2010 U.S. Census, Latinos now make up 50.5 million (16%) of the total population
and are expected to more than double to 128.8 million by 2060. Meanwhile, Latinos
currently comprise only 1 to 3% of the cancer clinical trial population (Sheikh, 2004).
Studies have shown that one of the reasons why minority cancer patients are less
likely to participate in clinical trials is a lack of knowledge of the procedures and
lack of awareness of their importance in cancer prevention and treatment (Anwuri et
al., 2013; Quinn, McIntyre, Gonzalez, Antonia, Antolino, & Wells, 2013; Geller,
Koch, Pellettieri, & Carnes, 2011; Cox & McGarry, 2003; Sateren et al., 2002;
Brown, Fouad, Basen-Engquist, & Tortolero-Luna, 2000). Adequate representation
of minority groups in clinical trials is crucial to health maintenance, as science has
demonstrated that there are ethnic differences in the metabolism of certain drugs and
treatments. Currently, less than 50% of American clinic trials capture or report
information about the participants’ ethnic background, making cross-ethnic
comparisons impossible (Sheikh, 2004).

14
Simultaneously, Latinos (both immigrant and native-born) experience greater
risk of diabetes, heart disease, obesity and high cholesterol (CDC, 2013). According
to the Centers for Disease Control and Prevention, the prevalence of obesity among
males under the age of 20 is highest among Mexican Americans. During 2004-2007,
the rate of preventable hospitalizations was higher among Latinos compared with
non-Hispanic whites. And Latinos continue to experience a disproportionate
incidence of HIV diagnoses (CDC, 2013). Striking health disparities among both
native-born and immigrant Latinos and a lack of practical and cultural
understandings of their health decision making make for a troubling forecast of the
livelihood of an emerging majority.
The methodologies presented in this dissertation were deployed in the context
of cervical cancer prevention as part of the Multilevel Study. Cervical cancer is one
of the most common reproductive cancers among women in the United States and is
the second most common cancer among women worldwide (American Cancer
Society, 2009). Almost 85% of cervical cancer deaths occur in the developing world
or among underserved and minority populations in developed countries (Wittet &
Tsu, 2008; World Health Organization, 2006). This inequity calls for the
implementation of aggressive interventions to increase rates of regular screening
among minority underserved women (Bazargan, Bazargan, Farooq, & Baker, 2004).
The major risk factor for cervical cancer is persistent infection with certain types of
human papillomaviruses (HPV) (Panamerican Health Organization, 2007). HPV
infection is the most common sexually transmitted disease in the United States

15
(Centers for Disease Control and Prevention, 2010) with more than six million new
infections reported every year. Factors that can increase the risk of cervical cancer
include not having regular Pap tests, lack of follow-up after an abnormal Pap test
result, dietary and nutritional factors, a family history of cervical cancer, a history of
sexually transmitted diseases, use of oral contraceptives, and having HIV (CDC,
March 2009; Warren, Gullett, & King, 2009).
The cervix is the fourth leading site of new cancer cases among Latinas in the
United States, with an incidence rate of 13.2 per 100,000 Latinas as compared to 8.2
per 100,000 among White women (American Cancer Society, 2009). Mortality rates
due to cervical cancer are 40% higher among Latinas as compared to Whites
(American Cancer Society, 2009). Latinas are two times more likely than African
American women and five times more likely than Caucasian women to display an
association between HPV infection and cervical cancer lesions (Tortolero-Luna et al.,
1998). In Los Angeles County specifically, the incidence of cervical cancer among
Latinas is as high as 14.3/100,000 compared to 9.3/100,000 for Asian women,
7.6/100,000 for African American women and 7.5/100,000 for White women (LA
County Department of Public Health, 2010).
Investigation into the barriers and conduits to cervical cancer prevention
among Latinas is a complex one. A deeper understanding of why Latinas exhibit
higher levels of cervical cancer than other ethnic groups is outside of the scope of
this dissertation. However, an understanding of how Latinas make health decisions
and a comparison of three different methodologies to capture that knowledge is a

16
preliminary and potentially informative step in discovering a connection between
communication practices and health outcomes.
Sociocultural Approaches to Health Communication
Traditional health communication campaigns often use a combination of
mediated and interpersonal approaches to influence changes in health behavior
(Hornik, 2002; Noar, 2006; Rice & Atkin, 2012, Atkin, 2001). A review by
Viswanath and Finnegan (2002) finds that low socioeconomic status groups, which
face the greatest threats of ill health, fail to benefit equally compared to higher
socioeconomic groups. The at-risk populations are most often left behind while
campaigns continue to benefit the health rich. A substantive body of evidence on
knowledge gap theory points out that health communication campaigns contribute to
the existing gaps between the rich and the poor (Finnegan & Viswanath, 1997;
Freimuth, 1990; Viswanath & Finnegan, 1995).
The Health Belief Model (HBM), for example, is a widely employed
theoretical framework that informs many health communication campaigns. HBM
suggests that for individuals to engage in preventive behavior (or change their
unhealthy behavior), they need to feel a high level of perceived susceptibility (risk of
contracting a specific disease) and perceived severity (possible negative
consequences of the disease) (Janz & Becker, 1984; Rosenstock, 1974; Becker,
Maiman, Kirscht, Haefner, & Drachman, 1977; Janz, Champion & Stretcher, 2002).
The susceptibility and severity perceptions together represent the perceived threat of
the disease, and this treat is weighed against the potential benefits and perceived

17
barriers of a preventive behavior. An additional construct, self-efficacy, measures
how confident individuals are in their abilities and likelihood of engaging in the
preventive behavior. And finally, cues-to-action are the stimuli that can trigger a
change in behavior and the adoption of preventive actions. Cues-to-action can
include messages in media campaigns, the influence of interpersonal conversations
about health and the advice of medical professionals (Janz & Becker, 1984; Babrow
& Mattson, 2003). One of the contributions of the HMB to health communication
campaigns is the finding that mass media efforts should emphasize the potential
benefits of behavior change rather than the risks of maintaining the unhealthy
behavior (Champion & Skinner, 2008).
In a critical review of health communication campaign approaches, Dutta-
Bergman (2005) argues that the HBM, along with the extended parallel process
model and the theory of reasoned action, have an individualistic bias, ignore the
sociocultural context in which individuals make decisions about their health behavior
and are limited by a purely cognitive focus. Dutta-Bergman (2005) suggests that
individual behavior is inevitably a component of collective culture, such that
individuals may act in ways they believe they are expected to act. Janz and Becker
(1984) also note that the HBM, as a psychosocial model, is limited to “accounting
for as much of the variance in individual’s health-related behaviors as can be
explained by their attitudes and beliefs (p. 2)”. They argue that other forces influence
health actions as well, such as habits, need of social approval, and economic and
environmental factors.

18
Thus, working from an understanding that individual health is not an isolated
phenomenon, public health research has been shifting toward an analysis of the
social, cultural and neighborhood-level factors that can impact healthy living. In
cancer research specifically, several studies investigate how sociocultural practices
can help both understand immigrant behavior and inform health promotion strategies
for hard-to-reach populations. Recent studies promote the ethnic tailoring of health
messages through their content, style and delivery as a strategy to improve the health
of Latinas (Hernandez & Organista, 2013;Quinn et al., 2013; Ramirez, 2013; Wells
et al., 2013; Cabassa, Molina, & Baron, 2012; Deavenport, Modeste, Marshak, &
Neish, 2011; Buki, Salazar, & Pitton, 2009; Oetzel, de Vargas, Ginossar, & Sanchez,
2007; Borrayo, 2004). Regarding Latinas and cervical cancer specifically, emerging
research has found that the ethnic tailoring of health messages can promote
knowledge and behavioral change when both cultural and stylistic dimensions are
considered (Baezconde-Garbanati, Murphy, Moran, & Cortessis, 2013; Moran,
Baezconde-Garbanati, Murphy, Frank, & Chatterjee, 2013; Murphy, Frank,
Chatterjee, & Baezconde-Garbanati, 2013).
Baezconde-Garbanati et al. (2013) find that while Latinas in Los Angeles
have higher cervical cancer incidence rates than other ethnic groups, they possess
knowledge of what Pap tests are and understand that the tests can prevent cervical
cancer. It is other barriers, such as lack of time, money, and support, that keep
Latinas from getting regular Pap tests (Baezconde-Garbanati et al., 2013). The
authors argue that systemic barriers to cervical cancer screening, such as the mistrust

19
of doctors, stem from experiences in which a doctor ignored or dismissed their
concerns (Baezconde-Garbanati et al., 2013). This mistrust of doctors coupled with
the finding that Latinas do health research “by talking to friends and family and
looking things up online or in books,” (Baezconde-Garbanati et al., 2013, p. 51)
supports the idea that Latinas turn to a variety of communication resources when
seeking health information. Baezconde-Garbanati et al. (2013) recommend
culturally-grounded and ethnically-tailored health promotion efforts that address
differences in health knowledge based on acculturation status and consider the
structural and systemic barriers to Pap test screening.
The impact of acculturation on health is another avenue through which
immigrant health has been explored from a more sociocultural perspective. Research
on acculturation and health has produced mixed understandings on what
acculturation means and how it might play a role as a health determinant.
Acculturation is most often conceptualized as the level of integration into a host
society, but it is most often measured by constructs such a birth place and language
use, assuming that individuals who are foreign-born and do not adopt the host
society’s primary language as their own are less acculturated. Because of the abstract
definitions of acculturation and the various methods of measurement, studies on the
connection between levels of acculturation and specific health outcomes have found
support for both positive and negative effects. For example, while high levels of
acculturation have been associated with poorer diet and nutrition (Dixon, Sundquist,
& Winkleby, 2000; Montez & Eschbach, 2008; Stimpson & Urrutia-Rojas, 2007;

20
Ayala, Baquero, & Klinger, 2008; Mainous, Diaz, & Geesey, 2008), women who
live in areas of high immigrant concentrations and who consider themselves more
acculturated have exhibited higher fruit, vegetable and fiber intakes (Espinosa de los
Monteros, Gallo, Elder, & Talavera, 2008). This distinction alone suggests that
health behaviors of immigrants, while influenced by their cultural practices, can
differ based on geography and other sociocultural factors. For a review of
acculturation research and measures in the context of Latino health, see Wallace,
Pomery, Latimer, Martinez, & Salovey (2010).
Due to the inconsistent results of the effect of acculturation on Latino
immigrant health, researchers are charged with the task of understanding Latino
health behavior from a more practical standpoint. One of the ways to overcome the
socio-cultural limitations of health communication strategies and to interrogate the
impact of external forces on health is by understanding how individuals gather
information about health in order to make health decisions. A communication
ecology perspective on health decision making moves beyond an individual-level
analysis to consider the interpersonal, mediated and organizational factors that can
promote or hinder specific behaviors. It also contextualizes health behavior by
acknowledging the multi-spatial nature of resources that are activated when
individuals are faced with a health decision. For immigrants this is particularly
pronounced, as they often navigate through a set of local and transnational resources
that inform their perspectives on health and influence their behaviors. Thus, this
dissertation investigates the types of communication resources patterns that Latinas

21
turn to for health information and how such patterns may impact general health and
cervical cancer prevention behaviors, namely the likelihood of obtaining regular Pap
tests, confidence in the ability to get regular Pap tests, and the likelihood of returning
for follow-up treatment after an abnormal Pap result.
Organization of the Dissertation
Chapter Two presents a communication ecology theoretical framework
through an exploration of the main theories that have contributed to its
conceptualization, MSD and CIT. The concept of transnational health is also
introduced as an exploratory theoretical and methodological approach towards
understanding the socio-cultural dimensions of immigrant health in more textured
ways.
Chapter Three identifies the methodologies used in the Multilevel Survey and
the HCE measure. It describes the background and development of the two
approaches and the measures and dimensions that are analyzed. This chapter also
includes a description of the sample characteristics of the study population.
Chapter Four presents findings from the deployment of the Multilevel Survey
and the HCE measure. First, communication resource patterns are identified through
the two approaches, revealing differences in patterns for each data collection method.
Second, the presence of transnational health behaviors and socio-cultural legacies in
Latinas’ decision making process are described and compared based on data
collection method. And third, variations in general health and self-efficacy regarding
screening behaviors are compared based on communication resources patterns.

22
Chapter Five describes the deployment of the Health Communication Asset
Mapping approach with a group of residents and practitioners in the community of
Boyle Heights. This pilot deployment of the HCAM protocol included the training of
residents to participate in data collection by walking the neighborhood and
identifying health communication assets, or spaces where health promotion and
health storytelling can occur. The training process is described and the final
collaborative map of health communication assets in Boyle Heights is presented.
Chapter Six summarizes the findings from the Multilevel Survey, the HCE
measure and the HCAM workshop through a discussion of how the three
methodologies inform us about the health information seeking behavior of Latinas
and how the different findings can suggest strategies for health promotion and
interventions.
Chapter Seven concludes this dissertation by describing the limitations of the
three approaches and discussing how a communication ecology perspective can help
researchers and practitioners further understand sociocultural determinants of health
by considering the role of communication practices.

23
CHAPTER TWO:
THEORETICAL FRAMEWORK

Communication Ecology
Studies of communication and community stem from the work of early
Chicago school sociologists (Park et al., 1925) who tried to identify the social and
environmental causes of contemporary social problems. Using the city as a social
laboratory, early studies of urban life conceived of the city as a natural environment
with its own ecological characteristics based on competition and accommodation.
Individuals interacted to form organic communities, and these sets of communities
formed the larger city. Urban residents, therefore, negotiated their lives and their
relationships to each other within this ecological system. These studies of cities
placed an emphasis on the relationship between individuals and their environments.
Subsequent variations of an urban ecology approach began to consider the influence
of the media in urban integration. Thus, the acknowledgment that environmental
factors influence social processes helped guide the forthcoming research on
communication and community by providing an ecological perspective.
Friedland (2001), for example, posits that only particular kinds of
communities facilitate interpersonal discussion and promote democratic participation.
Communities that are “communicatively integrated” are more likely to work
democratically as they formulate problems, find solutions and collectively learn from
them (Friedland, 2001, p. 360). The most effective way to determine if a community

24
is communicatively integrated is by studying its communication ecology, which
Friedland (2001) defines as “the range of communication activities that link
networks of individuals, groups, and institutions in a specific community domain” (p.
360). As globalization, communication technologies, and networks of association
transform community life, Friedland (2001) argues that we must rethink how
communities function and how research on communication and community can help
explain this transformation. Drawing from Habermas’ theory of communicative
action, which posits that the system and the lifeworld are connected through
communication, Friedland (2001) explores the interaction between systems and
social interactions within the context of local communities. System-level forces can
disturb, disrupt and penetrate the social interaction of communities, but as citizens
“engage in deliberation, collective problem-solving, and others forms of
communicative organization,” they can restore social integration (p. 373). Friedland
acknowledges the uncertainty of whether community-level interventions can
reinvigorate community life, but highlights the significance of an ecological
approach in such an effort.
This dissertation expands the concept of communication ecology as both a
theoretical and methodological tool for understanding the decision-making processes
that people (in this case immigrants) are faced with in their everyday lives. A
communication ecology is defined as a network of communication resources
constructed by an individual in pursuit of a goal and in context of their
communication environment (Ball-Rokeach et al., 2012). A communication ecology

25
approach considers communication connections that go beyond media and
interpersonal resources to include organizational, professional, and other resources
that apply to a specific goal in question. As such, the network of resources is
multilevel in that it allows the inclusion of micro (individual and interpersonal),
meso (local media and organizations) and macro (mass media and institutional) level
resources.
Previous applications of the communication ecology framework have
identified communication maps that serve as roadmaps to reaching and serving
ethnically diverse populations. Wilkin et al. (2007) argue that social change
interventions can benefit from employing the communication connection that is most
relevant to the target audience and to the goal at hand. If individuals, for example,
report that they turn to mainstream media for information about their local
community while the mainstream media in their community contains no local
coverage, this produces a disconnect between how media resources are engaged with
and the content that they actually provide. This type of disconnect is what creates a
weakened discursive connection between individuals and the media that serve them.
In studying immigrant groups, this is particularly significant, as ethnicity and
geography often “interact to produce geo-ethnic variations”, meaning that
individuals of the same ethnic group may have different information-seeking patterns
based on their residential environment (Wilkin et al., 2007). Thus, a communication
ecology approach that considers the varying ways in which individuals obtain
information across geographic spaces during a health problem-solving process would

26
produce more textured understandings of how communication resource patterns can
explain variations in health behaviors and outcomes.
The communication ecology approach is based, in part, on the Media
Systems Dependency (MSD) conception of individuals as goal seekers who
construct their own media systems (Ball-Rokeach, 1998). It is also an expansion of
the Communication Infrastructure Theory (CIT) premise that individuals are part of a
discursive neighborhood storytelling network (Kim & Ball-Rokeach, 2006; Ball-
Rokeach, Kim, & Matei, 2001). In this conception, the availability or accessibility of
communication resources in the environment is relevant but not determinant of
individuals’ communication ecologies. Within the range of mediated, interpersonal,
organizational, professional or other communication resources available in the
environment, individuals have a certain degree of agency to select which resources
they connect with in pursuit of a goal. An individual may also act within several
communication environments (e.g. local, national and global) depending upon the
nature of the goal and the perceived utility of available and accessible resources in
each environment. For example, in the current exploratory research with largely new
immigrant Latinas, both local and transnational communication resources are being
considered. The following discussion will unfold the theoretical underpinnings of the
present communication ecology framework through an understanding and expansion
of MSD and CIT.

27
Media Systems Dependency Theory
A media-system dependency is considered “a relationship in which the
capacity of individuals to attain their goals is contingent upon the information
resources of the media system—those resources being the capacities to (a) create and
gather, (b) process, and (c) disseminate information” (Ball-Rokeach, 1985, p. 487).
In this framework, media dependency helps explain certain dynamics of media
effects, particularly the question of how individuals engage with media and for what
purposes. While limited to media systems, MSD establishes an argument that
communication resources form part of a larger social structure that impacts
individual behavior. The extent to which individuals develop dependency relations
with the media is ultimately determined by the macro dependency relations media
have with other social systems; that is the role that the media plays in a specific
society.
The form and substance of individuals’ media dependency relations also
varies when the social environs become ambiguous or problematic. For example,
during times of crisis or natural disasters, a specific type of communication resource
(e.g. radio) may be more reliable and accessible than other forms of communication.
In this case, individuals may develop a strong dependency relation with radio during
emergencies because it has proved to be a quick and reliable source of information.
Thus, an individual’s media dependency during a specific moment is shaped more by
the perceived social role of a particular medium rather than the personal preferences
of the individual.

