- Top of page
An area of study that has attracted the attention of health communication scholars for the past several years is health disparities. Health disparities are differences in health outcomes between socially disadvantaged and advantaged groups. This special issue of the Journal of Communication is focused on communication strategies to reduce health disparities. It features 10 articles that report original empirical studies or literature reviews of health disparities-related research. Communication scholars working in this area have a distinct opportunity to conduct theory-driven applied research with the potential to promote the health and wellbeing of the most vulnerable among us.
Health communication scholarship is characterized by its focus on theory-driven applied research, what has been described by Stokes (1997) as “Pasteur's Quadrant” (see also Kreps, Frey, & O'Hair, 1991). Such research not only advances our understanding of communication theory but also has the potential, in the short or long run, to improve health and wellbeing.
An area of study that has been attracting the attention of health communication scholars for the past several years, and one that offers clear opportunity for theory-driven applied research, is health disparities. Braveman (2006) offers a comprehensive definition of the term health disparities:
A health disparity/inequality is a particular type of difference in health or in the most important influences on health that could potentially be shaped by policies; it is a difference in which disadvantaged social groups (such as the poor, racial/ethnic minorities, women, or other groups that have persistently experienced social disadvantage or discrimination) systematically experience worse health or greater health risks than more advantaged groups. (p. 180)
A more concise definition comes from the U.S. Centers for Disease Control and Prevention (CDC, 2011): “Health disparities are differences in health outcomes between groups that reflect social inequalities” (p. 1). Implicit in both of these definitions is the idea that health disparities are unnecessary and avoidable and, therefore, unjust and unfair (Whitehead, 1992). It is no wonder, then, that health communication researchers are interested in directing their efforts toward problems of health disparities.
Health disparities can be categorized according to differences in the incidence and prevalence of morbidity (e.g., HIV and diabetes) and mortality (e.g., infant deaths and heart disease-related deaths), as well as behavioral risk factors (e.g., cigarette smoking and adolescent pregnancy); access to healthcare and preventive services (e.g., health insurance and vaccination); and exposure to environmental hazards (e.g., housing and air quality; CDC, 2011). Instances of these disparities are evident throughout the world. For example, analyzing data from the Whitehall II cohort (Marmot et al., 1991), Steptoe et al. (2010) found that severity of coronary artery calcification was inversely related to grade of employment among men and women in London, England. Considering data from the 2004 and 2008 National Health Interview Surveys in the United States, Moonesinghe, Zhu, and Truman (2011) discovered significant differences in rates of uninsurance across all demographic and socioeconomic groups considered. In particular, the poor and near-poor were less likely to have insurance than the nonpoor, and Hispanics and non-Hispanic Blacks were less likely to have insurance than Asians/Pacific Islanders and non-Hispanic Whites. Using data from Chinese national surveillance systems, Carlton et al. (2012) uncovered substantial disparities in access to improved drinking water and sanitation across provinces, from a high in Shanghai of 99% to a low in Tibet of 23%. The authors estimated that in 2008, exposure to unsafe water and poor sanitation was responsible for 62,800 deaths and 2.81 million disability-adjusted life years,1 with most of the burden falling on young children.
The body of literature documenting health disparities around the world is voluminous, and there is an obvious moral obligation to work toward eradicating such disparities. Indeed, since early efforts at documenting the existence and nature of health disparities with the Black Report (Black, 1980) in the United Kingdom, many nations have taken steps to identify and reduce health disparities. Casas-Zamora and Ibrahim (2004) detail such efforts in the United States, the United Kingdom, Canada, Australia, New Zealand, and countries across Europe, Latin America, Africa, and Asia. For example, in the United States, the Institute of Medicine issued its landmark 2002 report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, which documented the extent of U.S. health disparities and the factors that contributed to them and recommended strategies to reduce them (IOM, 2002). In the United Kingdom, the “Independent Inquiry into Inequalities in Health” investigated health disparities related to socioeconomic status, ethnic status, and sex and made recommendations to address the social determinants of health implicated in the disparities (Acheson, 1998). Member states of the World Health Organization's European Region adopted the “Health for All” policy (Health21; World Health Organization, 1998) at the 51st World Health Assembly in May 1998. This policy provides guidance to countries on how to develop national health policies and adopt strategies to reduce health disparities within and across their borders.
