Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Thursday, December 13, 2007

Failure to Bridge the Health Gap Due to Neglect of Social Factors– Stephanie Chau

The United States takes great pride in being a nation well known for equality, opportunity, and diversity. According to the U.S. Census Bureau, one-third of the national population is comprised of minorities, which include African Americans, Hispanics, Asians, American Indians/Alaskan Natives, Native Hawaiians/Pacific Islanders, and individuals of multiracial origins (1). However, these minorities experience significant disparities in health, including healthcare access and quality, when compared to White, non-Hispanic Americans (2). For example, out of 22 core measures for quality of care, African Americans received poorer quality of care for 16 or 73% of the measures (2). Also, the death rates from HIV/AIDS and homicide were more than 200% higher for the Hispanic population when compared to non-Hispanic Whites (3). There have been significant improvements regarding quality and access to care for certain groups, including Asians/Pacific Islander and American Indians/Alaska Natives (2). However, disparities are still prevalent and worsening for other minorities, particularly for Hispanics, who are experiencing an increased rate of pediatric asthma hospitalizations and worse measures of access to care (2). The issue of healthcare disparities by race is a major public health issue, and Healthy People 2010 has identified the elimination of health disparities as an overarching goal (4).
In order to address the pressing concerns regarding health disparities, government health officials have developed various programs and interventions. An example is “Closing the Health Gap,” an educational campaign that aims to improve the health of racial and ethnic minority populations. Developed by the Office of Minority Health in the U.S. Department of Health and Human Services, this national program contains three key elements: Celebra La Vida Con Salud (Celebrate a Healthy Life), Take a Loved One for a Checkup Day, and Know What to Do for Life. The campaign utilizes public media outlets, community health fairs, and local partnerships to inform minority communities about healthier lifestyles and encourage greater healthcare access (3). However, “Closing the Health Gap” is an ineffective public health approach because it is overly centered on the individual and disregards the important social factors comprising Social Cognitive Theory, Social Marketing Theory, and Framing Theory.
Barriers in the Environment and Social Cognitive Theory
One of the primary reasons that make “Closing the Health Gap” an ineffective program is its reliance on incorrect assumptions regarding access to healthcare services and community support. These assumptions neglect geographic and economic barriers that disproportionately affect minority populations. At least 50% of African Americans, Hispanics, and Native Americans/Alaskan Natives have incomes less than 200% of the poverty level, compared to only 12% of Whites (5). A number of research studies have demonstrated a strong link between socioeconomic status and health status (6-9). Therefore, racial and ethnic minorities are more likely to be impoverished and experience decreased access and quality to healthcare services.
The social environment is an important factor in health disparities because it has a strong influence upon health behavior. Social Cognitive Theory uses modeling and self-efficacy to describe the interactions between social factors and health. In the modeling process, the behavior of certain prominent individuals serves as a guide for others to imitate (10, 11). Modeling is closely linked to mass communication, which uses visual and auditory media to publicize certain portrayals of behavior that observing audiences may try to adopt (10). Therefore, exposure to modeling in media portrayals, especially films and television, is an important part of the modeling process. Self-efficacy is another key to change because it involves a person’s confidence that they can do a behavior while overcoming various obstacles (11). The infrastructure and social support present in a community are critical in determining a person’s self-efficacy and the likelihood of modeling. Besides exposure to appealing models, successful modeling requires the ability to actually reproduce the behavior portrayed by the model as well as positive reinforcement (10). However, in communities that lack the appropriate healthcare infrastructure to serve the needs of minority groups, self-efficacy is reduced because community members may not believe that the behavior will result in the desired outcome. Without the belief in successful imitation and the necessary resources to reproduce positive health behaviors, modeling cannot occur. For instance, in areas characterized by racial residential segregation, differences in purchasing power and economic deprivation have impeded positive modeling and healthy behaviors (9).