28
MSD also contextualizes media behavior by considering how individuals
engage with media during problem-solving and goal-attainment processes. In this
sense, individuals are considered agentic goal-seekers who utilize media resources in
ways that make sense to them and in the context of their situation at hand. A goal-
specific orientation is thus useful because individuals are not always conscious of
their dependency relations, but they can explain why and how they engage with
certain media during specific contexts and for specific goals (Ball-Rokeach, 1985, p.
494).
As such, MSD helps us think about what motivates individuals to engage
with media and how these motivations may differ depending on the goals they are
trying to achieve. The MSD typology considers understanding, orientation and play
as three major dimensions that help explain media behavior. However, this
framework does not assume that individuals in the same society sharing the same
motivating goal will engage with the media in the same way. Instead, their
relationship with the media must be considered in context of the social environment,
the actual activities of the media system, the influence of interpersonal networks, and
the structural locations of individuals and the groups to which they belong. In this
framework, social environment is “intended to encompass all environs that may bear
upon individuals’ understanding, orientation, or play goals whether they be
international, national, community or interpersonal” (Ball-Rokeach, 1985, p. 498).
Thus, while MSD is primarily concerned with the relationship between
individuals and media systems, it acknowledges the influence of the larger social

29
structure. This dynamic is most effectively illustrated by the way in which
information travels from a media source through a community. While media provide
raw information, albeit with a certain degree of filtering and analysis, interpersonal
networks provide a majority of the information processing and re-interpretation that
helps information travel. Therefore, regardless of the dependency relationship that
individuals may have with a media system, the social environment can, to an extent,
strengthen or weaken that dependency relation.
As a theoretical construct, Communication Ecology builds upon two major
premises of Media Systems Dependency theory: (a) that individuals are agentic and
engage with the media system differently based on the goals they are trying to
achieve and (b) that individual dependency relations are influenced by the social
environment. Communication Ecology expands on MSD by considering individual
relationships with other forms of communication resources in addition to the
media—such as other individuals, local community organizations, and professionals.
It expands the goal typology of MSD by identifying the unique temporal unfolding
of communication resources for attainment of a specific and concrete goal—in this
case, health information gathering and problem solving. Therefore, the type of
communication ecology considered in this current work is specifically a Health
Communication Ecology (HCE).

30
Communication Infrastructure Theory
Communication Infrastructure Theory (CIT) is concerned with the
communication process through which individuals better understand their
environment and become members of a neighborhood instead of simply occupants of
a home. CIT is premised on the idea that neighborhoods are discursively constructed,
and that residents can construct their identity as members of a residential
neighborhood (Ball-Rokeach, Kim, & Matei, 2001). The process of storytelling a
neighborhood is bounded by the communication infrastructure of the neighborhood.
CIT provides an approach that highlights the “interplay between interpersonal and
mediated storytelling systems and their contexts” (Ball-Rokeach, Kim, & Matei,
2001, p. 396). The consideration of contextual factors allow for a more holistic
investigation of communication practices that include connections to ethnic media
and community institutions. This approach is ecological in nature for two major
reasons: a) it considers the connections between key neighborhood storytellers
(residents, local media, and community organizations) while b) investigating these
connections in context of the communication environment (or the communication
action context).
A theoretical expansion of MSD theory, CIT thus provides a more holistic
approach to understanding the ways in which communication practices impact
residential life. MSD posits that the media are part of a larger social system, and CIT
presents one approach to identifying the other influential components of that system
while considering contextual factors that may promote or inhibit neighborhood

31
storytelling. Much like Anderson’s (1983) conceptualization of imagined
communities that are constructed by individuals with shared visions and identities,
CIT posits that community is constructed through neighborhood storytelling. And
when that storytelling is fostered and sustained, community-level social change is
more likely to occur. Because residents have the ability to imagine their own
neighborhoods through storytelling, it is important to consider the multilevel
discursive contexts in which they exist so that their individual decision-making
practices are better understood.
The theoretical framework of Communication Ecology thus employs a
grounded approach that captures information gathering and problem solving for
specific goals or problems. However, the actions and decisions of residents are also
bounded by the availability of communication resources in their neighborhood and,
more importantly, by the discursive connections between neighborhood storytellers.
Thus, an exploration of the multilevel dimensions of CIT further contributes
to the theoretical development of a Communication Ecology construct. A
communication infrastructure consists of the neighborhood storytelling network
(STN) and the communication action context (CAC) in which it exists. The CAC is
of particular importance in this discussion, as it points to the significance of physical,
psychological, sociocultural, economic and technological dimensions of a
neighborhood that may impact how residents feel about their neighborhood and how
they interact with their neighbors. In the health context, the CAC plays a major role
in identifying how the availability of health resources in the communicative

32
environment may impact individual behavior. While health conversations about a
particular disease or health scare may permeate the neighborhood storytelling
network, the CAC can ultimately foster or hinder pro-active actions (such as
preventive treatment). For example, campaigns promoting breast cancer awareness
have found creative ways to promote conversations about the importance of
preventive mammogram screening. However, if a neighborhood does not have the
capacity to provide free or affordable mammogram screenings due to the limited
availability of community clinics, individuals’ potential to engage in preventive
behaviors will be limited. Therefore, individual health behaviors are constrained both
by the amount and nature of health information (disseminated through discursive
practices) and by the availability and accessibility of health services (a component of
the CAC).
Matsaganis (2008) conceptualizes the process through which neighborhood
institutions shape the decisions and the lives of urban residents. Through a
communication infrastructure approach, Matsaganis posits that institutions (such as
clinics, schools, churches, etc.) are also neighborhood actors that can promote or
hinder community health depending on their level of integration and participation in
the community. Just as residents and media organizations are integral components of
the storytelling network, community institutions can play a role in sharing health
information so that local health resources are made accessible to residents.
One feature of the residential communication environment that has been
heavily explored from a communication infrastructure approach is the indigenous

33
storytelling network that joins meso (local or geo-ethnic media and local community
organizations) and micro (residents as constituted in their interpersonal networks)
levels of analysis. Basically, the more that residents, local or geo-ethnic media, and
local community organizations are in a dynamic discursive conversation about the
residential area, the more integrated the network, and the more likely that residents
will be engaged and knowledgeable about available health resources. Thus, the
strength of the storytelling network is an important feature of the communication
environment that can affect communication practices; in this case, practices oriented
to achieving a health goal.
This storytelling network is discursively constructed, and the strength of
connections between the three components of the STN impact feelings of belonging,
collective efficacy and civic participation (Kim & Ball-Rokeach, 2006; Ball-
Rokeach et al., 2001) Applications of CIT have further explored the role of
community organizations and the ways in which they develop connections with other
key storytellers in order to promote social change (Broad, 2013). The role of geo-
ethnic media in community life has also been explored, particularly with an emphasis
of how ethnic media outlets engage with immigrants and often establish themselves
as advocates for a particular ethnic group (Matsaganis, Katz & Ball-Rokeach, 2011).
This dissertation presents a grounded research approach that allows
individuals to unfold the communication resource connections that play a role in
their health information gathering. However, individual connections are bounded by
the storytelling networks that they are a part of and the communication action

34
contexts of their local neighborhoods. Therefore, while individuals are agentic and
develop a unique clustering of communication resources when addressing a specific
problem or achieving a specific goal, their decisions are still dependent on the types
of resources that are available and the strength of connections between those
resources and other discursive components of the storytelling network.

Transnational Health
CIT considers residential places as “part of a much larger fabric of
association and identity that merges geographic with other spaces that do not require
shared locales (e.g., ethnic, cultural, lifestyle, or professional)” (Ball-Rokeach et al.,
2001, p. 393). In this same manner, health behaviors of immigrants can be influenced
not only by the environment in which they live, but also by the nature and frequency
of connections they have with people in their home country or by the cultural
practices that they maintain. For immigrants, transnational connections can take
many forms and serve different purposes. While some immigrants may maintain ties
to their home country as a way to sustain family cohesion, others may do so because
they rely on those connections to navigate their life in the host society. In the health
context, an investigation into transnational connections can further inform our
understanding of why immigrants may shy away from or be hesitant to engage in
health promotion behaviors.
One of the recommendations of the President’s Cancer Panel described in the
introductory chapter was to include cultural competency as part of medical school

35
and research training and encourage medical professionals to further understand the
health behaviors of the patients they serve. This is particularly vital to the success of
health promotion campaigns in immigrant communities because a lack of
understanding or acceptance of cultural health practices may contribute to feelings of
distrust or fear toward the mainstream medical system. The Panel also recommended
the deployment of evidence-based interventions to address sociocultural factors
underlying the disproportionate burden of cancer experienced by ethnic minorities.
The identification of a health-specific communication ecology combined with a
consideration of the multi-spatial nature of resources and cultural influences can help
inform culturally-relevant health intervention strategies. Both the Multilevel Survey
and the HCE measure reveal, albeit through different methodologies, the
communication resource patterns that can impact the health decisions of Latina
immigrants. The operationalization of these methodologies in a specific goal-
achievement process can suggest potential avenues through which to disseminate
health messages and promote preventive behaviors.
Following the Health Communication Ecology framework that considers the
network of resources that individuals turn to when addressing health problems, the
transnational component of this dissertation explores both the transnational
communication connections and the transnational health behaviors of Latina
immigrants. For the purposes of the current study, transnational communication
connections are defined as the nature of contact with individuals in the home country,
whether by traditional methods such as phone calls or letters, or more modern

36
methods such as text messaging and video chats. Transnational health connections
thus refer to the health-specific contacts with individuals in the home country. These
contacts may be temporally proximate (e.g., discussing health issues with a friend or
family member in the home country) or they may be socio-cultural legacies (e.g.,
using folk remedies extant in the home country). This conceptualization of
transnationalism is a bit different than traditional understandings of transnational
activities in the political or economic sphere. The health context helps capture more
practical and goal-oriented instances of everyday transnationalism. Identifying these
transnational health connections may contribute to more culturally appropriate
understandings of immigrant health
A common challenge in the life of an immigrant is the negotiation between
their presence in the host society and their social, political, emotional and cultural
attachments to their country of origin. Some immigrants may make the decision to
cut ties with their social networks back home; this decision can be influenced by
personal preference or by the logistic and economic difficulties of maintaining those
relationships. Other immigrants may decide to bridge their two worlds and sustain
social relationships back home while developing new connections in the
communities they settle in. The networked society in which we now exist makes it
easier for immigrants to engage in two worlds simultaneously. As Castells (2010)
notes, the shift from the traditional mass media to more horizontal networks of
communication has introduced “a multiplicity of communication patterns at the
source of a fundamental cultural transformation” (p. xviii). It has thus become much

37
easier, through information and communication technologies (ICTs), for immigrants
to maintain strong ties with family and friends back home if they choose to do so. As
Diminescu (2008) describes: “Yesterday the motto was: immigrate and cut your
roots; today it would be: circulate and keep in touch” (p. 568).
As described in the introductory chapter, the U.S. alone has experienced a
rapid influx of immigrants, particularly those from Latin American countries.
However, there is a limited understanding of how immigrant decision making may
be influenced by the nature of communication connections with the home country.
As part of the theoretical framework of this dissertation, a discussion of the impetus
for focusing on transnational connections is presented below.
While the concept of immigrant transnationalism has been heavily contested
and re-defined since it was introduced in the early 1990s, it remains a significant and
relevant phenomenon that is useful in understanding the everyday experiences of
immigrants and globalized communities. Immigrant transnationalism has been
traditionally understood as a transcendence of national boundaries, or an economic,
social, political or cultural connection to multiple nations (Schiller, Basch, & Blanc-
Szanton, 2006; Waldinger & Fitzgerald, 2004; Portes, Guarnizo, & Landolt, 1999;
Vertovec, 1999). For international immigrants, being transnational would mean to
maintain ties with both the home and host country. Arguably, the most prolific vein
of transnational research has focused on economic (financial remittances) and
political (voting in the home country) cross-border practices that complicate notions
of nationalism, assimilation and immigrant integration.

38
As globalization has heightened interconnectivity between nations, it has
become easier for immigrants to maintain ties with their home country while settling
in the host society. A longstanding concern has been the potential detrimental effect
transnational activity can have on the incorporation and integration of immigrants in
their local communities. Transnational scholars have long called for interdisciplinary
work that extends our understanding of transnationalism in both theoretically and
methodologically meaningful ways. In anthropology, sociology and political science,
the main hosts of transnational research, there is a consistent acknowledgment that
communication practices are an integral aspect of immigrant transnationalism. It is
uncommon, however, for this research to couple transnational and communication
theories in order to understand how and why communicative practices are important
in the lives of immigrants.
Our traditional understandings of transnationalism and immigrant integration,
largely based on economic and political dimensions, can benefit from investigations
into the more private socio-cultural activities that can also consist of cross-border
interactions. Rather than duplicate previous studies that identify the degree to which
immigrants are economically or politically connected to their home countries, this
dissertation explores potential influence of transnational activities in everyday life.
There is currently a great concern for understanding how immigrants negotiate
integration into the host society and maintenance of cultural, social and practical ties
to their home country. In order to better understand the daily lives of immigrants, or
to more effectively develop communication campaigns that target immigrant groups,

39
we must look beyond the local and the public. What is of interest in this study is
what transnational scholar Steven Vertovec calls “everyday transnationalism,” or the
aspects of social life that are affected by transnational ties (2009, p. 61).
While a deeper analysis of everyday transnationalism is outside the scope of
this current work, the communication ecology framework presented in this
dissertation begins to acknowledge the multi-spatial nature of the resources that
immigrants rely on as they make decisions and solve problems. An identification of
the transnational health practices of immigrants can bring us closer to determining
how such practices can be leveraged to promote immigrant health and address health
disparities. As will be described in more detail in Chapter Three, the idea of
transnational health arose from the development of a Communication Ecology
measure that I have led over the past two years. Through an investigation of the
communication resources that Latina women turned to when faced with a health
problem, I began to notice the presence of resources that were not situated in the
local community. Thus, the methodological development of the HCE measure
prompted an expansion of its conceptual definition by also considering the spatial
dimensions of communication resources.
This examination of health-related transnationalism builds upon prior
research on the nature of their health decision making, including the combination of
mainstream and alternative practices and local and transnational resources (Ransford,
Carrillo, & Rivera, 2010; Thomas, 2010; Koehn & Swick, 2006; Gastaldo, Gooden,
& Massaquoi, 2005; Murphy & Mahalingam, 2004; Messias, 2002). For example,

40
using a sample of Latino immigrants that include many uninsured and undocumented
respondents, Ransford et al. (2010) examine how Latino immigrants incorporate a
range of healthcare options (conventional medicine, Latino traditional medicine, and
religiosity) in their health-seeking behaviors. Ransford et al. (2010) present a
typology of immigrant health dynamics that include belief barriers (fears, anxieties,
concerns about approaching the health care system), structural barriers (absence of
translators, lack of health insurance, cost of care) and cultural alternatives (herbal
remedies, traditional healing, folk healers) that make up the Latino immigrant health-
seeking experience. Ransford et al. (2010) found that some Latino immigrants turned
to home remedies and traditional medicine as a first course of action while others
first seek mainstream treatment but then turn to other alternatives when they do not
receive the care they need. The preference for herbal medicine is what the authors
describe as a “quest for the natural,” in which respondents sought treatment that they
could trust because Western medicine seemed unnatural to the body (p. 870). In fact,
many respondents stated they would definitely seek care in Mexico if they had need,
even though half said they had not or could not consider that option. Due to easier
access to doctors, lower costs and higher medication doses, more time spent with
doctors, careful explanations, and a more holistic approach to treatment, seeking
healthcare in Mexico was considered a viable and almost preferable option. As one
respondent describes, “Yes, they [Mexican doctors] directly ask how you are feeling
and speak with you a longer amount of time than here; we feel a greater confidence
with them because they ask about the illness not the symptoms. That is the difference”

41
(Ransford et al., 2010, p. 872). However, when travel to Mexico is not an option (due
to financial or legal restrictions), a family member is often recruited to buy
medications in Mexico.
Messias (2002) also finds that Brazilian immigrant women rely on variety of
transnational health resources and practices, with the most common being
transnational medications. In this way, the migration process expands and blurs their
own identities since “being Brazilian was not only an identity, but also a health
resource” (p. 185). In Messias’ (2002) study the women were asked what they did to
take care of their health in the United States, and the most common responses
included exercise, diet, stress prevention, sleep and relaxation. To maintain healthy
lives the women also avoided medications, caffeine, unhealthy foods and smoking.
One of the reasons why migration disrupted this healthy lifestyle for the women was
because they were accustomed to live-in domestic help in Brazil and now had the
added pressure of preparing nutritious meals for their families (Messias, 2002, p.
186). The women managed the difficulties of being immigrant wives and mothers by
sharing information and resources with each other. “They exchanged information,
advice, transportation, instructions for preparing home remedies, Brazilian
medications, and prescription drugs obtained through American health care providers”
(p. 187). As one participant described, “My mother sends me Urobactrim [an
antibiotic]. She sends these medications from Brazil, because here, they say that they
[health care providers] only know how to give you Tylenol for pain” (p. 187).
Messias (2002) found that family, friends, neighbors and pharmacists were

42
considered reliable sources of information and medicine, and Brazilian immigrant
women often accepted a community approach to diagnosis and treatment:
Transnational medication practices, such as having a stock of Brazilian
prescription drugs, practicing self-medication, and sharing medications with
family and friends, were frequently noted. The women either brought
medications with them from Brazil or sent for them as the need arose.
Antibiotics and pain medications were among the most common ‘imported’
Brazilian medications…several other participants echoed the notion that U.S.
physicians only prescribe Tylenol, an attitude that has also been documented
among Mexican immigrants. (Messias, 2002, p. 187)
For those who could afford to travel back and forth to Brazil (legally
and financially), obtaining health care from Brazilian doctors was a common
practice. One of the most interesting findings in Messias’ work is the
connection between transnational health practices and identity. Some of the
immigrant women who had previously rejected more traditional Brazilian
health practices found themselves becoming more Brazilian when they lived
in the United States.
In terms of incorporating transnational perspectives in health
promotion, Gastaldo, Gooden, & Massaquoi (2005) consider the ways in
which immigrant women become transnational health promoters through the
navigation of health practices that cross local, national and international
networks. While immigrant women must navigate ways to care for

43
themselves and their families in the host society, they often also tend to the
family, or even their own children, that they leave behind. In this sense,
immigrant women must traverse national boundaries in an effort to be
transnational health promoters (Gastaldo et al., 2005). The idea of
transnational motherhood is also a component of transnational health, and
while it is out of the realm of this current study, it is an additional research
interest and one that will be explored in my future work.
While information-gathering sequences may differ from one
individual to another and from one ailment to another, it is clear that many
Latino immigrants share the experience of facing a variety of barriers to
accessing medical care and turn to both mainstream and alternative
treatments throughout the progression of an illness. Thus, an investigation of
transnational health practices among Latino immigrants may explain
differences in health knowledge and behavior—and thereby help to produce
more effective health communication strategies.
A communication ecology approach to immigrant health means that if
transnational resources are important in everyday problem solving, they will
organically appear in an individual’s goal-precipitated communication
ecology. For example, we cannot assume that both local and transnational
resources play a part in health maintenance among Latino immigrants in Los
Angeles; we can instead acknowledge the difference between available and
activated resources. What a communication ecology approach provides is a

44
more flexible definition of what types of communication resources are
important for immigrants in the context of a specific health goal.