The extent to which all of these efforts are actually reducing health disparities is an important question. Koh et al. (2010) reviewed several programs across local, national, and global levels that have been enacted to reduce health disparities and found considerable evidence of positive impact. Examples include reductions in cardiovascular disease and cancer in disadvantaged groups in England and reductions in maternal and child deaths in Ecuador. Buckner-Brown et al. (2011) reviewed a sample of CDC's Racial and Ethnic Approaches to Community Health programs (CDC, 2012) and identified an array of promising programs designed to address a host of disparities, including asthma, cancer, diabetes, and hepatitis. The authors emphasized the importance of partnerships with governments, businesses, and organizations to help disseminate research-based interventions.
Communication scholars have a clear role to play in many of the efforts to reduce health disparities. Freimuth and Quinn (2004) discussed how health communication researchers have expertise in mass media campaigns, entertainment-education programs, media advocacy efforts, new technology initiatives, and interpersonal level interventions such as patient-provider communication training, all of which can be brought to bear on the development, testing, and implementation of strategies to reduce disparities. Although there is the possibility that attempts to reduce disparities may actually exacerbate them if interventions are not disseminated and implemented equitably (Koh et al., 2010; Viswanath & Kreuter, 2007), as Perloff (2006) observed, bridging the literatures in health communication and health disparities promises to offer “new ideas, syntheses, and applications that may improve the quality of health care” (p. 757).
Indeed, the opportunity for health communication to contribute to disparities research is recognized now more than ever. Both the 2012 International Communication Association and the 2012 Kentucky Conference on Health Communication sponsored preconference events on the topic of communication strategies to reduce health disparities. Those two preconferences served as the genesis for this special issue of the Journal of Communication. In addition to articles by some of the researchers who participated in the preconferences, this issue also contains articles by other researchers in our field who address health disparities in their work. The peer-reviewed research in this issue represents a variety of perspectives and approaches to using communication strategies to reduce health disparities, including individual, patient-provider, and community-level interventions. We have reports of original empirical studies featuring multiple methods and theoretical perspectives and review pieces that provide incisive analyses of the literature. Although this special issue covers substantial ground, it should go without saying that the work presented here represents only a sample of the excellent scholarship being conducted by outstanding and committed researchers in our field who are studying communication strategies to reduce health disparities.
Our special issue begins with an article by Jeff Niederdeppe and colleagues, who provide a review of how health disparities are covered by the media. These authors note that while several communication researchers have investigated how interventions can reduce health disparities, comparatively few have considered how the mass media report on health disparities. Such reporting may have an impact on public perception and policy; thus, it is important to understand the way the media cover health disparities issues. After summarizing the current state of the literature, the authors suggest priorities for future research on how media shape public perceptions of health disparities and support for programs and policies to reduce them.
Next, Kenzie Cameron provides an introduction to and overview of health disparities intervention research. She chronicles the rise of this research in the United States and then profiles communication approaches to reduce health disparities in clinical preventive services by giving brief reports on four ongoing programs of research out of Northwestern University. Northwestern is one of only three institutions in the United States to receive funding from the Agency for Healthcare Research and Quality as a “Center of Excellence in Clinical Preventive Services.” The projects conducted by its researchers represent well the quality and diversity of interventions being developed to reduce health disparities.
In the following article, Rajiv Rimal and colleagues share some of the latest findings from their ongoing research in Malawi to reduce the spread of HIV. In particular, they explore the moderating effect of interpersonal communication on the impact of the Malawi BRIDGE Project. They argue that understanding such moderating effects is crucial in reducing health disparities in disadvantaged groups because members of these groups may be more likely to obtain health information through interpersonal sources than mediated sources. Campaign developers need to be aware of this potential and plan their efforts accordingly.
