Health and Risk Communication

This is an advance summary of a forthcoming article in the Oxford Research Encyclopedia of Communication. Please check back later for the full article.

In the United States, African American and Hispanic individuals are greatly over-represented among the population of the 1.2 million persons living with HIV/AIDS. However, African Americans and Hispanics are substantially under-represented in HIV/AIDS clinical trials. HIV/AIDS clinical trials are research studies that test and evaluate the safety and effectiveness of potential treatments for HIV/AIDS and the complications of HIV/AIDS with human volunteers. Through involvement in HIV/AIDS clinical trials, HIV-infected individuals can gain access to promising new treatments and a level of care and support services that may not otherwise be available to those with limited resources. As such, HIV/AIDS clinical trials are critical to the development of new medications and treatment regimens. The reasons for under-representation of African Americans and Hispanics are complex and multi-faceted. First, people of color experience barriers to HIV/AIDS clinical trials at the level of the individual; primary among those are fear and distrust of medical research, grounded in large part in the knowledge of past abuses of populations of color by medical research institutions, but also complicated by present day experiences of exclusion and discrimination in health care settings and the larger society, often referred to as “structural racism.” Moreover, people of color experience barriers at the level of social networks, such as peer norms that do not support engagement in clinical trials. Further, organizations that provide HIV primary care are not well positioned to help persons of color living with HIV/AIDS overcome these barriers to trials, and therefore, are less likely to refer them to trials compared to their white patients. In addition, people of color living with HIV experience a number of structural barriers to trials, such as difficulty with access and navigation of the trials system, which is unfamiliar and oftentimes daunting. Last, studies suggest that the inclusion and exclusion criteria of clinical trials exclude a greater proportion of people of color compared to white patients. The ACT2 Program is designed to reduce these types of barriers to HIV/AIDS clinical trials for people of color and thereby increase the proportion of those who will screen for and enroll in trials. The ACT2 Program is grounded in the antiracist stance to foreground how structural racism, which often manifests as exclusion, stress, discrimination, and poor access to health care resources, limits equitable participation in clinical trials. Motivational interviewing and a flexible, collaborative clinical method is the ACT2 Project’s main counseling approach. The ACT2 Project was tested in a rigorous randomized controlled trial and was found highly efficacious. Clinical trial research units can eliminate racial or ethnic disparities in HIV/AIDS clinical trials by implementing multi-component interventions such as ACT2 to build motivation and capability to access trials, offering repeated access to screening, and centralizing screening efforts where appropriate. Further, modifications to study inclusion criteria will be needed to increase the proportion of people of color who enroll in HIV/AIDS clinical trials.

Patient adherence (sometimes referred to as patient compliance) is the extent to which a patient’s health behavior corresponds with the agreed-upon recommendations of the healthcare provider. The term patient compliance is generally synonymous with adherence but suggests that the patient played a more passive role in the healthcare professional’s prescription of treatment, whereas the term adherence suggests that the patient and healthcare professional have come to an agreement on the regimen through a collaborative, shared decision-making process. Another term related to the concept of adherence is persistence (i.e., taking a medication for the recommended duration). Some patients are purposefully or intentionally nonadherent, whereas others are unintentionally nonadherent due to forgetfulness or poor understanding of the regimen. Patients may be intentionally nonadherent because of a belief that the costs of the regimen outweigh the benefits, for example. Nonadherence behaviors in medication-taking include never filling a prescription, taking too much or too little medication, or taking a medication at incorrect time intervals. Patient adherence is relevant not only in medication-taking behaviors, but also in health behaviors such as following a specific dietary regimen, maintaining an exercise program, attending follow-up appointments, getting recommended screenings or immunizations, and smoking cessation, among others.

There are a number of factors that predict patient adherence to treatment, but the relationship between provider-patient communication and adherence to treatment will be stressed here. Focusing on recent research, this article examines the concept of patient adherence, describes how provider-patient communication can enhance patient adherence, explains what elements of communication are relevant for adherence, and illustrates how interventions to improve communication can improve adherence.

The concept of ambiguity tolerance (TA), variously called Uncertainty Avoidance, Ambiguity Avoidance, or Intolerance, can be traced back nearly 70 years. It has been investigated by many different types of researchers from clinical and differential, to neuro- and work psychologists. Each sub-discipline has tended to focus on how their variable relates to beliefs and behaviors in their area of expertise, from religious beliefs to reactions to novel products and situations.

The basic concept is that people may be understood on a dimension that refers to their discomfort with, and hence attempts to avoid, ambiguity or uncertainty in many aspects of their lives. There have been many attempts to devise robust and valid measures of this dimension, most of which are highly inter-correlated and require self-reporting. There remains a debate as to whether it is useful having just one or more dimensions/facets of the concept.

Using these tests, there have been many correlational studies that have sought to validate the measure by looking at how those high and low on this dimension react to different situations. There have also been some, but many fewer, experimental studies, which have tested very specific hypotheses about how TA is related to information processing and reactions to specific stimuli. There is now a welcomed interest by neuroscientists to explore the concept from their perspective and using their methodologies.

These studies have been piecemeal, though most have supported the tested hypotheses. There has been less theoretical development, however, of the concept attempting to explain how these beliefs arise, what sustains them, and how, why, and when they may change. However, the concept has continued to interest researchers from many backgrounds, which attests to its applicability, fecundity, and novelty.

Within a range of health communication contexts, anger can be either a detriment to the receptivity of health promotion messages when poorly controlled, or a benefit to information processing when appropriately directed. In the former case, anger can disrupt cognitive processing, leading to a range of negative outcomes, including emotional turbulence and a preoccupation with anger-eliciting events that can severely limit the receptivity of health promotion and risk prevention messages. However, when properly directed and elicited in moderation, anger can motivate greater purpose and resolve in response to health threats, stimulate more active processing of health warnings, sharpen focus on argument quality, and direct greater attention to coping-relevant information concerning harmful health risks.

Regret is the prototypical decision related emotion. It is felt when the outcome of a non-chosen alternative is better than the outcomes obtained. Regret is a functional emotion that helps people to correct mistakes. It is also functional because people can anticipate regret beforehand, then choose in such a way as to avoid regret from happening. Researchers in economics proposed regret theory, an alternative to rational choice theory, which takes into account the anticipation of regret and its influence in choice. Researchers in psychology studied how anticipations of regret influence decision making in a variety of domains, including health behaviors. The findings suggest that interventions can be developed that are based on the idea that people are regret averse.

Many health- and risk-related behaviors have moral implications. Most obvious are altruistic behaviors like blood donation. However, issues related to promoting the wellbeing of friends and family members, such as being sure that they don’t drive drunk, and the generalized obligations that attend environmentally relevant behaviors like participating in recycling programs, also tap into moral concerns. For promoting such issues, moral appeals may be appropriate. Moral appeals are messages that acknowledge individuals’ evaluative beliefs about universal rights and wrongs. Appeals to morality produce a sense of obligation and responsibility because morals are viewed as self-evident facts.

Three explanations for why people engage in moral behavior are discernible in current scholarship, each with implications for structuring moral appeals: activation of social expectations, activation of personal norms, and arousal of emotion. The first of these is based on the subjective expected utility tradition. From this perspective, the key to successfully encouraging morally relevant behavior is maximizing benefits and minimizing costs. Because prosocial behaviors are enforced by social sanctions, many of these costs and benefits are socially bestowed. Thus, altruism at its core is hedonism. Theories that focus on activation of personal norms, in contrast, contend that people sometimes make decisions to donate blood, demonstrate for healthcare reform, recycle, and so on simply because they view it as their duty and responsibility to do so. When people realize in a concrete situation that their actions have consequences for the welfare of others, and that they are personally responsible for those outcomes, personal norms for the specific case are generated from internalized moral values. In this view, a central concern with moral appeals is ensuring that messages are aligned with internalized norms and that relevance and personal responsibilities are clearly communicated. Finally, theories of emotional arousal stress that although cognitive appraisals of personal and social norms are necessary, they are insufficient to incite people to selfless behavior. Rather, people engage in helping or altruistic behavior because moral appeals are emotionally arousing. Emotions associated with such appeals include empathic concern and guilt. Guilt appeals especially have been found to be as effective in eliciting compliance when behaviors have moral significance as other popular compliance-gaining strategies. Positive emphasis on responsibility and induction of hypocrisy are also techniques that rely on the appeal to moral beliefs.

This is an advance summary of a forthcoming article in the Oxford Research Encyclopedia of Communication. Please check back later for the full article.

When bystanders step in to prevent or reduce harm to others, they act as agents of primary and secondary health prevention. But theory and research suggest the bystander intervention process is complex, and multiple social-psychological and situational barriers imperil bystander action. Bystanders are often ill prepared to intervene when others are at risk for emotional or physical harm. They may not notice that someone needs help due to distraction from self-focus, engagement in social interaction, intoxication, or aspects of the situation like crowding or noise. Due to inadequate knowledge, bystanders may misdiagnose the situation and believe intervention is unnecessary. The negative consequences of non-intervention may be unknown to them, such that the situation fails to increase their empathic arousal and motivate their action. Lacking knowledge, they may not recognize the seriousness of the situation or the potential costs of inaction, and so are insufficiently alarmed. Pluralistic ignorance can arise when multiple uncertain bystanders conceal their concern and hesitate to act, assuming others’ inaction means intervention is inappropriate or unnecessary. When there are multiple witnesses, bystanders may assume their help is unneeded, place intervention responsibility on others, or feel less responsible for helping due to diffusion of responsibility. When the victim is not a member of their in-group, or is assumed to be at fault for their predicament, bystanders may feel less empathy and a reduced responsibility to help. Or, bystanders may assign responsibility for intervention to the victim’s friends or fellow in-group members, or to those “in charge” of the setting. Even when bystanders realize help is needed and take responsibility for helping, they may not act if they do not know how or lack confidence in their ability to successfully carry out the actions required to help. When they have the skills, they may not help if they perceive the costs of action might outweigh the benefits of action. Audience inhibition arising from group norms supporting inaction and from bystander worry about what others will think about them if they act unnecessarily or ineptly, can prevent bystander action by increasing bystanders’ perceived helping costs.

Recognition of bystanders as a potentially valuable public health asset has increased interest in promoting bystander intervention. Bystander intervention promotion and communication empower bystander action by combating intervention-and-audience-specific barriers to bystander intervention using targeted information, communications, and skills training. Theory and research suggest that effective promotions and communications foster context-specific attitudes, beliefs, norms, and skills such that bystanders: (a) Are able to quickly and accurately identify a situation as intervention-appropriate; (b) Experience action-motivating arousal (including empathy) in the face of the event; (c) Have positive attitudes towards intervention and perceive the benefits of action as outweighing the perceived costs; (d) Are empowered to act and feel confident in their ability to effectively intervene (bystander efficacy); and (e) Are resistant to evaluation apprehension and norms contraindicating action. Effective bystander intervention promotion draws on social psychology and communications studies, and best practices for health promotion and prevention programs. The application of social marketing and formative and summative program evaluation methods enhance the potential of bystander intervention promotions and communications to empower bystander action.

In an ideal world, people would adopt a positive attitude toward a healthy lifestyle as a result of carefully considering relevant and strong arguments. Attitudes based upon such considerations are believed to be stable and good predictors of related behavior, and less vulnerable to counterattitudinal messages. However, carefully evaluating arguments in such messages is difficult. First, people need to identify what information can serve as an argument and construe the argumentative relation between the information and the advocated claim. Next, they need to assess the extent to which the argument satisfies the criteria for a strong argument. What these criteria are depends on the type of argument at hand: an argument from analogy, for instance, should be evaluated with different criteria than an argument from authority. Argument scrutiny thus entails reconstruction, identification, and evaluation.

The good news is that even though argument scrutiny is a complex task, it seems that people are pretty well equipped to carry it out. Meta-analyses have shown that messages containing strong arguments are more persuasive than those containing weak arguments. In addition, there is evidence that people are sensitive to what extent a specific argument satisfies relevant criteria when evaluating arguments. The bad news is that people may use these skills not so much to make objective evaluations to reach a better decision, but rather to defend the type of behavior that they already feel they want to perform. That is, they use their argument evaluation skills to reason why the arguments in support of the behavior that they favor are stronger than the arguments against that behavior.

A premise in health promotion and disease prevention is that exposure to and consequences of illness and injury can be minimized through people’s actions. Health campaigns, broadly defined as communication strategies intentionally designed to encourage people to engage in the actions that prevent illness and injury and promote wellbeing, typically try to inspire more than one person to change. No two people are exactly alike with respect to their risk for illness and injury or their reactions to a campaign attempting to lower their risk. These variations between people are important for health messaging. Effective campaigns provide a target audience with the right persuasive strategy to inspire change based on their initial state and psychosocial predictors for change. It is often financially and logistically unreasonable to create campaigns for each individual within a population; it is even unnecessary to the extent to which people exist in similar states and share psychosocial predictors for change. A challenging problem for health campaigns is to define those who need to be reached, and then intelligently group people based on a complex set of variables in order to identify groups with similar needs who will respond similarly to a particular persuasive strategy. The premise of this chapter is that segmentation at its best is a systematic and explicit process of research to make informed decisions about how many audiences to consider, why the audience is doing what they are doing, and how to reach that audience effectively.

Affectionate communication comprises the verbal and nonverbal behaviors people use to express messages of love, appreciation, fondness, and commitment to others in close relationships. Like all interpersonal behaviors, affectionate communication has biological and physiological antecedents, consequences, and correlates, many of which have implications for physical health and wellness. Investigating these factors within a biological framework allows for the adjudication of influences beyond those attributable to the environment. In particular, there are observable genetic and neurological differences between individuals with a highly affectionate disposition and those less prone to communicating affection, suggesting that variance in the tendency to engage in affectionate behavior is not entirely the result of environmental influences such as enculturation, parenting, and media exposure. In addition, the expression of affection is associated with markers of immune system competence and appears to help the body to relax and remain calm. The biological effects of affectionate communication are perhaps most pronounced in situations involving either acute or chronic stress. Specifically, highly affectionate individuals are less likely than others to overreact physiologically to stress-inducing events. Whatever stress reaction they do mount is better regulated than among their less affectionate counterparts. Moreover, highly affectionate individuals—or simply those who receive expressions of affection prior to or immediately following a stressful situation—exhibit faster physiological recovery from their elevated stress. Perhaps unsurprisingly, therefore, being deprived of adequate affectionate communication is predictive of multiple physical and psychological detriments, including elevated stress and exacerbated depression, social and relational problems, insecure attachment, susceptibility to diagnosed anxiety and mood disorders, susceptibility to diagnosed secondary immune disorders, chronic pain, and sleep disturbances.