Maria K. Venetis
The degree to which patients are active and communicative in interactions with medical providers has changed in recent decades. The biomedical model, a model that minimizes patient agency in the medical interaction, is being replaced with a model of patient-centered care, an approach that prioritizes the individual patient in their healthcare and treatment decisions. Tenets of patient-centered care support that patients must be understood within their psychosocial and cultural preferences, should have the freedom to ask questions, and are encouraged to disclose health-relevant information. In short, this model promotes patient involvement in medical conversations and treatment decision-making. Research continues to examine approaches to effective patient-centered communication. Two interpersonal processes that promote patient-centered communication are patient question-asking and patient disclosure. Patient question-asking and disclosure serve to inform medical providers of patient preferences, hesitations, and information needs. Individuals, including patients, make decisions to pursue or disclose information. Patients are mindful that the act of asking questions or disclosing information, particularly stigmatized information such as sexual behavior or drug use, could make them vulnerable to perceived negative provider evaluations or responses. Thus, decisions to ask questions or share information, processes essential to the understanding of patient perspectives and concerns, may be challenging for patients. Various theoretical models explain how individuals consider if they will perform actions such as seeking or disclosing information. Research also explains the barriers that patients experience in asking questions or disclosing relevant health information to providers. A review of pertinent research offers suggestions to aid in facilitating improved patient-centered communication and care.
Central to many definitions of the term “cultural imperialism” is the idea of the culture of one powerful civilization, country, or institution having great unreciprocated influence on that of another, less powerful, entity to a degree that one may speak of a measure of cultural “domination.” Cultural imperialism has sometimes been described as a theory, especially where scholars build a case that the cultural influence of the stronger entity has had a pervasive, pernicious impact on the weaker.
The term evolved from 1960s neo-Marxist discourses within cultural, media, and postcolonial studies that contextualized the post–World War II “independence” wave of new nations emerging from colonial servitude. It was propelled by the writings of nationalist revolutionaries, revolutionary theorists, and their sympathizers of the 1950s and 1960s, but it has sweeping relevance across human history. The foremost western theorist of cultural imperialism in the West was Herbert Schiller. The concept was adopted and endorsed in the 1970s by both UNESCO and the Non-Aligned Movement.
Following Oliver Boyd-Barrett, the concept may denote a field of study embracing all relationships between phenomena defined as “cultural” and as “imperialism.” These encompass cultural changes that are (1) enforced on a weaker entity and (2) occur within both stronger and weaker entities through contact, contest, and resistance, including (3) assimilation of social practices encountered by the stronger in the weaker entity, and (4) original hybrids manifesting cultural traces of both stronger and weaker entities.
The concepts of cultural and media imperialism were much critiqued during the 1980s and 1990s, and many scholars preferred alternative concepts such as globalization and cultural globalization to analyze issues of intercultural contact, whether asymmetrical or otherwise. John Tomlinson critiqued the concept, identified four different discourses of cultural imperialism, and argued in favor of its substitution with the term “globalization.” Mirrlees has placed Tomlinson’s work in context by describing the dialectical—parallel but mutually aware—development of both a cultural imperialism and a cultural globalization paradigm. Both are influential in the 21st century.
“Imperialism” commonly references relations of conquest, dominance, and hegemony between civilizations, nations, and communities. “Cultural imperialism” relates primarily to the cultural manifestations of such relations. Culture and empire relate in many different ways, fueling different theories that often play on dichotomous discourses, including territorial/non-territorial, totalistic/partial, benign/malign, ephemeral/perpetual, superficial/essential, voluntary/involuntary, intended/unintended, welcome/unwelcome, forceful/peaceful, noticed/unnoticed, linear/interactive, homogeneous/heterogeneous, and acceded/resisted.
The concept has affinities with hegemony, the idea that stability in conditions of social inequality is achieved not mainly by force but by securing the consent of the masses (starting with co-option of their indigenous leaders)—through persuasion and propaganda—to the elite’s view of the world. This process is commensurate with forms of democracy that provide the appearance but not the reality of choice and control. Fissures within the ranks of the elites and within the masses create spaces for resistance and change.
Culture encompasses the totality of social practices of a given community. Social practices are manifest within social institutions such as family, education, healthcare, worship, labor, recreation, language, communication, and decision-making, as well as their corresponding domains. Any of these can undergo change following a society’s encounter with exogenous influences—most dramatically so when stronger powers impose changes through top-down strategies of command and influence.
Analysis of cultural imperialism often incorporates notions of media imperialism with reference to (1) print, electronic, and digital media—their industrialization, production, distribution, content, and capital accumulation; (2) cultural meanings that media evoke among receivers and audience cultures; (3) audience and media interactions in representations of topics, people, and ideas; and (4) relationships between media corporations and other centers of power in the reproduction and shaping of social systems.
