Chapter Fifteen

Communication Theory and Health Behavior Change:

The Media Studies Framework

John R. Finnegan Jr., Ph.DUniversity of Minnesota

K. Viswanath, Ph.DNational Cancer Institute

National Institutes of Health

Introduction

The word communication comes from the Latin “to make common to many” or “to give to another

as a partaker” (Oxford English Dictionary, 1986). It incorporates at least three complex ideas: 1)

conveying or exchanging intangible elements such as information, ideas, and meaning; 2) a union or

relationship implying mutual revelation, discovery, and effects; and 3) a recognition that these processes

occur at all levels of human experience. The word entered common English usage at about the same

time that printing technology emerged in 15th century Europe and made possible the growth and

diffusion of knowledge on a heretofore unattained scale.

Today we define human communication as the production and exchange of information and

meaning by use of signs and symbols (Gerbner, 1985). It involves processes of encoding, transmission,

reception (decoding), and synthesis of information and meaning. As political psychologist Harold D.

Lasswell (1948) put it, to study an act of communication is to pose the question: "Who Says What In

Which Channel To Whom With What Effect?" Thus Lasswell identified some key components of

communication study: the sender (who encodes and transmits); the content or message (communication

substance); the channel (the medium through which content is transmitted); the receiver or audience

(who decodes communication to derive meaning); and effect (some measurable outcome of the process).

Because of the centrality of communication in human affairs, many fields claim its study as an

empirical, critical, and applied phenomenon, public health included. Particularly applied

communication perspectives influence public health. That is, how do communication processes at all

levels of human experience contribute to, or detract from, health behavior change? Second, how can

communication strategies be used in a planned way to influence health behavior change?

The purpose of this chapter is to describe communication theories especially relevant to public

health and health behavior; to review and critique their application in the study of health behavior

effects; and finally to provide examples of how communication theory informs health behavior change

interventions. For reasons that will become clear shortly, we emphasize communication theory in a

media studies context applied to public health.

Organization of Communication Studies

Communication scholar George Gerbner (1985) has described a widely accepted framework for

communication studies that includes three main branches. The first is the study of how signs and

symbols combine into “codes” to create messages that convey meaning in a variety of social contexts.

This branch is called “semiotics,” the science of symbols, signs and codes. From an applied perspective,

this branch of communication studies is often concerned with the construction of "meaning." How do

signs, symbols, and codes combine to “construct reality” -- that is, influence us to think about things in

some ways and constrain us from thinking about them in other ways? Language, for example, is a

"code" that may be analyzed by its constituent signs and symbols to understand how meaning is

constructed. There are also aural and visual codes that communicate meaning as well (consider, for

example, how slow-motion in a film sequence communicates the ideas of beauty and grace).

The second branch Gerbner describes as the study of behavior and interaction through exposure to

messages. Here the emphasis is on measuring, explaining, and predicting communication effects on

cognitions, beliefs, attitudes, and public opinion. It is strongly influenced by the fields of psychology

and social psychology.

The third branch is the study of how communication is organized through large-scale social

institutions and systems, their history, regulation, and policy-making impact.

Levels of Study

Within each branch, communication study may be further broken down to examine effects at

various levels of human experience on a “micro to macro” continuum. At the level of the individual, for

example, we may study how a person processes information about health and converts it into action. At

the interpersonal level (dyadic), we may examine how two people interact and influence one another

relevant to some health behavior outcome. At the group or organizational level, we may examine how

formal or informal communication among many people influences health behavior change including,

perhaps, the effective delivery of a health-related service. Finally, at the level of the community, society

or culture, we may examine how communication contributes to health behavior change within the

constraints of social structure.

It is important to recognize that just as there is no single, unifying theory that explains and predicts

all human behavior, there is also no such theory that explains and predicts all communication effects.

Theories tend to diverge along the levels of analysis described above, but also according to effects

relevant to each discipline that studies communication. Some view this as symptomatic of

fragmentation in our understanding of communication. Others view this as a healthy theoretical

diversity necessary to understand human activity in many complex dimensions (Finnegan & Viswanath,

1989). In either case, current trends in communication research increasingly seek to connect and to

integrate effects across levels of analysis from the “micro” to the “macro” (Hawkins, Weimann &

Pingree, 1988).

All three branches and each level of study are important to understanding health behavior change.

Public health’s applied emphasis means that its approach to human communication is necessarily

eclectic. Most chapters in this book illustrate this diversity in their treatments of health behavior change

theories. Whether studied in individual, group or community contexts, most health behavior change

theories implicate critical roles and effects of communication. It is not the aim of this chapter to repeat

these insights, but to carry the discussion of communication and health behavior change into an area of

growing interest in public health: mass communication and its research framework, media studies.

The reasons for this emphasis are several. First, as communication scholars Clarke and Evans

(1985) have described, a media studies framework cuts across Gerbner’s three branches of

communication theory as well as “micro to macro” levels of analysis. It “consists in the study of media

by which information and entertainment are delivered in society, the conditions and processes by which

this content is shaped, and the effects that content and form exert on individuals...groups,” communities,

societies and cultures. Above all, communication in this context is “distinguished... by its social

complexity and self-conscious organization and use of technological instruments to extend and preserve

symbolic exchange in time and space.” These processes have important effects on public health in light

of the mass media’s ubiquity and their role as primary sources of our information about health and most

other human activities.

Second, communication effects on health behavior may be studied in this framework from the

perspective of day-to-day interactions but also as planned use of mass communication to influence

health behavior. Third, the “community-based” intervention campaign approach to influence health

behavior change has gained currency in public health during the past 20 years. This approach

recognizes the need to seek change in health behavior across multiple levels of human experience --

from the individual to the community (Rogers & Storey, 1987). Interventions are planned, multi-

strategy efforts that seek different dimensions of change that will lead to population shifts in health

outcomes (see especially chapters on planning and process models for a fuller treatment of this

approach). Mass communication has become a key part of this approach whether the object of change is

to build the community’s agenda for prevention, to change public policy, or to educate individuals about

specific health behavior changes. Media institutions play a crucial role in health behavior change

because they are key gatekeepers for disseminating information in social systems and because, as

socializing agents, they have a powerful impact in legitimizing behavioral norms.

Evolution of Communication Media

Anthropologists tell us that communication is as old as the human species. Almost as soon as

humans began to communicate with each other, they began developing tools to extend their contact

beyond interpersonal speech. It is likely that early drums were the first instruments intended to carry

messages to other humans at a distance. In a sense, mass media are an extension of those ancient drums,

yet they are relatively recent phenomena in human history. They emerged less than two centuries ago

(as did virtually all of modern society) in that spectacular release of creative and physical energy

historians call the Industrial Revolution. Although the printing press was invented in 15th century

Europe, it was not until the early 19th century that steam power was harnessed to the printing press for

mass production and distribution of information. Mass circulation daily newspapers, cheap enough for

all to afford at a penny per copy, first appeared in 1833 in New York City and soon all over the world.

In 1844, the speed of information for the first time in human experience exceeded the speed of the

fastest form of transportation. In that year, information was first transmitted electrically over wires in

Britain and the US, broken down into a series of dots and dashes. If you understood this “Morse Code,”

you could use this new telegraph both to send and receive information as far as the wires could reach.

By 1869, they reached across the Atlantic Ocean, first linking the European and North American

continents. The 19th century also gave birth to other communication technology: the photograph, the

telephone, recorded sound, moving pictures, and the first wireless transmission of sound. The 20th

century built on these advances by creating radio, television, the computer, global satellite networks, and

the World Wide Web, not to mention vast improvements in older technologies (Emery, Emery &

Roberts, 1996).

But while technology makes communication physically possible on a mass scale, it is human

organization of activity into a media system that is of key importance. That is, the media are

interconnected large-scale organizations that systematically gather, process and disseminate news,

information, entertainment and advertising worldwide. Many are small operations like your

neighborhood newspaper, while others are large corporations operating chains of media outlets and

employing tens of thousands of workers. Still others are global media empires operating in many

countries and cultures simultaneously. In some parts of the world, the media are owned and operated by

government rather than private enterprise. No matter the size or form of ownership, the media today are

all around us. They influence almost all dimensions of human life: economic, political, social, and

behavioral. From a public health perspective, the miracles of communication technology and the

evolving influence of the media in our lives pose both great promise and worrisome perils.

Major Study Areas: Message Production and Media Effects

There is a widespread popular and academic perception that media are "powerful," particularly that

they play strong roles in promoting, discouraging, or even inhibiting healthy behaviors. To understand

the nature of these roles requires us to evaluate how, where and with whom media interact and with

what consequences.

Two areas of research are germane. One deals with message production itself. It asks the question,

what are the social and organizational factors involved in media work that may impinge on the creation

of media messages influencing behavior change? Here, we are interested particularly in message

production through processes of creating news, information, advertising, and entertainment. In

Lasswell's (1948) terms, these are the sender and channel characteristics of mass media that form media

work and content.

The second area asks what are the consequences of media exposure on individuals, groups,

institutions and social systems? This question has been traditionally studied as "media effects.” Here, we

are interested in some of the major media effects hypotheses and their relevance to health behavior

change.

Media Message Production

Mass media organizations are bureaucracies in which tasks are specialized and routinized to enhance

efficiency in creating news, advertising, and entertainment. For example, journalists seek established or

official sources routinely to gather information that is used to create "news" (Sigal, 1987). The criteria

for using sources are usually straightforward: they should be credible, available and must be able to

supply reliable information. Sources thus essentially subsidize the process of gathering information

(Gandy, 1982).

Sources may be established spokespersons for government agencies, businesses or other powerful

groups and elites in the social system (Hilgartner & Bosk, 1988; Donohue, Tichenor & Olien, 1995).

Journalists routinize their news gathering process to insure predictability in an idiosyncratic world.

However, reliance on a regular supply of information from established sources means that groups

without social power are less likely to gain access to news making and therefore have less influence.

What becomes news is the product of the interaction of sources and media professionals. Sources

perform the key role of identifying social problems and bringing them to the attention of the media.

Sources, whether representing campaigns, government agencies, advocacy groups or other interests,

compete for media and therefore also for public attention in seeking to define and to increase the public

profile of an issue or problem.

For example, the US Surgeon General's office, a major official source of public health information,

regularly releases reports on the status of smoking and its effects on health in the United States. From

year to year, the report's emphasis differs to identify specific aspects of the smoking problem the Public

Health Service wishes to bring to the attention of news media and the general public (e.g., the increasing

prevalence of smoking among young women). Despite their dependency on such official sources, media

professionals also enjoy some autonomy in defining the problem particularly in the ways they construct

news stories. The definition of a social problem is crucial to how the public understands it; the actions

individuals or communities are likely to take to ameliorate the problem, the attention given the problem

by different groups and the knowledge acquired by them (Viswanath, et al, 1991).

Media Effects

The consequences of media dissemination of images, ideas, themes and stories are commonly

discussed under the rubric of media effects (Bryant & Zillman, 1994). At first blush, the term seems to

imply the unidirectional study of the media’s effect on some outcome (knowledge, opinion, attitude,

behavior) among individuals, groups, institutions or communities that are regarded as more or less

passive recipients of the effect (McLeod, Kosicki & Pan, 1991). However, media effects research also

looks at effects flowing in the opposite direction -- from audiences to the media. Moreover, strong

traditions in media research regard audiences not as passive recipients, but also as active seekers and

users of information (Blumler & Katz, 1974).

Media studies, like other social and behavioral sciences, also vary in the unit of analysis applied in

research -- from the individual to groups, communities and social systems. Table 1 provides an

overview of this variety in media studies and effects research. Major theories and concepts are

organized by level of analysis. At each level, we provide a few key studies and also the disciplinary

origin and relationship to other fields.

[Table 1 about here]

At the individual level of analysis, media studies emphasize effects on motivations, cognitions,

involvement, attitudes and behaviors as a result of exposure to media messages. A long-standing

interest has been the relationship between individuals' knowledge, attitudes and behaviors. Important

theories drawn from psychology and social psychology include hierarchies of effects, persuasion, and

social cognitive theories. These have been long-standing traditions in media effects research,

dominating the field for much of this century.

Specifically, researchers have looked at "learning hierarchies" in which knowledge change affects

attitudes that in turn affect behavior (K-A-B). Others have noted different hierarchies: "dissonance

attribution" in which behavior change affects attitude change which in turn affects knowledge (B-A-K);

and the "low-involvement" hierarchy in which knowledge change affects behavior which in turn affects

attitudes (K-B-A). More recently, researchers have suggested that there are not three distinct hierarchies

of effects, but a single continuum (Chaffee & Roser, 1986). The order of effects will depend on where

individuals or groups are positioned at the start with respect to some outcome.

Early persuasion studies by Hovland and colleagues at Yale (1953) were controlled experiments

testing various conditions under which opinion or attitude change would occur in the context of such

variables as source credibility, fear, organization of arguments, the role of group membership in

resisting or accepting communication, and personality differences. This line of research continues today

with an emphasis on cognitive processing of information leading to persuasion (Perloff, 1993).

Since the 1960s, media effects research has changed its dominant focus from attitude change to

studying the cognitive impact of mediated information (Beniger & Gusek, 1995) and has also

emphasized community and social systems levels of analysis. The latter happened partly because of

Latin American scholars' interest in developing new approaches to the use of mass communication in

guided social change projects in developing countries (Lee, 1980). Units of observation in this "macro"

level perspective have included populations in diverse community settings, groups, organizations, social

institutions and large-scale social systems including communities and nation-states. It has an obvious

connection to public health in which guided social change and community-based health interventions

have become ideal settings for testing macro social applications of communication strategies.

Because of their relevance to public health efforts to guide social and behavioral change, we review

and critique in greater detail four of the media effects perspectives listed in Table 1: the Knowledge

Gap, Agenda Setting, Cultivation Studies, and Risk Communication.

The Knowledge Gap

Conventional wisdom long held that persistent social problems could be resolved through public

education. To paraphrase the film Field of Dreams, the assumption was "if you tell them, they will

know." However, studies examining public knowledge on a variety of topics and issues have shown that

"they" did not always know. Moreover, knowledge and information turned out not to be equally

distributed across populations. Studies showed that people with more formal education learned and

knew more about many issues than people with less formal education (Hyman & Sheatsley, 1947;

Mosteller & Moynihan, 1972).

These findings were formally presented as the knowledge gap hypothesis by Minnesota researchers

Tichenor, Donohue and Olien (1970). They proposed that an increasing flow of information into a

social system (from a campaign, for example) is more likely to benefit groups of higher socioeconomic

status (SES) than those of lower SES groups. Increasing the information available in the system would

only exacerbate already existing differences between these groups. They supported this proposition

using studies of several topics including health. The disturbing implications were, of course, that public

campaigns would only perpetuate inequities. Because this called into question the entire basis of guided

social change efforts, it attracted the attention of scholars and policy makers.

As a media studies perspective, knowledge gap research arises from a longstanding sociological

tradition emphasizing how the structure and organization of communities and societies function as

means of social control and management of conflict. This tradition has long viewed the mass media as

important institutions of social control and conflict management. The hypothesis advanced our idea of

media effects in at least two important ways. It contradicted conventional wisdom that social

interventions are a simple panacea for resolving social problems. It also suggested that media have

differential impact on audiences -- impact that is importantly mediated by social structural conditions in

which audiences live. It was thus one of the first hypotheses in media studies to draw attention to the

role of environment in media effects on individuals (Viswanath & Finnegan, 1996).

Fortunately, subsequent studies found that knowledge gaps were not intractable. Researchers

discovered a variety of contingent and contributory conditions that could affect knowledge gaps and also

present opportunities for applications in public health campaigns (Table 2): content domains; channel

influence; social conflict and community mobilization; the structure of communities; and individual

motivational factors (Donohue, Tichenor & Olien, 1975; Ettema & Kline, 1977; Gaziano, 1983;

Viswanath & Finnegan, 1996).

[Table 2 about here]

Content, Channel Factors: Although studies have found SES-based knowledge gaps in the content

domain of health, others have suggested that as a general topic, "health" may appeal more broadly to all

SES groups (Ettema, Brown & Luepker, 1983; Snyder, 1990; Yows, et al, 1991; Zandpour & Fellow,

1992). That is, audiences may be more "involved" in the topic because, a priori, it affects everyone in

some way. This aspect, however, does not account for other factors influencing knowledge gaps. For

example, studies of channel influence show that people who obtain their news from print media are

usually more knowledgeable than those who receive it from other media (Viswanath & Finnegan, 1996).

There is, of course, a slight tendency for readers of newspapers to have more formal education than non-

readers. Television has the potential to be a knowledge equalizer among SES groups as the cost of

access through cable, digital satellite, and the Internet becomes more affordable. An additional

modifiable aspect of channel influence has to do with the link between media and interpersonal

communication. Tichenor, Donohue and Olien (1980) have suggested, for example, that interpersonal

discussion is helpful in narrowing knowledge gaps by reinforcing information received in mass media

channels.

Social Conflict and Mobilization: Media studies have also shown that where social conflict or

community mobilization occur, significant knowledge gaps are less likely to be found (Donohue,

Tichenor & Olien, 1975). Social conflict, an engine of social change, appears to increase public salience

about issues encouraging greater interpersonal communication. Mobilization of community groups,

institutions, and advocates to address a public problem has a similar effect even if overt conflict is not

present (Gaziano, 1983).

Community Structure, Pluralism: An important though largely non-modifiable factor affecting

knowledge gaps is the structure of communities themselves. Large communities are characterized by

greater specialization in interest groups, services and institutions including government, business, the

media and other organized centers of power. The potential for conflict is higher in these more pluralistic

communities because of such diversity and specialization. Small towns, on the other hand, are less

specialized and differentiated across all these sectors. Knowledge gaps are influenced by such

characteristics. For example, knowledge gaps are more likely in larger, more complex communities and

less likely in smaller less pluralistic communities (Donohue, Tichenor & Olien, 1975; Shinghi & Mody,

1976; Ettema, Luepker & Brown, 1983; Gaziano, 1988). However, some recent studies, particularly in

health communication, have reported findings counter to this: gaps were more likely to be found in

smaller communities (Viswanath et al., 1994). It has been suggested that in certain domains such as

health, the greater availability of diverse sources may work to the advantage of residents of larger

communities (Viswanath & Finnegan, 1996).

Motivational Factors: An important set of modifiable factors affecting knowledge gaps were

proposed by Ettema and Kline (1977). They argued that gaps between higher and lower SES groups

were not necessarily due to the effects of less formal education or economic deprivation, but to

differential levels of motivation, interest and salience in specific topics. They shifted the focus in

knowledge gap studies to the role of variables of individual difference. Support for this alternative

explanation appeared in several studies reporting that the association between knowledge and individual

variables such as interest, salience, motivation and involvement was greater than the association

between knowledge and education (Ettema et al., 1983; Zandpour & Fellow, 1992; Fredin, Monnett &

Kosicki, 1994). Contrary evidence has been reported by other studies (Griffin, 1990; Snyder, 1990;

Viswanath, 1990; Yows et al., 1991; McLeod & Perse, 1994). Viswanath and colleagues (1993), in a

study of a dietary health campaign, reported that even among those motivated, the more educated knew

more about diet and nutrition than the less educated.

Despite conflicting evidence on the role of motivational factors, it is clear that both individual level

and social structural variables are important in explaining knowledge gaps, however, future studies need

to do a better job in linking these different levels of analysis (Viswanath & Finnegan, 1995).

The importance of these subsequent studies is that they have given back to guided social change

efforts some modifiable factors that if appropriately understood and addressed, restore some of our

optimism about the use of interventions to address public problems. However, unlike the unbounded

optimism of the early days of public campaigns, these studies urge us to be "sober and wiser" in

considering structural factors that pose barriers to public campaigns. Public health regards it as an

ethical precept to address problems of the whole population, information "rich and poor" alike.

The Agenda-Setting Hypothesis

Mass communication research has long been concerned with the influence of mass media on

public opinion especially as they affect politics and policy-making. Early writers such as Walter

Lippman (1922) noted the media's behavior as a "restless searchlight" panning from one issue to the next

while seldom lingering long on any single issue. Later researchers such as Bernard Berelson (1948)

noted that while the media influence public opinion, the reverse is also true: public opinion influences

what the media report. Researcher Paul Lazarsfeld and colleagues (1948) also noted that media

attention itself confers status on public issues and raises their importance. These insights coalesced in

the 1970s as a focus on the mass media's role and influence in setting the public agenda of important

issues and problems.

Agenda setting has received a great deal of scholarly attention in part because of the re-emergence of

"powerful" effects media models (McCombs & Shaw, 1972). An axiom underlying this approach is that

mass media are not very successful in telling us what to think, but they are surprisingly successful in

telling us what to think about. The key idea here, quite simply, is that mass media are powerful in

setting the public agenda of important issues and problems. To quote a related axiom, if it doesn't

appear in the media, it isn't news.

Studies have shown high correlations between media coverage of issues and the public's opinion of

the importance and interest of issues. The hypothesis implies a strong if not direct link between the

media's agenda of important issues (reflected in news coverage) and the public's agenda of important

issues (the causal direction flows from the media to the public). In essence, agenda setting attributes a

"king-making" role to the media and also presents a number of opportunities for applications in public

health interventions (Table 3).

Types of Agenda-Setting Studies: Kosicki (1993) has suggested that there are actually three types

of agenda setting research: 1) public agenda setting which examines the link between media portrayal of

issues and their impact on issue priorities assigned by the public; 2) policy agenda setting which

examines the connection between media coverage and the legislative agenda of policy-making bodies;

and 3) media agenda setting which focuses on factors that influence the media to cover certain issues.

[Table 3 about here]

Recent research has suggested refinements in agenda setting theory (Kosicki, 1993). Initial

somewhat crude studies have given way to more empirically sophisticated designs with clearer causal

links (Iyengar & Kinder, 1987; Demers et al., 1989). In addition, the approach is being further refined

through several changes in the agenda setting perspective. One has to do with the idea that mass media

don't tell us "what to think." According to this view, the media not only tell us what's important in a

general way, they also provide ways of thinking about specific issues by the signs, symbols, terms, and

sources they use to define the issue in the first place. In this view, "public problems" are social

constructions. That is, groups, institutions, and advocates compete to identify problems, to move them

onto the public agenda, and to define the issues symbolically (Gamson & Modigliani; 1987; Hilgartner

& Bosk, 1988; Entman, 1993). This refinement is important because it suggests that the media's agenda

setting function is not completely independent but is built by various community groups, institutions,

and advocates. It also has a basis in the sociology of knowledge that emphasizes processes involved in

the "social construction of reality" (Berger & Luckmann, 1966). This has obvious implications and

applications for those in public health who seek to use the mass media to raise public salience and

awareness of specific problems.

Cultivation Studies

Cultivation studies are primarily concerned with the impact that mass media have on our

perceptions of "reality." The pervasive presence of television and visual media and their power to alter

perception is the starting point of this approach. Simply stated, researchers proposed that heavy TV

exposure often leads individuals to accept the TV-portrayed world as "real" (Gerbner, et al., 1980;

Stossel, 1997). That is, the more exposure to television, the more the congruence between viewers'

perception of reality and the mythic reality TV portrays (Gerbner et al.,1994; Weimann, 2000). In

essence, television "cultivates" a stilted view of the world, especially “mean-world syndrome.”

Types of Cultivation Studies: Cultivation studies have evolved into two types of research. The

first, message system analysis, seeks to examine the world that television constructs. For example, in a

long series of studies, Gerbner and colleagues (1980; 1994) have been tracking television's violent

content. They defined violence as "overt expression of physical force" by characters to compel victims

to act against their will and measured the frequency of such acts. In an early report (Gerbner et al.,

1980), they demonstrated an average of five violent acts per hour of prime time programming and

twenty acts of violence on weekend daytime television. They also tracked and recorded the gender, age,

ethnic and occupational composition of characters who frequent TV dramas. They reported that in the

TV world, men outnumber women, young people and senior citizens are underrepresented, and

professional and law enforcement personnel are over represented.

The second is cultivation analysis. Gerbner and his colleagues (1994) proposed that heavy

exposure to television has a profound effect on viewers' perception of social reality. Heavy viewers

were more likely to give "television answers" to opinion and knowledge questions compared to light

viewers. They were also more likely to develop “mean-world syndrome,” that is, to perceive the world

as violent and frightening out of proportion to reality; to be less trusting of others; to overestimate the

number of people employed in law enforcement; and to fear that they are more likely than statistically

true to become victims of crime. They also are likely to be more accepting of violence as a means of

dealing with social problems.

This cultivation of the television worldview is believed to occur through two distinct mechanisms:

mainstreaming and resonance. Mainstreaming is the "sharing of commonalty of outlooks."

Interestingly, irrespective of their sociodemographic background, heavy viewers of television tend to

share this worldview. As Gerbner and his colleagues (1980) asserted, heavy viewing "may serve to

cultivate beliefs of otherwise disparate and divergent groups toward a more homogeneous 'mainstream'

view."

Resonance is regarded as the more powerful mechanism. That is, the "reality" of television

programs for certain groups may in fact be congruent with the reality of their lives. In such cases, they

receive a "double dose" of the cultivation effect: television has stronger such effects for these groups. At

least one study has suggested that in some cases the source of “resonance” effects actually may be

“audience affinity.” That is, some audience segments may identify so highly with crime victims in the

news who resemble themselves that they then develop unreasonable fears about their own risk as victims

(Chiricos, Eschholz, & Gertz, 1997).

Although other research has raised questions about the nature of evidence supporting the

cultivation hypothesis, most researchers agree that television affects our perception of reality depending

on the level of exposure (Potter, 1999). Subsequent studies have added several contingent conditions

that could affect cultivation. For example, some research suggests that TV's cultivation effects become

weaker or disappear when controlled for other factors like age, gender, education, income, hours worked

per week, social ties and size of one’s community. Or, the fear of crime supposedly cultivated by heavy

TV viewing may be explained whereby heavy viewers live in high crime areas and may stay home

watching more television. Some have also argued that cultivation effect could be non-linear. That is,

television viewing may lead to a cultivation of a “television worldview” only up to a point (Potter,

1999). Still others argue that entertainment programming is not the only culprit in the distortion of

worldviews. The news media, politicians, government, and social and political advocacy groups often

seek to further their ends by raising public fear and concerns out of proportion to reality (Dorfman, et

al., 1997; Glassner, 1999).

Risk Communication

Communication about risk is a field of special concern in public health that bridges individual

and community levels of analysis. At the individual level, scholars have focused on an understanding of

cognitive mechanisms, and the development of expert and mental models of communication (Fischhoff,

1999; Maibach, 1999, Weinstein, 2000), issues of individual innumeracy (Lipkus et al., 2001,

Weinstein, 1999), confusion and misinformation (Weinstein, 2000), the efficacy of individualized

counseling and tailoring (Rimer, Glanz & Rasband) and the advantages to intensive, calibrated and

directed communication (Rimer & Glassman, 1999).

Moreover, at the individual level, researchers also emphasize the cognitive mechanisms by

which individuals are exposed to, and attend to information about risk; how they interpret risk

information in relation to themselves; and finally whether and how they act upon risk information to

alter their behavior (Slovic, Fischoff & Lichtenstein, 1981; Weinstein, 1984; Glanz & Yang, 1996).

This approach to the study of communication about risk owes much of its theoretical base to social

psychological models of behavior (discussed elsewhere in this volume) including Expectancy Value

Theories such as the Health Belief Model and the Theory of Reasoned Action (e.g., perception of

personal risk susceptibility and severity) but also to Self-Regulatory Models including Social Cognitive

Theory (e.g., self-efficacy beliefs that one can take effective action to reduce personal risk). This

approach is also a staple of communication research at the individual level that examines media effects

on knowledge, beliefs, and behavior.

Significant developments in the study of risk have also occurred at the community level

of analysis. Recent work on social problems and the accompanying discourse in the public

arena has attracted considerable attention. At the community level, studies of communication

about risk focus on the interaction of populations and social institutions (such as government

agencies, advocacy groups, and the mass media) in the formation and management of public

opinion and policy-making about risk. Here, risk communication studies owe much of their

theoretical basis to the agenda-setting and agenda-building perspectives but also to research

into the definition and "framing" of public issues. Risk communication research in this vein

has noted that risk is a "social construction,” a product of communication activity of social

institutions, advocates and the public (Hilgartner & Bosk, 1988, Sandman, 1987; Griswold &

Packer, 1991; Glanz & Yang, 1996).

Public definitions of risk will usually include some form of scientifically assessed risk

information ("objective") mediated by the political and social context of the risk (the "outrage" factor).

Social conflict is a critical variable in drawing attention to social problems and leading to arousal and

salience of the issue possibly leading to social action (Tichenor, Donohue & Olien, 1980, Viswanath &

Demers, 1999). This can have both negative and positive consequences depending on whether the actual

risk is low or high contrasted with whether public "outrage" is low or high. "Outrage" is a form of

community conflict that can have the effect of quickly propelling important information through the

population at all socioeconomic levels (this phenomenon relates to the knowledge gap discussed earlier).

In such case, there will be little difference in information holding among all socioeconomic groups

(Viswanath & Finnegan, 1996). Where "outrage" is low, on the other hand (or there is little publicity),

one might expect to find socioeconomic group differences in knowledge about risk. Either situation

may have an impact on policy-making about risk where the public is well or ill informed. Further,

community level of definition could be crucial to social action by powerful actors in the interest of

meliorating the unacceptable condition as can be seen in the case of AIDS in Africa.

Media Studies Applications in Health

In this section, we review examples of how some of these perspectives are useful in understanding

and evaluating health promotion and disease prevention efforts. Applying communication theories to

health behavior in the media studies framework occurs mainly along the two dimensions described

earlier: 1) effects of day-to-day interaction with media on health outcomes; and 2) effects of the

purposive use of media to achieve some health outcome, usually in the context of a planned campaign

intervention.

Day-to-Day Impact of Media on Health

The first category has linked media studies and public health for much of this century and shows

little sign of abating to judge by the amount of research generated. Its major concern is the effect of

media use itself on health-related behavior. As communication historians have noted, the emergence of

each new media technology has carried with it a "legacy of fear" about its harmful effects on the social

fabric, public health, and especially "vulnerable" groups such as children and adolescents (DeFleur &

Dennis, 1985). Thus in the 1930s, the Payne Fund sponsored some of the first empirical studies

examining the effects on youth of exposure to movies. The concern was whether they engendered

violent or other antisocial behavior. These studies approached the question more from a psychological

or social-psychological perspective but more recently investigators have used the Cultivation Studies

approach. The emphasis on "vulnerable" groups in such studies also stems from the fact that children

and the elderly are the heaviest users of television.

Violence and the Media. Concern about media impact grew dramatically after commercial

television first appeared in the late 1940s. By the early 1970s, the US Surgeon General (1972) was

expressing great concern about the effects of television violence on children and youth. The report

found disturbingly consistent associations between exposure to violent television content and aggressive

behavior, a link amplified by thousands of subsequent studies (Kelly, 1996; Wilson, et al, 1997; Singer

& Singer, 2001). This longstanding concern has not abated in the age of digital media. Despite content

rating systems implemented by the industry in the late 1990s, researchers continue to find high rates of

violent programming (also in video games) and accuse the industry of specifically marketing violence to

young people (Gerbner, 1998; Federal Trade Commission, 2000). In addition, studies show how young

people’s media use habits are changing with the introduction of new media including music CDs, video

games, computers, and the Internet integrated with older media like TV and radio (Livingstone & Bovill,

2001). A recent study of youth media habits by the Kaiser Family Foundation (1999) found that the

average American child now spends about 5.5 hours per day outside of school with media of all kinds.

That’s the equivalent of a full-time job each week! At the same time, few parents have media use rules

for their children and spend little time supervising their media use, the study found.

A key continuing challenge for this research, however, is the issue of causality: does youth

exposure to media violence cause violence in the real world? Because media are ubiquitous, it is

probably not possible to design a study that will ever solve this puzzle decisively. While many

researchers point to the consistency of exposure-aggression associations in myriad studies and the

media’s continuing obsession with violence (Willis & Strasburger, 1998; American Academy of

Pediatrics, 1999), real-world youth violence (homicides, assaults, rapes) has declined strikingly in the

US since the mid-1990s to the lowest levels in almost 30 years (Snyder, Sickmund & Bilchik, 1999).

So, it is evident that the relationship of media exposure to behavior is complex and variable (Hogben,

1998, Felson, 1996). If direct causal links are elusive, many researchers have noted cumulative

exposure effects leading to other equally disturbing outcomes such as desensitization toward real-world

violence or negative changes in perceptions about one's vulnerability to violence (“mean world

syndrome”). In a provocative departure from mainline research in this area, one investigator has

suggested that media violence may actually have a beneficial cathartic effect as an outlet for aggressive

impulses before they are acted upon in the real world (Fowles, 1999). In addition, he views the struggle

over media violence as part of the nation’s recurring “culture wars” over values in high and popular

culture.

Advertising and Entertainment. Advertising has raised additional public health issues also with

an emphasis on vulnerable groups such as children and adolescents. Both the social psychological and

Cultivation approaches to communication effects have informed research in this area. Recent studies

have suggested, for example, that cigarette advertising is extremely appealing to youth and plays a role

in influencing their decisions to start smoking (Ammerman, Ott, et al, 1999). Studies of alcohol

advertising and depiction of drinking in entertainment programming suggest that their effect on youth is

to alter perceptions in favor of the product's use by implying a false norm that "everybody drinks," by

suggesting falsely that one can't have a good time unless one drinks alcohol, and may also be linked to

drinking-related aggression (Grube & Wallack, 1994; Caswell & Zhang, 1998; Robinson, Chen &

Killen, 1998).

Other studies have illustrated concerns that excessive television use influences children's adoption

of sedentary lifestyles and may be partly responsible for increased rates of juvenile obesity, poor eating

patterns, high cholesterol, eating disorders, and other mental health problems (Myers & Biocca, 1992;

Wong, et al., 1992; Singer & Singer, 2001). Many of these studies also have public policy

ramifications. For example, some public health advocates have proposed major restrictions on

advertising or entertainment content or counter-advertising as solutions to the negative impact of media

exposure on the health (Sidney, et al., 1994; Stevens, 1998).

Studies have also examined the positive effects on health of media use (Barker, et al., 1993; Suman

& Rossman, 2000). These studies note that while media (especially television) may have negative

impact, they can and should be used to create positive impact in public health. This view especially

imbues the second dimension of media studies and health: effects of the purposive use of media in the

context of planned interventions.

Applications in the Planned Use of Media

The planned use of media communication to accomplish some health outcome pre-dates the

founding of the United States itself and may have started as a uniquely American cultural phenomenon

(Paisley, 1989). This American penchant for public campaigns continues unabated today but with a

deeper understanding of, and more systematic approach to the role of planning.

Many of the media communication theories discussed earlier are relevant to public health

community-based campaigns. In campaign and intervention planning frameworks (discussed in Part

Five), many media studies theories are useful in formative analysis and strategy development stages, and

in evaluating outcomes. In this section we provide examples of such applications.

Heart Disease Prevention and Media Communication

Beginning in the 1950s, epidemiological studies discovered that rates of heart disease varied

greatly around the world. It became apparent that these differences were due largely to socially

acculturated behavior patterns (Kromhout, Menotti & Blackburn, 1994). To reduce mass levels of

disease, investigators reasoned, would require multiple prevention strategies aimed at change in whole

populations. The rationale underlying this approach was a chain of causal links hypothesizing that

increasing exposure to such a campaign would increase participation and involvement leading to

behavior change (Mittelmark, et al. 1986). This in turn would result in increasing change in heart

disease risk factors and eventually disease reduction.

In the United States, federally funded community-wide prevention campaigns were started by

investigators in California, Minnesota, and Rhode Island. Multiple strategies were used in which media

communication played an important role. The idea of using multiple strategies was also informed by the

idea of "synergy." That is, strategies used together are more powerful in accomplishing behavior change

than if each were used alone (the effect of the whole being greater than the sum of the parts). This is

based on the idea that each individual strategy has strengths and weaknesses in the achievement of

health behavior change. For example, group educational settings (e.g., classes) are strong in presenting

an intensive, interactive experience but weak in their capacity to reach a high proportion of the

population. Mass media, on the other hand, are strong in their capacity to reach large numbers of

people, but weaker in their capacity to provide an intense, interactive experience. Campaign planning

frameworks seek to offset this individual weakness through the strengths of diverse strategies.

Media were used initially in each of the campaigns to increase public awareness of the problem of

heart disease, its major risk factors and associated lifestyle change strategies, and the programs them-

selves. In this sense, media were used first to build the "community agenda" for heart disease

prevention as a major concern worthy of public attention. A strength of mass media is their capacity to

expose many persons simultaneously to the same information and thus it is not surprising that public

awareness of prevention messages and programs increased dramatically and rapidly (Viswanath, et al.,

1994).

But a key issue for these and all public health campaigns is the extent to which they attain

exposure of all socioeconomic (SES) segments of the community because exposure is regarded as a

contingent condition for some kind of effect to occur (McGuire, 1989). Yet health campaign planners

are confronted with a number of important factors that influence exposure leading to behavior change.

As the Knowledge Gap makes clear, the tendency is for higher SES groups to acquire more information

faster than lower SES groups. In addition, people living in communities of varying size and complexity

may be differentially exposed to campaigns because of differences in communication systems. This

requires health campaign planners to assure in the development and evaluation of campaigns that social

structural factors are considered so they do not pose as serious barriers to the diffusion of exposure,

other intermediate effects, and behavioral outcomes.

In the heart disease prevention campaigns, a number of studies examined the question of exposure,

intermediate effects such as the distribution of prevention information, and behavior change itself.

Exposure and CVD Prevention Information

As a measure of intermediate exposure to the campaign, the Minnesota program tracked changes in

community awareness and the ability of the public to recall the program name. Of course, neither of

these intermediate outcomes was necessary to achieve behavior change, but they functioned importantly

as a process measure of campaign delivery. That is, due to the campaign, were people aware of the

CVD prevention activity, and could they recall (unaided) the name of the specific institutional source of

this activity? More importantly, did these effects vary by SES group?

During the five-year campaign, random population surveys were conducted in each of three

communities about every six months to monitor such changes (Viswanath, et al., 1994). Awareness in

the smallest community (population = 28,651), increased rapidly from 42 percent at six months to a

peak of 91 percent at three years and 88 percent at five years. In the regional community (population =

137,574), awareness increased from 30 percent at six months to a peak of about 86 percent at two years

and 76 percent at five years. In the suburb (population = 81,831), awareness increased from about 30

percent at six months to a peak of 84 percent at three years and 71 percent at five years. Recall of the

program name grew at about the same rate, but was lower in each community overall due certainly to

the more difficult task of recalling a name without prompting. The data were suggestive of the more

difficult task posed in conducting campaigns in more complex communities. In the regional community

and the suburb (part of a metropolitan area of two million), much more media communication was

required to maintain levels of awareness and name recall, which in any case were somewhat lower than

the smallest community in the study. The level of media communication required was more intense due

to the complexity of the larger communities: there are more available channels, more "noise" and

distractions than in the smallest community. But what about effects by SES segment?

The study showed that as predicted by the Knowledge Gap, CVD awareness and program name

recall were highest among high SES groups (measured by formal education) over the course of the five

years. However, importantly, the less educated groups (some college; high school or less) showed net

gains that were actually larger than the highest group (which started out higher at the beginning). So

although the "gaps" still existed, the campaign succeeded in narrowing them to a great extent as the

result of targeted communication efforts. Moreover, it's important to recognize that changes among

lower SES groups can and do occur but frequently lag behind higher SES groups. In our view, the

reason for this is primarily one of equal access to channels of communication and education which even

further raises the importance of channel influence analysis in campaign planning stages -- that is, what

channels are used most and are most effective with which groups (Finnegan, et al., 1993)?

5 A Day For Better Health: A National and Local Campaign Collaboration

The 5 A Day For Better Health Program is a national dietary campaign launched by the National

Cancer Institute (NCI) in 1991 to improve America’s consumption of fruits and vegetables. It is unusual

in that it represents one of the largest and most sophisticated campaigns to translate cancer prevention

research into public health applications. It is also unusual in that it is composed of national, state, and

local collaborations and public-private partnerships (Potter, Finnegan, Guinard, et al, 2000). Although

the message urging increased consumption of fruits and vegetables for better health was first articulated

by the US Department of Agriculture in 1916, it was not until the 1980s that strong scientific evidence

emerged to support it. Numerous studies concluded that one-third or more of cancer deaths could be

traced to diet-related causes (Doll & Peto, 1981; National Research Council, 1982; Department of

Health and Human Services, 1988). Moreover, a recent analysis of more than 200 epidemiological

studies of diverse populations with diverse lifestyles demonstrated that some 80 percent found a

significant association between consumption of fruits and vegetables and reduced cancer risk (World

Cancer Research Fund, 1997). Other studies have shown a strong association between decreased

cardiovascular risk and a diet rich in fruits and vegetables. Although the precise causal mechanism for

this reduced risk remains subject to further research (many researchers believe there are multiple

pathways to the effect), NCI concluded in the late 1980s that the evidence was persuasive enough to

warrant a recommendation to the public of increased consumption on the order of five servings a day

(Potter, Finnegan, Guinard, et al, 2000). National studies also showed that Americans’ consumption

was well below this recommended amount.

Planning for the campaign began in 1990. NCI initially set aside some $27 million for media,

contracts with local health departments and “nested” research studies examining the impact of

interventions with you in school settings and adults in workplace and social settings. By 1999, NCI’s

investment in the program had increased to more than $40 million. Also in 1990, NCI formed a

partnership with fruit and vegetable producers nationally (Program For Better Health Foundation), to

promote the program. The campaign kicked off in September 1991 consisting of media relations

strategies (e.g., efforts to increase news coverage of the message); advertising; point-of-purchase

programs and a number of funded intervention research studies in schools, worksites, and social settings

such as churches.

Although relatively well funded for a public health campaign, it is important to recognize that the

media environment surrounding food in the US is saturated with big-money advertising. For example,

in 1999 alone, commercial firms spent some $10 billion on food advertising. About $3 billion alone was

spent on fast-food advertising in 1999 (Gallo, 1999). News coverage also influences food choices

especially through reports of the latest research. Unfortunately, much reporting of diet and nutrition

studies results in confusing and inconsistent information for the average consumer. Studies have found,

for example, that as many as a third of the adult US population have given up on dietary change due in

part to confusing media reports (Weimer, 1999; Potter, Finnegan, Guinard, et al, 2000).

Against this background, the 5 A Day Campaign began to promote its message of increasing

consumption of fruits and vegetables. What has been achieved almost 10 years later? About 25 percent

of US adults recognize the slogan with more women than men responding (Potter, Finnegan, Guinard, et

al, 2000). More importantly, fruit and vegetable consumption has inched upward by about 0.12 servings

per day, with greater gains for Whites and Latinos in national surveys. This represents about a 4-

percentage increase from 1991 to 1997 in the proportion of US adults consuming at least 5 servings per

day. “Nested” studies of specific interventions showed larger increases. Among school-based youth

studies, the average effect size was 0.68 with a treatment-control difference at first post-test ranging

from 0.20 to 1.68 servings per day. Four “nested” studies in adult settings showed an average effect size

of 0.48 servings per day with a range of 0.20 to 0.85, effective across race, gender, and socioeconomic

groups (Potter, Finnegan, Guinard, et al, 2000).

A recent independent evaluation of the campaign concluded that although results have been small

but steady during the period, the campaign should continue to build on results thus far by intensifying

public-private partnerships, “reinventing” the 5 A Day message to continue media and public interest,

and continuing dietary behavior change studies and community collaborations. The campaign thus far

tends to confirm a conclusion of much public health campaign research: that local combined with

national efforts, and multiple intervention strategies can be effective in amplifying campaign effects.

Tobacco Trials: Agenda Setting for Public Health

As the 20th century drew to a close, tobacco control advocates appeared to be in the ascendancy.

Their efforts led to myriad lawsuits filed by states against the tobacco industry all over the country in the

late 1990s to recover smoking-related damages. Settlements have garnered billions of dollars from Big

Tobacco. This phenomenon represents something of a turnaround on the tobacco issue. Despite

hundreds of millions of dollars spent by the tobacco industry in advertising and lobbying to keep

smoking a “private” issue of individual rights, the public and the courts, it seems, now recognize that

smoking is also a community and public health issue, and is willing to hold the industry accountable.

It’s important to recognize that this didn’t occur overnight. Advocates’ modern tobacco control efforts

date from the US Surgeon General’s Report of 1964. It has taken more than 30 years to “reframe”

smoking decisively as a public health issue warranting industry legal accountability. To be sure, policy

changes have occurred along the way. In 1971, Congress banned electronic advertising of tobacco, and

in the early 1970s, many states passed laws outlawing smoking in public buildings. The media

themselves have often been less than cooperative with the overall tobacco control message. The fact is,

many media outlets have depended on tobacco advertising revenue.

It is tempting to view the lawsuits of the 1990s as a great success for tobacco control advocates

and a triumph for “media advocacy” approaches (Wallack, et al, 1993). But researchers raise the point

that campaign research in this area needs to continue. Logan and Longo (1999), for example, observe

that understanding how the “public resolves issues such as smoking cessation needs to be seen in a

broader context.” This broader context includes:

1) an assessment of the perceived credibility by the target audience toward mass media,news media, health care providers, tobacco firms, area health care agencies, the healthcare delivery system, and different classes of providers; 2) how smokers andnonsmokers differ on the linkage among biomedical, epidemiological, andtoxicological controversies; 3) how smoking issues are managed within arenas; 4) howarenas potentially undermine popular participation in public policy formation, and; 5)how in the creation of dialogue there should be dual emphases on the viability of theconcept and tactics (Logan & Longo, 1999).

Seen in this light, a lesson that public health campaign planners have learned is that without

continued attention and vigilance, public health challenges have a way of suddenly and unexpectedly

reasserting themselves.

Future Directions

There are several important issues in the application of media communication theory in health that

will continue to influence research in the new century. The first is continuing study of the media's

influence on vulnerable audiences such as children and adolescents. Although some in the "Baby

Boom" generation can recall a time without television, subsequent generations have been exposed to the

medium unrelentingly almost from birth, now joined by the Internet and many other new information

technologies. While we recognize that the media have powerful socializing effects for good, we also

recognize that the media's purpose is not primarily to support the goals of public health improvement

especially in light of its emphasis on advertising and entertainment. These frequently collide with the

goals of public health. Can the mass media as message producers par excellence be encouraged to do a

better job -- for example, to reduce content regarded as detrimental to public health goals?

The answer is an equivocal "maybe." There have been successes, notably efforts by public health

advocates to encourage television producers to include positive messages in their programs. Public

health advocates have continued to criticize violence in film and on television. Further successes in

encouraging the media to modify content at odds with the public health will depend in large measure on

the effectiveness of public health advocates in building the national agenda for such changes.

A second issue that will continue to be debated in the new century is the purposive use of mass

media to achieve health behavior change. Specifically, community health settings will continue to

provide an ideal environment to examine communication effects across levels of analysis. Of particular

interest is how communication at each level of analysis may influence or link to communication at other

levels. There undoubtedly are both structural and individual level factors responsible. For example,

Social Cognitive theorist Albert Bandura recently suggested that the "power" of any single channel of

communication (mass media or interpersonal) might depend on the complexity of the behavior change

being sought. The less complex the change, the more the influence of a single channel leading to

performance of the behavior (Bandura, 1994). On the other hand, the more complex the behavior, the

greater the need for multiple exposure to multiple sources. In this setting, the influence of any single

channel is relatively less.

Third is the issue of health disparities and how it relates to communication. Healthy People 2010,

the manifesto that guides the nation’s health objectives in the next decade, declares elimination of health

disparities as its one of its two goals the other being improving the quality of healthy life. By any count,

the data show that minorities and families with lower income and education suffer from greater disease

burden compared to Whites and those with higher income and education. Biology or genetic variation

alone does not explain the disparity as much as a combination of genetic, environmental and risk factors

together combine to create differences in morbidity and mortality between Whites and minorities and

upper and lower SES groups. For example, African Americans are more likely to suffer from cancer,

heart disease, diabetes and infant mortality compared to Whites (Haynes & Smedley, 1999, United

States, 2010). Similarly, Hispanics and Native Americans suffer unfavorably when compared with

Whites on rates of infant mortality, blood pressure, and infectious disease among others. Poverty,

inadequate access to health services and health information combine to create noxious soup of poor

health and chronic disease burden.

While the data are clear enough and the reasons behind the disparities many fold, a significant

strategy in eliminating disparities is to empower individuals to make healthy decisions and improve their

access to health services. Communication contributes to these circumstances at least insofar as structural

barriers of access and exposure continue to be too frequently ignored or overlooked. Communication

plays a significant role in informing people of risk factors and in helping them adopt preventive

behaviors. The current information environment is an embarrassment of riches providing significant

opportunities for targeting and tailoring information to the needy and we are only at the leading edge of

it.

Fourth, the emergence of new communication technologies provides opportunities and challenges

to health educators and researchers. The World Wide Web, newsgroups and other Internet innovations

offer information on an array of topics from diverse sources including health. Pew Internet & American

Life (Rainie & Packel, 2001) recently reported that almost 60 million Americans have used the net to

obtain medical and health information. This includes a substantially high number of African-Americans

and senior citizens. In theory, at least, the WWW could lead to a potential shift in control from the

source to the audience member. For example, the nature of the medium permits information to be

available "on demand" to users. Users can themselves generate, process and distribute information that

they think is critical and worth sharing. Thus, it appears that users can exert a greater degree of control

over the time, pace and topic of the information they seek.

However, there are two potentially serious issues that warrant closer examination. One has to do

with access to new media technologies and skills to use them effectively. A number of studies have

drawn attention to the increasing “digital divide” between households with higher income and education

compared to households with lower income and education (United States, 2000; Viswanath, McDonald

& Lavrakas, 2000). Further, minority households are less likely to have access to the “net” compared to

the Whites. Even though the recent data suggest that these gaps are closing, what is less appreciated is

the issue of quality of access. A majority still use dial-up modems that affect the access and download

time which is critical at a time when websites have become bandwidth intensive.

Another related issue is that of browsing style. One report suggests that lower income groups

spend more time on-line as opposed to higher income group who demonstrate more established usage

patterns. The number of “unique pages” visited is negatively related to income. In fact, the report

describes the higher-income” group’s browsing as “focused,” visiting fewer pages and spending less

time on the pages they visited (Media Metrix, August 2000). This might suggest that either the lower

income group may be finding it difficult to get the information they need, or that they may be spending

more time because of the “novelty” effect.

This brief review on disparities suggests that new media technologies have the potential to widen

the gap between those who can pay for access and have the skills, and those who can't. If so, a

significant portion of the population perhaps most in need of prevention information may be "out of the

loop" of important health information. In fact, the “digital divide” is a part of larger issue of

communication inequality where subscription to and use of telecommunication services including

telephones, cable TV, and access to the Internet and high speed networks among others are currently

unequally distributed and persistence of this trend could have potentially serious consequences over the

long term (Viswanath, 2001). It is also closely related to health disparities discussed earlier.

With respect to new technologies, a second concern has to do with the nature of control of

information. Unlike a traditional campaign in which campaign planners have more control over the kind

of information disseminated, the Internet offers less control but greater diversity. On the positive side,

this may give relatively greater freedom and autonomy to audience subgroups to seek the information

they require. On the other hand, health educators and health promotion advocates may have less control

over the accuracy and quality of health information. Given these twin challenges, the role of new media

technologies will become a significant area of public health application and scholarly inquiry that also

offers the promise to link interpersonal with mass media outcomes.

Finally, in light of the current preference in public health for community-based interventions, is

there a place for national media campaigns in public health? Some suggest that national campaigns are

a waste of time and resources that could be better spent mobilizing local communities for health

behavior change. Our judgment is that national media campaigns are important because they help build

a national prevention agenda on specific issues. Programs like the 5 A Day Campaign create a

foundation upon which local efforts can build. They can amplify local prevention efforts that are

typically more targeted and intense. The issues raised by national campaigns are usually of concern to

every community big or small. But national media campaigns should not be regarded as a substitute for

community prevention nor should they be expected in themselves to accomplish widespread behavior

change without local partnerships.

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TABLE 1. SELECTED COMMUNICATION THEORIES AND LEVELS OF ANALYSIS

Level of Analysis Theory/Concept Major Studies, Reviews Disciplinary Origin

1. Individual Hierarchies of Effects Ray, et al (1973)McGuire (1984)Chaffee & Roser (1986)

PsychologySocial Psychology

Persuasion Theories Hovland, et al (1953)Roloff & Miller (1980)Petty & Cacioppo (1981)McGuire (1985)Perloff (1993)

PsychologySocial Psychology

Social Cognitive Theory Bandura (1994) Social Psychology

2. Organization News Gatekeeping Donohue, et al (1995)Shoemaker (1991)

Sociology ofOrganizations

Reporter-SourceRelations

Sigal (1973; 1987) Sociology

Media Work Routines Roshco (1975)Tuchman (1978)

Sociology

Media Message Systems Gerbner, et al (1980)Turow (1992)

Sociology ofOrganizations

3. Communities andSocial Systems

Knowledge Gap Tichenor, et al (1980)Gaziano (1983)Viswanath & Finnegan(1995)

SociologyStructural/FunctionalismSocial Conflict

Diffusion of Innovations Rogers (1962; 1995) SociologySocial Psychology

4. Mass Society andCulture

Cultivation Studies Gerbner, et al (1994) Sociology ofMass Society

5. Cross-level Analysis

Definition, Framing ofSocial Problems

Iyengar & Kinder (1987)Entman (1993)Gamson & Modigliani(1987)Hilgartner & Bosk(1988)

SociologyPsychology

Risk Communication Weinstein (1984)Sandman (1987)Slovic, et al (1991)Glanz & Yang (1996)

SociologyPsychology

Agenda Setting McCombs & Shaw(1972)Kosicki (1993)

SociologyPsychologyPolitical Science

TABLE 2. KNOWLEDGE GAP CONCEPTS, DEFINITIONS, APPLICATIONS

Concept Definition Application

Knowledge Gap Difference in measured knowledgebetween groups of differingsocioeconomic status (SES) overtime.

Potential unintended consequenceof public health interventions toincrease SES-based differencesover time.

Knowledge Factual and interpretive informa-tion leading to understanding orusefulness for taking informedaction.

Communication of factual andinterpretive information aboutcauses and prevention of diseaseand skills for health improvement.

Information Flow Degree of availability of informa-tion on an issue or topic in a socialsystem such as a community.

Increasing community opportuni-ties (through multiple media andother channels) to encounterhealth information and knowledge

Socioeconomic Status (SES) Population units or subunitscharacterized on the basis ofdiffering education, income,wealth, or occupation.

Emphasis on information ofinterest and use to differing SESgroups; emphasis on channelstrategies designed to reachespecially low SES groups.

Social Structure/Pluralism Differentiation and interdepen-dence among community sub-systems including social institu-tions, organizations, interestgroups and other centers of powerand influence that maintain thesocial system; often influenced bysize of the community (the largerthe community, the greater thedifferentiation).

Highly differentiated communitiesincrease competition for publicattention to health information.While level of communicationactivity required is often moreintensive than in a smaller, lessdifferentiated community, publichealth resources permit dominat-ing the information flow butseldom; emphasis on targeting ofmedia and other strategies to reachgroups of interest.

Social Conflict Opposition or disagreement overan issue or problem often repre-senting a struggle for power andinfluence between social groups orleaders.

Controversy attracts mediaattention especially in highlydifferentiated communities; tendsto increase public interest and maylead to equalizing information ona topic across SES groups.

Mobilization Organized activity seeking tofocus community power andinfluence to address a problem orissue.

Media publicity about a publichealth issue is frequently driven bythe actions of social groups andleaders; increases public attentionand may lead to equalizinginformation across SES groups.

Motivation Factors influencing individuals toattend to, and act upon informa-tion and knowledge (e.g., personalinterest, involvement, self-effi-cacy).

Emphasis on strategies to increasemotivational factors to acquire andact upon information and knowl-edge.

TABLE 3. AGENDA SETTING CONCEPTS, DEFINITIONS, APPLICATIONS

Concept Definition Application

Media agenda setting Institutional roles, factors, andprocess that influence “the defini-tion, selection, and emphasis ofissues in the media.”

Work with media professionals tounderstand their work needs androutines in gathering and reportingnews.

Public agenda setting The link between issues portrayedin the media and the public’s issuepriorities.

Work with media professionals inadvocacy or partnership context tobuild the public agenda forimportant health issues.

Policy agenda setting The link between issues developedin policy-making institutions andissues portrayed by the media.

Work with community leaders andpolicy makers to build importanceof health issues on the media’s andpublic’s agenda.

Problem identification,definition

Factors and process leading to theidentification of an issue as a“problem” by social institutions.

Community leaders, advocacygroups, organizations mobilized todefine an issue and modes ofsolution or basis for action.

Framing Organized public discourse aboutan issue leading to the selectionand emphasis of some characteris-tics and dimensions and theexclusion of others.

Public health advocacy groups“package” an important healthissue for the media and the public(e.g., second-hand smoke framedas public’s involuntary exposure totoxic pollutant contrasted with“smokers’ rights” emphasis oftobacco advocates).

About the Authors...

JOHN R. FINNEGAN JR. (Ph.D 1985) is Professor of Epidemiology and Associate Dean for

Academic Affairs at the School of Public Health, University of Minnesota, Minneapolis. He teaches and

conducts research in community-based public health campaigns with an emphasis on communication

and media applications. His recent publications have appeared in , Preventive Medicine, The Journal of

the American Medical Association, Journal of Health Communication, and Evaluation and Program

Planning.

K. VISWANATH (Ph.D 1990) is a Senior Project Officer with the National Cancer Institute’s

Health Communication & Informatics Research Branch in the Division of Cancer Control and

Population Sciences, Bethesda, MD. He conducts research in media effects with an emphasis on

community, social structure, and conflict and is a frequent contributor to research in health

communication settings. His recent publications have appeared in Preventive Medicine, Journalism

Quarterly, and Health Communication.