Research Questions
The first two research questions, below, involve a comparison of the neo-
traditional Multilevel Survey (N=500) method and the Health Communication
Ecology measure (N=40) method. These comparisons are suggestive – not
conclusive – as the database for the HCE measure is very limited:
• RQ1: What are the primary communication resource patterns identified for
Latinas’ health-seeking behaviors when…
a) using the neo-traditional Multilevel Survey method?
b) using the Health Communication Ecology measure?
• RQ2: What roles do transnational health behaviors or socio-cultural legacies
play in Latinas’ health-seeking behaviors? Do the findings differ when
collecting data by the prompted Multilevel Survey method or the spontaneous
inclusion in the HCE measure?
The following research question is addressed using Multilevel Survey data
from 500 Latina respondents:
• RQ3: Are there variations in general health and self-efficacy regarding
preventive screening behaviors as a function of variations in communication
resource patterns?

45
The next research question is addressed using the deployment of Health
Communication Asset Mapping as a case study:
• RQ4: How does the Health Communication Asset Mapping methodology
further inform our conceptualizations of neighborhood-level health resources
and contribute to a communication ecology perspective?
And the final research question is addressed through a synthesis of the
findings from the Multilevel Survey, the HCE Measure and the HCAM approach:
• RQ5: What outreach and intervention strategies can the Multilevel Survey, the
HCE measure and the HCAM findings suggest?

46
CHAPTER THREE:
METHODOLOGIES OF THE NEO-TRADITIONAL MULTILEVEL
SURVEY AND THE HEALTH COMMUNICATION ECOLOGY MEASURE

Multilevel Survey: Sampling Procedure
The neo-traditional Multilevel Survey, which was collaboratively designed
by a team of researchers as part of the Multilevel Study, is still in the data collection
process. The subset used in this dissertation includes the study population of 500
Latina women surveyed between the months of April 2012 to December 2012. The
dataset was obtained using direct, in-person recruitment at multiple study sites: the
LAC+USC Medical Center Women’s Clinics (including the gynecology, family
planning and oncology departments), smaller community clinics that perform low-
cost or free cervical cancer screenings, and community sites such as laundromats,
parks, schools and health fairs. Eligibility requirements for participation in the
survey included: A self-identified Latina female between the ages of 21-50 with no
pre-existing cervical/ovarian/uterine/vaginal/vulvar cancer, not currently pregnant,
without a hysterectomy and either waiting to receive a Pap test at one of the
recruitment sites or have not had a pap test in the last three years (and thus
considered out of compliance with federal pap test guidelines). Out of compliance
women were recruited at both the LAC+USC and community sites, and for this
subset of the survey mainly laundromats in the vicinity of the LAC+USC Medical
Center. Recruitment sites for the Multilevel Survey were further expanded as data

47
collection continued after the development of this dissertation. Women under the age
of 21 or over the age of 50 were excluded from the study due to an interest in
capturing perspectives of women who are of childbearing age but not considered
minors, per IRB regulations. Women with a history of gynecological cancer(s) or
with prior hysterectomies were excluded due to their possible pre-exposure to
cervical cancer and other women’s health-specific topics covered in the survey.
The 45-minute survey was administered in person by a team of trained
interviewers in the language of choice of the participants. 71% of respondents chose
to take the survey in Spanish; the rest took the survey in English. As a research
assistant on the Multilevel Study, I participated in the development of the survey in
both English and Spanish, the construction of the survey instrument (a CATI-based
online platform), the training of interviewers, and also served as an on-site
interviewer.
Multilevel Survey: Measures
Media Systems Dependency
Previous applications of the MSD items have focused on the three original
goal-scenarios that are described in Chapter Two: orientation, understanding, and
play. Wilkin (2005) adds a health goal dimension to the original MSD measure in an
attempt to identify a health storytelling network. In this survey, the MSD items have
again been tailored to a health-specific goal-scenario to capture the health
information-seeking behaviors of Latinas in Los Angeles. The main MSD item
reads:

48
“Thinking of all the different ways of communicating and getting
information, such as…television, radio, books, magazines, flyers, movies,
internet, community organizations, talking with other people or any other
way, what are the two most important ways that you get information about
health for yourself or your family?”
In a sense, this framing can be considered an understanding type of goal, as
individuals seeking health information are often in search of questions regarding a
specific health problem they are facing. In this way, the MSD section in the
Multilevel Survey allows the respondent to think about health information seeking
when describing the communication resources they turn to. A hierarchical
relationship between response #1 and response #2 is assumed because the
participants are primed to rate the “two most important” ways of obtaining health
information. Thus, because the first mention comes to mind first, this suggests that
that resource is most important.
When respondents mentioned radio, newspapers, television or the Internet,
follow-up questions identified the type of media, the language in which they connect
with the media, and the specific media outlet where they obtain health information.
The media type follow-up question was developed to distinguish between
mainstream and geo-ethnic media outlets:
• “When you listen to the radio for health information, is it more often…
mainstream English commercial radio, public radio stations or radio
stations that target your area or that are produced for Latinos?”

49
• “When you read newspapers for health information, is it more often…
mainstream English newspapers (both print and online), community
newspapers, or newspapers that target your area or that are produced for
Latinos?”
• “When you watch television for health information, is it more often…
mainstream English commercial channels, public television channels or
television channels that target your area or are produced for Latinos?”
• “When you use the Internet for health information, which type of website
is it more often… mainstream English commercial websites, websites
from public or government organizations, or websites that target your
area or are produced for Latinos?”
The language follow-up question asks: “When you listen to the radio for health
information, what language do you listen in?” These questions are asked for
newspaper, television and Internet accordingly.
The final follow-up question for the initial MSD item captures more specific
information regarding the media outlets that individuals connect with when obtaining
health information for themselves or their family. The question asks: “When you
listen to the radio for health information, what is one radio station that you find most
helpful?” This is an open-ended question but the interviewer is provided with an
extensive list of pre-identified radio stations, television stations and newspapers in
Los Angeles. The inclusion of specific newspapers, radio stations, television

50
channels and websites is gathered to provide a practical guide for potential health
interventions.
Time Spent with Mainstream and Geo-Ethnic Media
Traditional surveys often measure media connections by the amount of time
that individuals spend with a particular media. In the Multilevel Survey I we include
time-spent variables but differentiate between time spent with mainstream media and
time spent with geo-ethnic media to determine the type of media connections that are
more prevalent. These items are used to reinforce the findings of the MSD items
described above and read as follows:
• “Approximately how many hours did you spend last week…reading
newspapers that are produced for your area or for Latinos?”
• “Approximately how many hours did you spend last week…listening to
radio stations that target your area or are produced for Latinos?”
• “Approximately how many hours did you spend last week…watching
television and cable channels that target your area or are produced for
Latinos?”
• “Approximately how many hours did you spend last week…reading
major English language newspapers?”
• “Approximately how many hours did you spend last week…listening to
major English language radio stations?”
• “Approximately how many hours did you spend last week…watching
major English language cable and television channels?”.

51
The response options are: none, a few minutes to less than one hours, one hour to
less than two hours, two to less than three hours, three to less than four hours, four to
less than five hours, and five or more hours.
Social Networks
To measure an interpersonal-level orientation in communication patterns for
obtaining health information, respondents were asked to identify the people with
whom they discuss women’s health issues specifically. They were primed to think
about conversations that occur organically among their family and peers, with the
following prompt:
“From time to time, most people discuss women’s health with friends, family,
and acquaintances. These discussions often get started because of something
that happens to them or their family and friends. Looking back over the last
year, who are the people with whom you discussed women’s health issues?
Please tell me their first name. You may name up to 5 people.”
Follow-up items to this question include the role that the persons named have in the
respondent’s life (e.g. mother, sister, friend, co-worker, etc.) and where that person
lives (e.g. in the same neighborhood, another city, another state or another country).
The social network items will be investigated through more traditional social
network analysis by other members of the Multilevel Study research team. In this
dissertation, these items were used to determine the geo-graphic nature of
interpersonal networks in the context of women’s health (either individuals that live
in the same household or neighborhood, or individuals that live in another country).

52

Subjective General Health, Behavioral Intention & Perceived Self Efficacy for
Screening Behaviors
These items are treated as dependent variables when determining if variations
in cervical cancer prevention behaviors are a function of variations in health
communication resource patterns. Research has found that health status is correlated
with cancer screening, with the directional effects varying for different ethnic and
age groups (Ioannou, Chapko, & Dominitz, 2003; Mandelblatt, Gold, O’Malley,
Taylor, Cagney, Hopkins, & Kerner, 1999); and that subjective health assessments
can be treated as valid health outcomes in different contexts (Andreasson, Szulkin,
Unden, von Essen, Nilsson, & Lekander, 2013; Cella et al., 2010; Phillips, 2011;
Miilunpalo, Vuori, Oja, Pasanen, & Urponen, 1997). In the neo-traditional
Multilevel Survey, subjective general health status is measured through a one-item
question that asks: “In general, would you say your health is… very poor, poor, fair,
good, very good or excellent?”
Perceived behavioral intention and self-efficacy measure the extent to which
individuals consider themselves able and likely to engage in a specific behavior.
Recent research has supported the idea that likelihood and confidence in the ability
to perform a specific task is a strong predictor of health behaviors in various contexts,
including exercise (Mitchell, 2010); diabetes management (King et al., 2010; Osborn,
Cavanaugh, Wallston, & Rothman, 2010); dental health (Buglar, White, & Robinson,
2010) and health maintenance for cancer survivors (Mosher, Lipkus, Sloane, Snyder,

53
Lobach, & Demark-Wahnefried, 2012; Haas, 2011; Heckman, Chamie, Maliski, Fink,
Kwan, Connor, & Litwin, 2011; Hoffman, von Eye, Gift, Given, & Rothert, 2009).
The perceived self-efficacy of screening behaviors considered for this dissertation
are the likelihood of getting regular Pap tests, confidence in the ability to get regular
Pap tests, and likelihood of returning for treatment after an abnormal Pap test result.
These items were selected because they focus on behaviors related to Pap test
screening and following up on Pap tests, and regular Pap tests can significantly
decrease the chances of obtaining cervical cancer:
• “How likely is it that you will get a Pap test at least every 3 years, on a
scale from 1 to 10 where 1 means ‘not at all likely’ and 10 means
‘extremely likely’?
• “How confident are you that you could get a Pap test at least every 3
years, on a scale from 1 to 10 where 1 means ‘not at all confident’ and 10
means ‘extremely confident’?”
• “How likely is it that you will return for follow-up treatment of an
abnormal Pap test result if necessary, on a scale from 1 to 10 where 1
means ‘not at all likely’ and 10 means ‘extremely likely’?”
Transnational Communication
The purpose of the transnational communication items is to identify the
method and frequency of communication between the respondent and their family or
friends in their home country. First, the respondent is asked to identify which country
or countries they or their family came from. This is an open-ended question, but the

54
interviewer is provided with a list of the most common Latin American countries of
origin for immigrants in the U.S. To identify immigrant status, respondents are asked
if they were born in the U.S. (to identify first-generation immigration) and if not,
how many years they ago they immigrated to the U.S. If they were born in the U.S.,
they are also asked whether a parent was born in the U.S. (to identify second-
generation immigration). For those with one parent born in the U.S., they are asked if
a grandparent was also born in the U.S. (to identify third-generation immigration).
Only first- and second-generation immigrants are subsequently asked the
transnational communication and transnational health items. Third-generation
immigrants are excluded from these questions because it would be more difficult for
them to identify their connections to family or friends in their grandparents’ home
country. To assess transnational communication practices, respondents are asked the
following questions on a 7-point scale:
• “How often do you talk on the phone with people in [HOME
COUNTRY]?”
• “How often do you send emails to people in [H.C.]?”
• “How often do you send text messages to people in [H.C.]?”
• “How often do you chat online (video or text) with people in [H.C.]?”
• “How often do you visit people in [H.C.]?”
The response options were: never; once or twice in my life; about once a year;
several times a year; about once a month; about once a week; several times a week.

55
Additionally, two more traditional types of transnational activity are measured,
economic and political connections to the home country:
• “How often do you send money to someone in [H.C.]?”
• “Have you ever voted in [H.C.]?”
Transnational Health
The purpose of the transnational health measure is to identify the method and
frequency of health-related activities that incorporate home country knowledge,
resources or support. These items are more related to socio-cultural legacies than
may impact health decision making and health behaviors. They also include a
combination of treatment-related activities and information-seeking activities:
• “How often do you use products from a botanica or a Latino market?”
• “How often do you use prescription medicine from [HOME
COUNTRY]?”
• “How often do you use non-prescription medicine from [H.C.]?”
• “How often do you talk to people in [H.C.] about health?”
• “How often do you travel to [H.C.] to get medical care?”
• “How often do you use home remedies that you or your family learned
about in [H.C.]?”
Multilevel Survey: Sample Characteristics
As described in the sampling procedure, all of the participants in the
Multilevel Study (in both the Multilevel Survey and the HCE measure) self
identified as Latinas. Table 3.1 summarizes the sample characteristics for the 500

56
respondents from the Multilevel Survey that will be explored as part of this
dissertation. Regarding age characteristics, 41% of the respondents were between the
ages of 41 and 50, 31% between 31 and 40, and 28% between 21 and 30.
Approximately one-third of the respondents (35%) self identified as married; while
another third (31%) reported that they were single and never married before. In terms
of education, 77% of the respondents reported having a high school education or less,
with less than 5% identifying as college graduates. Almost 70% of the respondents
were compliant with federal Pap screening guidelines, meaning that they receive a
Pap test at least every three years. For this study, compliance with screening
guidelines was at first a function of the recruitment site, with the expectation that the
women recruited at the clinic would be compliant because they were there to receive
a Pap test. As the study progressed, women who were non-compliant with Pap test
guidelines were also incorporated into the study and recruited at both the clinic sites
and local community sites. The inclusion of community study sites was initially a
mechanism for capturing a control population, that is a population that was not
receiving cervical cancer screening at the main study site. As it became challenging
to recruit non-compliant women, additional community sites were added to the
original study design. Thus, in this subset of 500 cases, a majority of the women
(70%) are compliant with the screening guidelines and 30% are non-compliant. As
data collection on the Multilevel Study continues, these compliant vs. non-compliant
dimensions will be more balanced and further investigated.

57
Immigration-related questions were asked to determine if the respondents
could be considered representative of an immigrant population. An overwhelming
80% of the respondents reported that they were born outside of the United States,
with 73% reporting they were born in Mexico, 12% in Guatemala and 11% in El
Salvador. Respondents were also asked how long ago they immigrated to the U.S.,
and 45% reported that they immigrated 20 or more years ago, 29% immigrated
between 11 and 19 years ago, and 25% immigrated 10 years ago or less. Overall,
these demographics closely align with the demographics of Latino immigrants in Los
Angeles.

58
Table 3.1. Sample Characteristics of Multilevel Survey (N=500)

N %
Age
21-30 139 27.8
31-40 156 31.2
41-50 205 41.0
Marital Status
single (never married) 157 31.4
living with a partner 95 19.0
married 175 35.0
separated or divorced 60 12.0
Education
high school or less 384 77.4
college graduate 23 4.6
Compliance with
Pap Requirements

compliant 349 69.8
non-compliant 151 30.2
Place of Birth
U.S. 105 21.0
foreign born 395 79.0
Country of Origin
(for foreign born)

Mexico 289 73.2
Guatemala 46 11.6
El Salvador 43 10.9
Immigration Tenure
10 years or less 100 25.3
11-19 years 116 29.4
20 years or more 177 44.8

59
Health Communication Ecology Measure
The HCE Measure was administered to 40 respondents who participated in
the Multilevel Survey. Immediately after the completion of the Multilevel Survey
respondents were invited to participate in an additional 15-minute activity. The only
eligibility requirement for the HCE measure was that the respondent completed the
Multilevel Survey in its entirety. Due to the time period of HCE measure data
collection, most of these respondents (35) were recruited at the LAC+USC Women’s
Clinic, while only five were recruited from local laundromats. The subset of the
respondents who participated in the HCE Measure activity match the characteristics
of the respondents in the 500 cases of the Multilevel Survey. They are all self-
identified as Latinas, are mostly foreign-born (83%) from Mexico (73%), 80% of
them are compliant with pap screen guidelines, and have similar levels of education
and length of residency in the United States.
Along with a team of researchers from the USC Metamorphosis project, I
have led the development of a multi-dimensional and multilevel measure of
individuals’ communication ecologies over the last two years. Grounded
Communication Infrastructure Theory (see: Chapter Two), an effort was made to
produce a quantifiable measure of communication ecologies, beginning with the case
of Latina women’s health. This effort required an ability to empirically assess the
temporal unfolding of information seeking for goal fulfillment by identifying which
communication resources an individual engages with and how those resources are
connected or constitute a network pattern. Thus, the capturing of communication

60
forces with respect to behavioral outcomes shifts from the traditional search for
which communication resource is most predictive to an assessment of which
temporal cluster of communication resources leads to the most efficacious outcomes.
As such, we cannot understand the influence of one resource without taking into
consideration the potential influence of all other resources in the deployed ecology.
The interest in capturing the temporal unfolding of problem solving led to the
development of a methodological tool that would facilitate both the elaboration and
documentation of an individual’s communication ecology.
A major challenge in this research was to develop a methodology that would
inform and expand the communication ecologies identified through the neo-
traditional Multilevel Survey described above. In this dissertation, the Multilevel
Survey and HCE measure will be compared based on the health outreach and
intervention strategies suggested by the different methodologies. Both the Multilevel
Survey and the HCE measure also allow for a comparison of how transnational
health behaviors and sociocultural legacies emerge through two different approaches:
the prompting in the Multilevel Survey and the spontaneous inclusion in the HCE
measure. A challenge for future research will be to test the predictive validity of the
HCE measure within the context of women’s health as well as future applications.
For the purpose of this dissertation, the HCE measurement development will be
described and preliminary results presented.