Media are logically subsumed as important components of cultural imperialism. Yet the significance of media can be understated. The concept of mediatization denotes that “knowledge” of social practices draws heavily on media representations. Social practices that are experienced as direct may themselves be formed through exposure to media representations or performed for media.
Discourses of cultural imperialism speak to major current controversies, including: cultural suppression and genocide; ideas of “globalization”; influential economic models of “capitalism” and “neoliberalism”; ideologies that are embedded in the global spread of concepts such as “modern,” “progressive,” “growth,” “development,” “consumerism,” “free market,” “freedom,” “democracy,” “social Darwinism” and “soft power”; cultural specificity of criteria and procedures for establishing “truth”; instrumentalization for the purposes of cultural conquest of academic disciplines such as psychoanalysis, economics, social anthropology, or marketing, or environmental crises, especially as linked to western ideologies that underwrite humanity’s “right” to dominate nature.
For most of the 20th century, telecommunications was a matter of national governance and thus of peripheral interest to the European Union. Then from the mid- to late-1980s, the EU began to develop an intensified policy package for the telecommunications sector. Telecommunications has now grown to become one of the most prominent and extensive policy areas addressed by the EU. But what accounts for such a remarkable Europeanization of telecommunications governance? In polar contrast to its origins, telecommunications has become a key focus in neoliberal economics and policy in effecting sectoral change. This development went hand in hand with arguments around propounding the benefits of economic globalization, which sustained a move to internationalize the organization of telecommunications to the European level along neoliberal lines. However, notwithstanding the remarkable growth of the EU governance framework for telecommunications, there are nuances in the analysis of the constant resistance to the wholesale Europeanization of telecommunications policy that provide evidence of a residual tension between national- and EU-level interests. This tension has been evident in policy proposals, decision-making, and implementation at key junctures for more since the late 1980s The policy has played key roles at different times, in particular, on the national level, involving governmental, regulatory, and commercial actors. Telecommunications thus provides a classic illustration of the balance that needs to be struck in the development of communications policies in the EU between supranational and intergovernmental interests. Now part of a converging electronic communications sector, this feature of telecommunications governance is as prominent today as it was in the very early days of EU telecommunications policy development in the mid- to late-1980s.
Patrick J. Ewell and Rosanna E. Guadagno
According to Nisbett and Ross, “Information may be described as vivid, that is, as likely to attract and hold our attention and excite the imagination to the extent that it is (a) emotionally interesting, (b) concrete and imagery-provoking, and (c) proximate in a sensory, temporal, or spatial way.” Despite a widespread belief held by scholars and practitioners alike that vividness enhances persuasion, most early studies on this topic found weak or nonexistent vividness effects. To further understand this relationship, subsequent research focused on explaining these inconsistent findings. Taylor and Thompson explored the different ways that vividness has been operationalized across studies. Guadagno, Okdie, Sagarin, DeCoster, and Rhoads elucidated the conditions under which vividness enhances or detracts from persuasion. Generally, the extant literature suggests that vividness is an effective means of enhancing persuasion when the main point of a communication is the sole component made vivid. These findings caution against attempts to persuade by increasing overall message vividness, because off-thesis or incongruent vividness has the unintended and undercutting consequence of distracting influence targets from the point of the communication. This conclusion is based on the results of individual empirical studies as well as meta-analytic findings. Literature on shock advertising as a specialized case of vividness also exists. Future research on vividness might further delineate when, how, and why vividness sometimes enhances and sometimes detracts from persuasion.
Joel Iverson, Tomeka Robinson, and Steven J. Venette
Risk can be defined using a mathematical formula—probability multiplied by consequences. An essential element of risk communication is a focus on messages within organizations. However, many health-related risks such as Ebola extend beyond an individual organization and risk is better understood as a social construction cogenerated within and between systems. Therefore, the process is influenced by systemic and supra-systemic values and predilections. Risk from a structurational perspective allows an understanding of the public as well as organizational responses to risk. Structuration theory provides a useful lens to move beyond seeing organizations as something that flows within an organization to understanding how organizations are enacted through communication. Structuration theory articulates the connections between systems and structures through the action of agents, whose practices produce and reproduce the rules and resources of social life. Within the structuration tradition, organizational communication scholars have shifted to an understanding of the communicative constitution of organizations (CCO). Specifically, one of the theories of CCO is the Four Flows Model. The four flows highlight the ways people enact organizations and provide a means to analyze the various ways communication constitutes organizations. The four flows are membership negotiation, activity coordination, reflexive self-structuring, and institutional positioning. Membership negotiation enacts the inner members and outsiders at a basic level including socialization, identity, and assimilation. Activity coordination produces collective action around a specific goal. Reflexive self-structuring is the decentralized enactment of structures for the organization through the communication of policies. Institutional positioning covers the macro-level actions where people in the organization act as an entity within the environment.