Celebra Con La Vida Salud attempts to promote preventative health measures and address health concerns specific to the Hispanic minority population. Its central feature involves a 12-city tour of health festivals in areas densely populated with Latinos that provide free health screenings for cholesterol, HIV, and diabetes (3). The cities on the tour include communities in southern California, Texas, and Florida, but completely neglects other cities with significant Hispanic populations, including Philadelphia and Las Vegas (3). The campaign does not attempt to address this geographic barrier with alternative provisions to these other areas. Recognition of the media’s importance in modeling could offset the failure to attend to geographic difficulties. However, Celebra Con La Vida Salud, as well as other parts of “Closing the Health Gap,” completely ignores collaboration with major media outlets, such as Hispanic telenovelas, that specifically target minority groups. Therefore, the campaign leaves opportunities to facilitate modeling unrealized since mass communication is not effectively employed.
Take a Loved One for a Checkup Day encourages individuals to visit a health care provider regularly and participate in health screenings. It focuses its efforts on a single day of the year and broadcasts health messages and tips on public radio. The campaign assumes that individuals will have the opportunity and resources to seek health services. However, the day that the campaign selected was Tuesday, September 18, 2007 (3). Most people work on weekdays, and their jobs may not include benefits such as vacation or time off to allow them to see a doctor. The main message is to get a check-up, but there is little information or resources to assist individuals about where or how they may be able to accomplish that action. Therefore, in minority communities where convenient points of healthcare access are unavailable, many individuals lack the self-efficacy and ability to see a physician. The “Closing the Health Gap” campaign does not take into account situations and circumstances in which the needed resources are unavailable. As a result, it is difficult for either modeling or self-efficacy to occur.
Cultural Values and Social Marketing Theory
Aside from its connection to modeling, mass communications is significant for its deep impact on social institutions and culture (10). As a consequence, successful health reforms require careful planning and formative research in order to employ appropriate communication channels and themes (12, 13). Social Marketing Theory recognizes the importance of the specific needs and desires of the target audience. Public health officials must identify the wants of the particular group and proceed to present the information and health services in a salient way. A proven example of Social Marketing is the success of the Florida Pilot Program on Tobacco Control, which utilized targeted youth marketing of the “truth” campaign to decrease youth tobacco use (14, 15). In contrast, “Closing the Health Gap” fails to adequately address specific concerns and appeal to cultural values of ethnic and racial minorities.
The first step in Social Marketing Theory is to understand the social environment and identify social norms, which are the conventional beliefs and codes of behavior for a group or culture (11). Shared racial perceptions may influence health behaviors such as blood pressure control and medication adherence (16). By encouraging families to attend health fairs together, Celebra La Vida Con Salud recognizes the Hispanic population’s strong family values. However, it fails to address other important values, particularly religion and spiritual beliefs in traditional folk healing, which appear to have significant roles in the healthcare for Latino groups (17, 18). These beliefs may also affect their behavior in seeing a doctor for a checkup, which is the focus of Take a Loved One for a Checkup Day. Instead of simply promoting regular health screenings, Marketing Theory would emphasize cultural values and increase cultural competency for providers so that patients would feel more inclined to access regular healthcare.
In addition to social norms, Social Marketing involves four main principles that address issues about product, price, place, and promotion (13). Although “Closing the Health Gap” uses radio messages, the Internet, and celebrities like Grammy nominee Nicole Mullen (3), it does not promote modeling or use effective communication. It fails to utilize pertinent media outlets such as Black Entertainment Television (BET). Nor does it take into account the price and place of the health behaviors it endorses. For Take a Loved One for a Checkup Day, it does not adequately consider the costs or necessary steps involved with seeking health services. Again, resource availability in underserved areas may also be an issue that the campaign fails to address. For example, Know What to Do for Life, the third part of “Closing the Health Gap,” is an educational campaign that aims to reduce infant mortality among African Americans because rates are nearly 2.5 times higher than for Whites (3). However, the program fails to recognize the social conditions that have a strong influence on individual health behaviors. The campaign urges African American pregnant women to pursue prenatal care, but issues of access and availability may prevent this health behavior despite the efforts and knowledge of the mother herself.
Framing Theory Requires More Than Education for the Individual
Although individual behavior influences health outcomes, studies have shown that individual behaviors are only one factor, and that social and physical factors may even have a larger role (6-9). Various aspects of the socio-physical environment may have strong effects on the correlation between low socioeconomic status and mortality that are unrelated to individual behaviors (7). Therefore, this evidence indicates that public health approaches must consider aspects of the social environment rather than only focusing on individual-level factors. Reliance on individual-level approaches such as the Health Belief Model has limited the scope of health interventions (19). Instead, Framing Theory provides alternative paradigms that encompass environmental factors and suggests different sociological strategies to effect change.
Framing Theory analyzes the relationship between beliefs and the production of meaning by media frames within economics, politics, and social movements (20). It suggests that the portrayal of a public health problem in the media strongly affects beliefs and behavior. The focus of frames can be either on the proximal factor (usually the individual affected by consequences of the central problem or behavior) or the more distal entity (usually a social institution related to the cause of the problem). Focusing on the individual is a downstream frame, while the latter is an upstream frame because it attempts to direct attention toward likely fundamental causes. “Closing the Health Gap” utilizes media messages primarily targeted at educating individuals. As a result, it develops a downstream frame that places a lot of responsibility on the individual and fails to account for social influences such as misconceptions and discrimination. The goals of the campaign are to increase awareness through publicity, free health fairs, and education. However, as noted before, individual behaviors and intentions are only a few components that determine actual health outcomes and affect disparities in health. To address the substantial social barriers that often confront underserved minority populations afflicted with health disparities, framing theory demands a shift toward an upstream frame that recognizes the role of socio-physical conditions on health behavior.
An upstream approach requires different strategies to effect change. The three major categories of sociological change strategies include rational-empirical, which emphasizes knowledge and education; normative-re-educative, which utilizes counseling and social norms; and power-coercive, strategies that involve policies and institutional change (21). “Closing the Health Gap” falls under the first category and heavily relies on mass communications and diffusion of ideas and innovations. However, these alone are insufficient. A multilevel approach that incorporates the normative-re-educative and power-coercive strategies would be most effective by implementing change on the community level, in addition to increasing awareness on the individual level.
“Closing the Health Gap” and other similar public health campaigns have paid little attention to the contextual background for health behavior and outcomes. This context includes aspects of cultural, economic, and sociopolitical conditions (22). In order to maximize the effectiveness of health programs, public health must develop more broadly based interventions, which are better alternatives to individual-level solutions that focus on intermediate, or proximal, causes (23). Therefore, the successful application of social and behavioral principles to a campaign such as “Closing the Health Gap,” entails multidisciplinary efforts within an upstream perspective. These efforts would complement education-focused strategies by identifying social and cultural norms and barriers. When additional strategies that involve persuasive counseling and institutional change address these norms and obstacles, there will be a subsequent effect on self-efficacy and individual behaviors.
Increasing the utilization of social and behavioral sciences in public health would have important implications for future health interventions. The effective use of formative research to identify core values and target social norms is essential in developing a successful public health campaign (12, 14). As society continues to become increasingly more technological, mass communications through various public media will become more important. Since the necessary resources involved in mass communications remain expensive and involve competition with private corporations and industries, the importance of formative research will only increase. At the same time, increased awareness and individually-based strategies have proven insufficient since they comprise only one part of the bigger picture surrounding health outcomes and disparities. Therefore, campaigns must employ ecological approaches that account for interactions between individuals and the social factors of the surrounding environment.
The inadequacy of “Closing the Health Gap” as an effective public health intervention illustrates the importance of applying social and behavioral theories to public health. By neglecting socio-physical barriers and failing to consider significant cultural norms that influence the behaviors and health outcomes of minorities, “Closing the Health Gap” reduces its effectiveness. Also, its downstream frame burdens individuals with the major responsibility of preventing health conditions such as preterm birth and diabetes that disproportionately affect these minority populations. However, studies have proven that health disparities endure independent of individual level factors. Therefore, both the failures of past individual-level interventions and the successes of the few campaigns based on formative research and social factors warrant the use of social theories such as Social Cognitive Theory, Social Marketing, and Framing Theory to improve the elements of “Closing the Health Gap” and help shape future public health interventions.
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