61
HCE Measure: Dimensions

The development and pilot testing of the HCE measure informed our
conceptual development of a communication ecology approach, in this way the
elaboration of the HCE measure was an iterative process. While the HCE measure is
still being tested and will not be finalized until we have administered the measure
with 200 participants as part of the Multilevel Study, we have learned about the
potential dimensions that a health communication ecology approach can contribute.
Firstly, we will be able to identify the first resource that an individual turns to when
addressing a specific health problem. This first communication resource can be an
important connection to identify as it may initiate a string of communication
connections or may truncate the information-seeking process. We hypothesize that
the first step an individual takes in the process of obtaining health information to
solve a health problem can have an effect on their eventual health decisions and
behaviors. A first resource that frightens the individual, for example, by providing a
negative perspective on a specific preventive behavior, can indirectly cause the
individual to not engage in the behavior. Similarly, a first resource that provides
many suggestions and directs the individual to more sources of information may
contribute to a more-informed and more engaged health decision-making process.
Secondly, we hypothesize that the number of resources identified in an
individual’s health communication ecology may speak to the types of health
decisions that they make, and ultimately their individual health outcomes. While a
very elaborated health communication ecology may indicate that the individual went

62
through an informed decision-making process by activating a number of different
communication connections, it may also indicate an over-abundance of information
that can possibly lead to confusion or resistance to continue with a preventive
behavior. As a methodological tool the health communication ecology measure will
at least allow us to understand, in a more holistic manner, how individuals get advice
about health and make decisions on which types of health behaviors to consider. At
this point we cannot support the notion that a more elaborated health communication
ecology would lead to more positive health outcomes, but we can investigate how
this approach provides a thicker description of how individuals make health
decisions and how communication connections can be avenues through which socio-
cultural determinants of health are performed. Such thick descriptions can expand on
the knowledge gained through a method such as a neo-traditional survey and
possibly provide alternative recommendations for health outreach and intervention
strategies.
Thirdly, we expect that the number of suggestions that come from each step
in the health communication ecology will provide a deeper understanding of the
ways in which resources are connected to each other and how individuals may or not
follow up with the suggestions that arise from those resources. For example, are
resources that provide additional suggestions more influential in an individual’s
decision making process? Or can additional suggestions overwhelm the individual
and cause them to turn to a completely different resource or perhaps give up on
trying to address their health problem? These questions will be explored in further

63
applications of the HCE measure so that we can track the way in which information
travels across interpersonal, organizational, mediated and professional levels.
Finally, the predominance of a specific type of resource may also be an
indicator of a strong or weak health communication ecology. One of the premises of
the health communication ecology approach is that individuals engage with sources
of information in different ways depending on the goal or problem that they are
dealing with. For women’s health in particular, an identification of the types of
resources that make a bigger impact in the health decision making of women can
suggest the appropriate and effective avenues through which to disseminate specific
health messages, for example a message regarding the importance of obtaining a pap
test. Thus, the categories of resources that individuals turn to when faced with a
specific health problem can most directly inform health outreach and intervention
campaigns by suggesting practical and applied approaches to health communication.
HCE Measure: Development

The general communication ecology measure development began with
several months of brainstorming and preliminary testing. Initially, we sought to
develop a game-like measure that would facilitate the organic storytelling of a
decision-making process. Based on the goal-specific orientation of the
communication ecology theoretical framework, we suspected that decision making
would be best elaborated in the context of a specific goal or problem. Similar to the
MSD survey items that ask how individuals obtain health information, the
communication ecology measure would need to be deployed in the context of a

64
common and relatable goal. Thus, our measure development began focusing on
health decision making and the elaboration of health communication ecologies.
Our first attempt to develop a measure and a method of administration began
with a very crude mapping exercise using poster board and paper flashcards (Figure
3.1). The respondent is presented with a scenario that describes a specific health
problem (e.g. a persistent rash on the forearm) and is asked what they would do to
address the problem. This grid is built according to the steps (first, second, third etc.),
that the respondent takes when dealing with a health problem. First, the respondent
indicates what her first step is (e.g. sister). Underneath her step, she lists any
suggestions she may have received from that step (e.g. neighbor, book, internet). She
continues to the second step etc., with arrows indicating when prior suggestions led
to a next step. We first tested this activity with African American and Latina mothers,
asking them what they would do if their child woke up with a rash that would not go
away.

65
Figure 3.1. Paper grid and flashcards for HCE measure development

We pilot tested this activity in both a group format and a one-on-one
interview format. We came to the conclusion that the group format was not
successful, as respondents had a hard time understanding the activity and performing
it on their own, even after a detailed example. However, the one-on-one interviews,
in which an interviewer filled out a grid together with the respondent, yielded
interesting results. For example, few media resources were mentioned as important
when addressing a health problem; the main resources used were health professionals
and specific treatments. Also, the first step in these health communication ecologies

66
was often interpersonal, even though respondents did not always follow up with the
suggestions from this resource. We found that Latina respondents also had more
interpersonal connections than African American respondents.
In the one-on-one interviews, respondents understood the HCE activity and
usually enjoyed it. However, we felt that the grid was limiting in that it required only
linear solutions while some of the steps were simultaneous. Also, we felt that the
predominance of health professional and treatments in the ecologies may be due to
the nature of the health problem (a rash, which is a short term problem calling for
immediate action), whereas other scenarios may elicit different communication
ecologies. We created digital representations of the paper grids in order to visually
compare individual differences in the ecological dimensions we were interested in—
mainly the number of communication connections and category (interpersonal,
media, organizational or professional) of the first resource connection. Further
dimensions of the HCE measure will be elaborated when data collection of 200
respondents is complete. Below are two representations of our respondents’ health
communication ecologies (Figure 3.2).

67
Figure 3.2. Textual representations of health communication ecologies during HCE
measure development

This grid-based mapping exercise helped us to identify and start to capture
two important building blocks that make up individuals’ communication ecologies—
the steps they take (or resources they turn to) and the suggestions/recommendations
that come from those steps. At the same time, some issues needed to be addressed: 1)
the grid-based interface was not as intuitive for the participant as we had hoped for,
and in many cases required much assistance from the interviewer. In other words, the
activity required too much of the participant, and the activity seemed more like a task
rather than a way to tell a story. 2) The structured nature of the activity sometimes
got in the way of letting the participants tell their story and let the different steps
unfold temporally. 3) Last of all, we needed a more reliable and systematic method
to collect, save, and present the data.

68
In our most recent development of the HCE measure we focused on two
things to address these issues: moving the activity to a digital platform, and more
clearly separating the interviewer’s role from the participant’s. We redesigned the
activity to include the following components: an introduction video that describes
communication resources and their role in health decision making, a Qualtrics survey
that captures the information being described by the respondent, a visual aid that
allows the interviewer and respondent to map out the participant’s steps in a less
structured manner, and a poster of communication resources which visually depict
the different types of resources that may be activated during health problem solving.
Below is a brief description of each component.
A. Introduction Video: A 3-minute slide cast using PowerPoint was created
to sensitize the participant to the range of possible media, interpersonal,
organizational, and expert/professional resources, the various patterns of problem
solving that we engage in in our everyday lives, and to explain what they will be
asked to do in the activity. The participant puts on a headset to watch and listen to
this slide cast (Figure 3.3) before starting the activity.

69
Figure 3.3. Screenshots of introduction video for health communication ecology
measure

The video includes an audio track that explains the goal of the activity and
describes how communication resources can be deployed. The script reads as
follows:
• “There are many ways to communicate and get information that helps us solve
problems and achieve goals. Sometimes we turn to media for information, such
as the television, radio, newspapers, books, magazines, or the Internet.
• There are also organizations we turn to such as churches, schools, libraries,
community organizations, or clinics where we might find useful information.
We may talk to people who have roles in these organizations. We also get
information from professionals such as doctors, nurses, pharmacists or natural
healers.

70
• And finally, we may turn to people we know, such as a spouse, a family
member, neighbor or co-worker. Discussions with people can include talking in
person, on the phone, chatting online, or exchanging emails.
• Media, organizations, professionals and people. I have given you examples of
the different ways we get information that helps us solve problems and achieve
goals. Often, as we learn about an issue and try to achieve our goal, we navigate
through various resources. Some resources may lead us to others.
• For example, a family member may recommend consulting with a community
organization, or an article we read may suggest to go online and look for more
information. Sometimes we do what they recommend, sometimes we don’t.
• Remember, there is no one way to solve problems. Different resources are more
helpful than others depending on the problem you’re dealing with.
• In the following activity, we will ask you about what you would to do deal with
a specific health problem. As the interviewer guides you through the activity,
please keep in mind the different ways of communicating, and how some
resources may lead you to others. We would like to learn about all of the
possible resources that would help you deal with the health problem.”
B. Qualtrics Survey: One of the major difficulties from previous versions of
the activity was figuring out how to collect data in ways that will allow us to make
meaningful and visual descriptions of the different communication ecologies. An
online survey was developed using Qualtrics to streamline a set of questions that
identify the steps, suggestions, and different characteristics of the steps (e.g.

71
type/name of resource, location of resource, and level of trust). Although we call this
a “survey,” it is more a method of data collection that is only seen and accessed by
the interviewer. In a sense, it is an interview guide that documents the
communication ecology as it is described by the respondent (Figure 3.4).
Figure 3.4. Screenshot of Qualtrics survey used to capture respondent’s elaboration
of their health communication ecology

72
C. Visual Aid Component: A tablet (iPad) and a simple mapping
application are used to display the steps and suggestions as the respondent identifies
them. This component helps both the respondent and interviewer keep track of the
steps and serves as a summary of the respondent’s communication ecology. As
displayed in the iPad screenshots in Figure 3.5, the mapping dimension adds to the
visual component of the activity (particularly when compared to the paper grid
format we had previously tested).
Figure 3.5. Screenshots of iPad visual mapping application that depict two different
health communication ecologies as elaborated by the respondent

D. Universe of Resources: At multiple points during the activity, the
respondent is asked to think about the different media, interpersonal, organizational,
and expert/professional resources that they may turn to when addressing a specific
health problem. We created a small poster (Figure 3.6) that visually depicts the

73
universe of communication resources. The poster was organized by communication
resource categories that were determined during our initial pilot testing of the
measure. We realized that the organization of possible resources in four categories
(media, organizational, professional and interpersonal) would help the respondent
distinguish between types of communication resources and would help the researcher
develop follow-up questions tailored to a specific type of resource. These follow-up
questions will be further described in the description of the measure administration
below.
Figure 3.6. Poster identifying universe of communication resources for HCE
measure

74
HCE Measure: Administration

Using these four components, the video introduction, Qualtrics survey, iPad
visual mapping and universe of resources poster, I administered the HCE measure
with 40 respondents who participated in the Multilevel Survey. The activity was
conducted in the language preference of the respondent, and in this case mostly in
Spanish. The video introduction and all materials were developed in both English
and Spanish. The deployment of the HCE measure within the context of the
Multilevel Study focused on two health goal scenarios: a persistent rash on the arm
and consistent heavy or abnormal periods. We incorporated a general health goal and
a women’s specific goal to identify differences in communication resource
connections based on the nature of the health problem. We also wanted to see
differences in the ecology for a health problem that is urgent and involves more
severe symptoms (e.g. heavy bleeding) and one that is less urgent and can be
managed in different ways (e.g. a rash). Participants elaborated their health
communication ecologies for these two goals. The initial promptings for each
elaboration read as follows:
• “Imagine that you woke up one day with a rash on your forearm. It is red and
itchy and doesn’t seem to be getting better. How would you go about finding
out what the problem is and dealing with it? Here is a list of media,
organizations, professionals or people where you may turn to. Where would you
go first for information or advice about how to deal with the rash?”

75
• “Imagine that your last few periods have been heavier and more painful than
usual. How would you go about finding out what the problem is and dealing
with it? Here is a list of media, organizations, professionals or people where you
may turn to. Where would you go first for information or advice about how to
deal with the heavy periods?”
After the initial prompting question, the respondent was guided through their
own narration of the steps they would take to solve each specific health problem.
When a resource was mentioned, they were asked follow-up questions to capture
more details about that specific resource. When an individual was mentioned as a
resource, the respondent was asked if the individual lived in their home, in their
neighborhood or in another city, state or country. This follow-up item was designed
to match the social network follow-up items in the Multilevel Survey. When an
organization was mentioned, the respondent was asked to name the specific
organization and to indicate if it was located in their local community. When a health
professional was identified as a resource, they were asked to identify where
specifically they could reach that professional and whether that location was in their
local community or outside of their community. When a media resource was
mentioned, the respondent was asked to identify which specific media outlet they
would connect with. Across all resources, a trust question was developed to measure
how much the respondent would trust that specific resource for health information or
advice. This follow-up question reads as follows: “On a scale of 1 to 10 where 1

76
means “not at all” and 10 means “a great deal”…How much do you trust this
resource [tailored to their response] for health information or advice?”
Thus, a complete string in the HCE measure would include the identification
of a communication resource they would turn to as they solve a specific health
problem, the details of that resource including how much they trust it as a source of
health information, and the elaboration of the suggestions or advice that would stem
from a connection with that resource. Figure 3.7 presents a flowchart that describes
the methodological flow of the HCE measure.
Figure 3.7. Health Communication Ecology Measure Methodological Flow

77
CHAPTER FOUR:
A COMPARISON OF THE COMMUNICATION RESOURCE PATTERNS
IDENTIFIED IN THE MULTILEVEL SURVEY AND THE HCE MEASURE

Health Communication Resource Patterns Identified by the Neo-traditional
Multilevel Survey
RQ1a asks what are the primary communication resource patterns identified
for Latinas’ health seeking behaviors. The initial MSD item in the Multilevel Survey,
which identifies the respondent’s top two ways of getting health information for
themselves or for their families, provides us with an introduction into the
communication connections that are relevant for this specific population and in the
context of health. The connections identified in the initial MSD question guide the
subsequent analyses as communication resource patterns are elaborated. Table 4.1
displays the frequencies and percentages for the top five ways of getting health
information within each response option.
Table 4.1. What are the two most important ways that you get health information for
yourself or your family?

Television Internet
Talking
with
Others
Flyers Radio Other
First
Response
169
(33.9%)
79
(15.8%)
72
(14.4%)
69
(13.8%)
--

56
(11.2%)
Second
Response
66
(15.0%)
56
(12.8%)
85
(19.4%)
80
(18.2%)
48
(10.9%)
--

78
Within the study population for the Multilevel Survey, the most common first
response for the initial MSD item was television, with 33.9% of the respondents
selecting it as their number one way of getting health information. Other forms of
getting information were mentioned much less often, including the Internet (15.8%),
talking with other people (14.4%) and brochures/pamphlets/flyers (13.8%). For the
second response, which follows a hierarchical progression as the second most
important way of getting health information, talking with other people accounted for
19.4% of the responses, with brochures/pamphlets/flyers (18.2%), the television
(15%), and the internet (12.8%) following closely behind. Newspapers were notably
absent from both responses, with only one respondent identifying newspapers as
their first response and only 11 identifying them as their second response.
While the top five resources within each response option differed slightly,
with radio only appearing in the second response, two resources emerge as most
common overall: television and talking with other people. To determine the most
common combination of resources mentioned, a cross-tabulation was performed with
the top five resources in each response (Table 4.2).

79
Table 4.2. Cross tabulation of top five resources mentioned in first and second
responses

MSD Second Response

MSD
First
Response

Television Internet
Talking
with
Others
Flyers Radio Other
Television --
23
(5.2%)
33
(7.5%)
27
(6.2%)
41
(9.3%)
9
(2.1%)
Internet
12
(2.7%)
--
25
(5.7%)
9
(2.1%)
1
(0.2%)
7
(1.6%)
Talking
with
Others
15
(3.4%)
10
(2.3%)
--
22
(5.0%)
1
(0.2%)
5
(1.1%)
Flyers
14
(3.2%)
8
(1.8%)
16
(3.6%)
--
3
(0.7%)
10
(2.3%)
Radio
7
(1.6%)
0
16
(3.6%)
4
(0.9%)
-- 0
Other
10
(2.3%)
9
(2.1%)
5
(1.1%)
8
(1.8%)
1
(0.2%)
--

While watching television and talking with other people appeared to be the
most common ways that respondents obtained health information, Table 4.2 reveals
that the most common combination of resources is actually television and radio, with
9.3% of the respondents selecting this combination as their top two ways of getting
health information for themselves or their families. The second most common
combination matches the original assumption, with 7.5% of respondents identifying
television and talking with other people as their top two ways of getting health
information. Thus, we can identify combinations of communication resources in two

80
different ways: by treating the first and second responses in isolation of each other
and by treating them as identifiable combinations of resources that we assume are
related. Overall, these results suggest that television, radio and interpersonal
connections are important factors in the health communication ecologies of Latina
women. Figure 4.1 displays the summary of communication patterns identified by
the initial MSD survey item.
Figure 4.1. Communication patterns for obtaining health information as identified by
initial MSD question (top two ways of obtaining health information)

Because television and radio emerged as popular responses in the initial MSD
question, these connections are explored further. When watching television for
health information, 79.1% of respondents reported that they watch geo-ethnic
television (television that is produced for their area or that targets Latinos
specifically). Mainstream television accounted for 17.4% and public television for
only 3.4%. In terms of language, 81% of respondents reported that they watch
Spanish-language television for health information while 19.1% watch television in
English. When listening to the radio for health information, 82.3% of respondents
reported that they listen to geo-ethnic radio, with 9.7% reporting mainstream radio
and 8.1% reporting public radio. In terms of language, 87.1% of respondents who
interpersonal television radio

81
listen to the radio for health information listen to it in Spanish while 12.9% listen in
English.
To reinforce the findings regarding the types of media resources that Latinas
connect with for health information, the time spent with media items were also
investigated. Respondents were asked how much time they spend with mainstream
and geo-ethnic media during the last week. Geo-ethnic media are defined as media
outlets that are produced for their geographic area or for Latinos in particular. Table
4.3 reports time spent with mainstream media and Table 4.4 reports time spent with
geo-ethnic media.

Table 4.3. Time spent with mainstream media during the last week

none less
than 1
hour
1-2
hours
2-3
hours
3-4
hours
4-5
hours
5 or
more
hours
Newspapers
389
(78%)
61
(12%)
23
(4.6%)
11
(2.2%)
2
(0.4%)
3
(0.6%)
11
(2.2%)
Radio
261
(52%)
54
(11%)
44
(8.8%)
36
(7.2%)
20
(4%)
15
(3%)
70
(14%)
Television
214
(43%)
49
(10%)
34
(7%)
47
(9%)
42
(8%)
33
(7%)
80
(16%)

82
Table 4.4. Time spent with geo-ethnic media during the last week

none less
than 1
hour
1-2
hours
2-3
hours
3-4
hours
4-5
hours
5 or
more
hours
Newspapers
342
(69%)
96
(19%)
30
(6%)
8
(2%)
9
(2%)
5
(1%)
9
(2%)
Radio
137
(27%)
65
(13%)
59
(12%)
56
(11%)
35
(7%)
32
(6%)
116
(23%)
Television
73
(15%)
36
(7%)
53
(11%)
47
(9%)
55
(11%)
38
(8%)
198
(40%)

Similar to the results of the MSD items which investigate what communication
resources respondents turn to for health information, the time-spent items suggest
that in general Latinas spend more time engaging with geo-ethnic media than
mainstream media, particularly with television and radio. 40% of respondents
reported that they spend more than 5 hours per week watching geo-ethnic television
and 23% reported the same for geo-ethnic radio. Both geo-ethnic and mainstream
newspapers seem to be largely absent from the general communication ecologies of
Latinas, with 69% and 78% of respondents, respectively, reporting that they do not
spend any time connecting with these media resources.
The follow-up MSD items also ask which specific media outlets Latinas find
most helpful when seeking health information. Table 4.5 displays the top three
television stations categorized by language and content focus (local vs. international)
and Table 4.6 displays the top three radio stations.

