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Journal of Communication ISSN 0021-9916

ORIGINAL ARTICLE

Advancing Equity in Clinical PreventiveServices: The Role of Health CommunicationKenzie A. Cameron1,2,3,4

1 Division of General Internal Medicine and Geriatrics, Department of Medicine, Feinberg School of Medicine,Northwestern University, Chicago, IL 60611, USA2 Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL 60611, USA3 Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago,IL 60611, USA4 Center for Advancing Equity in Clinical Preventive Services, Feinberg School of Medicine, NorthwesternUniversity, Chicago, IL 60611, USA

In 2002, the Institute of Medicine released its landmark report ‘‘Unequal Treatment:Confronting Racial and Ethnic Disparities in Health Care.’’ This report led to increasedefforts in identifying, assessing, and documenting racial and ethnic disparities in healthcare, as well as developing, testing, and implementing interventions in an attempt to reducehealth disparities throughout the United States. This article reviews the rise of healthdisparities research in the United States and reports on selected studies and interventionsdeveloped by researchers at the Northwestern University Feinberg School of Medicine. Theseinterventions have used communication and behavioral science theories and frameworksin their development and dissemination, particularly in the realm of clinical preventivemedicine.

doi:10.1111/jcom.12005

The past few decades have seen an increase in awareness of health disparities within theUnited States, as well as concentrated efforts in identifying, addressing, and reducingthese disparities with the goal of achieving health equity. Health communicationscholars have a crucial role to play within these efforts.

As evidenced by two publications in Patient Education and Counseling, whichprovide brief overviews of selected persuasion (Cameron, 2009) and interpersonal(Bylund, Peterson, & Cameron, 2012) theories, models, and frameworks, there isheightened interest among interdisciplinary researchers and medical practitionersregarding these foundations routinely used by health communication scholars. Themethodological and theoretical training health communication scholars receive, inaddition to their expertise in message development, dissemination, and effects, are

Corresponding author: Kenzie A. Cameron; e-mail: [email protected]

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Advancing Equity With Health Communication K. A. Cameron

of great collaborative benefit to researchers in other disciplines seeking to addresshealth disparities.

This article provides a brief overview of the rise of health disparities researchin the United States, with a particular focus on racial and ethnic disparities.Following this overview, I provide a description of four selected studies, highlightinghow the researchers used foundations of communication in the development anddissemination of their interventions.

Although this article focuses predominantly on racial and ethnic disparities inhealth and health care in the United States, it is important to recognize that manydifferent populations are affected by disparities, including residents of rural areas,women, children, individuals of differing sexual orientations or gender identity, theelderly, persons with disabilities, individuals of various religious beliefs, residents ofdiverse geographical areas, and persons with lower levels of socioeconomic status,among others. Indeed, many of the characteristics that have been linked historicallyto discrimination are now known to influence one’s health status (U.S. Departmentof Health and Human Services [HHS], 2011). Furthermore, health disparities area significant global concern. The Black Report, published in the United Kingdomin 1980, concluded that widespread health inequalities remained, even after theintroduction of the National Health Service (Department of Health and SocialSecurity, 1980). In 1998, the World Health Organization (WHO) Regional Office forEurope approved a ‘‘health for all policy framework’’ with a goal of ‘‘reducing socialand economic inequities in improving the health of the whole population’’ (WHO,1999, p. v). Addressing inequities in health has become a priority in many countries,both in the developed and the developing world (Braveman, 2006; Casas-Zamora &Ibrahim, 2004).

What is a ‘‘health disparity’’?

In response to a White House initiative, a definition of ‘‘health disparities’’ wasproposed in the United States in September 1999. Dr. Harold Varmus, the directorof the National Institutes of Health (NIH), assembled an NIH-wide working groupto develop a strategic plan to reduce health disparities. From this group, the firstNIH definition of ‘‘health disparities’’ emerged: ‘‘Health disparities are differencesin the incidence, prevalence, mortality, and burden of diseases and other adversehealth conditions that exist among specific population groups in the United States’’(National Cancer Institute, 2010).

In 2000, United States Public Law 106-525, also known as the ‘‘Minority Healthand Health Disparities Research and Education Act’’ (2010), provided a ‘‘legal’’definition of health disparities:

A population is a health disparity population if, as determined by the Director ofthe Center after consultation with the Director of the Agency for HealthcareResearch and Quality, there is a significant disparity in the overall rate of disease

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K. A. Cameron Advancing Equity With Health Communication

incidence, prevalence, morbidity, mortality or survival rates in the population ascompared to the health status of the general population. (p. 2498)

This Act also was responsible for the authorization of the National Center onMinority Health and Health Disparities, which transitioned in 2010 to being theNational Institute on Minority Health and Health Disparities (NIMHD) (U.S. HHS,2010a).

Simultaneously with NIH’s efforts to define health disparities, Congress requestedan Institute of Medicine (IOM) study to assess the extent of disparities in thetypes and quality of health services received by U.S. racial and ethnic minoritiesand nonminorities. Congress asked the IOM study to explore factors that maycontribute to inequities in care and to recommend policies and practices to eliminatethese inequities. These inquiries led to the IOM’s landmark report, released in2002, ‘‘Unequal Treatment: Confronting Racial and Ethnic Disparities in HealthCare.’’ This report, published in book format in 2003, concluded that many sourcescontribute to disparities; these sources are complex and involve numerous levels,including the individual patient and health care professional, health systems, andother administrative and bureaucratic systems and processes (Smedley, Stith, &Nelson, 2003).

Not surprisingly, lack of insurance was identified as one of the significant driversof health disparities; however, the report also discovered significant variations in therates of medical procedures completed by race, even when variables such as age,insurance, income, and severity of conditions or illness were comparable. The reportdocumented that racial and ethnic minorities in the United States are significantlyless likely to have insurance than the rest of the population, but it also noted thatthere is not one simple solution to addressing such health disparities (Smedley et al.,2003). For example, individuals living and working in low socioeconomic settingsare at increased risk for morbidity and mortality; Hispanic and non-Hispanic Blacksare significantly more likely to be uninsured than non-Hispanic Whites; a higherprevalence of chronic diseases including cancer, diabetes, and heart disease arereported in rural as opposed to urban areas; non-Hispanic Blacks and Hispanics areless likely to be vaccinated against influenza; babies born to Black women are between1.5 and 3 times more likely to die than those born to women of other races/ethnicities;and although there has been a significant decrease in the difference in life expectancybetween non-Hispanic Whites and non-Hispanic Blacks, non-Hispanic Black menhave the lowest life expectancy in the United States (Centers for Disease Control andPrevention [CDC], 2011; Lurie & Dubowitz, 2007; Olshansky et al., 2012).

The IOM report recommended the need to increase awareness among thegeneral public about the presence of health disparities, while concurrently increasingawareness among health care providers, insurance companies, policy makers, andother key stakeholders. Release of this report, as well as galvanization of clinical,research, political, and many other communities, has led to a continuing emphasison health disparities as they affect the population.



Due to the national spotlight placed on the challenge of health disparitiesand concurrent calls for awareness as we work toward achieving equity, there arenumerous annual or continuing reports compiled to document progress, challenges,and unexpected findings. The Agency for Healthcare Research and Quality (AHRQ)has published a National Health Disparities Report (NHDR) since 2003. In 2010,AHRQ started publishing a chapter in both the NHDR and the National HealthcareQuality Report that summarizes and integrates findings from both reports toemphasize the need to consider both the quality of health care and health disparitiessimultaneously.

The CDC published Health Disparities and Inequalities in the United States—2011,the first report in a planned periodic series to examine disparities in selected socialand health indicators, such as education, environmental hazards, income inequality,sexual orientation, health care access, and preventive health services. Also in 2011, theU.S. HHS unveiled their action plan related to racial and ethnic health disparities. Init, they call for ‘‘integrated approaches, evidence-based programs, and best practices’’to reduce disparities (U.S. HHS, 2011). Furthermore, one of the four overarchinggoals of Healthy People 2020 is to ‘‘Achieve health equity, eliminate disparities andimprove the health of all groups’’ (U.S. HHS, 2010b). However, the most recentpublished AHRQ reports, which include data from 2011, note that while health carequality is improving, we are not seeing the same improvement in terms of access tohealth care and health disparities (AHRQ, 2012a, 2012b).

The impact of health disparities

Research has identified disparities in risk factors, quality of life, morbidity, and lifeexpectancy among portions of the U.S. population (Truman et al., 2011). Thesedisparities have a significant impact on individual health, the health and well-beingof the society, and the economy and social structure of the country (Joint Center forPolitical and Economic Studies, 2010; Murray et al., 2006; U.S. HHS, 2011). Murrayet al. (2006) discussed the existence of ‘‘eight Americas,’’ defined by race, locationof county of residence, population density, race-specific county-level per capitaincome, and cumulative homicide rate, and the authors concluded that ‘‘disparitiesin mortality across the eight Americans, each consisting of millions or tens ofmillions of Americans, are enormous by all international standards’’ (p. e260). TheJoint Center for Political and Economic Studies reported that between 2003 and 2006‘‘the cost of racial/ethnic disparities in direct medical costs and lost productivity inthe U.S. exceeded $1.24 trillion’’ (2010, p. 6).

Although there have been significant successes in the reduction of some healthdisparities (e.g., decreased cancer deaths among individuals 65 and older; decreasedhospital admissions among Blacks and Hispanics for congestive heart failure;increased pneumococcal screening or vaccination among hospitalized Hispanicpatients), we still certainly have a long and difficult road to travel in reducing andeliminating such disparities (AHRQ, 2012a). Orsi, Margellos-Anast, and Whitman



(2010) analyzed health disparities between Blacks and Whites in the United States,considering 15 health status indicators: all-cause mortality, 10 specific indicators ofmortality, percentage of low-birthweight babies, percentage of no prenatal care in thefirst trimester, tuberculosis case rate, and primary and secondary syphilis case rate.Between 1990 and 2005, disparities between non-Hispanic Black and non-HispanicWhite populations at the national level narrowed significantly for seven of the 15measured indicators. Yet even in these areas where improvement was seen, the overallprogress was deemed to be ‘‘generally slow’’ (p. 352). For 6 of the 15 indicators,disparities widened (five significantly). The authors conclude that ‘‘there was nosignificant trend toward overall improvement (P = .85)’’ (p. 352).

The authors also explored the same health status indicators among Black andWhite residents of Chicago, IL. They found that 11 of the 15 indicators showeda widening of disparities (five significantly), and only four indicators showed anarrowing of disparities (two significantly) (Orsi et al., 2010). Thus, even thoughsome health status indicators are improving, and may be improving for multiplepopulations, improvement does not automatically equal a reduction in disparities.As we work to address both identified and suspected health disparities facing ournation, it is critical to ensure not only that programs and interventions are increasingthe use of preventive services among the population as a whole but also that we areworking toward achieving equity in health care.

Developing patient education tools to achieve equity in clinical preventiveservices

Communication strategies to reduce health disparities comprise several differentapproaches to intervention. Some approaches focus at an individual level, attemptingto change patient or provider attitudes and behaviors (e.g., Cegala & Post, 2006; Shawet al., 2006). Other strategies may address community (e.g., Meade, Menard, Luque,Martinez-Tyson, & Gwede, 2011), mass media (e.g., Campo et al., 2008; Hornik &Ramirez, 2006), policy (Niederdeppe, Bu, Borah, Kindig, & Robert, 2008), or mayhave a multilevel focus (Gorin, Badr, Krebs, & Das, 2012). Indeed, in 2006, an issue ofAmerican Behavioral Scientist was devoted to the topic of communication and healthcare disparities; this issue of the Journal of Communication continues to highlight thesignificant role of communication in addressing health disparities.

A focus of our work in the Division of General Internal Medicine and Geriatricsat the Northwestern University Feinberg School of Medicine has been on addressingracial and ethnic disparities in clinical preventive services. Screening tests such ascolonoscopy, mammography, or blood pressure measurement; counseling to preventtobacco use; preventive medications such as aspirin to reduce the likelihood of heartattack or stroke; and immunizations to prevent illnesses in infants, children, andadults (e.g., influenza, polio, herpes zoster, invasive pneumococcal disease) are allexamples of clinical preventive services. These services are provided by clinicians innumerous fields including preventive medicine and primary care (e.g., internal and



family medicine, pediatrics, behavioral health, obstetrics/gynecology, and nursing;U.S. Preventive Services Task Force [USPTSF], 2010). Significant disparities exist inthe United States related to many of these services (AHRQ, 2012a; Orsi et al., 2010;U.S. HHS, 2011).

Our intervention development process includes an initial identification of bothprimary and secondary learning goals in preparation for designing interventions withexplicit links to theoretical constructs, as well as the desired health behaviors, suchas increased exercise and better nutrition habits for those individuals diagnosed withdiabetes or prediabetes, completion of colorectal cancer screening, and receipt ofinfluenza vaccination (Cameron, Francis, Wolf, Baker, & Makoul, 2007; Cameronet al., 2009; Goel, Gracia, & Baker 2011; Kandula, Khurana, Makoul, Glass, & Baker,2012; Kandula et al., 2009). We build our interventions on principles, theories,models, and frameworks, many of which have come from the field of communicationor other social and behavioral fields, including social psychology, cognitive science,educational psychology, and anthropology. These theories often are juxtaposed withother frameworks, such as the chronic care model, with its focus on identifyingbasic elements to improve health care and health care systems at the organization,community, practice, and patient level (Wagner, 1998; Wagner, Austin, & Von Korff,1996). We work in collaboration with patients and health care providers to identifywords, graphics, and analogies to best communicate essential messages. We use aniterative design process in that we return repeatedly to our collaborating patients andproviders to ensure that we receive continual feedback and constructive criticism.

By using such methods, we are also employing some of the principles of commu-nity engagement described by the U.S. Department of Health and Human ServicesClinical and Translational Science Awards Consortium Community Engagement KeyFunction Committee Task Force on Principles of Community Engagement (2011).We work to ensure clarity regarding purposes and goals of the engagement effort,recognizing that partnering with the community is necessary for creating change andimproving health. We strive to design intervention and educational tools to assistwith information transfer, but not to replace the essential human interaction that isneeded to achieve optimal patient care.

We also pay close attention to issues related to health literacy. Health literacy,defined as ‘‘the degree to which individuals have the capacity to obtain, process, andunderstand basic health information and services needed to make appropriate healthdecisions’’ (Nielsen-Bohlman, Panzer, & Kindig, 2004, p. 2) has been identified as asignificant variable in numerous areas of health care and health disparities; limitedliteracy has been specifically linked to poor health knowledge, problems with the useof preventive services, delayed diagnoses, and poor health outcomes (Davis et al.,2001; Gazmararian et al., 1999; Nielsen-Bohlman et al., 2004). When developingpatient education materials, we ensure that the text, graphics, and narration we userelate to and teach the identified learning goal(s) in plain language. Our materials useactive voice, short sentences, common words, and simple graphics and pictures. Weavoid medical jargon and present information in a logical sequence, allowing learners



to build upon what they have learned. Information also is repeated and summarized asnecessary (Cameron, Baker, & Wolf, 2011; Kandula et al., 2012; Makoul et al., 2009).

Assessing patient education tools designed to address issues of healthdisparities

Below, I provide a very brief overview of four selected interventions designedwith attention to theory, health literacy, and ability to work within our currentsystem of care to achieve reduction of known disparities in the areas of influenzavaccination, cardiovascular disease, and breast and colorectal cancer screening. Theexamples chosen focus specifically on racial and ethnic disparities as opposed to otherdisparities, such as those related to education or income. Much of the work describedbelow is ongoing, part of a larger research trajectory, or has been completed onlyrecently. Hence, behavioral outcomes are not presented and only preliminary analysesare reported for some of the projects. Participants in these studies were from theChicagoland area, from a diversity of locations (senior centers, community centers,community clinics) representing varying races and ethnicities (African American,Hispanic/Latino, South Asian).

Influenza vaccination among African American seniorsInfluenza and influenza-related illnesses cause approximately 36,000 annual deathsin the United States, 90% of which occur among those ages 65 and older (CDC,2010). A major focus of influenza prevention is increased vaccination, which is themost effective prevention technique available (CDC, 2010). Vaccination rates amongindividuals 65 and older fall far short of the Healthy People 2020 goal of 90%: Recentestimates for influenza vaccination among this population were 70.8% ±2.3 (CDC,2012). Racial and ethnic disparities in influenza vaccination among those 65 andolder persist: Estimated rates of influenza vaccination as of the end of May 2011 fornon-Hispanic Black seniors were 56.1%; rates for Hispanic seniors were 66.8%; andrates for non-Hispanic Whites reached 67.7% (CDC, 2012).

We undertook a study to evaluate knowledge, attitudes, intentions, and pastbehaviors of African American seniors regarding influenza and the influenza vac-cine. Focus group (N = 121 participants) analyses using latent content and constantcomparative analysis, as well as the identification of emergent themes related tothe constructs of the extended parallel process model (EPPM: perceived severity,perceived susceptibility, self-efficacy, response efficacy; Witte, 1992, 1994), wereused to pinpoint key information needs among African American seniors. Analysesidentified barriers and facilitators to vaccination, knowledge, attitudes, and pastvaccination behaviors of participants. Familiarity with influenza and influenza vac-cination appeared to be fairly high, yet misconceptions remained: Many participantsnoted a belief that the vaccine gave them the flu, some believed the vaccine containsa live virus, and others expressed concern about the composition of the vaccine(Cameron et al., 2009).



Following this first wave of focus groups, we drafted an initial message and revisedit through three further waves of focus groups, allowing for focus group participantsto identify preferences for voiceover, format and images, the order of presentation,the strength of various images, and to provide an overall critique of the message.The final result was a 6-minute multimedia program that drew on the theoreticalframeworks of the EPPM (Witte, 1992, 1994), the theory of reasoned action/theoryof planned behavior (TRA/TPB; Ajzen, 1985, 1991; Ajzen & Fishbein 1980), andprospect theory (Kahneman & Tversky, 1979) to raise and refute widespread mythsabout influenza and the influenza vaccine. Using such existing theories as frameworksallowed us to identify leverage points on which to build the message, which wasthen woven into a structured narrative. For example, from the EPPM, we identifiedthat participants cited personal knowledge and health status to justify their personalperceptions of susceptibility, which led us to include a voiceover that stressed howeasy it was to catch the flu and that ‘‘even healthy persons’’ could get the flu. Similarly,participant perceptions of perceived severity ranged from perceptions of influenza asa nuisance, as incapacitating, and as deadly. Our final message addressed this rangewhile also stressing concepts related to response efficacy (vaccine effectiveness anddescribing exactly how the flu shot works to create antibodies within our bodies).Self-efficacy was stressed in information regarding the accessibility and affordabilityof the vaccine, and we tested both a gain- and loss-framed introduction to the video.

Analyses of a pilot test of the intervention are ongoing. Preliminary analysessuggest increases in knowledge and intention to be vaccinated among individualswho viewed the multimedia program.

Creating cardiovascular health promotion messages for a South Asian communityCoronary heart disease (CHD), a narrowing of the blood vessels supplying oxygento the heart, is the leading cause of death for both men and women in the UnitedStates; over 400,000 Americans die each year from the disease (National Heart Lungand Blood Institute, 2012). There is increasing evidence to suggest that South Asians(Asian Indians and Pakistanis) are at greater risk than other racial and ethnic groupsin the United States for CHD (Enas et al., 1996; Palaniappan, Wang, & Fortmann,2004). South Asians both report the lowest levels of physical activity and havehigher rates of overweight and obesity than other Asian groups in the United States(Lauderdale & Rathouz, 2000; Ye, Rust, Baltrus, & Daniels, 2009).

Researchers in our group conducted a survey and in-depth, semistructuredinterviews in English, Hindi, and Urdu to better understand current knowledgeand explanatory models, as well as misconceptions regarding CHD among SouthAsian immigrants (Kandula et al., 2010; Tirodkar et al., 2011a, 2011b). Specifically,respondents indicated their beliefs that psychosocial factors, such as stress, as wellas behavioral factors (e.g., diet), physiological factors (e.g., cholesterol, high bloodpressure, and diabetes), sudden adverse events (e.g., receipt of disturbing or shockingnews), and spiritual factors, contributed to or caused heart attacks (Tirodkar et al.,2011b).



To address the need for more culturally based messages, researchers designeda multimedia Patient Education Program (PEP) related to CHD for South Asianimmigrants. This PEP, consisting of six multimedia modules, was based on bothparticipants’ explanatory models identified in previous research and the Health BeliefModel (HBM; Becker, 1974; Janz and Becker, 1984) and the TPB. Perceptions ofseverity, susceptibility, and benefits were hypothesized to be mediators of CHDprevention behaviors; formative research identified attitudes, subjective norms, andperceived behavioral control as strong influences among the South Asian communityregarding CHD prevention behaviors (Kandula et al., 2012). The multimedia modulesincorporated elements of framing (Scott & Curbow, 2006), cultural targeting (Kreuter& McClure, 2004; Resnicow, Baranowski, Ahluwalia, & Braithwaite, 1999; SandersThompson et al., 2008), and use of fear appeals (Chaudhuri & Buck, 1995). The PEPbegan with a fear appeal, but it also included positive, gain-framed messages becausesuch messages have been identified as being effective in increasing behavioral intentand self-efficacy regarding CHD screening behaviors.

These modules were presented to members of the South Asian community viamultiple focus groups and individual interviews. Analyses identified four specificthemes that guided the revision of the PEP. Participants initially had a negativeresponse to the original targeted impact statement that focused on perceived severityand susceptibility (‘‘Heart attack is the number one killer of Asian Indians andPakistanis’’) because they felt as though it was an ‘‘attack.’’ Others were concernedthat the video did not adequately address the heterogeneity of the community inregards to age, gender, and body type. Participants’ strong beliefs in stress as a primarycause of CHD was voiced repeatedly; merely stating that stress was not the causeof heart attacks would be insufficient to eliminate myths widely held as cultural, ornormative, beliefs. Finally, the need for the message to address structural barriers toscreening (perceived behavioral control) was raised, such as where individuals whowere uninsured or underinsured could be screened for heart disease. The researchersthus integrated communication and behavioral theory with the identified explanatorymodels from the community to pursue what they termed ‘‘a community and cultural-centered approach’’ when developing preventive health messages (Kandula et al.,2012).

Researchers are currently engaged in evaluating the effect of these modules onknowledge and perceptions about CHD, as well as assessing its effect on individualswith varying levels of education. Future plans include assessing if the combinationof such a program with lifestyle counseling or action planning could assist in theinitiation and maintenance of behavior change to reduce CHD risk among SouthAsians.

Breast cancer screening among Latina womenIt is estimated that there will be 226,870 new cases and 39,510 deaths of womenfrom breast cancer in the United States in 2012 (National Cancer Institute [NCI],2012a). Current incidence rates project that approximately one in eight women will



develop invasive breast cancer during her lifetime (NCI, 2012b). Breast cancer isthe leading cause of cancer death among all women. Although Latina women havea lower overall incidence rate of breast cancer than non-Latina women, it remainsthe leading cause of cancer death among Latina women (American Cancer Society[ACS], 2009). Furthermore, Latina women are more likely than non-Latina womento be diagnosed at advanced stages; this disparity has been attributed to lower ratesof screening mammography (Smith-Bindman et al., 2006).

For this study, barriers to mammography screening among Latina patients wereidentified through both a literature review and a series of focus groups with Latinawomen. The focus group protocol was developed with attention to the HBM, assessingperceptions of severity, susceptibility, benefits, and an in-depth focus on barriersto screening among the target population (Goel et al., 2011). A brief multimediaprogram was developed to address the identified barriers through both visual andauditory messages, ensuring the message was appropriate for viewers of varying levelsof health literacy. The final multimedia intervention consisted of a 5-minute Spanish-and 4-minute English-language video (some difference in length of the videos wasdue to translation; the remainder was due to the inclusion of information abouttranslation services for the Spanish-language version).

Results from a pre-post pilot test of the intervention demonstrated an increase inknowledge, with the greatest increase seen among those women who had the lowestknowledge scores at baseline (Goel et al., 2011). Although no change was identifiedoverall in attitude scores, among the subsample of women who had negative scores atbaseline, 50% developed positive attitudes after viewing the multimedia intervention,suggesting that the intervention may be effective in increasing patient knowledge andattitudes regarding screening mammography. Ongoing research has incorporatedthe framework of social cognitive theory (SCT; Bandura, 1986) in understandingthat screening mammography behavior among Latina women can be explained bythe interaction of behavior, personal factors, and environmental influences. Thisresearch is assessing the effect of the developed intervention on mammographyscreening behavior among a sample of Spanish-speaking Latina women seeking careat a Federally Qualified Health Center (FQHC) (M.S. Goel, personal communication,April 9, 2012).

Addressing colorectal cancer screening among Hispanic/Latino and African AmericanadultsColorectal cancer (CRC) is the second leading cause of cancer death in the UnitedStates among men and women combined: An estimated 143,460 adults will bediagnosed with CRC in 2012, and an estimated 51,690 will die as a result of thedisease (ACS, 2012). CRC is ideally suited for early detection strategies, as pre-cancerous adenomas precede the development of malignancies (Levin & Murphy,1992); up to 60% of CRC deaths could be prevented with regular testing (U.S.HHS, 2012). The United States Preventive Services Task Force (USPTSF) stronglyrecommends that persons age 50–75 years of age undergo screening for CRC via fecal



occult blood tests (FOBT), fecal immunochemical test (FIT), flexible sigmoidoscopy,and colonoscopy (USPTSF, 2008a, 2008b).

However, recent estimates suggest that only 58.6% of American adults age50–75 years of age have been screened appropriately for CRC (CDC, 2012d).Screening rates are even lower among Black and Hispanic populations (Holden,Jonas, Porterfield, Reuland, & Harris, 2010; Jerant, Arellanes, & Franks, 2008);published rates of CRC screening among low-income minority patients have beenas low as 7% (Khankari et al., 2007). Barriers to CRC screening include access, lowpatient awareness, and perceived lack of provider recommendation of screening. Inrecent years we have seen an increase in CRC screening among Hispanic/Latino andBlack populations, yet significant disparities remain when these groups are comparedto a non-Hispanic White population. This trend indicates that although screeningrates are increasing among various racial and ethnic groups, disparities in screeningare not decreasing as desired, and equity is not being achieved (AHRQ, 2012a).

For over a decade, researchers at Northwestern University have collaboratedwith numerous community groups and organizations to develop and implementinterventions designed to increase CRC screening among minority, low-income, andlow-health-literate populations (Cameron et al., 2007; Davis et al., 2001; Khankariet al., 2007; Makoul et al., 2009). Throughout intervention development, we havedrawn upon numerous health communication and social science/behavioral theories,including the TPB, HBM, EPPM, SCT, and the information processing model(Wogalter, DeJoy, & Laughery, 1999). Additional frameworks and foundationsinclude a health literacy perspective (DeWalt, 2007; Doak, Doak, & Root, 1996) andcontinuous quality improvement (Deming, 1993). Each framework and foundationprovides a critical element to the systematic process of intervention development,taking into consideration the perspective of patients and providers and the healthsystem within which the encounters occur.

In 2004, we conducted a study to assess Hispanic/Latino perceptions about CRCand CRC screening, partnering with Erie Family Health Center in Chicago, Illinois.Participants completed an in-person structured interview developed using constructsfrom the HBM and the EPPM. Results of the 234 interviews, which were conducted inSpanish, demonstrated numerous litearcy issues among the participants, with 63.3%of them reporting their reading ability as ‘‘less than good.’’ A limited number ofindividuals was able to correctly identify a picture of the colon or correctly describea polyp. Less than half of participants (48.7%) perceived themselves at risk forCRC, although a vast majority recognized that tests for CRC were available to findearly signs and to help prevent CRC. Critical barriers identified included 65.7% ofparticipants reporting that CRC screening had not been mentioned to them by ahealthcare provider and 27.3% indicating they did not need to be tested because theyfelt fine and were not worried about CRC (Cameron et al., 2007).

On the basis of these findings, we developed a brief multimedia Patient EducationProgram/Programa Educativo para Patientes related to CRC and CRC screening,using the input of the community and the theoretical framework of the EPPM.



Specifically, the message aimed to increase perceived susceptibility to appeal to themajority of participants who did not see themselves at risk for CRC. Further, becausewe discovered that the screening tests themselves (FOBT and colonoscopy) were notviewed as particularly scary or humiliating to patients, we were able to focus ourmessage on the ease of completing the screening (self-efficacy), as well as the benefitsof screening, such as the ability to remove a polyp if discovered during colonoscopy,thus eliminating the chance of the polyp growing and turning into cancer (responseefficacy).

A pretest-posttest design resulted in significantly increased knowledge regardingkey terms (e.g., polyp), CRC screening, and anatomy and increased awareness ofprimary screening options for CRC among patients who viewed the program. Thesepatients reported a significantly increased willingness to be screened and increasedperceptions of personal risk for CRC (suceptibility). Over 90% of participantsreported an intention to discuss CRC screening with their provider (Makoul et al.,2009).

We are currently conducting an NCI-funded randomized controlled trial amongHispanic/Latino and African American patients in multiple FQHCs in Chicagothat utilizes this multimedia program as part of a combined physician-patientintervention to increase colorectal cancer screening. Critical in this ongoing studyis the combination of a focus at the patient level (exposure to the multimediaprogram) and intervention at the provider level (physicians are randomized to receivecommunication skills and health literacy related training). Multilevel interventionsthat include patients, providers, and systems are likely to be more effective inachieving lasting improved behavioral outcomes (Wagner et al., 1996). As patientsvoiced, if a recommendation by a physician is not provided to a patient, then thelikelihood of that patient completing CRC screening is much less—and may beeven impossible in the case of colonoscopy, where an order for the colonoscopy is aprerequiste for screening.

Models such as the chronic care model (Wagner, 1998; Wagner et al., 1996)recognize the need for multilevel interventions, as successful interventions oftenneed the buy-in and critical support of physicians, nurses, medical assistants, andadministrators in the practices where patients receive their care. Access to care, suchas access to affordable colonoscopies, is yet another significant barrier that remains.Issues of access may be more adequately addressed through policy interventions inconjunction with interventions addressing patient and provider education.

Future directions

These research trajectories related to assessing patient knowledge, attitudes, andintention; developing relevant and applicable multimedia and print interventions;and testing the effect of the interventions on knowledge, attitudes, intentions, andbehavior are firmly grounded in health communication and behavioral theories. Thisarticle describes the development and initial testing of numerous theoretically based



interventions; assessing the effect of these interventions on behavioral outcomes andon the ultimate goal of reduction in health disparities is still underway. The strongresearch base that has been built, not only by researchers at Northwestern but alsoby numerous social and behavioral researchers across the nation (e.g., Ashton et al.,2003; Kreuter & McClure, 2004; Kreps, 2006; Viswanath et al., 2012), has led to therecognition and support of multiple programs in the United States that are seekingto improve the delivery of clinical preventive services.

One such program is the Centers of Excellence in Clinical Preventive Services,established by AHRQ in 2011. As the lead Federal agency charged with conductingresearch to improve health care, AHRQ has the mission ‘‘to improve the quality,safety, efficiency, and effectiveness of health care for all Americans’’ (AHRQ, 2012c).Its Centers of Excellence program has the goal of supporting research to advanceunderstanding of how to optimally deliver clinical preventive services, especiallythose recommended by USPTSF.

AHRQ funded three Centers of Excellence: The Research Center for Excellencein Clinical Preventive Services at the University of North Carolina, with a focuson improving safety and appropriate use of services; the Center for Excellence inResearch in Implementation Science and Prevention (CRISP) at the Anshutz MedicalCampus at the University of Colorado, with a focus on increasing utilization ofpreventive health services in primary care; and the Center for Advancing Equityin Clinical Preventive Services at Northwestern University’s Feinberg School ofMedicine, with a focus on strategies to reduce health disparities. In particular, ourCenter at Northwestern aims ‘‘to expand and accelerate the development, testing,and dissemination of innovative, practical, effective, generalizable interventionsto increase equity of access to and use of clinical preventive services’’ (Centerfor Advancing Equity in Clinical Preventive Services, 2012). Together, these threecenters intend to serve as a national resource in assisting with the development,transformation, and support of research in clinical preventive services throughoutthe United States.

Health communication scholars are poised to collaborate in these efforts to addresshealth disparities in clinical preventive services through identifying innovative andfeasible ways of expanding communication beyond the clinical encounter. Clinicians’time to discuss health issues within an encounter is very limited; health caresystems need to employ strategies to integrate and improve communication before,during, and after a patient visit. These strategies could focus on providing patientsinformation about appropriate use of services, increasing utilization of services, andaddressing issues of health disparities. Harnessing the potential of the electronic healthrecord and patient portals, researchers can develop patient education materials inconjunction with information systems. For example, systems now allow us to identifyaverage-risk patients ‘‘newly eligible’’ for clinical preventive services, such as CRC orbreast cancer screening, and pneumococcal or herpes zoster vaccinations. With priorphysician approval, relevant information (e.g., about recommended vaccinations,cancer screenings) can be ‘‘pushed’’ to these patients for them to review before a



scheduled physician visit. There remains a great need for innovative development andevaluation of tools to assist in patient understanding of the need for such preventiveservices, and in engaging patients, physicians, and health care systems to identifyinterventions that are optimally effective in encouraging use of these services.

Future research will also be needed to assess the generalizability and replicabilityof the developed interventions in the realm of clinical preventive services. Followingstringent empirical testing, these theoretically based interventions will be poised forbroader dissemination and integration into the health systems as we strive to reducenumerous racial and ethnic disparities in clinical preventive services.

Conclusion

As much of a role as those of us engaged in health communication scholarship haveto play in reducing health disparities and advancing equity in clinical preventiveservices, it is always good advice to remember that we do not accomplish greatchange on our own or in a vacuum. The root causes of disparities are numerousand complex, and thus, not surprisingly, they require multifaceted solutions. Asnoted by Kathleen Sebelius, U.S. Secretary for Health and Human Services, ‘‘it istime to refocus, reinforce, and repeat the message that health disparities exist andthat health equity benefits everyone’’ (U.S. HHS, 2011, p. 1). Those of us in thefield of health communication are well prepared to collaborate with basic and socialscientists, clinicians, providers, policy makers, advocates, and patients themselves,to ensure this message is not overlooked and to work together toward identifyingnovel, effective, and feasible strategies to achieve our collective goal of health equity.Together we can work to achieve one of the goals set by Healthy People 2020: ‘‘Toachieve health equity, eliminate disparities, and improve the health of all groups’’(U.S. HHS, 2010b).

Acknowledgments

I am grateful to Vanessa Ramirez-Zohfeld for her assistance with technical aspects ofthe article. I would like to recognize Namratha Kandula, Mita Goel, Stephen Persell,Gregory Makoul, and David Baker, for it was under their direction that many ofthe studies discussed in this article were developed and implemented. I thank NancyGrant Harrington and the Kentucky Conference on Health Communication for theopportunity to present the work that my colleagues and I have been engaged in toaddress health disparities in this country. I appreciate the comments, feedback, andsuggestions of the reviewers and Mac Parks, and extend a second heartfelt thank youto Nancy Grant Harrington for her tireless work as Editor of this special issue, andher suggestions and comments on the article. K. A. Cameron is currently funded bythe Agency for Healthcare Research and Quality 1 P01 HS021141-1 (D.W. Baker,PI) and the National Cancer Institute 1R01 CA140177 (K. A. Cameron, PI). Thecontents of this article are the responsibility of the author and do not necessarily



represent the official views of AHRQ or NCI. Research and projects discussed inthis article were funded by the following: Influenza (Centers for Disease Controland Prevention Career Development award 8K01 CD000285, K. A. Cameron, PI);Cardiovascular Disease among South Asian immigrants (The National Heart, Lung,and Blood Institute; Career Development Award 5K23 HL 084177, N.R. Kandula, PI;Advanced Rehabilitation Research Training Award from the National Institute onDisability and Rehabilitation Research Grant H133P980014 funding Dr. Tirodkar asa post-doctoral research fellow); Breast cancer (AVON Foundation ‘‘Supporting theSafety Net’’ Award, M.S. Goel, PI); and Colorectal Cancer screening (The NationalCancer Institute, 1R01 CA140177, K. A. Cameron, PI; American Cancer Society,RSGT-08-149-01-CPPB, G. Makoul, PI; American Cancer Society-Illinois DivisionGrant PSB-10, G. Makoul, PI).

References

Agency for Healthcare Research and Quality. (2012a, March). National Healthcare DisparitiesReport, 2011. Rockville, MD: AHRQ. Retrieved from www.ahrq.gov/qual/qrdr11.htm

Agency for Healthcare Research and Quality. (2012b, March). National Healthcare QualityReport, 2011. Rockville, MD: AHRQ. Retrieved from www.ahrq.gov/qual/qrdr11.htm

Agency for Healthcare Research and Quality. (2012c). Retrieved from http://www.ahrq.gov/news/press/pr2011/cpscenterspr.htm

Ajzen, I. (1985). From intentions to actions: A theory of planned behavior. In J. Kuhl & J.Beckman (Eds.), Action-Control: From cognition to behavior (pp. 11–39). Heidelberg,Germany: Springer.

Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and HumanDecision Processes, 50(2), 179–211. doi: 10.1016/0749-5978(91)90020-T

Ajzen, I. & Fishbein, M. (1980). Understanding attitudes and predicting social behavior.Englewood Cliffs, NJ: Prentice Hall.

American Cancer Society (ACS). (2009). Cancer facts & figures for Hispanic/Latinos 2009 –2011. Atlanta, GA: ACS. Retrieved from http://www.cancer.org/Research/CancerFactsFigures/CancerFactsFiguresforHispanicsLatinos/cancer-facts--figures-for-hispanics-latinos-2009-2011

American Cancer Society (ACS). (2012). What are the key statistics about colorectal cancer?Atlanta, GA: American Cancer Society. Retrieved from http://www.cancer.org/Cancer/ColonandRectumCancer/DetailedGuide/colorectal-cancer-key-statistics

Ashton, C. M., Haidet, P., Paterniti, D. A., Collins, T. C., Gordon, H. S., O’Malley, K., &Street, R. L., Jr. (2003). Racial and ethnic disparities in the use of health services. Journalof General Internal Medicine, 18(2), 146–152. doi: 10.1046/j.1525-1497.2003.20532.x

Bandura, A. (1986). A social foundation of thought and action: A social cognitive theory.Englewood Cliffs, NJ: Prentice Hall.

Becker, M. H. (Ed.) (1974). The health belief model and personal health behavior. HealthEducation Monographs, 2, 324–508.

Braveman, P. (2006). Health disparities and health equity: Concepts and measurement.Annual Review of Public Health, 27, 167–194. doi: 10.1146/annurev.publhealth.27.021405.102103



Bylund, C. L., Peterson, E. B., & Cameron, K. A. (2012). A practitioner’s guide tointerpersonal communication theory: An overview and exploration of selected theories.Patient Education and Counseling, 87(3), 261–267. doi: 10.1016/j.pec.2011.10.006

Cameron, K. A. (2009). A practitioner’s guide to persuasion: An overview of 15 selectedpersuasion theories, models and frameworks. Patient Education and Counseling, 74(3),309–317. doi: 10.1016/j.pec.2008.12.003

Cameron, K. A., Baker, D. W., & Wolf, M. S. (2011). Integrating health literacy in healthcommunication. In T. Thompson, R. L. Parrott & J. Nussbaum (Eds.), Handbook ofhealth communication (pp. 306–319). Mahwah, NJ: Erlbaum.

Cameron, K. A., Francis, L., Wolf, M. S., Baker, D. W., & Makoul, G. (2007). InvestigatingHispanic/Latino perceptions about colorectal cancer screening: A community-basedapproach to effective message design. Patient Education and Counseling, 68(2), 145–152.doi: 10.1016/j.pec.2007.04.004

Cameron, K. A., Rintamaki, L. S., Kamanda-Kosseh, M., Noskin, G. A., Baker, D. B., &Makoul, G. (2009). Using theoretical constructs to identify key issues for targetedmessage design: African American seniors’ perceptions about influenza and influenzavaccination. Health Communication, 24(4), 316–326. doi: 10.1080/10410230902889258

Campo, S., Askelson, N. M., Routsong, T., Graaf, L. J., Losch, M., & Smith, H. (2008). Thegreen acres effect: The need for a new colorectal cancer screening campaign tailored torural audiences. Health Education & Behavior, 35(6), 749–762. doi: 10.1177/1090198108320358

Casas-Zamora, J. A., & Ibrahim, S. A. (2004). Confronting health inequity: The globaldimension. American Journal of Public Health, 94(12), 2055–2058. doi: 10.2105/AJPH.94.12.2055

Cegala, D. J., & Post, D. M. (2006). On addressing racial and ethnic health disparities: Thepotential role of patient communication skills interventions. The American BehavioralScientist, 49(6), 853–867. doi: 10.1177/0002764205283805

Center for Advancing Equity in Clinical Preventive Services. (2012). Retrieved from http://prevention-for-all.org

Centers for Disease Control and Prevention (CDC). (2010). Prevention and control ofinfluenza with vaccines: Recommendations of the Advisory Committee on ImmunizationPractices (ACIP). MMWR. Morbidity and Mortality Weekly Reports, 59(RR-8), 1–62.

Centers for Disease Control and Prevention (CDC). (2011). CDC health disparities andinequalities report – United States, 2011. MMWR. Morbidity and Mortality WeeklyReport, 60(Suppl), 1–114.

Centers for Disease Control and Prevention (CDC). (2012a, January). Cancer screening –United States, 2010. MMWR. Morbidity and Mortality Weekly Report, 61, 41–45.

Centers for Disease Control and Prevention (CDC). (2012b, March). March flu vaccinationcoverage. Atlanta, GA: CDC. Retrieved from http://www.cdc.gov/flu/professionals/vaccination/nfs-survey-march2012.htm#age-adults

Chaudhuri, A., & Buck, R. (1995). Affect, reason, and persuasion—advertising strategies thatpredict affective and analytic-cognitive responses. Human Communication Research,21(3), 422–441. doi: 10.1111/j.1468-2958.1995.tb00353.x

Davis, T. C., Dolan, N. C., Ferreira, M. R., Tomori, C., Green, K. W., Sipler, A. M., &Bennett, C. L. (2001). The role of inadequate health literacy skills in colorectal cancerscreening. Cancer Investigation, 19(2), 193–200. doi: 10.1081/CNV-100000154



Deming, W. E. (1993). The new economics for industry, government, and education.Cambridge, MA: Massachusetts Institute of Technology.

Department of Health and Social Security. (1980). Inequalities in health: Report of a researchworking group. London: DHHS. Retrieved from http://www.sochealth.co.uk/public-health-and-wellbeing/poverty-and-inequality/the-black-report-1980/

DeWalt, D. A. (2007). Low health literacy: Epidemiology and interventions. North CarolinaMedical Journal, 68(5), 327–330.

Doak, C. C., Doak, L. G., & Root, J. H. (1996). Teaching patients with low-literacy skills (2nded.). Philadelphia, PA: JB Lippincott.

Enas, E. A., Garg, A., Davidson, M. A., Nair, V. M., Huet, B. A., & Yusuf, S. (1996). Coronaryheart disease and its risk factors in first-generation immigrant Asian Indians to theUnited States of America. Indian Heart Journal, 48(4), 343–353.

Gazmararian, J. A., Baker, D. W., Williams, M. V., Parker, R. M., Scott, T. L., Green, D. C., &Koplan, J. P. (1999). Health literacy among Medicare enrollees in a managed careorganization. Journal of the American Medical Association, 281(6), 545–551. doi: 10.1001/jama.281.6.545

Goel, M. S., Gracia, G., & Baker, D. W. (2011). Development and pilot testing of a culturallysensitive multimedia program to improve breast cancer screening in Latina women.Patient Education and Counseling, 84(1), 128–131. doi: 10.1016/j.pec.2010.05.014

Gorin, S. S., Badr, H., Krebs, P., & Das, I. P. (2012). Multilevel interventions and racial/ethnichealth disparities. Journal of the National Cancer Institute. Monographs, 44, 100–111. doi:10.1093/jncimonographs.lgs015

Holden, D. J., Jonas, D. E., Porterfield, D. S., Reuland, D., & Harris, R. (2010). Systematicreview: enhancing the use and quality of colorectal cancer screening. Annals of InternalMedicine, 152(10), 668–676.

Hornik, R. C., & Ramirez, A. S. (2006). Racial/ethnic disparities and segmentation incommunication campaigns. The American Behavioral Scientist, 49(6), 868–884. doi:10.1177/0002764205283806

Janz, N. K., & Becker, M. H. (1984). The Health Belief Model: A decade later. HealthEducation Quarterly, 11(1), 1–47. doi: 10.1177/109019818401100101

Jerant, A. F., Arellanes, R. E., & Franks, P. (2008). Factors associated withHispanic/non-Hispanic white colorectal cancer screening disparities. Journal of GeneralInternal Medicine, 23(8), 1241–1245. doi: 10.1007/s11606-008-0666-1

Joint Center for Political and Economic Studies (2010). Patient protection and affordable careact of 2010: Advancing health equity for racially and ethnically diverse populations. DC:Washington.

Kahneman, D., & Tversky, A. (1979). Prospect theory: An analysis of decision under risk.Econometrica, 47(2), 263–291. doi: 10.2307%2F1914185

Kandula, N. R., Khurana, N. R., Makoul, G., Glass, S., & Baker, D. W. (2012). A communityand culture-centered approach to developing effective cardiovascular health messages.Journal of General Internal Medicine, 27(10), 1308–1316. doi: 10.1007/s11606-012-2102-9

Kandula, N. R., Nsiah-Kumi, P. A., Makoul, G., Sager, J., Zei, C. P., Glass, S., & Baker, D. W.(2009). The relationship between health literacy and knowledge improvement after amultimedia type 2 diabetes education program. Patient Education and Counseling, 75(3),321–327. doi: 10.1016/j.pec.2009.04.001

Kandula, N. R., Tirodkar, M. A., Lauderdale, D. S., Khurana, N. R., Makoul, G., & Baker, D.W. (2010). Knowledge gaps and misconceptions about coronary heart disease among



U.S. South Asians. American Journal of Preventive Medicine, 38(4), 439–442. doi: 10.1016/j.amepre.2009.12.034

Khankari, K. E., Osborn, C. Y., Makoul, G., Clayman, M., Skripkauskas, S.,Diamond-Shapiro, L., & Wolf, M. S. (2007). Improving colorectal cancer screeningamong the medically underserved: a pilot study within a Federally Qualified HealthCenter. Journal of General Internal Medicine, 22(10), 1410–1414. doi:10.1007/s11606-007-0295-0

Kreps, G.L. (2006). Communication and racial inequities in health care. American BehavioralScientist, 49(6), 760–774. doi: 10.1177/0002764205283800

Kreuter, M. W., & McClure, S. M. (2004). The role of culture in health communication.Annual Review of Public Health, 25, 439–455. doi: 10.1146/annurev.publhealth.25.101802.123000

Lauderdale, D. S., & Rathouz, P. J. (2000). Body mass index in a US national sample of AsianAmericans: effects of nativity, years since immigration, and socioeconomic status.International Journal of Obesity and Related Metabolic Disorders, 24(9), 1188–1194. doi:10.1038/sj.ijo.0801365

Levin, B., & Murphy, G. P. (1992). Revision in American Cancer Society recommendationsfor the early detection of colorectal cancer. CA: A Cancer Journal for Clinicians, 42(5),296–299. doi: 10.3322/canjclin.42.5.296

Lurie, N., & Dubowitz, T. (2007). Health disparities and access to health. Journal of theAmerican Medical Association, 297(10), 1118–1121. doi: 10.1001/jama.297.10.1118

Makoul, G., Cameron, K. A., Baker, D. W., Francis, L., Scholtens, D., & Wolf, M. W. (2009).A multimedia patient education program on colorectal cancer screening increasesknowledge and willingness to consider screening among Hispanic/Latino patients.Patient Education and Counseling, 76(2), 220–226. doi: 10.1016/j.pec.2009.01.006

Meade, C. D., Menard, J. N., Luque, J. S., Martinez-Tyson, D., & Gwede, C. K. (2011).Creating community-academic partnerships for cancer disparities research and healthpromotion. Health Promotion Practice, 12(3), 456–462. doi: 10.1177/1524839909341035

Minority Health and Health Disparities Research and Education Act. (2000). United Statespublic law 106-525. Retrieved from: http://www.gpo.gov/fdsys/pkg/PLAW-106publ525/pdf/PLAW-106publ525.pdf

Murray, C. J. L., Kulkarni, S. C., Michaud, C., Tomijima, N., Bulzacchelli, M. T., Iandiorio,T. J., & Ezzati, M. (2006). Eight Americas: Investigating mortality disparities across races,counties, and race-counties in the United States. PLoS Medicine, 3(9), 1513–1524. doi:10.1371/journal.pmed.0030260

National Cancer Institute. (2010). Health disparities defined. Retrieved from http://crchd.cancer.gov/disparities/defined.html

National Cancer Institute. (2012a). Breast cancer. Retrieved from http://www.cancer.gov/cancertopics/types/breast

National Cancer Institute. (2012b). Breast cancer risk in American women. Retrieved fromhttp://www.cancer.gov/cancertopics/factsheet/detection/probability-breast-cancer.

National Heart Lung and Blood Institute. (2012). Who is at risk for coronary heart disease?Retrieved from: http://www.nhlbi.nih.gov/health/health-topics/topics/cad/atrisk.html

Niederdeppe, J., Bu, Q. L., Borah, P., Kindig, D. A., & Robert, S. A. (2008). Message designstrategies to raise public awareness of social determinants of health and population healthdisparities. The Milbank Quarterly, 86(3), 481–513. doi:10.1111/j.1468-0009.2008.00530.x



Nielsen-Bohlman, L., Panzer, A. M., & Kindig, D. A. (Eds.) (2004). Health literacy: Aprescription to end confusion. Washington, DC: National Academic Press.

Olshansky, S. J., Antonucci, T., Berkman, L., Binstock, R. H., Boersch-Supan, A., & Rowe, J.(2012). Differences in life expectancy due to race and educational differences arewidening, and many may not catch up. Health Affairs, 31(8), 1803–1813. doi: 10.1377/hlthaff.2011.0746

Orsi, J. M., Margellos-Anast, H., & Whitman, S. (2010). Black-White health disparities in theUnited States and Chicago: A 15-year progress analysis. American Journal of PublicHealth, 100(2), 349–356. doi: 10.2105/AJPH.2009.165407

Palaniappan, L., Wang, Y., & Fortmann, S. P. (2004). Coronary heart disease mortality for sixethnic groups in California, 1990–2000. Annals of Epidemiology, 14(7), 499–506. doi:10.1016/j.annepidem.2003.12.001

Resnicow, K., Baranowski, T., Ahluwalia, J. S., & Braithwaite, R. L. (1999). Culturalsensitivity in public health: Defined and demystified. Ethnicity & Disease, 9(1), 10–21.

Sanders Thompson, V. L., Cavazos-Rehg, P. A., Jupka, K., Caito, N., Gratzke, J., Tate, K. Y.,& Kreuter, M. W. (2008). Evidential preferences: cultural appropriateness strategies inhealth communications. Health Education Research, 23(3), 549–559. doi: 10.1093/her/cym029

Scott, L. B., & Curbow, B. (2006). The effect of message frames and CVD risk factors onbehavioral outcomes. American Journal of Health Behavior, 30(6), 582–597. doi: 10.5993/AJHB.30.6.5

Shaw, B., Gustafson, D. H., Hawkins, R., McTavish, F., McDowell, H., Pingree, S., & Ballard,D. (2006). How underserved breast cancer patients use and benefit from eHealthprograms. The American Behavioral Scientist, 49(6), 823–834. doi: 10.1177/0002764205283803

Smedley, B. D., Stith, A. Y., & Nelson, A. R. (Eds.) (2003). Unequal treatment: Confrontingracial and ethnic disparities in health care. Washington, DC: National Academies Press.

Smith-Bindman, R., Miglioretti, D. L., Lurie, N., Abraham, L., Barbash, R. B., Strzelczyk, J., &Kerlikowske, K. (2006). Does utilization of screening mammography explain racial andethnic differences in breast cancer? Annals of Internal Medicine, 144(8), 541–553.

Tirodkar, M. A., Baker, D. W., Khurana, N., Makoul, G., Paracha, M. W., & Kandula, N. R.(2011a). Explanatory models of coronary heart disease among South Asian immigrants.Patient Education and Counseling, 85(2), 230–236. doi: 10.1016/j.pec.2010.10.002

Tirodkar, M. A., Baker, D. W., Makoul, G. T., Khurana, N., Paracha, M. W., & Kandula, N.R. (2011b). Explanatory models of health and disease among South Asian immigrants inChicago. Journal of Immigrant and Minority Health, 13(2), 385–394. doi: 10.1007/s10903-009-9304-1

Truman, B. I., Smith, C. K., Roy, K., Chen, Z., Moonesinghe, R., Zhu, J., & Zaza, S. (2011,January 14). Rationale for regular reporting on health disparities and inequalities –United States. MMWR. Morbidity and Mortality Weekly Report, 60(Suppl), 3–10.

U.S. Department of Health and Human Services, Clinical and Translational Science AwardsCommunity Engagement Key Function Committee Task Force on the Principles ofCommunity Engagement. (2011). Principles of community engagement (2nd ed.). NIHPublication No. 11-7782. Retrieved from http://www.atsdr.cdc.gov/communityengagement/index.html

U.S. Department of Health and Human Services (HHS). (2010a). Healthy people 2020.Rockville, MD. Retrieved from http://healthypeople.gov/2020/about/default.aspx



U.S. Department of Health and Human Services (HHS). (2010b). NIH announces instituteon minority health and health disparities. Retrieved from http://www.nih.gov/news/health/sep2010/nimhd-27.htm

U.S. Department of Health and Human Services (HHS). (2011, April). HHS action plan toreduce racial and ethnic disparities: A nation free of disparities in health and health care.Washington, D.C. Retrieved from http://www.minorityhealth.hhs.gov/npa/templates/content.aspx?lvl=1&lvlid=33&ID=285

U.S. Department of Health and Human Services (HHS). (2012). Health SystemMeasurement Project: Percentage of adults who receive colorectal cancer screening asappropriate. Retrieved 07/18/2012 from https://healthmeasures.aspe.hhs.gov/measure/25

U.S. Preventive Services Task Force (USPTSF). (2008a). Screening for colorectal cancer.Retrieved from http://www.uspreventiveservicestaskforce.org/uspstf/uspscolo.htm

U.S. Preventive Services Task Force (USPTSF) (2008b). Screening for colorectal cancer: U.S.preventive services task force recommendation statement. Annals of Internal Medicine,149, 627–637.

U.S. Preventive Services Task Force (USPTSF). (2010). Prevention and chronic care program:Improving primary care. Retrieved from http://www.ahrq.gov/clinic/uspstfix.htm

Viswanath, K., Nagler, R. H., Bigman-Galimore, C. A., McCauley, M. P., Jung, M., &Ramanadhan, S. (2012). The communications revolution and health inequalitites in the21st century: Implications for cancer control. Cancer Epidemiology, Biomarkers &Prevention, 21(10), 1701–1708. doi: 10.1158/1055-9965.EPI-12-0852

Wagner, E. H. (1998). Chronic disease management: What will it take to improve care forchronic illness? Effective Clinical Practice, 1(1), 2–4.

Wagner, E. H., Austin, B. T., & Von Korff, M. (1996). Organizing care for patients withchronic illness. The Milbank Quarterly, 74(4), 511–554. doi: 10.2307/3350391

Witte, K. (1992). Putting the fear back into fear appeals: The extended parallel process model.Communication Monographs, 59(4), 329–349. doi: 10.1080/03637759209376276

Witte, K. (1994). Fear control and danger control: A test of the extended parallel processmodel. Communication Monographs, 61(2), 113–134. doi: 10.1080/03637759409376328

Wogalter, M. S., DeJoy, D. M., & Laughery, K. R. (1999). Warnings and risk communication.Philadelphia, PA: Taylor and Francis.

World Health Organization (1999). Health21: The health for all policy framework for theWHO European Region. In European health for all (Vol. 6). Copenhagen, Denmark:World Health Organization.

Ye, J., Rust, G., Baltrus, P., & Daniels, E. (2009). Cardiovascular risk factors among AsianAmericans: results from a National Health Survey. Annals of Epidemiology, 19(10),718–723. doi: 10.1016/j.annepidem.2009.03.022


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