The next three articles all focus on aspects of human papillomavirus (HPV) vaccination and cervical cancer prevention. Cervical cancer is the third most common cancer and the most common cause of cancer deaths among women worldwide (Ferlay et al., 2010; World Health Organization, 2012). Because HPV infection has been determined to play a causal role in the development of cervical cancer, with HPV “present in virtually all cervical cancer cases worldwide” (Bosch, Lorincz, Muñoz, Meijer, & Shah, 2002), vaccination against HPV represents a highly effective strategy for prevention of cervical cancer. Encouraging women to engage in cervical cancer screening and HPV vaccination, therefore, is a crucial task for health communication researchers. Elisia Cohen and colleagues consider the role of lay patient navigators in helping disadvantaged women obtain follow-up care after receiving abnormal cervical cancer screening (Pap test) results. Their target population is women living in Appalachian Kentucky, an area of the United States particularly hard hit with health disparities. After identifying barriers to patient follow-up care through survey research, these authors use in-depth interviews to explore lay patient navigator strategies to overcome barriers to care. They consider how patient navigation may be usefully considered as assisted uncertainty management and offer ideas for improving patient navigation training.
Robin Vanderpool and colleagues report the results of a randomized controlled trial that tested the effectiveness of a DVD-based intervention designed to increase adherence to the HPV vaccination series among young women in Appalachian Kentucky. These researchers used formative research and a model of intervention development to guide the design of the DVD, which had content on relevant health information, personal motivation and normative cues, and skills training to increase efficacy. Their work provides an excellent example of research that is both theoretically driven and translatable to community practice settings.
Another example of theory-based translatable work comes from Sheila Murphy and her colleagues, who report on a DVD-based intervention designed to test the effects of narrative versus nonnarrative messages on knowledge, attitudes, and behavioral intentions related to Pap testing among women of different ethnicities in Los Angeles, California. The researchers also explore the theoretical mechanisms responsible for the effects of narrative. They argue that understanding how narrative operates to influence outcome variables is critical if we are to move beyond standard didactic messaging so prevalent in clinical settings.
Kathryn Greene and colleagues share some of their newest work on self-disclosure and social support for African Americans with HIV. They argue that disclosing a positive diagnosis is the first step in accessing much needed social support, which, in turn, can enhance health and potentially reduce disparities. These authors have developed a brief disclosure intervention designed to help persons with HIV make disclosure decisions. The article reports the results of an initial study to test the impact of the intervention on disclosure self-efficacy, anxiety, and worry, and it also presents a qualitative analysis to explore strategies to tailor the intervention to African Americans.
The next article comes from Mohan Dutta and colleagues, who share their ongoing research on strategies to reduce food insecurity among disadvantaged populations in India and the United States with their “Voices of Hunger” projects. For persons who struggle with food insecurity, not experiencing hunger constitutes part of the definition of what it means to be healthy. Using a culture-centered approach, these researchers conducted participatory ethnographies with several members of food insecure communities in West Bengal, India, and Indiana in the United States to explore and develop solutions to the problem of food insecurity.
Another example of community-focused research comes from Holley Wilkin, who presents a review of research using communication infrastructure theory as it relates to the reduction of health disparities. Disparities experienced by different groups of disadvantaged individuals can be exacerbated by geographic- or community-level factors. Communication infrastructure theory is a potentially valuable perspective that acknowledges these factors and offers a theoretically grounded approach for developing interventions to have an impact at the community level. The author discusses the opportunities for expanding this line of research beyond neighborhood storytelling networks to include elements of the broader communication ecology.
Finally, our issue concludes with a study from Rebekah Nagler and colleagues, who share their experiences from the “Click to Connect” project, a study designed to improve Internet use and health literacy in an underserved population. The authors describe the strategies they used to recruit and retain their study population, the cost implications of the recruitment and retention strategies, and the challenges and successes they experienced over the course of the study. Although research with underserved populations can be resource intensive, the authors argue that such investment is necessary if we are to successfully conduct our intervention studies and ultimately reduce health disparities.
Together, the 10 articles in this special issue represent the diversity found in health communication research to reduce health disparities. They reflect how our knowledge of health disparities is enriched through multiple theoretical perspectives, methodological approaches, and interdisciplinary collaborations. And they show promise for the kind of impact we can have on reducing the burden of disease and promoting the health and wellbeing of the most vulnerable among us. I hope that these articles serve as motivating examples of the kind of theory-based applied research that is possible in health communication.