83
Table 4.5. Top three television stations that Latinas find most helpful when seeking
health information

Station Name Language Content Focus
Univision (KMEX)
67.4%
Spanish local & international
Telemundo (KVEA)
8.5%
Spanish local & international
Fox (KTTV)
7.6%
English local

Table 4.6. Top three radio stations that Latinas find most helpful when seeking
health information

Station Name Language Content Focus
K-Love 107.5FM
(KLVE)
20.7%
Spanish local & international
Univision America 1020AM
(KTNQ)
10.3%
Spanish local & international
La Raza 97.9FM
(KLAX)
7.6%
Spanish local & international

We have now learned that for this particular study population, television,
radio and interpersonal connections are important sources of health information. The
MSD survey items provide a deeper understanding of the types of media that Latinas
turn to, most notably geo-ethnic and Spanish-language television and radio. Figure
4.2 depicts the pattern of communication resources that Latinas connect with when

84
obtaining health information as uncovered through the initial MSD question and the
follow-up media-specific items in the Multilevel Survey.
Figure 4.2. Communication resource patterns for obtaining health information as
identified by the MSD items in the Multilevel Survey

Another component of the Multilevel Survey that could better inform our
understandings of the communication resources that individuals turn to for health
decision making are the interpersonal (social network) items that identify who
respondents talk to specifically about women’s health issues. The social network
items ask participants to identify up to five people with whom they speak to about
women’s health issues. The follow-up items to each of those people ask whether they
live in the same house as the respondent, in the same neighborhood, in another city,
state or in another country. Table 4.7 describes the distribution of local vs.
interpersonal television radio
geo-ethnic geo-ethnic
Spanish
radio
Spanish
television

85
transnational geographies for the people named in the respondent’s women’s health-
specific social network.
Table 4.7. Geographic distribution of health-specific social networks

Local
(same house or
neighborhood)
Transnational
(home country)
Person #1
N=435
278 (64.2%) 26 (6.0%)
Person #2
N = 325
195 (60%) 19 (5.8%)
Person #3
N = 176
100 (56.8%) 12 (6.8%)
Person #4
N = 49
23 (49.0%) 5 (10.2%)
Person #5
N = 20
9 (45%) 2 (10%)
TOTAL
N = 1005
605 (60.2%) 64 (6.4%)

Very few respondents reported that the people with whom they discuss women’s
health issues live in another country, therefore we can assume that for this particular
subset of cases and through this methodology, local interpersonal connections play a
bigger role than transnational connections.
In summary, RQ1a asks what communication patterns for health information-
seeking can be identified through a neo-traditional survey that considers mediated
and interpersonal connections at both the local and transnational level. With the
addition of the social network items, we can now identify a more specific
communication connection that Latinas turn to when addressing a health issue:

86
friends or family who live in their home or in the local area. Figure 4.3 depicts a
revised pattern of communication resources that Latinas connect with when
obtaining health information as uncovered through the MSD survey items and the
social network survey items of the Multilevel Survey.
Figure 4.3. Communication resource patterns for obtaining health information as
identified by the MSD items and the social network items in the Multilevel Survey

Health Communication Resource Patterns Identified by the HCE Measure
RQ1b asks what are the primary communication resource patterns identified
for Latinas’ health seeking behaviors when using the Health Communication
Ecology measure.
As described in the previous chapter, the HCE measure was deployed as part
of the Multilevel Study and presented two problem-solving scenarios: a general
interpersonal television radio
geo-ethnic geo-ethnic
Spanish
radio
Spanish
television
local

87
health problem of a persistent rash and a women’s health problem of heavy and
abnormal periods. Table 4.8 presents a textual representation of the health
communication ecologies identified through the general health rash scenario.
Table 4.8. Health communication ecologies for general health goal

STEP 1 STEP 2 STEP 3 STEP 4 STEP 5
mother sister clinic
neighbor clinic
doctor son internet pharmacy doctor
mother clinic
sister spouse mother clinic
neighbor co-worker hospital
doctor
relative pharmacy hospital
internet doctor
spouse clinic
spouse pharmacy clinic
spouse internet sister hospital
sister friend clinic
spouse internet hospital
internet sister clinic
doctor natural healer mother friend
spouse sister clinic
brother internet friend hospital
internet pharmacist mother doctor
mother internet flyer/brochure hospital
mother pharmacy clinic
friend hospital
mother pharmacy hospital
mother friend doctor
mother pharmacist clinic
pharmacy friend doctor
pharmacy friend hospital
daughter clinic
internet mother friend hospital
clinic mother hospital
internet sister mother clinic
sister relative clinic
mother clinic
internet mother hospital
internet mother clinic doctor
spouse mother hospital

88
mother internet co-worker clinic
internet pharmacy clinic
clinic
mother internet pharmacy clinic

The most common first step in addressing the problem of a persistent rash
was mother, with 25% of the respondents reporting that the first thing they would do
if they experienced this problem would be to turn to their mothers for information or
advice. The most common second step identified is the Internet, with 16% of the
respondents reporting that they would turn to the Internet for health information as a
secondary resource. Only one respondent elaborated a health communication
ecology that consisted of five steps, most included three steps and two respondents
reported that all they would do if they experienced this problem is go directly to the
clinic or doctor.
Categorically, interpersonal resources account for 63% of the first step
identified, followed by media (20%), organizational (10%), and professional (8%)
resources. Interpersonal resources in the first step category included mostly mothers
(38%), spouses (23%) and sisters (12%). When media resources emerged as a first
step, this always consisted of connecting to the Internet to find information or advice.
No other media connections besides the Internet were identified in any of the steps
elaborated through the rash scenario. The four organizational resources mentioned
were pharmacies and clinics. Professional resources were identified as a first step
three times and always consisted of doctors.

89
The same activity conducted with the abnormal or heavy periods scenario
yielded different ecologies than those identified through the general health scenario
(Table 4.9).

Table 4.9. Health communication ecologies for women’s health goal

STEP 1 STEP 2 STEP 3 STEP 4 STEP 5
friend clinic
spouse mother hospital
doctor neighbor sister daughter hospital
friend mother spouse hospital
sister mother spouse doctor
relative co-worker hospital
spouse hospital
hospital
doctor
hospital
spouse daughter hospital
spouse hospital
sister hospital
spouse friend hospital
sister daughter hospital
spouse mother doctor
spouse clinic
friend hospital mother hospital
internet mother spouse hospital
hospital
hospital
friend relative hospital
daughter hospital
spouse friend hospital
mother clinic hospital
hospital
hospital
daughter clinic
clinic
mother clinic
hospital
daughter sister clinic hospital
spouse mother daughter hospital
sister hospital
pharmacy mother hospital

90
spouse mother sister hospital
mother internet clinic
spouse hospital
clinic
mother internet doctor

The most common first step in addressing the problem of consistent heavy or
abnormal periods was spouse, with 28% of the respondents reporting that the first
thing they would do if they experienced this problem would be to turn to their
spouses for information or advice. The most common second step identified is
mother, with 20% of the respondents reporting that they would turn to their mothers
for health information as a secondary resource. In this scenario, only one respondent
elaborated a health communication ecology that consisted of five steps, most
involved only two steps and 10 respondents reported that they would go directly to
the clinic or doctor if they experienced abnormal periods. Respondents who reported
they would go straight to the doctor when experiencing abnormal periods were
probed to think about anything they might to before making the decision to go see a
doctor.
In this scenario, interpersonal resources account for 73% of the first step
identified, followed by organizational (23%), media (3%), and professional (3%)
resources. Interpersonal resources in the first step category included mostly spouses
(38%), mothers (10%), sisters (12%) and friends (10%). Daughters also emerged as
the first step in addressing the problem of abnormal periods in three of the cases. The

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four organizational resourced mentioned were pharmacies and clinics. Professional
resources were identified as a first step three times and always consisted of doctors.
In the one case when media emerged as a first step in addressing the health problem,
this consisted of connecting to the Internet to find information or advice. No other
media connections besides the Internet were identified in any of the steps elaborated
through the period scenario.
A comparison of the types of resources that emerged throughout each type of
health communication ecology based on the problem scenario can also inform our
understandings of how individuals may activate different resources for different
purposes. Table 4.10 compares the distribution of resource categories in the full
ecologies elaborated through the two different scenarios.
Table 4.10. Resource category representation in general health and women’s health
communication ecologies

Interpersonal
Resources
Media
Resources
Organizational
Resources
Professional
Resources
General Health
Scenario (rash)
43% 13% 44% 44%
Women’s Health
Scenario (period)
52% 3% 40% 5%

The comparison of the representation of communication resource categories
in the two different scenarios suggests that there is a difference in the ways in which
individuals gather health information depending on the problem they are addressing.
The ecologies in the general health scenario included an almost equal distribution of

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interpersonal, organizational and professional resources. In general, the rash scenario
elicited more elaborated ecologies that included the combination of different types of
communication resources. In comparison, the ecologies in the women’s health
scenario included mostly interpersonal and organizational resources. In general, the
abnormal period scenario elicited less elaborate ecologies that often focused on the
treatment of the problem (e.g. going straight to the hospital in the first or second
step) rather than ways to find out about the problem (e.g. talking to someone about
the symptoms). Figure 4.4 is a representation of the communication resource patterns
identified through the general health and women’s health scenarios in the HCE
measure.
Figure 4.4. Communication resource patterns for general health and women’s health
goals as identified by the HCE Measure

General Health

Women’s Health

There were no other media connections aside from the Internet identified in
the health communication ecologies for a general health goal and the women’s health
professional
(doctors)
organizational
(clinics)
interpersonal
(mothers)
organizational
(hospitals)
interpersonal
(spouses)

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goal. In fact, the ecologies elaborated through this methodology varied greatly from
those elaborated through the neo-traditional Multilevel Survey. This distinction,
which will be further discussed in Chapter Six, suggests two important things: 1)
communication ecologies can differ based on the specific goal or problem that is
being addressed and 2) communication resource connections are elaborated
differently based on the way in which the health communication ecology is captured.
Transnational Connections Identified by the Multilevel Survey and the HCE
Measure
RQ2 asks what roles transnational health behaviors or socio-cultural legacies
play in Latinas’ health seeking behaviors and if these findings differ when collecting
data by the prompted Multilevel Survey method or the spontaneous inclusion in the
HCE measure.
In the neo-traditional Multilevel Survey, the transnational communication
measure is an exploratory set of questions that attempts to describe the nature and
frequency of transnational connections for this particular population. Table 4.11
reports the frequencies for the different types of transnational connections measured.
For this particular subset of respondents, there was very little transnational activity
captured. In four of the five activities measured (emailing, texting, chatting and
visiting someone in the home country), almost 70% of the respondents reported that
they have never engaged in such practices. Talking on the phone with someone in the
home country was the one item that had more of a balanced distribution, with 59% of
respondents reporting that they do so at least once per month. Traditional economic

94
and political transnational practices were also measured, with 40% of respondents
reporting that they have never sent money to someone in their home country while
43% send money to someone in their home country at least several times a year.

Table 4.11. Frequencies for transnational communication practices

never
several times
per year or less
once per month
or more
Talk on phone with
someone in home country
78 (17%) 112 (24%) 277 (59%)
Email someone in home
country
353 (76%) 31 (7%) 83 (18%)
Send text messages to
someone in home country
330 (71%) 25 (5%) 112 (24%)
Chat online with someone in
home country
298 (64%) 44 (9%) 125 (27%)
Visit someone in home
country
315 (68%) 143 (31%) 9 (2%)

The transnational health measure in the Multilevel Survey is an exploratory
set of questions that attempts to describe the nature and frequency of transnational
health practices for this particular population. Table 4.12 reports the frequencies for
the different types of transnational health activities measured.

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Table 4.12. Frequencies for transnational health practices

never
several times
per year or less
once per month
or more
Use products from a
botanica or Latino market
197 (42%) 202 (43%) 67 (14%)
Use prescription medicine
from home country
301 (65%) 152 (33%) 13 (3%)
Use non-prescription (OTC)
medicine from home
country
280 (60%) 169 (36%) 17 (4%)
Talk to people in home
country about health
157 (34%) 173 (37%) 136 (29%)
Travel to home country for
medical care
434 (93%) 32 (7%) 1 (0.2%)
Use home remedies learned
about in home country
122 (26%) 259 (56%) 85 (18%)

An item that stands out is traveling to the home country for medical care, with 93%
of respondents reporting that they have never done so. Instead, we see the presence
of a transnational interpersonal network, with 34% of the respondents reporting that
they have never talked to someone in the home country about health, and 29%
reporting that they do so at least once per month. The items regarding medicine from
the home country produced similar results, with a majority of the respondents
reporting that they have never used prescription medicine from the home country
(65%) and never used non-prescription medicine from the home country (60%).
In the HCE measure, most of the interpersonal resources mentioned where
reported as living in the same house or the same neighborhood as the respondent. In
the general health ecologies, interpersonal resources (usually mothers) that lived in

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Mexico were included as a step in six different cases. In the women’s health
ecologies, both sisters and mothers that lived in Mexico where included as a step in
two different cases. Thus, the elaboration of goal-specific health communication
resource patters through the HCE measure revealed very limited instances of
connecting with transnational resources. This lack of transnational resources is more
evident in the women’s health scenario (abnormal periods) than the general health
scenario (persistent rash), suggesting again that Latinas turn to different resources
depending on the problem they are addressing. In this case the main difference
between the two health scenarios is that one is considered less urgent or life-
threatening than the other.
Comparing Variations in General Health and Self-Efficacy of Screening
Behaviors by Communication Resource Connections
RQ3 asks if there are variations in general health and self-efficacy regarding
preventive screening behaviors as a function of variations in communication
resource patterns. As described in Chapter Three, both general health and self-
efficacy feelings regarding cervical-cancer screening can be considered health
determinants. This research question will be explored using the Multilevel Survey
subset of 500 Latina respondents in the following ways:
• First, the relationship between independent communication connections
(television, radio, interpersonal or the Internet) and general health & self-
efficacy outcomes will be measured.

97
• Second, the relationship between communication connection patterns (e.g.
television and radio; television and interpersonal) and general health &
self-efficacy outcomes will be measured.
From the original MSD item, which asked how individuals obtain information about
health, we learned that television was the most common first response. Independent
t-tests were conducted to measure the relationship between watching television for
health information and cervical-cancer related determinants including general health,
likelihood of getting regular Pap tests, confidence in the ability to get regular Pap
tests, and likelihood of returning for treatment after an abnormal Pap test result
(Table 4.13).
Table 4.13. Independent t-tests: Connection to television for health information and
cervical cancer-related determinants

Television
Connection
Mean (SD)
No
Television
Connection
Mean (SD)
df t-value Sig.
General health 3.36 (.869) 3.63 (.893) 496 3.360 .001**

Likelihood of getting
regular Pap tests

9.03 (2.04)

8.98 (2.18)

492

.301

.764

Confidence in ability to
get regular Pap tests
9.13 (2.06) 8.76 (2.25) 492 1.864 .063

Likelihood of returning
for treatment after
abnormal Pap result
9.83 (.783) 9.77 (.895) 495 .689 .491
*Significant at the p<.01 level.

Respondents who identified the television as one of the two most important
ways of obtaining health information are more likely to report worse general health

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(M = 3.36) than those who did not identify the television (M = 3.63), t(1,496) =
2.147, p=.001. Levene’s test of equal variances showed a significant difference in
variance for the identification of television as one of the top two ways of obtaining
health information and confidence in the ability to get regular Pap tests, F(1,492) =
6.604, p= .01. However, no significant differences existed between respondents who
identified television as one of their top two ways of obtaining health information and
those who did not when it comes to confidence in getting regular Pap tests. No
significant differences existed for likelihood of getting regular Pap tests or likelihood
of returning for treatment.
When the responses to the initial MSD question were observed in terms of
what combinations of resources respondents turned to for health information, radio
emerged as a significant connection when combined with the television. For this
reason, independent t-tests were conducted to measure the relationship between
connecting with radio for health information and the same four cervical-cancer
related health determinants (Table 4.14).

99
Table 4.14 Independent t-tests: Connection to radio for health information and
cervical cancer-related determinants
Radio
Connection
Mean (SD)
No Radio
Connection
Mean (SD)
df t-value Sig.
General health 3.40 (.877) 3.51 (.893) 496 .914 .361

Likelihood of getting
regular pap test

9.13 (1.88)

8.99 (2.15)

492

.498

.619

Confidence in ability to
get regular Pap tests
9.10 (1.88) 8.91 (2.21) 492 .642 .521

Likelihood of returning
for treatment after
abnormal Pap result
9.84 (.518) 9.79 (.882) 495 .397 .691

There were no significant differences between radio connection and the four cervical
cancer-related health determinants.
Because 60% of the respondents reported using the Internet, independent t-
tests were conducted to determine possible differences in general health and feelings
of self-efficacy regarding cervical cancer screenings between those who mentioned
the Internet as a way of obtaining health information and those who did not (Table
4.15).

100
Table 4.15. Independent t-tests: Connection to Internet for health information and
cervical cancer-related determinants

Connection
to Internet
Mean (SD)
No
Connection
to Internet
Mean (SD)
df t-
value
Sig.
General health 3.63 (.912) 3.45 (.879) 496 1.986 .048*

Likelihood of getting
regular Pap tests

9.30 (1.84)

8.90 (2.20)

492

1.905

.040*

Confidence in ability to
get regular Pap tests
9.09 (2.00) 8.87 (2.23) 492 .988 .323

Likelihood of returning
for treatment after
abnormal Pap result
9.81 (1.02) 9.80 (.771) 495 .115 .909
*Significant at the p<.05 level.

Respondents who identified connecting to the Internet as one of the ways of
obtaining health information are more likely to report more positive general health
(M = 3.63) than those who did not identify the Internet (M = 3.45), t(1,496) = 1.986,
p<.05. Similarly, respondents who identified connecting to the Internet as one of the
ways of obtaining health information are more likely to report a greater likelihood of
getting regular Pap tests (M = 9.30) than those who did not identify the Internet (M =
8.90), t(1,492) = 1.905, p<.05. Levene’s test of equal variances also showed a
significant difference in variance for connecting to the Internet for health information
and confidence in the ability to get regular Pap tests, F(1,492) = 5.110, p < .05.
However, no significant differences existed between respondents who identified the
Internet as one of their top two ways of obtaining health information and those who
did not when it comes to confidence in the ability to get regular Pap tests.

101
A second approach to investigating differences in health outcomes based on
communication connections is to treat the connections as significant combinations
that may produce different results. In this sense, rather than treating a specific media
connection in isolation from all other potential connections, these connections are
analyzed as a combination of connections. The combination of communication
connections further informs our understanding of how individuals obtain information
and stems from a communication ecology perspective that observes the role of
communication resources in relation to each other. The most common combination
of resources identified was connecting to both television and interpersonal resources
to obtain information. Thus, independent t-tests were conducted to determine the
relationship between this specific communication pattern and the four cervical-
cancer related health outcomes (Table 4.16).
Table 4.16. Independent t-tests: Connection to television and talking with others for
health information and cervical cancer-related determinants

Television &
Interpersonal
Connection
Mean (SD)
No Television
&
Interpersonal
Connection
Mean (SD)
df t-
value
Sig.
General health 3.45 (.794) 3.50 (.898) 496 .303 .762

Likelihood of getting
regular pap tests

8.94 (2.24)

9.01 (2.11)

492

.182

.856

Confidence in ability to
get regular Pap tests
8.52 (2.67) 8.96 (2.13) 492 1.141 .254

Likelihood of returning
for treatment after
abnormal Pap result
9.91 (.522) 9.79 (.863) 495 .776 .438

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Levene’s test of equal variances showed a significant difference in variance
for the combination of television and interpersonal connection and likelihood of
getting regular pap tests, F(1,492) = 9.141, p < .05. However, no significant
differences existed between respondents who identified the combination of television
and talking with others as their top two ways of obtaining health information and
those who did not when it comes to likelihood of getting regular pap tests. Levene’s
test of equal variances also showed a significant difference in variance for the
combination of television and interpersonal connection and confidence in the ability
to get regular Pap tests, F(1,492) = 4.148, p < .05. However, no significant
differences existed between respondents who identified the combination of television
and talking with others as their top two ways of obtaining health information and
those who did not when it comes to confidence in the ability to get regular Pap tests.
To further investigate differences between communication connection
patterns and health outcomes, the combination of television and radio was also
included. While this combination of resources did not emerge from the original MSD
question, it did appear as the most common ranking of the top two most important
ways of getting health information. Table 4.17 presents the results of independent t-
tests with connection to television and radio and the four health outcomes.

103
Table 4.17. Independent t-tests: Connection to television and radio for health
information and cervical cancer-related determinants

Television &
Radio
Connection
Mean (SD)
No
Television &
Radio
Connection
Mean (SD)
df t-value Sig.
General health 3.76 (.888) 3.48 (.889) 496 1.927 .024*

Likelihood of getting
regular pap test

9.38 (1.74)

8.97 (2.14)

492

1.159

.048*

Confidence in ability to
get regular Pap tests
9.23 (1.92) 8.91 (2.19) 492 .893 .372

Likelihood of returning
for treatment after
abnormal Pap result
9.95 (.218) 9.79 (.878) 203 3.111 .002**
*Significant at the p<.05 level. **Significant at the p<.01 level, equal variances not assumed.

These analyses produced slightly different results than the previous combination of
television and interpersonal connections. Those who identified the television and
radio as the first and second (respectively) most important ways of obtaining health
information are more likely to report more positive general health (M = 3.76) than
those who did not identify the television and radio (M = 3.48), t(1,496) = 1.927,
p<.05. Those who identified the television and radio as the first and second
(respectively) most important ways of obtaining health information are more likely
to get regular pap tests (M = 9.38) than those who did not identify the television and
radio (M = 8.97), t(1,492) = 1.159, p<.05. Those who identified the television and
radio as the first and second (respectively) most important ways of obtaining health
information are also more likely to return for treatment after an abnormal Pap result

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(M = 9.95) than those who did not identify the television and radio (M=9.79),
t(1,203) = 3.111, p<.005.
In the initial MSD question, talking with others to get health information was
the most common second response. Independent t-tests were conducted to measure
the relationship between talking with others for health information and the same four
cervical-cancer related health outcomes (Table 4.18).
Table 4.18. Independent t-tests: Connection to talking with others about health
information and cervical cancer-related determinants

Interpersonal
Connection
Mean (SD)
No
Interpersonal
Connection
Mean (SD)
df t-
value
Sig.
General health 3.51 (1.025) 3.50 (.824) 496 .108 .914

Likelihood of getting
regular Pap tests

9.10 (1.93)

8.96 (2.19)

492

.658

.511

Confidence in ability to
get regular Pap tests
8.99 (2.12) 8.90 (2.20) 492 .434 .664

Likelihood of returning
for treatment after
abnormal Pap result
9.81 (.833) 9.79 (.851) 495 .273 .785

Levene’s test of equal variances showed a significant difference in variance for the
identification of talking with others as one of the top two ways of obtaining health
information and general health, F(1,496) = 7.039, p < .01. However, no significant
differences existed between respondents who identified talking with others as one of
their top two ways of obtaining health information and those who did not when it
comes to general health. Similarly significant differences were found between those

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who did have an interpersonal connection and those who did not in terms of the other
health outcomes.
To further explore how the nature of an individual’s interpersonal
connections (local vs. transnational) impact health outcomes, independent t-tests
were conducted between local interpersonal connections and health outcomes (Table
4.19). The social network items were transformed into a dichotomous variable with
the following two dimensions: cases where the first two individuals mentioned in
their health social network are local, and cases where the first two individuals
mentioned are not local (either live in another city, state or country). The variables
were transformed in this way to only measure the influence of the first two
individuals that respondents talk to about health issues since only 35% of
respondents mentioned more than two people overall.

Table 4.19. Independent t-tests: Connection to local interpersonal social network
and individual health outcomes
Local
Interpersonal
Network
Mean (SD)
Non-local
Interpersonal
Network
Mean (SD)
df t-
value
Sig.
General health 3.47 (.895) 3.51 (.902) 429 .484 .629

Likelihood of getting
regular pap tests

9.05 (2.14)

9.08 (2.01)

427

.148

.882

Confidence in ability to
get regular Pap tests
8.99 (2.13) 8.97 (2.13) 426 .118 .906

Likelihood of returning
for treatment after
abnormal Pap result
9.84 (.708) 9.68 (1.14) 429 1.832 .048*
*Significant at the p<.05 level.

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Respondents who reported that the first two individuals that they talk to about health
issues live in their house or in their neighborhood are more likely to return for
treatment after an abnormal Pap result (M = 9.84) than those who reported that the
first two individuals live in another city, state or country (M = 9.68), t(1,429) = 1.832,
p<.05. No other cervical cancer-related outcome differences were identified based on
the presence of a local or non-local interpersonal network.
To further explore the role of transnational communication connections in the
health outcomes (general health and self-efficacy regarding screening behaviors) of
Latinas, independent t-tests were conducted between the different types of
transnational communication connections and the four cervical cancer-related
determinants. Only the relationship between talking on the phone with someone in
the home country and health determinants produced significant differences (Table
4.20).

107
Table 4.20. Independent t-tests: Talking on the phone with someone in the home
country and cervical cancer-related determinants

Transnational
Talk
Mean (SD)
No
Transnational
Talk
Mean (SD)
df t-
value
Sig.
General health 3.48 (.891) 3.54 (.801) 463 .579 .563

Likelihood of getting
regular Pap tests

8.91 (2.25)

9.54 (1.19)

459

2.360

.019*

Confidence in ability to
get regular Pap tests
8.91 (2.20) 9.28 (1.70) 459 1.386 .166

Likelihood of returning
for treatment after
abnormal Pap result
9.80 (.900) 9.87 (.547) 462 .698 .485
*Significant at the p<.05 level.

Respondents who reported that they talk to on the phone with someone in the home
country are more likely to report a lower likelihood of getting regular Pap tests (M =
8.91) than those who do not talk on the phone with someone in the home country (M
= 9.54), t(1,459) = 2.360, p<.05. Levene’s test of equal variances also showed a
significant difference in variance for talking on the phone with someone in the home
country and confidence in the ability to get regular Pap tests, F(1,459) = 7.374, p
< .05. However, no significant differences existed between respondents who talk on
the phone with someone in the home country and those who did not when it comes to
confidence in the ability to get regular Pap tests.
Differences in general health and self-efficacy feelings were also tested based
on each of the transnational health practices individually and in combination.

108
However, only differences in health outcomes based on talking to someone in the
home country produced any significant relationships (Table 4.21).
Table 4.21. Independent t-tests: Talking to someone in home country about health
and cervical cancer-related determinants

Transnational
Health Talk
Mean (SD)
No
Transnational
Health Talk
Mean (SD)
df t-
value
Sig.
General health 3.47 (.908) 3.53 (.813) 462 .730 .466

Likelihood of getting
regular pap tests

8.83 (2.34)

9.39 (1.53)

458

2.664

.008*

Confidence in ability to
get regular Pap tests
8.88 (2.21) 9.14 (1.96) 458 1.225 .221

Likelihood of returning
for treatment after
abnormal Pap result
9.79 (.871) 9.89 (.818) 461 .459 .646
*Significant at the p<.05 level.

Respondents who reported that they talk to someone in the home country about
health are more likely to report a lower likelihood of getting regular Pap tests (M =
8.83) than those who do not talk to someone in the home country about health (M =
9.39), t(1,458) = 2.664, p<.05.

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CHAPTER FIVE:
A CASE STUDY OF HEALTH COMMUNICATION ASSET MAPPING

HCAM Workshop Development
In addition to capturing individual and community-level barriers and conduits
to cervical cancer prevention through a neo-traditional quantitative survey and the
HCE measure, the Multilevel Study is interested in understanding neighborhood-
level dynamics in more grounded ways. Health Communication Asset Mapping
(HCAM) is a methodology that identifies physical and social spaces in a
neighborhood where health promotion activities would mesh with the everyday
fabric of community life. These discursive spaces may or may not overlap with other
types of assets in that they are the everyday spaces where residents feel comfortable
talking with fellow residents about health-related concerns. Spaces, for example
where residents could seek and offer health advice or let others know about a new
health threat or a new health resource. The HCAM method includes the training of
residents, practitioners and community organizers so that they can participate in and
guide data collection and the production of digital and print maps that highlight
spaces in their community where health promotion can occur.
To identify a pilot neighborhood for the HCAM protocol, we reviewed
demographic data from medical charts of female patients who received care at the
Los Angeles County USC Medical Center’s (LAC+USC) Women’s Clinic, the main
recruitment site for the Multilevel Study. We learned that almost 20% of 962

110
Women’s Clinic patients lived in a cluster of zip codes that form the Boyle Heights
neighborhood. The total population of Boyle Heights is estimated at 99,000, making
it one of the densest neighborhoods in the city and county. According to the 2010
U.S. Census, Boyle Heights is approximately 92% Latino, 3% Asian, 2% White and
1% Black. Approximately 52% of the residents are foreign born, predominantly from
Mexico. The household median income is approximately $30,000, which is
comparable to other lower-income communities in Los Angeles. Boyle Heights has
an established historical identity and is experiencing a surge of community
revitalization, making it an ideal site for a health-specific intervention
After the selection of Boyle Heights as the study site, the research team
decided that a more participatory process that involved community organizers and
community health practitioners would reveal a more grounded Boyle Heights ‘health
communication asset map’. The team partnered with a local community organization
called East Los Angeles Community Corporation (ELACC) to collaboratively
develop the scope of the HCAM project. The partnership also agreed that to make
the mapping more participatory and build asset-mapping capacity within community
practitioners, the project participants should be community organizers, community
health promotores, and neighborhood leaders with familiarity with the Boyle Heights
neighborhood. A group of 23 promotores, organizers, and neighborhood leaders who
all were conversant in Spanish were recruited to participate in an HCAM workshop
in October of 2012.

111
HCAM Deployment
The goal of the HCAM workshop was to train residents, practitioners and
community organizers on how to conduct community health research through
participatory data collection and the production of digital and print maps that
highlight spaces in their community where health promotion can occur. Workshop
participants were first trained on how to identify potential health communication
assets and then went out to the field in teams of two to map eight sub-areas in Boyle
Heights. The training involved group discussions about what spaces could be
considered health communication assets and how these spaces could be used for
community health promotion. Printed and projected PowerPoint slides were provided
to guide the participants through the planned activities and definitions employed
during the training component (Figure 5.1).
Figure 5.1. PowerPoint slides used during HCAM workshop

112
Each mapping team was provided with mapping forms where they listed the health
communication assets they noticed as they walked the neighborhood. They
described each asset, noted the exact location, and took a photograph.
Figure 5.2. Fieldwork instructions and mapping form used during HCAM workshop

Fieldwork Instructions
walk through the major streets in your team’s
assigned area
identify spaces you consider health
communication assets
take a photograph of the space and mark on map
write down details on the Mapping Form
return to Las Margaritas by 1pm or earlier to
work with team to print and download pictures
Mapping Form

113

Among the eight teams, which each consisted of 2-3 participants, an average
of 20 assets were identified per team. The abundance of health communication assets
identified by the workshop participants had to be streamlined during the post-
fieldwork workshop activities so that only a limited number of assets were selected
to be included in the visual map highlighting health communication assets in Boyle
Heights. However, the research team built a digital database of all the health
communication assets identified by all mapping teams in order to produce GIS maps
with the types of assets represented (Figure 5.3).
Figure 5.3. GIS map of health communication assets identified in HCAM fieldwork

114
After the workshop participants finished the asset mapping of the sub-areas,
the research team moderated a discussion of the experience and asked each mapping
team to select three or four health communication assets that stood out as likely
places where health information could be discussed or disseminated. The group then
voted on the most influential assets and these were used to create a digital and
printed map of Boyle Heights health communication Assets that would be distributed
through community and academic networks. After the selection of the top health
communication assets, the researchers and participants held a discussion regarding
what other resources could be displayed on the map and how this map could be
shared with residents and health practitioners. Workshop participants were then
invited to a follow-up meeting where the aesthetics and text of the final map (Figure
5.4) were reviewed with the help of a graphic designer.

115
Figure 5.4. Final collaborative map (front and back) developed through HCAM
workshops

116

1. LAC+USC Medical Center
Also known as County/USC, this is the
largest healthcare provider in Los Angeles
County. LAC+USC is one of the few medical
centers in LA that provides low-cost or
free health services, including emergency,
gynecological and pediatric care.
2. East Los Angeles
Occupational Center
ELAOC provides technical training and
job placement for adults and high school
students. It was chosen as a health
communication asset because it is a space
where health fairs or workshops with
residents can be held.
3. Proyecto Pastoral
This community building organization
provides training, education and social
services for the Boyle Heights community.
It is a space that can promote health
by organizing change from within the
community.
4. Self Help Graphics
This is a non-profit visual arts center that
hosts many art events and workshops
for residents of all ages. They are a vital
community resource that can incorporate
health topics in their arts and culture
programs.
5. White Memorial
Medical Center
White Memorial is a not-for-profit, faith-
based, teaching hospital. It provides
inpatient, outpatient and emergency
services to the community, including
general medical care and women’s and
children’s services.
6. Mariachi Plaza
This historic square includes restaurants,
a Metro Gold Line station, and shops such
as the bookstore Libros Schmibros. It has
traditionally served as a gathering place
for the community and would be a good
place to share information with residents.
7. Mendez Learning Center
The Center is a small public high school
that prepares students for success while
maintaining a focus on family and
community. Health can be promoted here
through educational activities that are
already in place.
8. Boyle Heights Technology
Youth Center
This community resource center is part
of the LA Youth Opportunity Movement
and includes an alternative high school,
recording studio and computer lab. It is a
good space to `share health information
with young residents.
9. Hollenbeck Park
This park is very well known in the
community as a space where many
events occur, including large health fairs.
Hollenbeck park is a place where families
go to relax and spend time interacting
with other residents.
10. Stevenson Parents Center
As part of Stevenson Middle School,
the Center was created to promote
the involvement of parents in youth
education. The center can be a good place
to promote community health through
educational activities.
GET INVOLVED! A healthy
Boyle Heights depends on
residents, community
organizations, and health
workers sharing health
information. Here are some
examples of resources to share:
This work was supported by the National Cancer Institute for Barriers to Cervical
Cancer Prevention in Hispanic Women: A Multilevel Approach, which was an
award to the University of Southern California (R01CA155326 - Murphy/
Ball-Rokeach). The content is solely the responsibility of the authors and does
not represent official views of the NCI or of the National Institutes of Health.
There are many spaces in the community where
people gather or feel comfortable talking about health.
Below we highlight some of the health communication
assets in Boyle Heights.
ENVIRONMENTAL JUSTICE
& AIR POLLUTION:
Air Quality Management District
(AQMD): report pollution in your
neighborhood (noise, smells, &
smoke from local industry; pollut-
ing vehicles) – 1-800-CUT-SMOG
Clean Up Green Up: Find out how
to get involved in local environ-
mental justice work. Visit
www.CLEANUPGREENUPLA.org
CLINICA ROMERO:
For information about pap tests,
mammograms, and pre-natal care
213-989-7700 FOR NEW PATIENTS
BUILDING HEALTHY
COMMUNITIES
BOYLE HEIGHTS
COLLABORATIVE:
A collaborative of nonprofit groups
working to make Boyle Heights a
healthier community by improving
employment, education, housing,
safety, environmental conditions,
healthy food access and more. For
information, please contact Joel
Perez at JOELBHC@YMCALA.ORG.
EAST LOS ANGELES
WOMEN’S CENTER:
Ensures that all women, girls, and
their families live in a place of
safety, health, and personal well-
being, free from violence and abuse,
with equal access to necessary
health services and social support.
DIRECT LINE: 323-526-5819,
BILINGUAL RAPE & BATTERING
HOTLINE: 800-585-6231,
AIDS HOTLINE: 800-400-7432
211: A countywide human services
crisis intervention, information and
referral assistance hotline.
311: A citywide toll-free number
that provides immediate access to
information and more than 1,500
non-emergency city services
BOYLE HEIGHTS BEAT:
A bilingual community newspaper
produced by youth. Adult con-
tributors also share their stories
on BOYLEHEIGHTSBEAT.COM/
PULSODEBOYLEHEIGHTS.COM.
Find out how to be a community
contributor by visiting the site or
calling 323-834-975.
Corra La Voz
Spread The Word
“We chose Hollenbeck Park
because it is very well known
among the community, and
in fact there was a health fair
when we stopped there.”
HOW WE MADE THIS MAP:
Promotoras de Salud, community
organizers, and researchers
walked the neighborhood and
mapped good spaces where health
communication can occur.
For more information on this map
go to www.metaconnects.org.

117
After a successful HCAM workshop and map development, we believe there is much
potential for the incorporation of community-level health fieldwork that privileges
the expertise of residents and local practitioners. The challenge now is to develop a
dissemination and evaluation protocol to aid researchers in the post-mapping process
so that the mapping data can be incorporated in health campaigns and interventions.
With the addition of the HCAM tool, public health researchers and practitioners can
gain a more grounded understanding of the communities they seek to serve.

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CHAPTER SIX:
SUMMARY & DISCUSSION OF FINDINGS

The communication ecology approach presented in this dissertation proposes
the study of communication practices in the context of a particular goal or problem.
The health communication ecology approach, specifically, considers how
communication practices may be inextricably linked to health decision-making, and
ultimately to individual health outcomes and behaviors.
RQ5 asks what outreach and intervention strategies can be suggested by the
Multilevel Survey, the HCE measure and the HCAM findings. Indeed, these three
methodologies have yielded different understandings of how Latinas obtain health
information and the connection between communication resource patterns and
cervical cancer-related health determinants. The goal of this dissertation was to
contribute a theoretical and methodological perspective that can help improve the
ways we understand and promote immigrant health. The context of cervical cancer
prevention among Latinas lends itself to a communication ecology approach because
it helps identify the communication resources that are utilized in health information
seeking.
The identification of these communication resource patterns can benefit
health promotion efforts by suggesting communication strategies that include
resources that individuals turn to when faced with a health problem. There is a
crucial difference in the communication connections that individuals report when

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asked about general behaviors and those that they report when asked about a specific
health goal. The main difference is that general communication resource connections
can change dramatically depending on the goal at hand. Health communication
resource connections, however, suggest the communication resources that an
individual would actually activate when addressing a specific problem. Thus, health
interventions that are tailored to ethnic groups might more effectively impact health
behavior if they engage the communication channels that are active in the health
communication ecologies of specific population. Doing so would not only help
produce culturally-relevant health promotion materials, but would also increase the
chances that those materials will reach their intended audience. The following
discussion provides a synthesis of the findings in the three different approaches and
suggestions for outreach strategies suggested by those findings.
One of the reasons the Multilevel Survey was labeled as a neo-traditional
survey is because it includes items that identify how individuals obtain information
about health across a variety of platforms and resources. Traditionally,
communication-related survey items ask about general media connections, and most
often connections to mainstream media rather than geo-ethnic media. When
conducting research on immigrant populations, it seems appropriate to consider the
range of sociocultural connections that may promote or hinder particular behaviors.
One technique of investigating sociocultural practices is through the identification of
the ways which individuals obtain information for themselves or their families. The
MSD items in the Multilevel Survey allow the respondent to identify the

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communication connections that are relevant to them and allow researchers to know
more about the nature of those connections. The social network items and
transnational items in the Multilevel Survey allow us to further understand what an
interpersonal connection looks like for Latina immigrants and to measure how
certain types of connections may explain differences in health behaviors.
RQ1a asked what primary communication patterns for Latinas’ health-
seeking behaviors can be identified through the Multilevel Survey and the HCE
measure. From the Multilevel Survey we learned that television, interpersonal and
radio connections were relevant for this sample of Latinas within the specific health
context. The absence of newspapers is not a surprising one considering that
newspaper readership has been declining in both mainstream and geo-ethnic
platforms and Latinos have traditionally connected more with television and radio
sources. A first look at the initial MSD question would imply that television and
interpersonal connections would be the most common pair of health information-
seeking practices, but by looking at the cross-tabulation of the top five resources
mentioned in each response, we notice a different pattern. Surprisingly, the
combination of television and radio connections emerges as the most common
combination of resources. Treating such combinations as practices that may work in
conjunction brings us closer to an ecological understanding of how individuals
obtain information for specific decisions. In this case we learn that Latinas may be
turning to both television and radio when they seek health information, and that the

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combination of such connections may impact the types of health decisions that they
make.
The follow-up MSD items elaborate health communication resource patterns
even further by revealing the types of media connections that are relevant in a health
scenario. Through these items we observe that geo-ethnic media, and Spanish-
language media in particular, play a major role in providing health information to
Latinas. Even further, the identification of specific media outlets provides a practical
guidebook around which health communication campaigns can be designed. The
respondents in this study identified popular television channels and radio stations as
sources of health information; the incorporation of relevant health messages in these
platforms could produce an effective health communication strategy. This
elaboration of communication resource patterns for health is further supported by the
results of the time-spent items that ask about time spent with mainstream and geo-
ethnic media separately. Here we learn that 40% of the respondents watch geo-ethnic
television at least five hours per week. The time-spent with media question format is
a more traditional measure, but it is often only asked in the context of media in
general without a consideration of the difference between mainstream and geo-ethnic
media. These findings further support the idea that immigrant populations would
most effectively be reached through the communication channels that they actually
connect with, in this case Spanish-language television and radio.
By asking Latinas to name the people that they speak to about women’s
health and also identify where these individuals live, the Multilevel Survey helps us

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gain a better understanding of how their health information travels. For this subset of
cases from the Multilevel Survey it appears that Latina immigrants have a very
locally-based social network, with most of their interpersonal connections happening
in their home or in their neighborhood. Therefore, the health communication patterns
for this study population as elaborated through a combination of the initial MSD
question, the media specific follow-up items, and the social network items suggest
the importance of geo-ethnic media and local interpersonal networks.
Health communication strategies that incorporate geo-ethnic and local
interpersonal resources in their outreach may more effectively tap into the health
storytelling network of that specific population. A communication ecology
perspective can be particularly useful here as it can identify the patterns in which
hard-to-reach groups connect with communication resources and thus suggest a
multimodal strategy for reaching those groups. For example, through the Multilevel
Survey we learned that when Latinas in Los Angeles want to find health information
for themselves or their families, they activate the following resources: television,
radio and interpersonal sources. We also learned that television and radio was the
most common resource combination. A health intervention focused on Latinas could
use this finding to tailor a health message to a television format and increase its
impact by reinforcing the message with a follow-up radio commercial. When Latinas
see and hear the complementary messages in these platforms, they may be more
receptive to the information presented because the platforms themselves are familiar
sources of health information. Thus, because a communication ecology approach to

123
quantitative research can capture communication resource patterns in the context of a
specific population and a specific health issue, it can suggest detailed and culturally-
relevant strategies for health promotion among immigrant and minority groups.
An additional goal of the Multilevel Survey component of this dissertation
was to determine if there are differences in general health and self-efficacy feelings
regarding cervical cancer screening behaviors based on communication resource
patterns (RQ3). First, each communication resource connection identified in RQ1a
was measured in terms of how it may impact differences in health determinant
outcomes. An analysis of television alone would suggest that connecting to the
television for health information may lead to worse self-assessed general health. This
is the only significant finding when observing the role of television by itself. When
measuring differences in health outcomes based on a connection to radio for health
information, no significant differences were found. Because of the high rate of
Internet connectedness for this study population (60%), differences based on
connecting to the Internet for health information were also measured. In this case,
respondents who connected to the Internet were more likely to report better general
health and a greater likelihood of getting regular Pap tests. This finding is an
interesting one, and suggests that the Internet may be a more relevant connection
than how it was represented in the initial MSD item. Connecting to the Internet for
health information is now a common practice for many populations, and should be
included in future research to determine how Latinas specifically incorporate the
Internet in their communication ecologies.

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The second approach to comparing health outcomes based on communication
connections was to treat such connections as combinations of resources that are
related to each other. As we identified in the initial MSD item, the combination of
television and talking with others appeared like the most common combination when
seeking health information. This combination, however, did not yield significant
findings in terms of differences in general health and self-efficacy. The cross-
tabulation of response #1 and response #2 in the initial MSD item revealed that
television and radio was the most common combination of resources when seeking
health information. When health outcomes were compared based on the
identification of these two resources as the first (television) and second (radio) most
important ways of obtaining health information, more significant findings emerged.
Respondents identifying this combination of connections were more likely to report
better health outcomes, a greater likelihood of obtaining regular Pap tests, and a
greater likelihood of returning for treatment after an abnormal Pap result. These
findings suggest that looking at communication connections in combination may be a
more predictive strategy when investigating how communication practices impact
health decision-making, and ultimately health behaviors and outcomes.
The HCE measure is presented as a potential research tool that can further
explain how individuals make decisions about health by capturing the ways in which
they navigate across various communication resources. RQ1b asked what are the
primary communication resource patterns identified for Latinas’ health-seeking
behaviors when using the HCE measure. These resource patterns were elaborated in

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a way that the respondent was able to narratively and visually identify the steps they
would take to solve specific health problems (a rash and abnormal periods in this
case). The health communication ecologies identified through the HCE measure
differed based on the problem that was being addressed and also differed from the
communication patterns identified in the Multilevel Survey.
When asked what they would do if they experienced a persistent rash, Latinas
reported that they often turn first to their mothers for information or advice, and then
follow up with connecting to the Internet for health information. Besides the Internet,
media connections did not emerge as components of Latinas’ general health
communication ecologies, instead interpersonal, organizational and professional
resources were activated. Therefore, the HCE measure suggests that when faced with
a general health problem, Latinas turn to their mothers first then follow-up with
clinics and doctors in their additional problem-solving steps.
When asked what they would do if they experienced abnormal periods,
Latinas reported that they often turn first to their spouses for information or advice,
and then follow up with talking to their mother about the health problem. In this
scenario, only one health communication ecology identified connecting to the
Internet as one of their steps. Instead, interpersonal and organizational resources
were activated. Therefore, the HCE measure suggests that when faced with a
women’s health problem, Latinas turn to their spouses first then follow-up with
clinics in their additional problem-solving steps. The ecologies reported in the
women’s health scenario were also less elaborated, suggesting that fewer

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communication resource connections are activated when the problem seems more
urgent or life-threatening.
These findings paint a different story than the communication patterns
identified through the Multilevel Survey. This difference is expected, as the HCE
measure captures active information seeking for the purpose of achieving a particular
goal. The Multilevel Survey, while still informative regarding communication
patterns for obtaining health information, preferences specific connections rather
than identifying them through a spontaneous storytelling process. The HCE measure
would suggest that the promotion of general health among Latinas should operate
across interpersonal, organizational and professional levels. This would mean, for
example, that mothers are a major source of health information and knowledge for
Latinas and should be included in multilevel strategies for health promotion. A
health communication campaign that capitalizes on the connection between Latinas
and their mothers and incorporates the involvement of clinics and doctors may more
effectively promote behavioral change, in this case compliance with cervical
screening guidelines. The HCE measure would also suggest that the promotion of
women’s health among Latinas should find ways to involve spouses, who seem to be
the first resource that Latinas turn to when they experience a women’s health
problem. This finding would need to investigated further to determine if the brief
ecologies identified in the women’s health scenario are not a function of the urgency
and severity of the abnormal pap scenario. The incorporation of the full HCE
measure dataset (N=200) will help flesh out some of these differences.

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The Multilevel Survey was also considered neo-traditional because it
includes items that measure the nature and frequency of transnational connections.
As described in Chapter Two, these connections can also impact the health decisions
and behaviors of immigrants. While the concept of transnational health is a fairly
new idea and the methodology of looking at transnational communication and
transnational health connections is exploratory, this dissertation is an early attempt to
understand how individuals may be engaging in transnational practices in their
everyday lives. RQ2 asks if transnational health behaviors and socio-cultural legacies
play a role in health seeking behavior and how these dynamics are captured
differently than those in the HCE measure.
From the Multilevel Survey we learn that while many Latinas do talk on the
phone with someone in the home country quite regularly, very few of them send
emails, text messages, or chat online with someone in the home country more than
once per month. Many respondents (69%) also have never returned to visit their
home country since they came to the U.S., such a reality is probably a symptom of
financial barriers and citizenship status combined. When measuring differences in
cervical cancer-related self-efficacy based on transnational communication practices,
talking on the phone with someone in the home country is linked to a lower
likelihood of getting regular Pap tests but not linked to any of the other health
outcomes or feelings. This finding is a bit more difficult to untangle, but it does
parallel the finding that Latinas in this study tend to turn to more local interpersonal
resources for health information. The possibility that communicating with

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individuals in the home country may lead to more negative health outcomes warrants
further investigation. Transnational health practices were also investigated to
determine if Latinas engage in transnational practices directly related to health
decision-making and health behaviors. Unsurprisingly, almost all of the respondents
(93%) report that they have never traveled to their home country for medical care.
While this finding makes sense considering that 69% of the women have never
returned to their home country, it brings to question the assumption that many Latino
immigrants travel to their home country for medical care. Again, this concept of
transnational medical care is a new approach to understanding immigrant health and
should be explored through a combination of quantitative and qualitative
methodologies.
Questions about the use of prescription and non-prescription medicine from
the home country also produced very limited results in the Multilevel Survey, with a
majority of the women reporting that they do not use medicine from their home
country. However, when considering differences in health outcomes based on
talking to someone in the home country about health specifically, we again see the
negative impact of transnational interpersonal connections. Respondents who
reported talking to someone in the home country about health were more likely to
report a lower likelihood of obtaining regular Pap tests, which supports the finding in
the transnational communication analyses. No other differences in health outcomes
were observed based on all other transnational health connections. This might be a
reality of the study population, but it might also be a weakness in the design of the

129
measures themselves. In my future research I plan to continue developing both the
transnational communication and transnational health measures in a survey format
and also developing more qualitative ways of understanding the influence of
transnational connections on health behavior.
Interestingly, the HCE measure, the only instances when transnational
connections emerged as part of the health problem-solving process was a few cases
in which the respondent’s mother or sister lived in their home country of Mexico.
Otherwise, the ecologies elaborated in both the general health and women’s health
scenario suggest that transnational connections are less important in these specific
processes than local connections. Again, this can suggest the limited role of
transnational connections in the health-seeking behaviors of Latinas or it can reveal a
weakness in the measurement of transnational practices. Further testing of the HCE
measure can contribute a more conclusive evaluation of the socio-cultural and geo-
spatial nature of Latinas’ health communication ecologies.
Finally, while the Health Communication Asset Mapping approach is still in
the pilot testing and needs further elaboration on its theoretical and practical
contributions, the HCAM case study presented in this dissertation showcases an
additional method of developing multilevel health outreach and intervention
strategies. The HCAM approach is innovative in that is grounded in the perspectives
of residents who live and work in the neighborhoods where the study population
resides. Participants in the Boyle Heights HCAM workshop identified businesses,
churches, community organizations, hospital and clinics, libraries, public spaces and

130
schools as health communication assets where health promotion can occur. They
selected the most important assets and presented them on a map of the community
with suggestions for how these spaces can participate in health promotion activities.
The goal of the Boyle Heights Health Communication Assets Map is to provide a
community health guidebook that practitioners and health workers can utilize when
seeking community partnerships or health promotion venues. This guidebook
contributes another way of understanding the multilevel dimensions of individual
health promotion by considering the perspectives of local residents and promoting
the involvement of community institutions.

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CHAPTER SEVEN:
LIMITATIONS AND CONCLUSION

Recent studies on health disparities have proposed the deployment of
community-based research as a way to understand the socio-cultural determinants of
health and propose strategies to eliminate disparities that plague ethnic and minority
groups (Dutta, Anaele, & Jones, 2013; Rhodes, Duck, Alonzo, Daniel-Ullloa, &
Aronson, 2013; Hicks et al., 2012; Israel et al., 2010; Hernigan, Salvatore, Styne, &
Winkleby, 2012; Minkler, 2010; Wallerstein & Duran, 2010). Dutta et al. (2013)
posit that a culture-centered approach (CCA), which captures the perspectives of
those affected by health disparities and combines them with empirical data on
structural health determinants, can most effectively promote social change. Such an
approach would begin filling the gap between top-down health promotion programs
and the lived experiences of marginalized individuals (Dutta et al., 2013, p. 160).
The CCA approach has been operationalized through academic and community
partnerships that identify structural barriers to health through conversations with
community members, stakeholders and other communities (Dutta et al., 2013). These
participatory conversations across levels of influence are what produce culturally
relevant strategies for overcoming structural and sociocultural barriers to health.
The methodologies presented in this dissertation speak to the work being
conducted in the CCA model. The Multilevel Survey captures perspectives on
women’s health directly from immigrant Latinas who suffer most from cervical

132
cancer disparities. The HCE measure is an attempt to capture the lived experiences
of Latinas even further by encouraging them to think about the ways in which they
obtain information in order to address specific health problems. The
contextualization of health in a way that allows respondents to describe their actual
behavior as realistically as possible can help inform strategies for encouraging
healthy behaviors. And the HCAM approach most closely aligns with a cultured-
centered model of eliminating health disparities because it invites residents and
community health workers to suggest strategies for health promotion within
neighborhood spaces. As such, this dissertation brings together three different
methodologies that are grounded in an overarching theoretical framework and all
suggest strategies for culturally-relevant outreach and intervention efforts.
Culturally-centered research, however, is not always an easy undertaking, and carries
with it several notable limitations.
Specifically, the analysis of the Multilevel Survey findings used for this
dissertation include a subset of a much larger survey sample which will encompass
two years of on-the-ground data collection. This speaks to the time investment
required to develop multilevel and neo-traditional quantitative surveys, to create an
instrument that can be used by interviewers that have experience working with the
study population and to recruit respondents under specific eligibility requirements.
Projects like the Multilevel Study are large endeavors that require multiple layers of
planning and coordination, thus lengthening the timeline for data collection
completion. While this dissertation investigated a subset of 500 cases, the arguments

133
made here can be strengthened by replicating data analysis methods in the larger
Multilevel Survey dataset of 1,800 Latinas in Los Angeles. This larger dataset will
undoubtedly uncover more generalizable findings by strengthening the significant
relationships that began to emerge in this dissertation.
A limitation of both the Multilevel Survey and the HCE measure is that
individuals are self reporting and self identifying their behaviors, thus provide
subjective perspectives on health behaviors. The Multilevel Survey is limited in that
it requires respondents to answer questions about health communication resource
connections that may not be relevant in the lived experiences of the population. The
HCE measure attempts to capture a more realistic account of health problem-solving
but is also limited to very specific health problems. The two scenarios in the HCE
measure may differ too much in that the abnormal periods scenario is a lot more
urgent and frightening, thus pushing respondents to imagine themselves going
straight to a clinic or doctor instead of learning more about the problem. Also, the
hypothetical framing of the scenarios, which was selected after pilot testing of both
hypothetical and recollection methods, may limit the elaboration of communication
ecologies if respondents have never experienced those specific problems before.
Overall, the HCE measure shows potential in identifying strategies of reaching
immigrant populations through the communication resources they activate while in a
health problem-solving mode. Again, the replication of the analyses presented in this
dissertation within the large HCE measure dataset of 200 cases will help identify

134
more generalizable communication resource connections in both health-seeking
scenarios and yield stronger findings.
The HCAM workshop, participatory fieldwork and collaborative map design
activities most closely align with the culture-centered approach to addressing health
disparities. Participatory research, however, is also a time intensive process as it
requires the recruitment and coordination of community members that are interested
in promoting health in their communities. The HCAM case study presented in this
dissertation describes the participatory process of identifying spaces where health
promotion can occur, but stops short of suggesting practical strategies for sharing
health information and influencing preventive behaviors. Thus, synergies between
the Multilevel Survey, the HCE measure and the HCAM approach need to be
developed further so that all three methodologies contribute to a cohesive
understanding of immigrant health. This cohesion can inspire more practical and
grounded strategies for promoting health in underserved communities.
This dissertation is an exploratory attempt to design a research model that
negotiates the space between culture-centered approaches and traditional health
communication research. The communication ecology conceptual and
methodological development presented in this dissertation was prompted by a
growing suspicion about the kind of information that is generally gathered about
people’s deployment of communication resources – often based on survey data that
treat each resource in isolation from the others. This suspicion derived from an
ecological orientation that suggested that communication resources are not deployed

135
in isolation from one anther, but are deployed in context of all available resources
and in context of a group’s cultural preferences and experiences. A contextual and
ecological approach to understanding and promoting immigrant health, and cervical
cancer prevention specifically, can inform health interventions because it captures
everyday intricacies that differ across cultures and geographies. These intricacies can
help us understand the ways in which immigrants solve health problems and
therefore tailor health interventions in ways that can closely parallel health-seeking
behaviors.
Another implication of an ecological approach is that we need to get at the
relative importance of communication resources, not the more absolute importance
of resources in isolation from one another. If our suspicions were correct, then public
health interventions guided by more traditional measures potentially would be
misinformed. For example, a great deal of money and effort has gone into traditional
media campaigns by way of public service announcements and entertainment
education initiatives. We know from prior research that the tantalizing appeal of
mainstream media, in its capacity to potentially reach large numbers of people, turns
out to be misleading when it comes to many different ethnic groups that connect
more strongly to geo-ethnic media than to mainstream media and to interpersonal
resources in their efforts to attain everyday goals. A contribution of this dissertation
research, thus, is to develop a better guide to health interventions efforts in their
quest to reach a variety of target populations.

