© 1999 by Oxford University Press
Journal of the National Cancer Institute Monographs, No. 25, 23-26,
1999
© 1999 Oxford University Press
Communicating Health Risk to Ethnic Groups: Reaching Hispanics as a Case Study
Affiliations of authors: E. E. Huerta, Cancer Risk Assessment and Screening Center, Washington Hospital Center, Washington, DC; E. Macario, Porter Novelli, Washington, DC.
Correspondence to: Elmer E. Huerta, M.D., M.P.H., Cancer Risk Assessment and Screening Center, Washington Hospital Center, 110 Irving St., N.W., Rm. C1179, Washington, DC 20010.
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UNITED STATES: A MULTICULTURAL SOCIETY |
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The United States is increasingly becoming a culturally heterogeneous society. In 1990, 75% of the people in the United States were white of European descent, 12.3% were African-American, 9.0% were Hispanic-American, 2.8% were Asian-American, and 0.7% were Native-American. It is projected that by the year 2021, these proportions will change: only 53% of the U.S. population will be white of European descent, the number of Asian-Americans and Hispanic-Americans will triple, and the number of African-Americans will double (1).
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HEALTH RISK MESSAGES: NOT EFFECTIVELY REACHING ETHNIC GROUPS |
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Adequate understanding of health risks by the public can help to reduce the incidence and mortality of certain diseases, including cancer. The process of risk communication, however, has been studied infrequently with minority and lower-income communities, even though they may be at greatest risk (2,3). Epidemiologic research has long shown that ethnic minorities suffer disproportionately from illness and death (4). One reason for this gap may be that pertinent health messages have not reached ethnic groups effectively (5). As many health professionals corroborate, communicating health messages in a culturally appropriate and sensitive manner (regardless of the specific health issue or disease in question) has become a challenge that can no longer be ignored. One way to begin addressing this issue is to move beyond the simple, direct translation of health messages already being used with the mainstream (white) population to messages that are culturally as well as linguistically appropriate (6).
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DEFINING CULTURE |
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Social scientists have been intrigued with the concept of culture and with the challenge of defining "culture" for many years (7). "Culture" is a system of shared beliefs, customs, values, and behaviors that members of a society transmit from generation to generation and use to cope with one another and their world (3).
To communicate health risk information that is culturally appropriate, it is critical to understand that people are the product of past experiences, cultural beliefs, and cultural norms and are thus culturally unique. It is also important to remember that there is as much diversity within cultural groups as there is across cultural groups (8,9).
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DEFINING ETHNICITY |
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Ethnicity, conceptually, resembles the concept of culture in that it is collectively created over the course of generations out of the shared experience of a group of people who come to identify themselves as a group with unique history and origins (7). Confusion of the term ethnicity with the constructs of culture stems from the fact that ethnicity is generally used to represent at least three distinct constructs: 1) "ethnicity" or the collective culture of a minority cultural group with some distinctive cultural characteristics within a larger society, 2) "ethnic origin" or a classification system on the basis of one's biologic ancestors, and 3) "ethnic identity" or the extent to which an individual chooses to incorporate a particular ethnic classification into his or her sense of self (7).
The term ethnicity, therefore, is a multiplex concept with a variety of possible contributing attributes (e.g., intermarriage, self-identification, migration, level of acculturation, political and religious ties to the ethnic group, place of residence, socioeconomic status, and educational achievement) (10). Which ethnicity becomes the dominant culture at home when an individual from one ethnic group marries an individual from another ethnic group? Does the male's or the female's ethnic background define the household? What about the children—how will their upbringing shape their views of health and disease? Try defining your own ethnicity—a formidable challenge you will more than likely discover. What traditional customs, passed through several generations, did you experience during your upbringing? Do you use home remedies that your ancestors used generations ago? What beliefs about health and cancer were translated to you from generations before?
Ethnicity remains a vital force in the United States. But, for many years, in striving to have a strong identity, the United States fostered the notion of the "melting pot," the idea that ethnic group distinctions are irrelevant and can be subsumed by a common American national identity. However, we have not "melted"—there is increasing evidence that ethnic values and identification are retained for many generations after immigration (11). Rather than a "melting pot," the United States is more a mosaic or garden salad where each of our cultural differences retains its integrity while coexisting contiguously.
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DISTINCT ETHNIC VALUES OR THE DANGER OF STEREOTYPING |
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Although there are important sociodemographic differences among individuals in ethnic groups (according to factors, such as country of origin, educational attainment, and acculturation level), ethnic groups (e.g., Hispanics or Asians) seem to share core cultural values that differentiate them from other groups (6). Whereas a danger of stereotyping exists, knowledge of an ethnic group's core values is an excellent starting point for successful health risk communication (6,12). Despite the danger of stereotyping, it plays an important role in how we communicate—our communication depends in part on how we characterize the recipients of our messages (12).
To be successful with Hispanics, for example, health communication messages need to consider the following core Hispanic values: "familialism" (the significance of the family to the individual), "collectivism" (the importance of friends and extended family in helping to solve problems), "simpatia" (the need for smooth interpersonal relationships in which criticism and confrontation are discouraged), "personalismo" (the preference for relationships with members of the in-group), "respeto" (the need to maintain one's personal integrity and allow for face-saving strategies), and "power distance" (certain persons, such as the powerful, the elderly, and the educated, should be treated with special deference) (6). Keller and Stevens (3) have also discussed the importance of using critical family and kinship members to support and encourage health-promoting behavior among Hispanics. Johnson and Delgado (8) agree on the importance of family among Hispanics but recommend avoiding superficial references to family and, instead, encourage the identification of powerful images and messages that can activate positive behaviors directly linked to prevention goals.
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"COLLECTIVIST" VERSUS "INDIVIDUALIST" CULTURES |
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Cultures differ in the extent to which they pay attention to context and in the way communication takes place. Differences in social behavior can be found between "collectivist" and "individualistic" cultures (13). When communicating health risk information, it is important to consider which of these two types of culture you are trying to reach.
People in collectivist cultures pay more attention to context when they communicate than do people from individualistic cultures (13). Collectivists are not as explicit, direct, or clear as the individualists. By paying attention to the paralinguistics (emotional expression, gestures, touching, distance between bodies, body orientation, level of voice, and eye contact) but ignoring the verbal message, people from some cultures can easily misunderstand what a person from an individualistic culture is saying (13). Time orientation, perceptions of personal space, exposure to private body parts, and discussion of intimate issues have unique variability across cultures (3).
In individualistic (low-context) cultures, people distrust what is not said clearly; the best arguments are presented first to attract attention and generate a desire to hear the whole argument (13). In contrast, the argument is presented climactically in collectivist (high-context) cultures—the messenger starts with peripheral arguments and gets to the punch line only after the other person has had time to react to and "digest" the information (13). Differences between these two types of culture have implications for the impact of health communication messages.
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DEFINING ACCULTURATION |
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Recent immigrants are ones who have arrived in the United States during the past 10-15 years. Are they people who have been acculturated to the U.S. way of life? It depends. Acculturation is "the process by which the collective culture of a group is changed through contact with another culture" (7) or the degree to which members have immersed themselves in the culture of the country in which they live. Some second-, third-, or fourth-generation Americans differ from the dominant culture in values, lifestyle, and behavior and still consider themselves to be immigrants by the simple fact that they are "descendants of immigrants."
Whether or not a family lives in an ethnic neighborhood will influence the extent to which a family's cultural heritage will be preserved, such as the types of food consumed. This phenomenon can be observed by the "McDonaldization" process. In immigrants' home countries, grains, legumes, vegetables, and fruits may have been the staple diet; on arrival to the United States, these nutritious foods are often replaced with hamburgers, hot dogs, French fries, and soda. This transition occurs in part because this type of "fast food" is 1) the "American" way, 2) inexpensive, and 3) quick. Even though recently arrived immigrants who have higher socioeconomic and educational levels tend to behave more like the dominant culture, they do not, ironically, engage in healthier lifestyles necessarily.
Palinkas et al. (14) found that cessation and prevention programs that target Hispanic populations must be especially sensitive to sex-specific acculturation processes that create a discrepancy between the desire to adopt the lifestyles of the dominant culture and the recognition of the concomitant health-related risks. The results of the study by Palinkas et al. provided evidence for the argument that health-related behaviors and rates of disease begin to approximate those of the dominant society with increasing acculturation, despite their potential harmful consequences. Although the prevalence of smoking in the United States is apparently in decline, the majority of Hispanics (who possess relatively low socioeconomic status [SES] and work mainly in blue-collar occupations) adopt the smoking behaviors of non-Hispanic whites of similar SES, who have the highest rates of current cigarette smoking in the general population. The study (14) showed that Hispanic women are especially likely to adopt these smoking behaviors with increasing acculturation because cigarette smoking symbolizes the acquisition of greater status equality associated with changing sex roles and employment opportunities as well as the abandonment of Hispanic cultural sanctions and social pressures, which traditionally worked to prevent cigarette smoking in women but not in men.
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ETHNICITY AND PERCEPTIONS OF HEALTH RISK |
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The level at which ethnic groups have severed ties with their country of origin plays a role in determining how they feel about life, death, and illness (11). Studies (11) have shown that ethnic groups differ in 1) their reports of pain, 2) what they label as a symptom, 3) how they communicate about their pain or symptoms, 4) their beliefs about the cause of their illness, 5) their attitudes toward helpers (doctors and therapists), and 6) what treatment they desire or expect.
Hispanic women, for example, are more likely than non-Hispanic women to fear cancer and have fatalistic attitudes toward the disease (e.g., that illness is a matter of chance or fate and that fast recovery from illness is a matter of good luck) (15). Roche et al. (16) found that cancer terms (e.g., "yearly," "mammogram," "diagnosed," "risk factors," "at risk," and "cancer") mean different things to English speakers (non-Hispanic women) and Spanish speakers (Hispanic women). For example, more than four times as many women interviewed in English as women interviewed in Spanish correctly defined "at risk." Incorrect responses commonly implied that you are at risk if you do not have check ups. Thirty-two percent of the women interviewed in English in the study by Roche et al. (16) study understood "risk factors" as opposed to only 13% of the women interviewed in Spanish. Incorrect Spanish responses included defining "risk factors" as having cancer or as being ill and not taking care of yourself.
Place of residence may influence knowledge, attitudes, and behavior toward health and disease. Previous studies have shown that Hispanic women underuse cancer screening services. Morgan et al. (17), however, found that urban Hispanic women engage in relatively high levels of cancer preventive behaviors, even though they tend to have a limited knowledge base of cancer coupled with misperceptions of cancer (e.g., beliefs that bumps and bruises cause cancer and that surgery causes cancer to spread).
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"RISK TRADE-OFF" SCALE |
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Given that life events differ so widely among ethnic groups, how is the concept of health risk perceived? People have a "risk trade-off" scale: On one side of the scale is what to do; on the other side is what not to do. Both the health information one receives and one's cultural beliefs are factors that determine the weight of each side of the scale. The middle of the scale marks the behavior in which an individual engages, or how an individual negotiates the relative weight of each side of the scale. This trade-off, or balancing of the two sides of the scale, is essential to understanding and realizing that health decisions change depending on the cultural group to which an individual belongs and consequently on the unique distribution of weight on each side of the scale.
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IMPORTANCE OF A TRUSTED MESSENGER |
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For a messenger to successfully communicate a health message to a receptor, the messenger must be familiar with the subjective culture of the people with whom he or she communicates. Accuracy implies that both the source and the recipient of a message assign the same meaning to it (13). Most important, the messenger needs to be trusted by that community, and the cultural group should identify with him or her. A survey (5) sponsored by the Morehouse School of Medicine and the New America Wellness Group found that 61% of Hispanics, 28% of blacks, and 11% of whites said seeing a doctor of the same ethnicity was important to them.
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CASE STUDY: THE "CUIDANDO SU SALUD" MODEL |
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Dr. Elmer Huerta's case study describing how mass media are used to reach Hispanics successfully will illustrate some of the aforementioned points. Kevin Kose, President, National Public Radio, once stated: "Radio, of all the media, is the most ephemeral and powerful force for transmitting ideas. It's a human voice from a remote location to another human being. And it's ubiquitous." Radios are especially integral to the Hispanic culture; they are kept in one's pocket and, therefore, are a personal companion. In Latin America, birthdays, deaths, and other family and community announcements or events are communicated via the radio. In 1994, 87.9% of Hispanics in the United States listened to Spanish-language radio on a daily basis. Hispanic adults 18 years or older listen to more than 2 hours of Spanish-language radio each day, on average (18).
About 78% of Hispanic-Americans more than 5 years of age speak a language other than English at home. Nearly 49% of Hispanics in 1991 reported that they spoke English very well, whereas 14% said they spoke English well, and 37% said they spoke it poorly or not at all (19). Because ethnic identity is inseparable from the language of the members of a group, health messages transmitted via the radio will be more successful if they are in the native language of the ethnic group (3,20,21). Spanish-language radio should, therefore, be considered as a medium for reaching Hispanics with health-risk messages (especially for the more linguistically isolated Hispanics who may not be exposed to messages transmitted through other channels) (6).
In large urban areas, Hispanics often depend on local Spanish-language broadcast and print media for news and entertainment [this is important because, among other reasons, urban Hispanic women tend to have inadequate levels of knowledge and misperceptions about cancer (17)]. Since 1989, Dr. Elmer Huerta's radio show, "Cuidando su Salud" ("Taking Care of Your Health"), has provided daily disease-prevention and health-promotion messages to Hispanics on a Washington, DC-area Spanish-language station. The show lasts 2 minutes, is aired three times a day during news segments, and has recently been expanded to reach more than 70 radio stations across the United States and Puerto Rico. By April 1999, 1847 different individual programs had been produced. Using Healthy People 2000 guidelines, these programs included 717 on health promotion (including programs on tobacco, nutrition, fitness, family planning, alcohol, violence, and mental health), 210 on health protection (including programs on unintentional injuries, food and drug safety, and environmental health), 875 on preventive services (including cancer, acquired immune deficiency syndrome, infectious diseases, maternal and infant health, and policy issues affecting Hispanics), and 45 on other health topics.
A synergy of health-message placement is created by expanding the channels to television, print, and the Internet. Not only are Dr. Huerta's Spanish-language radio vignettes aired daily, but health messages are also discussed during his daily radio talk shows and television show on Saturdays. A quarterly newsletter and information on the Internet further extend the reach to the community.
Dr. Huerta's radio show has been used successfully to recruit people for research projects (22) and cancer clinical trials (23,24). The radio component of Maryland's Centers for Disease Control and Prevention-funded Breast and Cervical Cancer Campaign involved a single program that was aired three times 1 week apart in 1993. By June 1994, 655 women had been screened, 44% of whom were Hispanic. This ethnic breakdown of women screened contrasts sharply with the proportions of Hispanics in the two participating Maryland counties: 7% in Montgomery County and 4% in Prince George's County. At least one third of the Hispanic women attending the screening program had learned about it from "Cuidando su Salud" (23). More than 300 Hispanic women were recruited for the National Cancer Institute's (NCI) Breast Cancer Prevention Trial during the 3-week period after a series of five programs aired (23). According to NCI's Cancer Information Service, the number of Spanish-speaking callers jumped 700% after Dr. Huerta's radio reports began to promote the service's toll-free number (24).
Dr. Huerta's success is especially striking given the often fatalistic way Hispanics view cancer. Much of the success of Dr. Huerta's health communication can be attributed to his understanding and incorporation of Hispanic cultural characteristics into message delivery. Feedback from the Hispanic community indicates their desire for health messages to begin with the larger context in which the health message is embedded and move gradually toward the hook or the bottom line—Hispanics, then, fall into the category of a collectivist culture and prefer this style of communication. Dr. Huerta's shows start broad and culminate in the "Big Bang Health Message." Hispanics, moreover, view physicians with authority and respect (6,25). Because Dr. Huerta is Hispanic and a physician, the messages that he disseminates are credible. In other words, because the recipients trust Dr. Huerta as the messenger, his health messages reach the Hispanic community effectively. "Cuidando su Salud" is proof that knowing and respecting audience characteristics is key to effective health communication.
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CONCLUSION: TAILOR HEALTH MESSAGES BASED ON CULTURAL BELIEFS |
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Knowledge of ethnic differences in risk communication is paramount to the success of a health message (26). Careful attention to culture-specific conceptualizations of a health issue and to appropriate channels for diffusion of health information will help hone the message. When health information such as cancer risks is communicated, messages (and the words used in those messages) must be tailored in a way that will be culturally meaningful and appropriate—this also almost always means communicating in the native language of the cultural group (3,21). Including members of the cultural group as partners in the development and implementation of intervention strategies, moreover, has resulted in significant desirable changes in health risk behavior in several risk-reduction programs (3).
Effective message development, additionally, needs to consider differences among an ethnic group's subgroups. The diversity within subgroups is derived not only from national origin (e.g., Mexican-American, Puerto Rican, Cuban-American, or Central or South American) but also from socioeconomic status, level of education, place of residence (urban or rural), and level of acculturation (8,9). Williams and Flora (9), for example, used the social marketing principle of audience segmentation and disaggregated a Hispanic audience to examine heterogeneous behaviors and lifestyles. Their analysis resulted in six mutually exclusive subgroups, based on self-reported behavioral changes to improve health. Subgroups differed significantly in communication, behavioral, psychological, and demographic dimensions, indicating they may require unique campaign planning strategies.
There is a fine balance between targeting an entire ethnic group with the same broad message and tailoring specific messages to ethnic subgroups or psychobehavioral segments within an ethnic group. Broad health campaigns, such as "Cuidando su Salud," may serve as catalysts for behavioral change, whereas local, more segmented campaigns may be necessary to reinforce a broader health program. Health communications professionals must bear in mind both the uniqueness of an individual and the uniqueness of the cultural group of the individual. Only when these considerations are taken into account can health messages be translated into behavioral change (21).
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REFERENCES |
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21 Locke DC. Increasing multicultural understanding: a comprehensive model. Newbury Park (CA): Sage Publications; 1992.
22 Shankar S, Huerta EE, Gutierrez-Mohamed M, Crespo CJ. Community involvement in assessing health needs of immigrant Salvadoreans living in the Washington DC area. Ethnicity Dis 1998;8:1-9.[Medline]
23 Huerta EE, Weed DL. Cuidando su salud: Spanish-language radio in preventive medicine and public health. Cancer suppl 1998;83:1805-8.
24 Skolnick AA. Hard to reach Hispanics get health news via physician's radio, TV shows. JAMA 1997;278:269-72.[CrossRef][Medline]
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26 Singer M. Confronting the AIDS epidemic among i.v. drug users: does ethnic culture matter? AIDS Educ Prev 1991;3:258-83.[Medline]
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