When considering the public reaction to Ebola, a simple way to evaluate risk perception is the intersection of dread and control. The U.S. public considered Ebola a serious risk. From a structuration perspective, the viral nature of twitter, media coverage, and public discussion generated resources for fear to be exacerbated. Structuration theory allows us to position the risk beliefs as rules and resources that are reproduced through discourse. The organizational implications fall primarily into the two flows of institutional positioning and reflexive self-structuring. For institutional positioning, U.S. healthcare organizations faced general public dread and perceived lack of control. Within the United States multiple policies and procedures were changed, thus fulfilling the second flow of organizational self-structuring. The Ebola risk had a significant impact on the communicative constitution of health-care organizations in the United States and beyond. Overall, risk is communicatively constituted, as are organizations. The interplay between risk and health-care organizations is evident through the analysis of American cases of Ebola. Structuration theory provides a means for exploring and understanding the communicative nature of risk and situates that risk within the larger systems of organizations.
Walid A. Afifi
The turn of the 21st century has seen an explosion of frameworks that account for individuals’ decisions to seek or avoid information related to health risks. The four dominant frameworks are Risk Perception Attitude Framework, the Risk Information Seeking and Process model, the Planned Risk Information Seeking Model, and the Theory of Motivated Information Management. A comparison of the constructs within each and an examination of the related empirical tests reveal important insights into (a) factors that have consistently been shown to shape these decisions across these approaches and (b) constructs in need of additional theorizing and empirical testing. Specifically, the analysis suggests that uncertainty, efficacy, affect, risk perceptions, and subjective norms all play crucial roles in accounting for decisions to seek or avoid risk-related information. However, inconsistencies in the direction of influence for uncertainty or information discrepancy, risk perceptions, and negative affect argue for the need for considerably more theoretical clarity and empirical rigor in investigations of the ways in which these experiences shape decision making in these contexts.
Mental models of health risks are the causal beliefs that comprise one’s inference engines for the interpretation and prediction of health and illness experiences and messages. Mental models of health risks can be parsed into a handful of common elements, including beliefs about causes, consequences, and cures as well as identifying information such as symptoms and timing. Mental models research deriving from a risk and decision analysis framework emphasizes exposure sources and pathways as part of causal thinking as well as how interventions may reduce or increase the risk. Mental models can be developed as a function of one’s goals or the problem in a specific context, rather than as coherent, stable knowledge structures in long-term memory. For this reason they can be piecemeal and inconsistent in the absence of expertise or experience with the risk. Derived often by analogy with more familiar risks, mental models of health risks can lead to effective health behaviors but also to costly inaction or misplaced action. Assessing mental models of hazardous processes can contribute to the design of effective risk communications by identifying the concrete information message recipients need to cope with health risks, thereby making or strengthening common-sense links between risk and action representations. Although a wide variety of research methods are used to investigate mental models, achieving this level of specificity requires attention to substantive details. Researchers are beginning to better understand the interactions between mental models of risk and their social, cultural, and physical contexts, but much remains to explore.
Soyoon Kim and Brian G. Southwell
Typical discussion about the success of mediated health communication campaigns focuses on the direct and indirect links between remembered campaign exposure and outcomes; yet, what constitutes information exposure and how it is remembered remain unclearly defined in much health communication research. This problem mainly stems from the complexity of understanding the concept of memory. Prolific discussions about memory have occurred in cognitive psychology in recent decades, particularly owing to advances in neuroimaging technologies. The evolution of memory research—from unitary or dichotomous perspectives to multisystem perspectives—has produced substantial implications for the topics and methods of studying memory. Among the various conceptualizations and types of memory studied, what has been of particular interest to health-communication researchers and practitioners is the notion of “encoded exposure.” Encoded exposure is a form of memory at least retrievable by a potential audience member through a conscious effort to recollect his or her past engagement with any particular unit of campaign content. While other aspects of memory (e.g., non-declarative or implicit memory) are certainly important for communication research, the encoded exposure assessed under a retrieval condition offers a critical point at which to establish the exposure-outcome link for the purpose of campaign design and evaluation. The typical methods to assess encoded exposure include recall and recognition tasks, which can be exercised in various ways depending on retrieval cues provided by a researcher to assess different types and levels of cognitive engagement with exposed information. Given that encoded exposure theoretically relies on minimal memory trace, communication scholars have suggested that recognition-based tasks are more appropriate and efficient indicators of encoded exposure compared to recall-based tasks that require a relatively high degree of current-information salience and accessibility. Understanding the complex nature of memory also has direct implications for the prediction of memory as one of the initial stages of communication effects. Some prominent message-level characteristics (e.g., variability in the structural and content features of a health message) or message recipient-level characteristics (e.g., individual differences in cognitive abilities) might be more or less predictive of different memory systems or information-processing mechanisms. In addition, the environments (e.g., bodily and social contexts) in which people are exposed to and interact with campaign messages affect individual memory. While the effort has already begun, directions for future memory research in health communication call for more attention to sharpening the concept of memory and understanding memory as a unique or combined function of multilevel factors.
Michael L. Hecht and Michelle Miller-Day
Adolescent substance use and abuse has long been the target of public health prevention messages. These messages have adopted a variety of communication strategies, including fear appeals, information campaigns, and social marketing/branding strategies. A case history of keepin’ it REAL, a narrative-based substance abuse prevention intervention that exemplifies a translational research approach, involves theory development testing, formative and evaluation research, dissemination, and assessment of how the intervention is being used in the field by practitioners. The project, which started as an attempt to test the notion that the performance of personal narratives was an effective intervention strategy, has since produced two theories, an approach to implementation science that focused on communication processes, and, of course, a school-based curriculum that is now the most widely disseminated drug prevention program in the world.
At the core of the keepin’ it REAL program are the narratives that tell the story of how young people manage their health successfully through core skills or competencies, such as decision-making, risk assessment, communication, and relationship skills. Narrative forms not only the content of curriculum (e.g., what is taught) but also the pedagogy (e.g., how it is taught). This has enabled the developers to step inside the social worlds of youth from early childhood through young adulthood to describe how young people manage problematic health situations, such as drug offers. This knowledge was motivated by the need to create curricula that recount stories rather than preaching or scaring, that re-story health decisions and behaviors by providing skills that enable people to live healthy, safe, and responsible lives. Spin-offs from the main study have led to investigations of other problematic health situations, such as vaccination decisions and sexual pressure, in order to address crucial public health issues, such as cancer prevention and sex education, through community partnerships with organizations like D.A.R.E. America, 4-H clubs, and Planned Parenthood.
The disruption information seeking and processing (DISP) model is a variation on the risk information seeking and processing (RISP) model. While both the DISP and the original RISP models seek to predict how individuals will search for and attend to information in response to a perceived hazard, DISP aims to broaden analysts’ view of the sorts of information individuals may seek in such situations. It does so by expanding the repertoire of social psychology theory on which the model is constructed to include ideas from the literatures on sensemaking and identity maintenance.
A major argument of DISP is that on many occasions the information that people seek in response to a risk will not be directly related to the risk itself. For example, if you hear a news bulletin on an outbreak of food poisoning associated with ground beef, the next thing you look for may not be information on the risks of E. Coli, but a recipe for chicken. While the observation that people seek non-risk-related information in response to risks is a broad one, the DISP concerns itself with one particularly important aspect of this idea.
Specifically, based on research in the sensemaking and identity maintenance traditions, the DISP model proposes that, for information seekers, the self and the various identities in which individuals are personally invested are often as much the objects in need of interpretation as the hazardous environment. The implication of this is that when faced with a risk, individuals are likely to pay attention not just to information on the risk itself (the sort of information prioritized by RISP), but on the identities impacted by the hazard—for example, how a person’s acceptance of or strategy for coping with the risk might affect her self-image as being a good parent, a conscientious employer, etc.
The DISP also proposes that some hazard situations are likely to be more disruptive to individuals’ sense of self than others—namely instances where the individual has a high vested interest in a particular identity that is challenged by the hazard combined with a low sense of self-efficacy with respect to remediating the hazard. A typical example would be a parent who prides herself on keeping her kids safe, who finds out about an environmental risk to children in her neighborhood, but who cannot afford to move.
According to the DISP model, in such a circumstance the individual would likely become more attuned to information about the countervailing positive aspects of the neighborhood, such as good schools or a low crime rate. These sorts of information, which do not pertain to the risk directly, but are nonetheless sought as a consequence of the risk, exemplify the manner in which DISP seeks to expand the focus of the original RISP model. In the parlance of DISP, the model adds a “self-relevant” information dimension to RISP’s original focus on “risk-relevant” information.
Finally, the DISP model proposes the notion of “norm trumping,” suggesting that individuals experiencing disruption in the face of a hazard—who run afoul of the set of social norms associated with an identity in which they are highly invested—are likely to pay particular attention to self-relevant information that emphasizes alternative sets of norms that help to preserve or reconstitute a desired sense of self.
This model has yet to be tested empirically.