136
Erwin, Trevino, Saad-Harfouche, Rodriguez, Gage, & Jandorf (2010) argue
that cultural dimensions should not be categorically relegated as a barrier to cancer
screening, but instead should be contextualized as part of the experience of being a
Latino subgroup in the United States. Erwin et al. (2010) posit that culturally
sensitive health interventions should not only customize educational messages, but
should also determine who should be the appropriate messengers and through what
venues health messages should be delivered. As such, a culturally relevant
intervention would be one that “reflects shared perspectives, beliefs, practices, life
experiences and the history of the subgroup to be addressed” (Erwin et al., 2010, p.
694).
Similarly, Kagawa-Singer, Dadia, Yu, & Surborne (2010) describe how while
sociocultural values have been linked to cancer outcomes, there is a very limited
understanding of how culture is defined and operationalized. This limited
understanding of sociocultural practices in the context of health is what produces a
deficiency in cultural competency in the clinical setting. Kagawa et al. (2010) argue
that “culture, through its worldview or construction of reality, provides a way to
make sense of life events, especially during trying times, such as when a person
develops cancer” (p. 17). In this sense, culture is considered “the multilevel,
multidimensional, dynamic, biopsychosocial, and ecological system in which a
population exists” (Kagawa et al., 2010, p. 17). This conceptualization of culture is
useful when considering why cultural practices can influence health behaviors. If
culture is a mechanism through which health is understood, particularly during a

137
health crisis, then communication practices are properties of that mechanism through
which culture is performed.
In conclusion, an investigation into the communication connections of a
specific ethnic group and in the context of a specific health goal would thus provide
a revealing perspective on how cultural practices can impact health decisions,
behaviors, and outcomes. In turn, a deeper understanding of the communication
resources that individuals rely on for health information would reveal the
communication patterns that would be most likely to improve the receptivity and
effectiveness of health interventions. For example, identifying the communication
resources that are most relevant during health information seeking can inform both
the development and the delivery of health promotion messages. Understanding the
temporal activation of such resources during a specific health scenario can suggest
strategies for the promotion of preventive health behaviors through multiple avenues.
And identifying the neighborhood-level spaces where health messages and practical
health information can be shared provides a practical guide for promoting health at
the community level. In this way, the Multilevel Survey, the Health Communication
Ecology measure and the Health Communication Asset Mapping provide a
multilevel and ecological perspective on health behavior. Thus, this dissertation
considers how discursive practices regarding health are part of the larger cultural
mechanism that influences health behavior, and how an ecological understanding of
those practices would help further contextualize immigrant health.

138
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APPENDIX: HCE Measure Data Collection Instrument
Activity #1: Hypothetical Rash
Activity #2: Hypothetical Heavy & Painful Period

1. INTRODUCTION & INSTRUCTIONS

Q1.1 AUDIO FROM INTRODUCTION VIDEO:
There are many ways to communicate and get information that helps us solve
problems and achieve goals. Sometimes we turn to media for information, such as
the television, radio, newspapers, books, magazines, or the internet.

There are also organizations we turn to such as churches, schools, libraries,
community organizations, or clinics where we might find useful information. We
may talk to people who have roles in these organizations. We also get information
from professionals such as doctors, nurses, pharmacists or natural healers.

And finally, we may turn to people we know, such as a spouse, a family member,
neighbor or co-worker. Discussions with people can include talking in person, on the
phone, chatting online, or exchanging emails.

Media, organizations, professionals and people. I have given you examples of the
different ways we get information that helps us solve problems and achieve goals.
Often, as we learn about an issue and try to achieve our goal, we navigate through
various resources. Some resources may lead us to others.

For example, a family member may recommend consulting with a community
organization, or an article we read may suggest to go online and look for more
information. Sometimes we do what they recommend, sometimes we don’t.

Remember, there is no one way to solve problems. Different resources are more
helpful than others depending on the problem you’re dealing with.

In the following activity, we will ask you about what you would to do deal with a
specific health problem. As the interviewer guides you through the activity, please
keep in mind the different ways of communicating, and how some resources may
lead you to others. We would like to learn about all of the possible resources that
would help you deal with the health problem.

INTERVIEWER INSTRUCTIONS FOR VISUAL AID COMPONENT: AFTER A
STEP HAS BEEN IDENTIFIED (IN Q2.1 FOR “STEP 1”, IN Q5.1/Q5.2/Q5.4 FOR
“STEP 2”), TYPE IN THE RESOURCE NAME AND PLACE ON THE VISUAL
MAP.

150

AFTER IDENTIFYING TWO STEPS TAKEN (NOT INCLUDING
RECOMMENDATIONS), RECAP IN SECTION Q7.1

2. IDENTIFYING RESOURCE 1
Q2.1 Imagine that you woke up one day with a rash on your forearm. It is red and
itchy and doesn’t seem to be getting better. How would you go about finding out
what the problem is and dealing with it? Here is a list of media, organizations,
professionals or people where you may turn to. Where would you go first for
information or advice about how to deal with the rash?

Media (001-010)
m the television (001) m a magazine (003) m the radio (005) m a flyer (007) m a brochure (009)
m a book (002) m a newspaper (004) m the Internet (006) m a movie (008) m other ( ) (010)

Organizations (011-020)
m a community
organization (011)
m a school (013) m a clinic (015) m a hospital (017)
m a club or interest
group (019)
m a church or religious
organization (012)
m a library (014) m a pharmacy (016) m a business (018) m other ( ) (020)

Professionals (021-028)
m a doctor (021) m a pharmacist (023) m a natural healer (025) m a promotora (027)
m a nurse (022) m a therapist (024) m a counselor (026) m other ( ) (028)

People (029-040)
m my spouse/partner
(029)
m my father (031) m my brother (033) m my son (035) m my friend (037)
m my neighbor
(039)
m my mother (030) m my sister (032)
m my daughter
(034)
m another relative
( )(036)
m my co-worker
(038)
m other ( )
(040)

3. RESOURCE 1 DETAILS

151
IF Q2.1= 001-010 (MEDIA) THEN…
Q3.1 You said you would first turn to [PIPE FROM Q2.1=RESOURCE 1] to
address the rash.
IF Q2.1=001 (TELEVISION) THEN: What is the name of the station or
program?
IF Q2.1=002 (BOOK) THEN: What is the name of this book?
IF Q2.1=003 (MAGAZINE) THEN: What is the name of this magazine?
IF Q2.1=004 (NEWSPAPER) THEN: What is the name of this newspaper?
IF Q2.1=005 (RADIO) THEN: What is the name of the station or
program?
IF Q2.1=006 (INTERNET) THEN: What is the name of the website?
IF Q2.1=007 (FLYER) THEN: Where did you get this flyer?
IF Q2.1=008 (MOVIE) THEN: What is the name of this movie?
IF Q2.1=009 (BROCHURE) THEN: Where did you get this brochure?
IF Q2.1=010 (OTHER) THEN: Can you give us more information about
this?
( ALL TEXT ENTRY RESPONSES )

Q3.2 On a scale of 1 to 10 where 1 means “not at all” and 10 means “a great
deal”…How much do you trust this media for health information or advice?
Not At All A Great Deal
1 2 3 4 5 6 7 8 9 10
…SKIP TO Q4.1
IF Q2.1=011-020 (ORGANIZATION) THEN…
Q3.3 You said you would first turn to [PIPE FROM Q2.1=RESOURCE 1] to
address the rash. What is the name of this organization?
( TEXT ENTRY )

Q3.4 Is it located in your local community?
000 No
001 Yes

Q3.5 On a scale of 1 to 10 where 1 means “not at all” and 10 means “a great
deal”…How much do you trust this organization for health information or
advice?
Not At All A
Great Deal
1 2 3 4 5 6 7 8 9 10

IF Q2.1=015 (CLINIC) THEN…OTHERWISE SKIP TO Q4.1
Q3.6 Is it the clinic you have visited today?
000 No, it is a different clinic.

152
001 Yes, it is this clinic.
…SKIP TO Q4.1
IF Q2.1=021-028 (PROFESSIONAL) THEN…
Q3.7 You said you would first turn to [PIPE FROM Q2.1=RESOURCE 1] to
address the rash. Where does this professional work? (ASK FOR NAME OF
HOSPITAL/CLINIC, ADDRESS OR INTERSECTION)
( TEXT ENTRY )

Q3.8 Are they located in your CURRENT local community?
000 No
001 Yes

Q3.9 On a scale of 1 to 10 where 1 means “not at all” and 10 means “a great
deal”…How much do you trust this professional for health information or
advice?
Not At All A
Great Deal
1 2 3 4 5 6 7 8 9 10
…SKIP TO Q4.1
IF Q2.1=029-040 (PEOPLE) THEN…
Q3.10 You said you would first turn to [PIPE FROM Q2.1=RESOURCE 1] to
address the rash. Where does this person live?
001 in my house
002 in my neighborhood
003 in another neighborhood in my city
004 in another city in my state
005 in another state in the United States.
006 in another country (specify): ( TEXT ENTRY )

Q3.11 On a scale of 1 to 10 where 1 means “not at all” and 10 means “a great
deal”…How much do you trust this person for health information or advice?
Not At All A
Great Deal
1 2 3 4 5 6 7 8 9 10
…SKIP TO Q4.1

4. RESOURCE 1 RECOMMENDATIONS

Q4.1 In addition to getting information or advice about how to deal with the
rash from [PIPED FROM Q2.1=RESOURCE 1], would you also get any
recommendations about other media, organizations, professionals or people you

153
could turn to to deal with this problem? Please select all recommendations from
the list. (SHOW LIST)

Media

Organizations

Professionals

People
q the television q a community
organization
q a doctor q my spouse/partner
q a book q a church or religious
organization
q a nurse q my mother
q a magazine q a school q a pharmacist q my father
q a newspaper q a library q a therapist q my sister
q the radio q a clinic q a natural healer q my brother
q a website q a pharmacy q a counselor q my daughter
q a flyer q a hospital q a promotora q my son
q a movie q a business q other ( ) q another relative
q a brochure q a club or interest
group
q my friend
q other ( ) q other ( ) q my co-worker
q my neighbor

q other ( )
Q4.2 If there were no recommendations, select below.
m No recommendations …SKIP TO Q5.2

IF Q4.1= (AT LEAST ONE RESPONSE IS SELECTED) THEN…
Q4.3 Recommendations that came from [PIPED TEXT FROM
Q2.1=RESOURCE 1] were [PIPED TEXT FROM
Q4.1=RECOMMENDATIONS 1]. Would you turn to any of those
recommendations to deal with the rash problem?
001 Yes, I would follow up with one of those recommendations…SKIP
TO Q5.1
002 No, I would go somewhere else to get information or deal with the
rash
…SKIP TO Q5.2
003 No, that is all I would do to deal with the rash
…SKIP TO Q5.4

154
5. IDENTIFYING RESOURCE 2
IF Q4.3=01 (YES, I WOULD FOLLOW UP…) THEN…
*this one only if they have multiple recommendations, otherwise skip right to Q6 to
ask about the ONE recommendation they mentioned

Q5.1 Which one of these recommendations would you follow up with first to
deal with the rash?
000 [CARRY FORWARD RESPONSE(S) FROM Q4.1] …SKIP
TO Q6.1
IF Q4.3=02 (NO, I WOULD GO SOMEWHERE ELSE…) THEN…
Q5.2 What else would you do to deal with the rash after [PIPED TEXT FROM
Q2.1=RESOURCE 1]? Here is the list of media, organizations, professionals or
people where you could go to for more information or advice. What would you
do next? Please select one. (SHOW LIST)

Media (001-010)
m the television (001) m a magazine (003) m the radio (005) m a flyer (007) m a brochure (009)
m a book (002) m a newspaper (004) m the Internet (006) m a movie (008) m other ( ) (010)

Organizations (011-020)
m a community
organization (011)
m a school (013) m a clinic (015) m a hospital (017)
m a club or interest
group (019)
m a church or religious
organization (012)
m a library (014) m a pharmacy (016) m a business (018) m other ( ) (020)

Professionals (021-028)
m a doctor (021) m a pharmacist (023) m a natural healer (025) m a promotora (027)
m a nurse (022) m a therapist (024) m a counselor (026) m other ( ) (028)

People (029-040)
m my spouse/partner
(029)
m my father (031) m my brother (033) m my son (035) m my friend (037)
m my neighbor
(039)

155
m my mother (030) m my sister (032)
m my daughter
(034)
m another relative
( )(036)
m my co-worker
(038)
m other ( )
(040)

Q5.3 If you would not do anything else, select below.
m I would not do anything else to deal with the rash
…SKIP TO Q11.1 (ACTIVITY 2)
IF Q4.3=03 (NO, THAT IS ALL I WOULD DO…) THEN…
Q5.4 If the rash didn’t go away, is there something you would do about it at a
later time? Here is the list of media, organizations, professionals or people
where you could go to for more information or advice. . What else would you do
if the problem didn’t go away? (SHOW LIST)

Media (001-010)
m the television (001) m a magazine (003) m the radio (005) m a flyer (007) m a brochure (009)
m a book (002) m a newspaper (004) m the Internet (006) m a movie (008) m other ( ) (010)

Organizations (011-020)
m a community
organization (011)
m a school (013) m a clinic (015) m a hospital (017)
m a club or interest
group (019)
m a church or religious
organization (012)
m a library (014) m a pharmacy (016) m a business (018) m other ( ) (020)

Professionals (021-028)
m a doctor (021) m a pharmacist (023) m a natural healer (025) m a promotora (027)
m a nurse (022) m a therapist (024) m a counselor (026) m other ( ) (028)

People (029-040)
m my spouse/partner
(029)
m my father (031) m my brother (033) m my son (035) m my friend (037)
m my neighbor
(039)
m my mother (030) m my sister (032)
m my daughter
(034)
m another relative
( )(036)
m my co-worker
(038)
m other ( )
(040)

Q5.5 If you would not do anything else, select below.

156
m I would not do anything else to deal with the rash
…SKIP TO Q11.1 (ACTIVITY 2)

6. RESOURCE 2 DETAILS

NOTE: AFTER “RESOURCE 2” HAS BEEN IDENTIFIED IN Q5.1~Q5.5,
QUESTIONS Q3.1~Q3.11 WILL BE REPEATED TO IDENTIFY MORE
DETAILED INFORMATION ABOUT “RESOURCE 2”.

7. RECAP: RESOURCE 1 & 2

Q7.1 Let’s recap your story. INTERVIEWER USE MAP TO POINT TO
EACH STEP AND RECAP:

“The first thing I would do to deal with the rash is [PIPED FROM
Q2.1=RESOURCE 1]. Next, I would turn to [PIPED FROM
Q5.1/Q5.2/Q5.4=RESOURCE 2] to get more information or advice about the rash.”

8. RESOURCE 2 RECOMMENDATIONS

Q8.1 Let's continue with your story. What recommendations would you get
from [PIPED FROM Q5.1 OR Q5.2 OR Q5.4 = RESOURCE 2] about other
media, organizations, professionals or people you could go to for more
information or advice about the rash? Please select all recommendations from
the list. (SHOW LIST)

Media

Organizations

Professionals

People
q the television q a community
organization
q a doctor q my father
q a book q a church or religious
organization
q a nurse q my sister
q a magazine q a school q a pharmacist q my brother
q a newspaper q a library q a therapist q my daughter
q the radio q a clinic q a natural healer q my son
q a website q a pharmacy q a counselor q another relative ( )
q a flyer q a hospital q a promotora q my friend

157
q a movie q a business q other ( ) q my co-worker
q a brochure q a club or interest
group
q a neighbor
q other ( ) q other ( ) q other ( )

Q8.2 If there were no recommendations, select below.
m No recommendations …SKIP TO Q9.2

IF Q8.1= (AT LEAST ONE RESPONSE IS SELECTED) THEN…
Q8.2 Recommendations that came from [PIPED TEXT FROM Q5.1 OR Q5.2
OR Q5.4=RESOURCE 2] were [PIPED TEXT FROM
Q8.1=RECOMMENDATIONS 2]. Would you follow up with any of those
recommendations to deal with the rash problem?
001 Yes, I would follow up with one of those recommendations.
…SKIP TO Q9.1
002 No, I would go somewhere else to get information or deal with the
rash
…SKIP TO Q9.2
003 No, that is all I would do to deal with the rash problem.
…SKIP TO Q9.4

9. IDENTIFYING RESOURCE 3

NOTE: AFTER “RESOURCE 2 RECOMMENDATIONS” HAVE BEEN
IDENTIFIED IN Q7.1~Q7.2, QUESTIONS Q5.1~Q5.5 WILL BE REPEATED TO
IDENTIFY THE NEXT STEP, WHICH WILL BECOME “RESOURCE 3”.

THE CYCLE
“IDENTIFYING RESOURCE”
>“DETAILS ABOUT THE RESOURCE”
>“RECOMMENDATION FROM RESOURCE”
>“IDENTIFYING NEXT RESOURCE”
.
.
.
.
CONTINUES UNTIL ALL RESOURCES HAVE BEEN IDENTIFIED BY
PARTICIPANT.
11. SECOND ACTIVITY

158
Imagine that your last few periods have been heavier and more painful than
usual. How would you go about finding out what the problem is and dealing
with it?
[SURVEY FORMAT REPEATS]

12. CLOSING SCRIPT

Thank you for your participation. Your story will help us understand the
resources that women turn to when dealing with health problems.

Abstract (if available)

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Asset Metadata

Creator Gonzalez, Carmen (author)

Core Title Immigrant health in context: a communication ecology approach to understanding health behavior

School Annenberg School for Communication

Degree Doctor of Philosophy

Degree Program Communication / Jewish Communal Service

Publication Date 10/14/2015

Defense Date 09/10/2013

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag communication ecology,health communication,immigrant health,OAI-PMH Harvest

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Ball-Rokeach, Sandra J. (committee chair), Baezconde-Garbanati, Lourdes (committee member), Bar, François (committee member)

Creator Email cagonzal@gmail.com,cagonzal@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c3-338599

Unique identifier UC11296503

Identifier etd-GonzalezCa-2102.pdf (filename),usctheses-c3-338599 (legacy record id)

Legacy Identifier etd-GonzalezCa-2102.pdf

Dmrecord 338599

Document Type Dissertation

Format application/pdf (imt)

Rights Gonzalez, Carmen

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA