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Beyond Access: Communication Beyond Access: Communication Inequality and its Implications for Inequality and its Implications for Health Disparities Health Disparities

K.

• K. “

“Vish Vish” ” Viswanath Viswanath

Harvard School of Public Health Harvard School of Public Health Dana Dana-

• Farber Cancer Institute

Farber Cancer Institute

Abundance of health information Abundance of health information

10 20 30 40 50 60 70 80

1980-4 1985-9 1990-4 1995-9 2000-4

Years Heart Disease Tobacco/Smoking Obesity HIV/AIDS

# of Stories (in thousands)

FIGURE: Print news coverage of health issues.

Health Health-

• related news stories

related news stories increasing increasing

1 2 3 4 5 6 7

1980-4 1985-9 1990-4 1995-9 2000-4

Years Heart Disease Tobacco/Smoking Obesity HIV/AIDS

# of Stories (in thousands)

FIGURE: Ethnic print coverage of leading health issues.

Figure 1. National TV News Coverage of Leading Health Issues

20 40 60 80 100 120 140 160

1980-4 1985-9 1990-4 1995-9 2000-4

Years Heart Disease Tobacco/Smoking Obesity HIV/AIDS # of Stories

Differential Disease Burden Differential Disease Burden in the Population in the Population

• Higher incidence rates:

Higher incidence rates:

• Black males more likely to develop

Black males more likely to develop any type of cancer than White any type of cancer than White males males

• Higher death rates:

Higher death rates:

• Black women are more likely to

Black women are more likely to die from breast cancer than White die from breast cancer than White women. women.

• Cardiovascular disease

Cardiovascular disease

• SES disparities in smoking

SES disparities in smoking

Cigarette Smoking Among Adults Cigarette Smoking Among Adults by Education 1980 by Education 1980-

• 2004

2004

5 10 15 20 25 30 35 40 1980 1985 1990 1995 2000 2004 less than 12 12 13-15 16 or more

Year

Percent

Source: National Health Interview Surveys: 1980, 1985, 1990, 1995, 2000, 2004.

Estimated Prevalence of Diabetes in Adults Estimated Prevalence of Diabetes in Adults ( (> >20yrs.) by Race/Ethnicity 20yrs.) by Race/Ethnicity 2002 and 2005 2002 and 2005

2 4 6 8 10 12 14 16 2002 2005 White African American American I ndian Hispanic

Source: American Diabetes Association available at http://www.diabetes.org/diabetes-statistics/prevalence.jsp

Year Percent

Obesity Prevalence by Obesity Prevalence by Education Level 1991 Education Level 1991-

• 2001

2001

5 10 15 20 25 30 1991 1998 2000 2001

Less than HS HS Some College College

Year

Source: CDC, BRFSS, 1991-2001

Percent

Why do these disparities exist? Why do these disparities exist?

• Social determinants:

Social determinants:

• Social cohesion

Social cohesion

• Social stratification

Social stratification

• Social Class

Social Class

• SES

SES

• SEP

SEP

• Social networks

Social networks

• Neighborhood conditions

Neighborhood conditions

• Social policies

Social policies

Multilevel approach to Multilevel approach to epidemiology epidemiology

Figure: Adopted from Kaplan (2004).

What links social determinants What links social determinants with health outcomes? with health outcomes? Communication one potential Communication one potential thread linking proximal to thread linking proximal to distant factors and their distant factors and their

• utcomes to health
• utcomes to health

Multilevel approach to Multilevel approach to epidemiology epidemiology

Figure: Adopted from Kaplan (2004).

Functions of Communication in Functions of Communication in Health Health

• Informational:

Informational: acquire acquire knowledge knowledge

• Instrumental:

Instrumental: enables action enables action

• Social control:

Social control: defines social defines social norms norms

• Communal:

Communal: access to social access to social capital capital

Structural Influence Model of Structural Influence Model of Communication (SIM) Communication (SIM)

e s H e a Social Determinants Socioeconomic Position

• Education
• Income
• Employment
• Occupation

Place

• Neighborhood
• Urban versus

rural Mediating/ Moderating Conditions Socio- Demographics

• Age
• Gender
• Race/Ethnicity

Social Networks

• Social Capital

Social Networks

• Resources

Health Communication Outcomes

• Health Media

Use & Exposure

• Information

seeking

• Attention
• Information

Processing Health Outcomes

• Knowledge
• Health Beliefs
• Comprehension
• Capacity for

action

• Incidence
• Health Behaviors
• Prevention
• Screening
• Treatment
• Survivorship
• End-of-life care

Communication may play a role in linking SES, resources and health

• utcomes.

Communication Inequality Communication Inequality Differences among social classes in the generation, manipulation, and distribution of information at the group level and differences in access to and ability to take advantage of information at the individual level.

Dimensions of communication Dimensions of communication inequality inequality

• At the societal level

At the societal level

• Differences in the generation,

Differences in the generation, manipulation and distribution of manipulation and distribution of information among social information among social groups. groups.

• Capacity to act on information

Capacity to act on information

Dimensions of communication Dimensions of communication inequality inequality

At the individual level

Differences in:

Access to and use of information

channels

Attention to health content Seeking Information Recall, knowledge and

comprehension

Capacity to act on information

Recent Work Recent Work

SES, Race and Ethnicity are associated with

subscription to cable or satellite TV

and the Internet

daily readership of newspapers Attention to health content in

different media

Differential time with different

media

Knowledge gaps in health (Viswanath, 2005; Viswanath, In Press; Viswanath et al., In Press; Ramanadhan & Viswanath, In Press)

Figure 6. Days Read Newspaper in Last Week, by Race

20 40 60 Never 1-3 4+ Days P e rc e n t (% ) White African-American

Figure 4. Days Read Newspaper in Last Week, by Education

20 40 60 Never 1-3 4+ Days P e r c e n t (% ) HS or Less Some College Plus

Figure 5. Days Read Newspaper in Last Week, by Income

10 20 30 40 50 60 Never 1-3 4+ Days P e r c e n t (% ) <$24,999 $25,000 - $49,999 $50,000+

Percent Report Access to Percent Report Access to Cable/Satellite % Cable/Satellite % Internet % Internet % Education (n=6,149) Education (n=6,149) HS or Less HS or Less 77.17 77.17 38.17 38.17 Some College Plus Some College Plus 83.25 83.25 80.64 80.64 Income (n=6,149) Income (n=6,149) <$24,999 <$24,999 70.91 70.91 35.52 35.52 $25,000 $25,000 -

• $49,999

$49,999 79.20 79.20 62.69 62.69 $50,000+ $50,000+ 89.53 89.53 87.64 87.64 Employment Status (n=6,131) Employment Status (n=6,131) Employed Employed 82.03 82.03 73.52 73.52 Not Employed Not Employed 78.70 78.70 47.36 47.36 Race (n=5,666) Race (n=5,666) White White 82.56 82.56 66.02 66.02 African African-

• American

American 77.30 77.30 55.81 55.81 Ethnicity (n=5,666) Ethnicity (n=5,666) Non Non-

• Hispanic

Hispanic 81.72 81.72 66.42 66.42 Hispanic Hispanic 77.08 77.08 44.94 44.94

Access to Information Services among Different SES and Racial Ethnic Groups

Note: For all ethnicity assessments, multi-racial persons were excluded from the analysis. Data from HINTS.

Total Pop Total Pop (1,000) (1,000) TV Viewing % TV Viewing % Prime Time TV Prime Time TV viewing % viewing % Cable Viewing % Cable Viewing % Radio Listening % Radio Listening % Newspaper Newspaper Reading % Reading % Total Total 206,900 206,900 94.3 94.3 83.3 83.3 76.6 76.6 84.2 84.2 79.8 79.8 ETHNICITY ETHNICITY White White 179,897 179,897 94.1 94.1 83.2 83.2 77.6 77.6 84.6 84.6 79.8 79.8 Black Black 24,218 24,218 96.4 96.4 86.0 86.0 71.4 71.4 84.0 84.0 83.4 83.4 Asian Asian 5,366 5,366 90.5 90.5 75.7 75.7 68.3 68.3 78.5 78.5 69.8 69.8 Other Other 3,419 3,419 92.4 92.4 78.8 78.8 72.3 72.3 78.3 78.3 75.0 75.0 Spanish Speaking Spanish Speaking 25,792 25,792 94.4 94.4 81.4 81.4 69.9 69.9 85.9 85.9 64.7 64.7 EDUCATION EDUCATION Not high school Not high school graduate graduate 34,784 34,784 94.0 94.0 81.3 81.3 64.7 64.7 74.0 74.0 61.7 61.7 High School High School graduate graduate 66,320 66,320 95.4 95.4 85.4 85.4 78.3 78.3 83.0 83.0 79.8 79.8 Attended College Attended College 56,111 56,111 94.2 94.2 83.0 83.0 79.2 79.2 88.2 88.2 83.8 83.8 College Graduate College Graduate 49,685 49,685 92.9 92.9 82.0 82.0 79.5 79.5 88.7 88.7 88.1 88.1 EMPLOYED EMPLOYED Full Time Full Time 110,707 110,707 93.6 93.6 82.5 82.5 79.5 79.5 91.0 91.0 81.8 81.8 Part Time Part Time 21,788 21,788 93.1 93.1 81.3 81.3 76.4 76.4 88.8 88.8 80.5 80.5 Not Employed Not Employed 74,405 74,405 95.6 95.6 84.9 84.9 72.3 72.3 72.9 72.9 75.7 75.7 HOUSEHOLD HOUSEHOLD INCOME INCOME Less than Less than $10,000 $10,000 12,433 12,433 91.3 91.3 78.7 78.7 55.3 55.3 69.1 69.1 63.3. 63.3. $10,000 $10,000 -

• $19,999

$19,999 21,824 21,824 95.8 95.8 84.4 84.4 63.5 63.5 73.4 73.4 69.4 69.4 $20,000 $20,000 -

• $29,999

$29,999 23,868 23,868 94.3 94.3 83.3 83.3 68.2 68.2 79.0 79.0 74.2 74.2 $35,000 $35,000 -

• $34,999

$34,999 11,797 11,797 94.4 94.4 83.6 83.6 70.4 70.4 79.8 79.8 75.5 75.5 $30,000 $30,000 -

• $39,999

$39,999 11,209 11,209 95.3 95.3 83.9 83.9 73.5 73.5 83.1 83.1 78.5 78.5 $40,000 $40,000 -

• $49,000

$49,000 20,895 20,895 94.6 94.6 83.4 83.4 76.6 76.6 87.6 87.6 81.0 81.0 $50,000 + $50,000 + 104,874 104,874 94.1 94.1 83.4 83.4 84.7 84.7 89.4 89.4 85.7 85.7

Major Media and their Audience Demographics in the United States*

*United States Bureau of Census, Statistical Abstract of the United States, 2004-5, available at http://www.census.gov/prod/2004pubs/04statab/infocomm.pdf

Percentage of Respondents who went “online” to look for Health Information in the United States*

10 20 30 40 50 60 % Series1 Series1 50.7 42.8 47.5 52 47.5 55 42.1 55.9 ALL Hispani c Blacks Whites Income <$50 K Income $50 K + High School Attende d or

Inequality in access to and use of Inequality in access to and use of information channels: Language information channels: Language barriers Language barriers: barriers Language barriers:

3 3-

• 40% non

40% non-

• English speakers in the

English speakers in the United States United States

Media exposure and language of Media exposure and language of interview, weighted interview, weighted

English English-

• responding

responding Spanish Spanish-

• responding

responding P P-

• value

value Radio Radio (hrs/day) (hrs/day) 3.0 3.0 2.1 2.1 2.9 2.9 1.1 1.1 1.0 1.0 <.001 <.001 TV TV (hrs/day) (hrs/day) 3.2 3.2 <.001 <.001 Newspaper Newspaper (days/wk) (days/wk) 2.8 2.8 <.001 <.001 Magazines Magazines 1.5 1.5 .001 .001

