Public Health Communication
A. SUSANA RAMÍREZ, PhD, MPH
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Health & the Media: Teaching Media Effects to Public Health Students During a Pandemic

12/21/2020

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This is the third in a 4-part series reflecting on teaching during a pandemic semester. In the first part, I described how I prepared for teaching remotely; in the second part, I reflected on how teaching in a pandemic has improved my teaching effectiveness. In this post, I want to describe the content of my class and share how students learned to be more critical consumers of information. 
 
I got to teach my favorite class, Health & the Media, an upper-division elective that generally enrolls mostly public health majors. The overarching aim of the course is to provide students with an understanding of the ways the media influence public health outcomes. We don’t have a communication department on campus so this is likely the only time students will be exposed to communication theory. 
 
In the past, I had relied on three books to achieve the course goals: Merchants of Doubt; Health, Risk and News; and Social Networks and Popular Understanding of Science and Health. In combination with a few chapters from an actual communication textbook, these readings were fun for me to teach and effective for the students. Alas, Health, Risk and News is out of print and hard to find now; while searching for a replacement, I found out that Merchants of Doubt had been made into a documentary! Then it hit me: Students might enjoy (and, ahem, be more likely to complete the assignment) watching a film more than reading a book. So I decided to be more intentional about selecting course “texts”. As much as I enjoyed Social Networks & Popular Understanding of Science, much of the information I wanted students to be able to apply from that book was relevant to understanding the infodemic accompanying the current pandemic – and the World Health Organization, among others, had put together some terrific interactive content. 
 
That left the drier content to cover: Should I just assign the usual textbook chapters? No! It turns out I have super talented friends and one of them just published a book that held considerable promise for entertaining my students while teaching them principles of communication theory. 
 
One last point: I made the decision early in the course design process not to focus this course exclusively on COVID19 or even more broadly, on contagious disease communication. Although I made the decision for my own mental health (remember, I am a human dealing with the pandemic world too), the majority of the students told me the appreciated the course as a respite from the never-ending flow of COVID19 news. 
 
The course was structured around three themes. 
 
Part 1: Making Science News
First, we discussed the processes of making and then translating science for lay audiences. We started by talking about how science happens and the potential for science to biased. We learned about the competing – sometimes clashing – values of scientists and journalists, and the news industry, and how these influence the way scientific information is produced for non-scientists. We also discussed audience features that make it hard for non-scientists to interpret scientific and health information. Some resources that were especially helpful for this section:

  • TED and TEDx Talks
    • Chimananda Ngozi Adichi at TEDGlobal 2009 – The danger of a single story
    • Mona Chalabi at TEDNYC – 3 ways to spot a bad statistic
    • Nina Teicholz at TEDxEast – The Big Fat Surprise
    • Megan Kamerick at TEDxABQ – Women should represent women in media (10:18)
  • Three short animated videos by TEDEd 
    • Can you spot the problem with these headlines? (4:50)
    • This one weird trick will help you spot clickbait (5:25)
    • How to choose your news (4:32)
  • Reading: Anything by Ed Yong but especially: “Why the coronavirus is so confusing: A guide to making sense of a problem that is now too big for any one person to fully comprehend” The Atlantic
  • Documentary films:
    • Merchants of Doubt
    • Picture a Scientist
  • Podcast: Scene on Radio S4 E11 “More Truth”
 
About halfway through this first section I realized students were having a hard time understanding the material. Even the students who reported spending hours engaging with the materials in preparation for our live class sessions were not able to answer what I considered to be basic questions. And without this foundational understanding, we couldn’t have the discussions I wanted to have in class. I built in more scaffolding for note-taking and engaging with the content. I asked them to ask themselves and to write in their notes: What is the author/speaker/film arguing? What is the main claim and what kind of evidence are they using to support this argument? I devoted the first 10 minutes of class (sometimes more) to deconstructing these questions for everything they read. We worked through multiple examples together and I reinforced these lessons through individual “minute papers”, team activities, and quizzes. Doing this transformed the energy in the class: I could tell students were more engaged and interested. They asked better, more specific questions that I could actually answer or help them to figure out how to answer. Although it was definitely challenging, students were able to appreciate the benefit of improving their reading comprehension skills.   
 
We ended this section with a discussion of the infodemic, including media literacy activities to help empower students to stop the spread of misinformation. Timely and incredibly useful resources:

  • First WHO Global Infodemiology Conference 2020  
    • How to protect yourself in an infodemic (2:08)
    • Conspiracies, rumors, and falsehoods: The truth about why the infodemic is so dangerous and what we can do about it (18:52) Claire Wardle, First Draft News.
    • A New Digital Reality: How Fake News and Misinformation are Derailing the Largest Vaccination Effort in History - A Case Study of Polio Programme (25:04) Rustam Haydarov, UNICEF. 
  • Think ‘Sheep’ before you share to avoid getting tricked by online misinformation. First Draft News
  • Audrey Tang, Digital Minister of Taiwan at TED2020 – How digital innovation can fight pandemics and strengthen democracy (48:55; to 6:05 is a very informative introduction of Taiwan’s digital strategy)
  • Go Viral Online Game
 
Part 2: Advertising and Marketing and Poor Health
In the second part of the class, we moved from thinking about the news information environment to consider the other major source of information and misinformation that affect health: Corporations. We used the public health pandemics of obesity and diabetes as a case study to examine how advertising and marketing of junk foods and sugary beverages contribute to poor population health. My favorite resources for this section were:

  • The documentary film El Susto!
  • Revealed: how junk food and alcohol brands turned Covid-19 into the world’s largest marketing campaignThe Telegraph.
 
Part 3: Comedy and Social Change
The first two-thirds of the course can seem fairly depressing because we focus on how media contribute to poor public health. So to end the semester on a positive note, in the final third of class, we used A Comedian & An Activist Walk Into A Bar to consider how media might be used to effect positive social change and improve population health outcomes. This was so much fun! 
Published by the University of California Press, the ebook was available to students via the University of California library system. This made it affordable (well, free) and also easily accessible to my students. Each chapter was 20-25 pages, which, although the text was sometimes dense, it did not feel like too much to ask students to do given the relatively light reading they’d had throughout the rest of the semester. Each chapter corresponded (roughly) to a specific communication theory that I wanted to cover. Students read each chapter, then we discussed the theory in class and watched some of the comedic clips discussed in the book. This was a highly effective way of teaching. Because they had read both descriptions and analyses of the clips beforehand (and although the book was published this year, almost all of the content was still new to my students!), students were able to bring their developing comprehension and analytic skills to bear on the content themselves. Below I will list a quick summary of the chapters we read in class and the clips that I selected to accompany each chapter.
 
A Comedian & an Activist Walk into a Bar, Chapter 1, “Why comedy, and why now?”  
Although this book focuses on comedy specifically, the theories they use are drawn from and can be applied more broadly to entertainment media of all types. This first chapter does a good job of introducing the idea of media effects, media ecology, and outlining the argument that the many ways people encounter media in their lives make this a good historical moment for thinking about how comedy can cut through the clutter to make positive social change and what that looks like.  
 
Along with reading Chapter 1, students watched a clip of a comedy and social change incubator program run by one of the authors of the book and a funny TED talk about moving from stories to action. 
  • American University’s Yes And Laughter Lab 2019 Trailer
  • Sisonke Msimang at TEDWomen2016 – If a story moves you, act on it
 
A Comedian & an Activist Walk into a Bar, Chapter 2, “How comedy works as a change agent” 
Chapter 2 elaborates relevant theories, charting the paths through which comedy can affect social change. Discussing this chapter allowed me to link back to earlier class materials that had hinted at but not mentioned media effects theories. Because the students are public health majors, it is important to convey the ways systems, policies, and environments affect population health. Thus, in class discussions of this chapter, we focused on the agenda-setting role of media and on cultivation effects. Helpful resources for this chapter: 
  • Media Effects (2:59)
  • Mr. Sinn: “Agenda Setting Theory: Media Theories” (5:15)
  • Podcast: TED Radio Hour “Painfully Funny, Part 1 - Sandi Toksvig: Can Social Change Start with Laughter?”(12:29)
  • Michelle Wolf on The Daily Show: "The All-Male Panel on Women's Health" (3:15)
  • Master of None, The Thanksgiving Episode (2:34)
 
A Comedian & an Activist Walk into a Bar, Chapter 3,  
Chapter 3 defines different types of comedy and provides examples of each. I almost did not assign this chapter, but I am so glad that I did because it provided a great way to show students how this content might be personally relevant to them. I created a collaborative online assignment on Google Sheets that they completed in teams of 3-5 students. They first had to select a public health problem they care about. Then they identified specific examples of each genre from their own media diets dealing with the issue they selected. Finally, they reflected on the kind of outcome or effect that each genre was best for, and the outcomes, audiences, or effect that might be counterproductive to public health goals. This was a powerful exercise for students because it forced them to reckon with their own media diets; most students had never thought about how they learn from content they choose to consume as entertainment. It was also a great strategy for me to gain insight into the kinds of content that current students are consuming – I was surprised by both the diversity of public health issues they care about and with the sources they found. I would be happy to share the assignment with anyone who emails me to request it.
 
A Comedian & an Activist Walk into a Bar, Chapter 4, “Can laughter help save the planet?”
Chapter 4 specifically focused on the ways comedy could shape public support for policies to reduce the human impact of climate change. This week’s clips were taken straight from the chapter and were big hits with the students. Part of the chapter reported on an experiment testing the relative efficacy of satirical communication compared with straight news about climate change. I showed the videos used in the experiment and asked the students to work in teams to answer reading comprehension questions about the experimental results. 

  • Last Week Tonight with John Oliver “A statistically representative climate change debate”  (4:26)
  • Funny or Die satirical public service announcement “Old people don’t care about climate change”   
  • Funny or Die satirical public service announcement “Climate Change Denial Disorder”
  • News condition: Facts First, "Climate Change is Real"  
  • Control condition: "Overhead in LA with Nina Dobrev"  
 
A Comedian & an Activist Walk into a Bar, Chapter 5, “Beyond poverty porn”
This chapter gave me the chance to talk about framing and priming. In addition to reading this chapter, they watched a TEDx talk about confirmation bias that helped us to link the theories from A Comedian & An Activist back to earlier content about misinformation and communication of science. In class, we watched a few clips referenced in the book. This class was a tough one to teach for me personally and I actually gave a belated trigger warning: I grew up poor and I have witnessed the kind of abject poverty depicted in these clips. And I know that this kind of poverty exists here in California’s Central Valley, and I suspect that at least a few of my students may have experienced it. So the examples in this chapter hit a little too close to home. Nonetheless, they were effective ways to talk about framing and priming. 
  • Alex Edmans at TEDxLondonBusinessSchool – What to trust in a “post-truth” world (17:40)
  • Satirical sketch featuring an impersonation of Sally Struthers, In Living Color (1991): “1-555-FEED-ME”
  • Satirical sketch, Saturday Night Live (2004): “39 Cents”
  • RADI-Aid, a parody of the campaigns satirized by In Living Color & SNL, by Norwegian advocacy organization SAIH: “Let’s Save Africa – Gone Wrong”
 
A Comedian & an Activist Walk into a Bar, Chapter 7, “Creative collaborations: How comedians and social justice advocates work together”
We ended the semester with Chapter 7, which provides specific guidance for how advocates (in my case, public health professionals) can work with comedians to accomplish their goals. Many of my students want to work in health promotion among vulnerable communities, so this was a great primer for things they might consider. 
 
As I reflect on teaching this semester, I realize how interdisciplinary my classroom is. I hope that some of the materials I have provided above will prove helpful to readers. I am also happy to provide the complete syllabus and assignments to anyone who requests it (and promises to use it for good!). Stay tuned for the final installment of this series, where I’ll focus on the substantive content of my course, and what we learned about Health & the Media using the diverse course materials I curated for this semester.
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Information overload links communication and health disparities

2/5/2019

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For years now, I have been struggling to understand how communication can both contribute to health disparities and also be used to solve disparities. One important aspect has been teasing out dimensions of "culture" that affect the kinds of information people have access to as well as the effects that information has on their attitudes, behaviors, and health outcomes. 

In one recent study, published in Social Science & Medicine, we tackled the construct of "fatalism" we tackled the construct of fatalism. Fatalism refers to a set of beliefs about the causes and controllability of diseases. Specifically, beliefs that individuals are powerless to influence health or illness, since these are controlled by external forces – you’ll get cancer if you’re meant to get cancer, for example. Based on the literature – including embarrassingly enough some of my own prior work – we expected the Mexican-American women we interviewed to exhibit high levels of fatalism. 

We didn’t find that. There was some modest fatalism indicated in the quantitative survey, but it was clear through the interviews that this group largely didn’t hold fatalistic beliefs. They very well understood that poor diet can cause diabetes, obesity, and heart disease. And they knew that diet was within their individual control. 

So they rejected fatalistic beliefs in favor of clear explanation of link between behaviors and disease. However, despite knowing that diet is technically within one’s control, many participants felt that their ability to act on knowledge was constrained by internal and external factors. Internal factors include cooking skills and motivation to prepare healthy foods as well as personal tastes. External factors include physical access to healthy foods (many participants live in food deserts where fresh and healthy foods are not available) or financial access (40% of the sample was food insecure). 

I argue that this finding is consistent with the critique of fatalism as reflecting an accurate appraisal of the structural barriers to health that exist for vulnerable populations, and suggests why in quantitative studies, participants might respond in ways that could be characterized as fatalistic but are rather acknowledgements of the very real constraints.

Another important finding was that Mexican-American women felt overwhelmed by the nutrition information environment. There is too much information about diet, and it is confusing.

The perceived conflict in the public information environment has at least two negative consequences: First, this tells us something about trust in information sources. Perceiving the information environment as consisting of contradictory knowledge engendered mistrust in public information sources for nutrition information. This mistrust can have long-term consequences for interventionists who want to use those sources to disseminate critical health information. The second outcome is directly related to health outcomes and disparities: The contradictions reported in news and other public sources sow confusion about the “right” healthy course of action. This confusion could lead to inaction or a rejection of advice on the grounds that it might change in the future, just as the prior messages have changed. 

These findings are relevant not just for nutrition or health contexts, and also are part of the conversation about what “fake news” and deliberate misinformation campaigns are doing to society. 

Yet despite feeling overwhelmed with too much information, participants described important information gaps. They wanted specific information: How to operationalize the basics. So there is still room for skills-based nutrition education.

So what does this all have to do with health disparities? Well, I find it interesting that fatalism as a construct is usually associated with ethnic minorities and people in structurally vulnerable situations. But I think this is irresponsible because it can lead to rather simplistic solutions such as trying to change fatalistic attitudes that are not really the source of the health issue, or too easy dismissal of structural issues. 

This study thus expands understand of how communication can contribute to health disparities. One of the mechanisms that appears to link fatalism to disease risk is information overload – that is, the exposure to excessive and conflicting information but with little guidance on how to determine the relative value of information from different sources. Information overload – sometimes mischaracterized as fatalism – may lead to confusion that negatively impacts the adoption of preventive behaviors, ultimately contributing to disparities. 

A more indirect route through which information overload may contribute to disparities reflects the nature of the information environment and its perceived relevance for specific subgroups. In this study, Mexican-American women simultaneously describing having TOO much but NOT ENOUGH of the right kind of information. This desire for deeper knowledge & specific skills may be attributable to structural barriers that limit the ability to access appropriate information (this is a form of information inequality). 

But…it’s also possible that the information is there but not perceived as appropriate for this particular audience. Somehow bicultural women are not identifying with the messages, so I still need to work on figuring out how to do that…stay tuned! But to help with the information overload issue, we’ve created a measure of diet information overload that is in press in Patient Education & Counseling, and hopefully, it will be widely adopted and allow for better discrimination of information overload from fatalism and also to assess how people respond to the information environment.

What other "cultural" values do you think have served to hide structural issues that harm the health of vulnerable populations? 
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What Mexican-American women think of when they think of healthy foods - and what that means for communicating about health in a culturally appropriate manner

1/4/2019

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I spend a lot of my time doing research related to understanding how to communicate in a culturally appropriate manner with bicultural audiences. This is increasingly important because bicultural Latinos are a growing segment of the US population and yet epidemiological evidence suggests they are at high risk for poor health. 

In one study published last year in the Journal of the Academy of Nutrition and Dietetics, we found that Mexican-American described food as central to expressing cultural identity. Yet Mexican food traditions were characterized as unhealthy; many preferred American foods, which were seen as healthier. Among the participants who expressed a desire to eat healthfully, to do so meant to reject Mexican ways of eating.

This study raises questions about the nature of the “dietary acculturation paradox.” While food—the eating of Mexican foods—is central to the maintenance of ethnic identity throughout acculturation, negative perceptions about the healthfulness of Mexican foods introduce tension into Mexican-American women’s self-identification. This study suggests a subtle contradiction that may help to explain the dietary acculturation paradox: While previous research has suggested that as Mexicans acculturate to the United States they adopt unhealthy diets, this study finds evidence that they do so at least in part due to perceptions that American diets are healthier than Mexican diets. Implications for interventions to improve Latinos’ diets include an emphasis on the family and use of Spanish linguistic cues. Finally, messages that simply advocate for “traditional” diets should be reconsidered because that message is discordant with perceptions of the healthfulness of such foods.

How would you go about designing effective nutrition education messages for this group? 
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    A. SUSANA RAMