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Communication and Community Development for Health Information:

Constructs and Models for Evaluation

by

John E. Bowes
School of Communications
University of Washington
Seattle, WA 98195-3740
jbowes@u.washington.edu

 

Review prepared for the National Network of Libraries of Medicine

Pacific Northwest Region, Seattle, December, 1997

 

Introduction:

The perspective of this review is taken from a deceptively simple vantage: community development and communication. In turn, these derivative fields draw from a wide assortment of more established literature encompassing traditional fields such as sociology, telecommunications, informatics, business management and public health.

Our purpose is to suggest variables, methods and techniques - with their associated models - that may lead to better assessment of programs delivering health information to hard-to-reach rural areas and minority communities. The basic organization followed is:

For each of these categories, we summarize key characteristics and describe major examples.

Community and Communication

The study of community and communication has a history extending back to the turn of the century. Scholars of then nascent social science such as Dewey and Park [1] wondered how mass media could create unity and commonality among people faced with their increased dispersion in large cities of the industrial revolution or the distant frontier of an unsettled West. A little earlier in the 1890s, the French sociologist, Gabriel Tarde, distinguished public opinion as a collective community voice organized in part by media comment.[2] By the late 1920s, the idea of communication and community were inseparable. Not only was the daily interaction of citizens essential to collective action, their media served to stimulate and direct it. Many community needs from education to public health became entwined with information technologies and the growing list of agencies with professional and public information mandates.

The concept of community itself has varied understandings across the disciplines that study it. Hillery, for example collected and contrasted some 94 definitions of the term.[3] This variety withstanding, he developed three essential components: (a) persons in social interaction; (b) within a geographic area; (c) having one or more additional common ties. Somewhat more elegantly, Bracht referred to a community as " . . a group of people sharing values and institutions." [4] Its components included, " . . locality, an interdependent social group, interpersonal relationships, and a culture . . "[5] Dewey pointed out the essential nature of communication to these components in that it permitted an intellectual and conscious sustenance of the communal common good. It was and is a necessary prerequisite.

In recent years, the idea of community as a physical place has been discounted somewhat in favor of "virtual" communities.[6] The development and spread of interactive, computer-based media have removed the geographical constraints of traditional broadcast and print media.. The internet and direct broadcast satellites are two new cases where distance makes little difference to the information community congregated at their terminals. Thus it is useful to consider that communication doesn't simply support the traditional community, it can alter the very definition itself.

The point of the foregoing is to introduce the importance of telemedicine and medical informatics to this review in addition to more traditional communication fields. As specialties developed in the past two decades, they have accelerated the availability of health information through technology for hard-to-access groups and venues, greatly transforming the economics and potentials of this effort.

 

The Rural and Hard-to-Reach Groups

The other major condition of this review is that it is directed to health communication among disadvantaged peoples in unpopulated areas, such as Native Americans and the rural poor. The reforms over the past decade in US health care have been profound with widespread managed care and federal government re-evaluation of its healthcare role. Rural areas, though touched by such change, have not solved their core healthcare problem: how to ". . . get health care providers and services into rural areas and keep them there."[7] Yet these regions are the most needy, having lower incomes, poorer health, higher percentages of elderly, fewer local medical practitioners and lower rates of insurance.[8] Rural circumstances militate against good health insurance plans and other funding innovations for the lack of large employers and adequate incomes. Managed heath care and multi-provider delivery systems may increasingly concentrate care in larger, more distant facilities in search of economies of scale and surer funding. The outcome, progressively, is a decamping of good health care from rural regions.[9]

Would communications technologies reasonably penetrate this growing isolation? Unfortunately, these technologies are also wanting in rural areas. Native Americans (including American Indians, Aleuts and Eskimos) in these venues have proportionally the fewest telephones, the fewest personal computers and least modems for network connectivity. This lack is particularly acute for the young and very old of these regions.[10] While some of this situation is for lack of infrastructure (the adequacy of rural telecommunications wiring and service providers), the core problem traces to costs, incomes and perceived utility of the technology.[11] Telephone costs, particularly installation, may be high. Reaching resources may involve toll calls more frequently than for urban residents. Then there is the problem of information "literacy" - how to express needs in terms technologies can help answer.

The situation seems paradoxical: one of the best solutions to rural isolation encounters a series of barriers based on both material and social-psychological issues. As a study for Congress on Native American access to telecommunications concluded:

"Telecommunications technology offers many opportunities to help Native Americans deepen their cultural roots, empower their communities, strengthen Native governments and address daunting challenges such as very high unemployment and poverty rates and poor health conditions. The promise of telecommunications is by no means assured, however [emphasis theirs]. Indeed, if Native Americans, collectively, do not gain better understanding and control of this technology, the result could be to further undermine Native culture, community, sovereignty, and self-determination."[12]

The interplay of communication technology and its use among the least technologically literate will be a theme in this review.

 

Literature Reviewed:

An eclectic mix of research, review and professional training literature was examined both in traditional and electronic form. Considerable resources on health communication and rural regions exist on the Internet as the possibilities of this technology are readily put to practice as an informational fix to growing rural health care problems. Many rural medical programs are interlinked in this way, variously disseminating medical help, recruiting health professionals seeking to work in rural areas, trading news of telemedicine advances and advertising grant programs.[13]

There is much in the traditional communications literature and allied social sciences, particularly in the growing research specialty of health communications. More than two dozen universities offer specialty programs in this field based in the traditional social sciences or schools of communication. Similarly, programs in medical informatics have joined more established departments of public health in many major medical schools. Together, these programs have produced a growing corpus of applied research..

Governments, particularly at the federal level in the United States and Canada, have increased their efforts to understand the rapid changes in health care and information by commissioning studies and research reviews. The now disbanded Congressional Office of Technology Assessment (OTA) was particularly useful in its several major reports on rural telecommunications and health care status.

We review literature from the following specialties:

Medical informatics and telemedicine have much to say about "community health information networks" but many paths are followed from this point.[14, 15] Patient information and standards for record-keeping is a recurrent concern[16] as is medical education for physicians, providing public health and epidemiological data, and promotion of citizen involvement in health issues.[17]

Public health considers the widest range of community health communication implications.[18] These include technology and scientific information transfer across cultural lines, rural development, patient-provider communication, and support of community health centers.

Communication and mass communication have held eclectic interest in health communication and information. As a derivative fields they borrow their concepts widely from other disciplines, mixing them with ones of their own invention. Having a role in this review are:

The variety of models, variables and interventions available from the foregoing is considerable and far beyond the scope of this paper to treat exhaustively. Rather, attention is placed on what we think are key variables that have been used frequently in prior research, have some demonstrated importance and perhaps have heuristic or conceptual value for future assessment design. The emphasis - judgmentally - is upon those seen as most useful in assessing rural-directed information programs.

 

Process Components

In this section we exploit a review of literature for key models, inputs, interventions and outcomes. Later, we examine methodological and evaluation issues.

Models

It is useful to consider models initially rather than as a concluding stroke; they are an abstraction of relationships in a communication/information process.[23] As such, they are a guide to input variables, a description - schematically - of processes and a summary of possible outcomes from community bio-medical information. They direct attention toward relevant inputs and outcomes, and methods of evaluation.

Both the communication literature generally and public health in particular have been rich in generating models. Historically, there has been a progression from postwar years to the present from considering education and change in individuals to that of groups and communities. Most recently, this kind of conceptualization has been spurred by the growth of computer mediated communication, such as with the internet, and the social configurations resulting when distance is not a factor. Some models remain simple descriptions of process, fixed in time and circumstance of a particular program. In this review, we favor models based on testing both project-specific and generalized, conceptual goals.

 

Models based on Communication and Change:

From study of advertising, journalism, wartime persuasion and education, several important communication processes have been mapped. Drawing largely on the social sciences, useful generalizations, at first rather simple, have grown in complexity to explain effective communication. We review several (below) that offer important concepts and processes.

Transmission Models were typical of early postwar thinking about human communication. With roots in engineering and information science, formulations such as the Shannon-Weaver Model[24] and Berlo's human communication adaptation of it,[25] showed simple, linear information flow from mass media to individuals.[26] A metaphor to the telephone equipment originally diagrammed, human communication was pictured as a one way message flow from a source, passed through media channels, "decoded" (semantically) by audiences and applied to daily life. Emphasis rested upon the receptivity of audience members to a mass media or institutional message or simply being exposed to it. Considerations of attitudes, values, belief, basic demographics such as gender, education and social/income class were inputs governing the influence of the communication.

Transmission was popular in the immediate postwar years for conceptualizing mass communication in ways congenial to a commercial media system seeking greater influence upon consumers. Simple and mechanistic, these models served to organize key variables of a burgeoning new medium, television. They are apparent in modern public health studies that examine solely the recall of messages or compliance behavior by the public. Like basic advertising research, the outcomes consist of attitudes, information recall or behaviors compliant with the message. In this aging view, communities and consumers are vessels to be filled and directed by media content.

By the early 1960s, a social component was developed as the Westley-McLean Two Step Flow Model.[27] This elaboration recognized the importance of social networks to the dissemination of media information. Intervening the early transmission model's direct path from media or institution to the audience was an interpersonal network of friends and co-workers. These people often were persuasive providers of media information, mixed with their advice and experience. This improvement recognized the complexity in transmission of media information: it is often filtered and promoted through personal influence.

Key in this process are opinion leaders who mediate agency or mass media content on behalf of friends and family. Abundant research over the past 40 years attests to the power of these informal "experts" and their ability to amplify (or frustrate) the best of media campaigns. An elaboration by Robinson of the two-step model is shown in figure 1. The activity there is of "opinion givers" discussing media content with each other and with "opinion receivers" who use this filtered content with information directly from the media. The community, thus, is part of media information creation as well as the audience for it.

Figure 1: Information and opinion flow shown in revised "two-step" model, from Robinson. [28]

Diffusion models, still highly useful 35 years after inception, rest on an individual's decision (and speed) to innovate or adopt a practice. Based on research extending back to the beginning of the century, diffusion research accelerated with postwar international development efforts. First cast for individuals and later expanded to groups, in this process model one moves in

Figure 2: Rogers' Diffusion Model (1995) [29]

 

sequence from first awareness to eventual confirmation (or rejection) of the adoption decision. Applied to both individuals and communities, this model has had long and productive application to community health and adoption of biomedical information. From networks of physicians adopting new pharmaceuticals to analyses of seat belt campaigns, the model has provided considerable explanatory worth.[30, 31]

Diffusion models have been productively extended to an organizational setting. Though distinct differences mark communities apart from organizations, stages shown in figure 3 resemble those found in processes of decision formation common to community health questions. Issues like water fluoridation, condom distribution, no smoking ordinances and heart disease prevention all have involved community governments either as agents or facilitators.[32]

In public opinion processes, such as suggested by Bernard Hennessy,[33] collective problems set the community's agenda for action (agenda setting). Discussion ensues - and often argument - about likely solutions (matching). Solutions are adapted and fitted (reinvention). Community support and other responsibilities to the solution are defined (clarifying). The practice ultimately becomes a normal part of community functioning (routinized). With an extensive research base, Rogers' model has adapted well to change - from a focus on the individual to one of social networking and group decision-making.

Figure 3: Five stages in organizational innovation, from Rogers.[34]

 

Co-orientation models acknowledge the reciprocal nature of communication common in negotiation and community-based programs where citizen input is a part of fashioning the delivery of expert information. Though originally conceived for interpersonal communication, co-orientation has been extended to group and mass communication situations.[35, 36] These models have shown their value in diagnosing "gaps" in information networks. The model is predicated upon contrasting message agreement or compliance with message understanding. To accomplish the latter, the recipient must recognize the differences in ascribed meaning between the source and him/herself.

Figure 4: Co-orientation, showing accuracy, agreement and perceived agreement relationships. Arrows show comparisons made.

 

Accuracy measures the extent to which each party's estimate coincides with the other's described position or perception. Agreement assesses actual overlap in described position. Agreement perceived suggests the level of discrepancy or congruence with the other. Though a simple model, it juxtaposes two historically important themes in communication; that of persuasion v. accurate or understood communication. Persuasion seeks agreement of the information client with the agency, often regardless of whether the information is understood. Compliance may be secured under these conditions, but may eventually fail since it is not based on a correct perception of what an agency meant. Irrational or mistaken adoption has often occurred in behavior change or technology transfer campaigns. But discontinuance, dissatisfaction or irrational use may be at high levels. The difference here, in short, is that between short-termselling and teaching lasting change. The model has tested a number of information diffusion efforts, largely technical information about environmental change.[37]

The utility of this model is its diagnostic capacity. Rather than test for message receipt, comprehension or compliance, this model tests mutuality of perception; that the meaning and implication of the message is shared between agency and client - regardless of whether the communication is from agency to client or the reverse. For public heath information, the implication is the simple idea that misunderstanding technical information is common; that it is necessary to test what individuals make of it.

Grunig's Nested Segmentation and Situational Theory: Grunig's formulation is not a process model, but shows well the context in which health information is considered. Each individual has multiple memberships, ranging from active interest groups or publics on issues like abortion or AIDS to broad social categories reflecting general lifestyle and ability to understand biomedical information. As one departs from the "inner nests," these memberships become broader, less distinct and less predictive of information effects.

Figure 5: Grunig's segmentation. [38]

 

Grunig's key idea is audience segmentation. By understanding an individual's membership in communities, publics, subcultures (etc.), the barriers to an information campaign can be anticipated. Of special note are the inferred variables of the individual: his or her perceptions, cognitions and attitudes. With these, the researcher can determine if: (a) the audience recognizes a given situation as a problem; (b) whether they are involved in the situation; (c) whether one has a sense of personal control in the situation; and (d) whether they have a solution to offer. If one responds affirmatively to most of this list, they will more likely seek and process information about the situation.[39]

To add further complexity, these segments shift with time and situation. The passing of time gradually alters some (one becomes "middle aged"), but situational forces alter others, such as sudden income declines, political shifts and disease (the newly informed HIV + person commonly often sees his or her future rather differently following testing). These shifts affect people's receptivity to messages and their communication behavior, often in a short period of time.

 

Summary: These basic models introduce several important concepts to our discussion.

 

Models Based in Community Health and Education:

Another group of models is more specific to explaining media, community development or health agency communication effects. Our representation is selective by choosing models typifying important processes in biomedical and technical information, which show key variables. Several deserve attention: Social Learning Models and more comprehensive community health education models, such as the Stanford Process and PRECEDE, describe the entire cycle of campaign planning. Though these models have distinct communication elements, they show a more complete process of community health intervention than the former.

Social Learning Models. Traditionally, health education has been grounded in behavior change theories such as the Health Belief Model, the Theory of Reasoned Action and Bandura’s Social Learning/Cognitive Theories. Central is the individual's attitude towards adopting health practices.[40, 41] In the Health Belief Model, successful campaigns are contingent upon value being placed on a particular outcome (such as longevity) by a person and his estimate of how likely a given health action will produce that outcome.[42] Individual perceptions of severity and susceptibility to disease are taken with co-variables, such as demographics, personal information from others and experience with illness, as predictors of taking action.

Figure 6: Health Belief Model from Janz & Becker.[43]

 

More generally, the social learning paradigm extends this process to learning from the mass media. In examining the harmful effects of televised or cinematic violence, Bandura examined co-variables, such as demographics, personal information from others and illness with other family members, that are "modifying factors" to media influence - a social learning or experiential component.

A key concept is self-efficacy, a person's belief about his or her control over one's behavior and motivation in a social environment.[44] Related is the idea of expectation; that one's behavior materially affects outcomes. Self-effective people see clearly the link of personal actions to outcomes that affect them. In earlier work by Julian Rotter, these individuals were shown to have a sense of internal control in contrast to those who believe that they hold little sway over their future - victims of fate.[45]

Later variations added the ideas of "behavioral intention;" that is, the individual's prior behavior, their attitude toward the behavior advocated in the campaign and subjectively held norms.[46] These new conditions, though making the model more complex, worked productively to predict outcomes about health risks such as marijuana and alcohol use. The major improvement given, methodologically and conceptually, is a better elaboration of causal forces as predisposing beliefs in individual decisions about health behaviors. The major drawback is that there is little consideration of the totality of the health information process at a community level.

The Stanford Process Model is a linear plan for health information on oral rehydration therapy (ORT) and other practices to eliminate infant diarrhea (as PROCOMSI, or Proyecto de Comunicacion Masiva Aplicada a la Salud Infantil). Staged in rural Honduras in the 1980s, the plan coordinated an extensive print, broadcast and interpersonal campaign aimed at a narrow set of infant health issues. The knowledge and behavioral change objectives were based in education, social learning and social marketing. "Formative" evaluation allowed systematic development of messages by checking effects at several interim points. The main difference from the previous model is a focus on specific communication inputs and learning rather than prior motivational

Figure 7: The Stanford Process Model, from D. Foote, et al.[47]

 

states and perceived self-efficacy. Outcomes are assessed at several points as the campaign unfolds. Near-term effects are message exposure (stage 3), while stages 4 and 5 concern attitude shifts and knowledge gains. End stages look at behaviors showing improved hygiene, infant care and nutritional practices (stages 6 and 7) and morbidity/mortality (stage 8). Later we discuss the contrast of impacts and outcomes, shown clearly here between near and long-term consequences of the study's interventions. In common with other models (Rogers' Diffusion Model and PRECEDE), there is a movement from message exposure, through cognitive change to behavioral changes and the outcomes they enable.

The PRECEDE Model or "Predisposing, Reinforcing, Enabling Causes in Educational Diagnosis." This complex schematic focuses on organization and diagnostic work. Proceeding from right to left, six phases work backwards causally from social and epidemiological outcomes and social factors through behavioral causes of health problems to (finally) educational and administrative roots. Health communications figures heavily in these last two stages and is elaborated into three components: "direct" communication to the community to promote "predisposing factors" like knowledge and values about health; "indirect" communication to staff who in turn would "reinforce" community health information; and community "training" to "enable" community health information through better local organization. Where communications models are strong on messages, media and audience, this model emphasizes the mutually supportive organization needed to field a major campaign, the goal states desired and the path to them. Above all, this model shifts focus from one largely of educational needs, as in the social learning model, to the social, political, organizational and regulatory issues in community health planning.  

Figure 8: PRECEDE model, from Brecken, et al.[48]

The PRECEDE model was later revised by Green (as the PROCEED model). In addition to some streamlining of the earlier work, the author suggests the kind of diagnostic evaluation needed at each stage. These are added in the last text line of the chart and are considered later in this review.

The PATCH Model was developed as a networking and planning model mandated by the Healthy Communities 2000 Project.[49] Vertical and horizontal communication are encouraged as part of this large public health effort. Vertical communication involves national, state and local "levels" while horizontal ties link government, NGOs and voluntary groups. The goal is to give local voice, participation and focus to what otherwise could be a top-down structure. Commendable as this team approach is, the model lacks many diagnostic, process and variable identification features found in previous examples.

While these models all have applicability in some ways to rural and hard-to-reach minorities, none are specific to those conditions. Mass communication, by its historical nature, has only lately come to regard audience segmentation and niche programming as essential. With channels numbering in the hundreds, commercial researchers are now seeing value in reaching smaller, better understood audiences. Marketplace pressures, however, direct attention to those likely to spend. The rural poor hold little sway in this reckoning.

 

Summary: These models vary considerably in inclusiveness and complexity, ranging from the basic Health Belief Model to the complexity of PRECEDE with attention to not only the clients of health behavior change, but the institutional and social milieux in which such change arises. In this variety they do have some important commonalities:

While these models all have applicability in some ways to rural and hard-to-reach minorities, none are specific to those conditions. Mass communication, by its historical nature, has only lately come to regard audience segmentation and niche programming as essential. With channels numbering in the hundreds, commercial researchers are now seeing value in reaching smaller, better understood audiences. Marketplace pressures, however, direct attention to those likely to spend. The rural poor hold little sway in this reckoning.

 

Inputs: Key Variables of the Community - Communication Matrix

The implication of "inputs" is that of presumed causes or preconditions of health communication. In short, these are the independent variables governing the function and outcomes of an information program. While myriad possibilities exist of important or at least situationally useful variables, the accounting below is largely confined to inputs suggested by the models just reviewed. The variables we describe are not meant to be exhaustive; rather they are indicative, typical and important to a given class. Outcome variables, the dependencies of inputs and processes, are considered as a separate section.

It should be noted that differences among some variables may be more abstract then real. For example, individual characteristics of community members verge on their collective memberships. Social status both is indicative of individual income, occupation and education as well as group identity - such as being among the childless, married, professional and under 40 years old (the DINK - dual income no kids - or Yuppie).

More confusing is the linkage of observable indicators (education and income, say) with inferred variables such as innovativeness, risk-taking, and internalized locus of control. This frequent problem of drawing conceptual boundaries brings issues of measurement validity which we take-up later. For the moment, it suffices to realize that clean distinctions are difficult in practice and operational confounding is commonplace.

The models we have reviewed have many elements in common. In rough summary, most recognize:

There is a rich supply of additional elements to consider which distinguish models:

Message characteristics also may include the kind of appeals or logic to adopt a practice. In communication research during the Second War, there was an understandably preoccupation with persuasive appeals and propaganda. Techniques long taught to high school students, such as fear appeals, placed a premium on short term persuasion rather than long-term rational adoption of a practice. Other, more subtle manipulations were developed involving social reinforcement. Use of media forums and community discussion organized by local change agents helped adapt a mass message to community conditions. Though persuasion was still paramount, the interpersonal links gave distant communications a local face and better acceptance. These practices are still used to enhance the effectiveness of rural education programs.

Persuasion goals were overshadowed in the late 1960s by efforts to appeal to audience uses and gratifications. This perspective did not necessarily result in a new class of message variables; rather, it emphasized the importance of considering audience desires in designing message strategies. One message approach did not fit all. "Uses and gratifications" brought the simple idea that research was needed to analyze audiences prior to campaigning. As audiences differed, so too would the messages each received. The early imperatives of propaganda were now tempered with the need to appeal to smaller, better-understood audience segments.

Additionally, production qualities are of obvious importance, but are less amenable to easy isolation and quantification. Suffice to say that such judgments rest on aesthetics, production skills, good scripting or writing and so on in a way that is meaningful and compelling to a targeted audience.

 

Processes or Interventions

Tones, Tilford and Robinson offer the following typology of community health interventions (table 1).

Table 1: Typology of community health interventions, from Tones, et al. [56]

 

Fundamentally, two major dimensions are considered: general community health development where the intervention is used to strengthen in situ community resources, and "top-down" focused campaigns that may consult the community, but are otherwise centrally managed. Other dimensions include solo agency programs contrasted to involvement by a mix of agencies and of situations where health is either the sole concern or is among several community development goals.

A goal of community development is the internalization of community health practices, ones that will endure when the project ends and field workers withdraw. In contrast, a centrally managed program can possibly coordinate resources better and manage complex interventions on a large scale. There is, however, risk of the community becoming dependent on a project's support and administrative expertise.

What are actual interventions or processes that show promise? These are hard to glean from the skeleton of models. Actual projects better flesh out what is done and what may work. We consider several influential projects below:

The Stanford Three Community Study: The TCS study was begun in 1971 and extended through 1975. The purpose was to investigate the influence of large-scale intervention on the knowledge, attitudes and risk-related behaviors in two medium-sized cities.[57] Results were compared to an "untreated" control community. Objectives included lowering blood pressure, plasma cholesterol and body weight through increased physical activity, better diet and smoking cessation. Their interventions, summarized, are shown in table 2, below:

Table 2: The Health Communication-Behavior Change Model, from Farquahar, et al. [58]

 

The model is based on three core psychological processes with behavioral consequences: (1) cognitive structures or knowledge; (2) affective structures or motivation and (3) action structures or behavior. In a quasi-experimental design, two major interventions were compared. In one community, mass media alone were used for coronary heart disease (CHD) reduction. In a comparable community, media were supplemented by face-to-face skills training, incentives and support for high risk participants and their spouses. Media products varied: television and radio spot announcements, newspaper stories, cookbooks, transit posters and health pamphlets. Pilot and pretest studies assured that media products were tailored to local idioms, cultural experience and knowledge. As hypothesized, in treated communities, CHD rates showed improvements compared to the control. Initially, media combined with intensive face-to-face techniques had the strongest effects, followed by the media-only community. But later, for some measured effects, differences declined between the two experimental towns. For knowledge, media alone seemed to have an effect equal to the combination treatment of media and face-to-face interventions. But others, such as smoking cessation, seemed to require the social support, medications and face-to-face communication of the combined condition.

Stanford Five City Project: The FCP study differed from the previous in several key respects: there was a greater age range of subjects; objectives included maintenance of the education program as a goal; the study had an extensive "community mobilization" component; and community heart attack and stroke (CHD/CVD) rates were monitored. These changes and a 14 year study duration (begun in 1978) attempted to enhance the generality of the previous work. Again, a quasi-experimental design was used, but in five communities to afford a greater number of control comparisons for testing threats to internal validity. Both cross-sectional surveys and cohort panel surveys were used for data collection. Variables assessed included communication, psychological, behavioral, physical, and physiological indicators.[59]

Flora, Maccoby and Farquahar in their review of these studies offer three "primary principles."[60]

The Minnesota Heart Health Program: Though the medical goals of the Minnesota program were nearly identical to the Stanford studies, its emphasis on strengthening community infrastructure was different. A three step plan was used: the research team's "community analysis" first identified community and special interest leaders to serve on advisory boards and become involved in training. "Task forces" then were constituted to develop strategies and influence the community. The final phase took place with "social system support" and the movement of task force member into schools, unions, clubs and churches. In practical terms, this meant a varied repertoire of techniques - from food labeling in supermarkets and restaurants as "heart healthy," to favorable employer insurance rates for employees complying with low risk behaviors, and improved opportunities for physical activity in all age groups.

In general terms, the key design feature in the MHHP is pervasive and tight community integration in multiple places and circumstances. While there was an imposed structure in planning and development (the task forces), delivery of interventions was by neighbors in familiar places and social settings. The study's sponsors wanted involvement where citizens and communities easily identify with a movement and "take responsibility jointly with health professionals . . for making decisions and carrying out activities."[61] The researchers believe the programs they started, because of deep community involvement, will persist long after the study is concluded.

The Pawtucket Heart Health Program: This program closely resembles the MHHP in its interventions, seeking a blend of top-down imposed planning and grass-roots citizen participation. As before, the point was a seamless integration of heart healthy practices in routine life of the community. To promote this, there were four "social action" principles for designing interventions:[62]

The project reported significant gains in community weight reduction, improved hypertension levels and program participation.

Other Projects: There are other projects deserving of mention. The North Karelia Project (Finland) had the same goals as the CHD reduction projects just described, but its European context was reflected in its ability to coordinate schools, the national health service and provide direct aid. With considerable government resources at hand, interventions could be large scale and be sustained.[63] Similar in some respects was the Forty Family Pilot Study, a broad development effort for improvement of health care along with the social and economic well-being of remote Alaskan communities.[64] As in North Karelia, substantial interventions were made by government agencies, impacting not only health, but income, housing, employment and general education. In both, citizen organization and input were present, but much less dominant than in the interventions discussed previously. Despite their "top-down" character, reported results have been impressive.

What can be drawn in common from this group of studies with particular relevance for rural and minority groups?

 

Outcomes, Evaluation and Methodological Issues:

In studies we reviewed, considerable attention is given to outcomes. Outcomes are, after all, the expensive "deliverables" of years of work measuring improvement in the health and health awareness of citizens. In 1987, an ad hoc work group of the American Public Health Association, collaborating with the Center for Health promotion and Education of the Centers for Disease Control, developed five criteria for health promotion and education programs, including that " . . a health promotion program should be organized, planned, and implemented in such a way that its operation and effects can be evaluated."[65] Funding agencies, increasingly, are requiring up to 15% of budgets be devoted to formal evaluation of sponsored programs.

Israel, et al. develop five major conceptual design issues shown in table 3. A key point is that evaluation is not confined to the final outcomes of a program. Indeed, as suggested in the Green's PRECEDE model, evaluation is recurrent through the life of a project, beginning with a pre-program needs assessment. Critical, as the table indicates, are choices about who should be queried and in what detail about what. What are criterions to be met, if any? Is a mandated level of improvement in, say, awareness to be set as a goal? Or is the assessment compared to what would be if there was no program? Are assessments quantitative, measurable or qualitative comments about well-being? Taken together, these give assessment a high order of complexity.

Table 3: Design issues for outcomes evaluation, from Israel, et al. [66]

Commonly, comprehensive evaluations, such as shown in the PRECEDE models and the Stanford Projects, have four parts (below). Smaller studies may have perhaps one or two:

"Much emphasis in evaluation has been placed upon assessing impact and outcomes . . . often resulting in knowledge about whether objectives of a program were met, but not about what produced those observed outcomes."[67]

Process data, thus, are most useful when analyzed together with outcome data. Recognition in the Stanford Three City Study that smoking cessation benefited from social support in combination with media information probably could not have been clearly gleaned from examining outcome differences among treatment groups alone. A qualitative feel for what participants were experiencing as learned in a process evaluation likely gave the needed insight for this important conclusion.

Outcome Indicators: Taking impacts and outcomes together, they organize into several distinct classes:

 

Methodological Issues: In any systematic social science endeavor, there are always measurement and methodology problems. Good studies really are judicious compromises of a number of countervailing forces, ranging from cost limitations to the ambitiousness of the program's agenda. It is well beyond this review to provide a catalogue of such issues; rather, our focus is upon major questions and problems reported in the kinds of studies described above. Israel et al. provided a particularly well organized discussion of methodological problems in evaluating health education programs.[68] Major issues include:

 

Synthesis and Recommendations for the NNLM

The communication and community literature is far richer in its consideration of white Middle America or of remote third world peoples than it is of North America's own rural minorities. We must often rely on advice from examples that don't fit our target population well. From this thin research base, we may strain to see implications for improving delivery of biomedical information available from the National Libraries of Medicine: a rich, technical database of high utility to medical research but more distant from the common problems of community health interventions. The effort is necessary, nevertheless, to develop the best extensions possible to rural Native American communities.

The central problem, we argue, is to translate the advice of a research library to the daily needs of distant consumers who may be low in scientific or technical knowledge, but highly in need of practical health advice suited to their lifestyle. The rural health paraprofessional may be the best opportunity to refashion this advice to practical in-service solutions. To effect this, an exchange is needed. NNLM personnel can learn those community health needs that are informational, then determine if the "answers" are available in their collections. Community agents could better learn how to locate needed information in the NNLM system (and the expert human help they may need), in effect translating their questions into forms the system can answer.

But this is a more complex transaction than this quick sketch suggests. Consider several likely steps to using NNLM information, beginning with a community health problem:

Table 5: Steps or process of NNLM information transfer.

To elaborate:

Problems: The ability to state a need as a "problem" is not automatic. Psychological discomfort, physical illness and feelings of neglect may be potent in a community, but may not yet be crystallized as an "action" item for local institutions. Until a problem can be described, communicated and achieves some collective recognition, it likely won't be recognized beyond an individual's sense of apprehension.

Problem Components: Problem orientation speaks to how a problem is framed. Alcoholism, for example, can be seen as a medical problem, a family or social problem, an individual moral problem, or a community safety problem. How it is handled differs according to orientation. The police perspective differs markedly from the medical.

Is the problem even seen as one of information? Useful medical information may not germinate solutions if problems are perceived as a lack of resources, general education or traditional values. What can mere research information do to overcome these potent obstacles? Moreover, if community institutions deny problems exist or cannot speak to socially sensitive ones (such taboos as AIDS, drug use and promiscuous sex), a solution is "constrained" in the sense that unresponsive community institutions may frustrate individuals' efforts to cope. However fearful one is about alcohol abuse by children, if the community refuses to effectively enforce drinking age rules, there's little hope for individual efforts.

Constraint may be profoundly psychological. Much in the literature we review speaks to an individual's internalized sense of control, that one's behavior materially affects health outcomes. If this relationship is not seen, outcomes are perceived as a matter of chance or fate - sapping any motive for attending information designed to improve health. Of what use would it be?

Other problems are contingent; they require an encompassing, broad cooperation to work a solution. Community-wide dietary changes, for example, oblige suppliers, sellers and preparers of food to cooperate. They are all part of a system of provision that needs informal agreement on goals to operate.

Resources also play. "Heart healthy" diets may require more expensive, nutritious foods. Effective diabetes control, for example, may need persistent monitoring of blood sugar, test kits and drugs, costing in both human and cash resources. Informational solutions do not exist in a vacuum, satisfied only by timely provision of research data. Cash, social and human services, and education may be equally essential accompaniments.

Mediating Personnel: Who actually forms the liaison between expert information and the rural user? The wealth of diffusion research suggests that these individuals be similar in outlook and culture (e.g. "homophilous") to those they serve. Yet the very technology that accelerates a cost-efficient presence of a medical library in rural venues forces a stark contrast of urban high-tech medical libraries to the village clinic, putting them virtually side-by-side. While the technology may permit rapid communication between them, will the participants know what to say? The solution may be a long process of training field workers to use NNLM products, and - perhaps more difficult - refashioning NNLM data to better suit field conditions. Mediators need a high level of empathy, an ability to psychologically span the gaps of venue, education and culture that mark research library experts apart from a distant, rural community and its healthcare personnel.

NNLM Access: Both the technology and personnel deployment of the NNLM play important roles. Computer-mediated libraries are commonplace, but prosper where telecommunications infrastructures are modern and economically accessed. The distances and low population densities of rural regions frustrate this. As well, access means the human resources to accommodate inexpert patrons and to translate community needs in terms addressable by an NNLM research archive. Our sense is that this human bridge must be highly attentive to learning the structure and folkways of distant Native American communities, developing into a two-way information flow where community comment is given careful attention. Too little is known otherwise to allow for good a priori assumptions and set programs that follow.

Efficacy: Only with carefully chosen criteria and regular assessment can the efficacy of NNLM efforts be charted. Long-term outcome analysis is the gold standard of health information: does it improve lives in real, measurable terms? But proximal indicators of process and impact evaluation are needed to calibrate and manage expensive outreach programs. We believe mediating personnel are the mineshaft canaries of this process, those most sensitive to its success or failure. So while criteria and the validity of assessment strategies may pose complexities, the key "bridge" personnel usually can be identified with some ease.

What should be considered as hallmarks of short-term efficacy? From a communication and community perspective, there are several we suggest:

Who provides this information and how? Our recommendation is to start with community health workers and their counterparts in the affiliated NNLM. These individuals likely will provide qualitative information, giving considerable detail on local biomedical information use and problems in its transfer from the NNLM. More systematic techniques - focus groups, interviews of community leaders and sample surveys - provide a wider intake of community information. Unfortunately, these methods are costly in time, labor and cash. But they are inexpensive in contrast to years of wasted effort spent in poorly designed information transfer programs.

 

General Conceptual and Implementation Issues

Several critiques reviewed discussed the importance of theory in contrast to an exclusive focus on descriptive needs in designing evaluation programs. Most of the models shown above used variously elements of social learning, marketing, diffusion and change, uses and gratifications, and homeostatic theories. This theory basis provided a generality to research findings extending beyond the peculiar circumstances a study described. It allowed each study to contribute to a cumulative body of knowledge. However, there are unmet needs that should be considered in future evaluation research.

 

 

Notes

1 J. Dewey. The Public and Its Problems, (Chicago: Gateway Books, 1946).

2 E. Katz. "On Parenting a Paradigm: Gabriel Tarde's Agenda for Opinion and Communication Research," International Journal for Opinion, 1991.

3 G. Hillary. "Definitions of Community: Areas of Agreement," Rural Sociology, 20: 111-123 (1955).

4 N. Bracht, [ed.] Health Promotion at the Community Level (Newbury Park, CA: Sage, 1990), 47.

5 C. Bell and H. Newby, An Introduction to the Sociology of the Local Community (New York: Praeger, 1971), 32.

6 H. Rhinegold. Virtual Community: Homesteading on the Electronic Frontier, (Reading, MA: Addison-Wesley, 1993).

7 US Congress, Office of Technology Assessment. The Impact of Health Reform on Rural Areas, (Washington, DC: USGPO, 1996), 1.

8 Ibid.

9 US Congress, Office of Technology Assessment. Health Care in Rural America, (Washington, DC: USGPO, 1990), 11

10 US Congress, National Technology and Information Administration. Falling Through the Net: A Survey of the "Have Nots" in Rural and Urban America. (Washington, DC: USGPO. July, 1995) 1-7.

11 Ibid.

12 US Congress, Office of Technology Assessment. Telecommunications Technology and Native Americans: Opportunities and Challenges. (Washington, DC: USGPO, August, 1955), p. 2.

13 The National Rural Health Assn., Internet resource, URL http://www.nrharural.org/ (10/11/97) and Rural Health Futures: Integrated Rural Health Information Networks, Internet resource, URL http://www.pageplus.com/~ruralfut/doc5.htm (9/26/97).

14 US Congress, Office of Technology Assessment. "Bringing Healthcare Online: The Role of Information Technologies" OTA-ITC-624 (Washington, DC: USGPO, September 1995), 96ff.

15 Ibid. 97.

16 Ibid. 127.

17 M. Field (ed.) Telemedicine: A Guide to Assessing Telecommunications in Health Care, (Washington, DC: National Academy Press, 1996)

18 D. Breckon, J. Harvey and B. Lancaster. Community Health Education: Settings, Roles and Skills for the 21st Century [3rd Ed.] (Gathersburg, MD: Aspen Publications, 1994)

19 E. Rogers. Diffusion of Innovations, (New York: the Free Press, 1995).

20 S. Fine. The Marketing of Ideas and Social Issues (New York: Praeger, 1981).

21 E. Rogers and D. L. Kincaid. Communication Networks: Toward a New Paradigm for Research (New York: Free Press, 1981), 79-142.

22 B. Dervin and B. Greenberg. "The Communication Environment of the Urban Poor." In G. Kline and P. Titchenor Current Perspectives in Mass Communication Research, (Beverly Hills, CA: Sage, 1972), 210-233.

23 K. Stamm and J. Bowes. The Mass Communication Process: A Behavioral and Social Perspective, (Dubuque, IA: Kendall-Hunt, 1990), 227.

24 C. Shannon and C. Weaver. The Mathematical Theory of Communication, (Urbana, IL: U of Illinois Press, 1949).

25 D. Berlo. The Process of Communication, (New York: Holt) 1960.

26 J. Klapper. The Effects of Mass Communication, (New York: Free Press, 1960).

27 B. Westley and M. McLean. "A Conceptual Model for Communication Research," Audio-Visual Communication Review, 3: 3-12.

28 J. Robinson. "Interpersonal Influence in Election Campaigns," Public Opinion Quarterly, (Fall, 1976.

29 Op Cit. Rogers (1995), 163.

30 Ibid. 299.

31 W. Gantz. "Seat Belt Campaigns and Buckling-up: Do the Media Make a Difference?" Health Communication, 2(1): 1-12.

32 K.Hein, et al. "Adolescents and HIV: Two Decades of Denial," in S. Ratzan (ed.) AIDS: Effective Health Communication for the 90s, (Washington, DC: Taylor & Francis, 1993), 215-232.

33 B. Hennessy. "Public Opinion" [4th ed.], (Monterray, CA: Brooks/Cole Publishing, 1981) 21.

34 Op Cit. Rogers (1995) 45.

35 S. Chaffee, J. McLeod and J. Guerrero. "Origins and Implications of the Coorientational Approach in Communication Research" Paper presented to the Association for Education in Journalism Convention, Berkeley, 1969.

36 S. Chaffee and J. McLeod, "Sensitization in Panel Design: A Coorientational Experiment" Journalism Quarterly, 45: 661-669.

37 K. Stamm and J. Bowes . "Communication During an Environmental Decision," Journal of Environmental Education, 3: 49-56.

38 J. Grunig. "Publics, Audiences and Market Segments: Segmentation Principles for Campaigns," in C. Salmon (ed.) Information Campaigns: Balancing Social Values and Social Change, (Belmont, CA: Sage, 1989), 207.

39 Op Cit. Stamm and Bowes, 142-143.

40 M. Caserta. "Health Promotion and the Older Population: Expanding our Theoretical Horizons." Journal of Community Health. (June, 1995) 20: 283.

41M. Rothman. Hierarchical Comparison of Structural Equation Models: An Application to Models of Health Behavior. (Ph.D. Dissertation, College of Education, University of Washington, 1983), 7ff.

42M. Becker. The Health Belief Model and prediction of dietary compliance: a field experiment. Journal of Health and Social Behavior. (1977) 18(4): 348-66,.

43 N. Janz and M. Becker. "The Health Belief Model: A Decade Later," Health Education Quarterly, (1984) 11(1): 1-47.

44A. Bandura. Social Learning Theory, (Englewood Cliffs, NJ: Prentice-Hall, 1977).

45 J. Rotter. Social Learning and Clinical Psychology. (New York: Prentice-Hall, 1954).

46 I. Ajzen and M. Fishbein. Understanding Attitudes and Predicting Social Behavior, (Englewood Cliffs, NJ: Prentice-Hall, 1980.

47 D. Foote, et al., The Mass Media and Health practices Evaluation in Honduras: A Report of the Major Findings, A report by Stanford University and Applied Communication Technology to the US Agency for International Development (USAID), June, 1985, p. 7.

48 D. Breckon, J. Harvey and B. Lancaster. Community Health Education: Settings, Roles, and Skills for the 21st Century (Gathersburg, MD: Aspen Publishers, 1994), 123.

49 L. Green and M. Kreurter. "CDC's Planned Approach to Community Health as an Application of PRECEDE and an Inspiration for PROCEED," Journal of Health Education, (1992) 40.

50 H. Hyman & P. Sheatsley. "Some Reasons Why Information Campaigns Fail," Public Opinion Quarterly, (1947) 11: 413-423.

51 SRI International. "Exploring the World Wide Web Population's Other Half" Palo Alto, CA, June, 1995 Internet resource on URL: http://future.sri.com/vals/vals-survey.results.html.

52 Op Cit. Rogers (1995), 182.

53 T. Shibutani. Improvised News: A Sociological Study of Rumor, (Indianapolis: Bobbs-Merrill, 1966).

54 J. Bowes et al.., "Communication of Technical Information to Lay Audiences," Report of the Communication Research Center, University of Washington, May, 1978.

55 Op Cit. Rogers, (1995) 212ff.

56 K. Tones, S. Tilford and Y. Robinson. Health Education: Effectiveness and Efficiency, (London: Chapman & Hall, 1990).

57 J. Farquahar, et al. "Community Education for Cardiovascular Health," Lancet, (1977) 1192-1195.

58J. Farquahar, N. Maccoby and D. Solomon, "Community Applications of Behavioral Medicine," in E. Gentry (ed.) Handbook of Behavioral Medicine, (New York: Guilford, 1984), 437-478.

59J. Flora, N. Maccoby and J. Farquahar. "Communication Campaigns to Prevent Heart Disease: The Stanford Community Studies," in R. Rice and C. Atkin (eds.) Public Communication Campaigns [2nd edition], (Thousand Oaks, CA: Sage Publications, 1989), 240.

60Ibid. 251.

61 R. Carlow, et al. "Organization for a Community Cardiovascular Health Program: Experiences from the Minnesota Heart Health Program. Health Education Quarterly, 11: 243-252.

62 J. Elder et al. "Organizational and Community Approaches to Community-wide Prevention of Heart Disease: The First Two Years of the Pawtucket Heart Health Program," Preventive Medicine, (1986) 15: 107-117.

63 A. McAlister, et al. "Theory and Action for Health Promotion: Illustrations from the North Karelia Project." American Journal of Public Health, (1982) 72: 43-55.

64 Op. Cit. Simmons.

65 American Public Health Assn., Workgroup on Public Health Promotion/Disease Prevention. "Criteria for the Development of Health Promotion and Education Programs," American Journal of Public Health, (1987) 77: 89-92.

66 B. Israel, et al. "Evaluation of Health Education programs: Current Assessment and Future Directions," Health Education Quarterly, (1995) 22(3): 364-389.

67 Ibid.

68 Ibid.