Clayman, Viswanath, Hesse, Arora (2004) Clayman, Viswanath, Hesse, Arora (2004)

Info sources credibility ratings and Info sources credibility ratings and language of interview, weighted language of interview, weighted

English English-

• responding

responding Spanish Spanish-

• responding

responding P P-

• value

value Radio Radio 2.46 2.46 2.61 2.61 2.99 2.99 2.24 2.24 2.43 2.43 2.47 2.47 .07 .07 TV TV 3.03 3.03 ns ns Internet Internet 2.83 2.83 <.001 <.001 Newspaper Newspaper 2.70 2.70 .002 .002 Magazines Magazines 2.75 2.75 .001 .001

(range 1 (range 1-

• 4, with 4 being highest)

4, with 4 being highest)

Clayman, Viswanath, Hesse, Arora (2004) Clayman, Viswanath, Hesse, Arora (2004)

Inequality in Inequality in attention

attention to health

to health information information

• Education and income positively

Education and income positively influence degree of attention to influence degree of attention to media media

• No difference in self

No difference in self-

• reported

reported attention to media by race or attention to media by race or ethnicity ethnicity

• Differences in attention to media

Differences in attention to media by language by language

Percent paying Percent paying “ “A lot/Some A lot/Some” ” attention to attention to health information on various media, by health information on various media, by education (HINTS) education (HINTS) 2 4 6 8

T V R adio N e w spaper M a g a zine s Inte rn e t

M e d ia S

• u

rc e Percent (%) H S

• r Less

S

• m

e C

• lle

g e P lu s

2 4 6 8

T V R a d io N e w s p a p e r M a g a z in e s In te rn e t

M e d ia S

• u

rc e Percent (%) H S

• r L

e s s S

• m

e C

• lle

g e P lu s

Percent paying “A lot/Some” attention to health information on various media, by

• education. Data from HINTS.

Attention paid to health information on mass Attention paid to health information on mass media by different groups (HINTS) media by different groups (HINTS)

Percent (%)

10 20 30 40 50 60 TV Radio Newspaper M agazines Internet W hite Black Am erican Indian / Alaskan Native

Percent (%)

1 2 3 4 5 6 T V R a d io N e w sp a p e r M a g a zin e s In te rn e t W h ite B la ck A m e rica n In d ia n / A la ska n N a tive Attention paid to health information on mass media outlets. Data from HINTS.

Nonseeker n=247 Seeker n=498 Income (% With Annual Income Less than $35K) 50.12 % 37.35 % Education (% With HS or Less Education) 68.20 % 47.09 % Concentration of Minorities 17.91 % Non-white; 6.10 % Hispanic 11.18 % Non-white; 3.97 % Hispanic

Cancer Information seekers and non-seekers in the United States* *From the Health Information National Trends Survey, National Cancer Institute: http://www.cancercontrol.cancer.gov/hints /index.jsp

Inequality in comprehension and Inequality in comprehension and knowledge of health information knowledge of health information

• Confusion due to plethora of

Confusion due to plethora of information at each stage information at each stage

• Prevention

Prevention

• Diagnosis

Diagnosis

• Treatment

Treatment

• Navigation of health system

Navigation of health system

• Change over life course

Change over life course

• 38% of HINTS respondents

38% of HINTS respondents < high < high school education reported school education reported “ “too many too many recommendations recommendations” ” to follow for to follow for cancer prevention cancer prevention

Inequality in comprehension and Inequality in comprehension and knowledge of health information knowledge of health information

• Issue of health literacy in the

Issue of health literacy in the informed decision making informed decision making environment environment

• 47

47-

• 51% of US adults lack basic

51% of US adults lack basic literacy skills (1992 NALS) literacy skills (1992 NALS)

• The Knowledge gap hypothesis

The Knowledge gap hypothesis

The Knowledge Gap The Knowledge Gap Hypothesis Hypothesis

• Increasing flow of information

Increasing flow of information into a social system is more into a social system is more likely to benefit groups of higher likely to benefit groups of higher socioeconomic status (SES) socioeconomic status (SES) than those of lower SES groups, than those of lower SES groups,

• thus widening the already

thus widening the already existing gaps in information existing gaps in information rather than narrowing them rather than narrowing them

• (Tichenor, Donohue & Olien, 1980).

(Tichenor, Donohue & Olien, 1980).

Factors that influence knowledge Factors that influence knowledge gaps at the Structural level* gaps at the Structural level*

• Problem Definition

Problem Definition

• Risk versus non

Risk versus non-

• risk

risk

• Social Conflict and Mobilization

Social Conflict and Mobilization

• “

“Outrage Outrage” ” and conflict and conflict

• Community Pluralism

Community Pluralism

• Urban versus rural differences

Urban versus rural differences

• Specialization

Specialization

*Viswanath & Finnegan, 1996 *Viswanath & Finnegan, 1996

Factors that influence knowledge Factors that influence knowledge gaps at the gaps at the Individual level Individual level * *

Prior Knowledge (Price & Prior Knowledge (Price & Zaller Zaller, , 1993). 1993). Motivation Motivation Interest Interest Salience Salience Interaction between motivation & Interaction between motivation & SES SES

*Viswanath & Finnegan, 1996 *Viswanath & Finnegan, 1996

Figure 9. Percent saying that their chances of cancer increase by "a lot or some" with exposure by Education

10 20 30 40 50 60 70 80 90 100

Smoking Exposure to Sun Risk Factors Percent HS or Less Some College Plus

10 20 30 40 50 60 70 80 90

Percent

Smoking Exposure to Sun

Income

Percent saying that their chances of cancer increase by "a lot or some" with exposure by Income

<$24,999 $25,000 - $49,999 $50,000+

Inequality in capacity to act on Inequality in capacity to act on health information health information

• Action is subject to opportunity

Action is subject to opportunity structure and built environment structure and built environment

• Examples from Energy balance

Examples from Energy balance

• Access to green space

Access to green space (Sallis et al.,

(Sallis et al., 2002) 2002)

• Availability of grocery stores

Availability of grocery stores (Block

(Block et al., 2004, Moore et al., 2006) et al., 2004, Moore et al., 2006)

• Neighborhood disorder

Neighborhood disorder (King et al.,

(King et al., 2002, Perkins et al., 1993) 2002, Perkins et al., 1993)

Trajectories of communication Trajectories of communication inequality inequality

• Will disparities disappear with

Will disparities disappear with technological advances? technological advances?

• Decrease in cost of technology

Decrease in cost of technology will lead to saturation? will lead to saturation?

• With improvement comes greater

With improvement comes greater demand for more high demand for more high-

• end

end equipment equipment

• Not a one time expenditure

Not a one time expenditure

• Trend towards convergence of

Trend towards convergence of channels and content channels and content– – what are what are the implications? the implications?

Implications for inequality Implications for inequality research research

• What does convergence of technologies

What does convergence of technologies mean to access to and use of different mean to access to and use of different channels? Would it be cost efficient and channels? Would it be cost efficient and more affordable if most information and more affordable if most information and entertainment be obtained from a small set entertainment be obtained from a small set

• f media delivery systems and services?
• f media delivery systems and services?
• Is the constant change and improvement in

Is the constant change and improvement in technologies of information delivery technologies of information delivery systems likely to be a deterrent for those systems likely to be a deterrent for those who cannot afford to update their who cannot afford to update their technologies? technologies?

Implications for inequality Implications for inequality research research

• Does the increasing sophistication in using

Does the increasing sophistication in using and operating the new technologies likely and operating the new technologies likely to leave certain groups at a disadvantage? to leave certain groups at a disadvantage?

Members of the Lab Members of the Lab

Kelly Blake, MHS Katrina Bond, MPH True Brewster, CURE Susan Koch-Weser, Dr.Ph. Stacy Petta, MA Shoba Ramanadhan, MPH Emily Zobel, SM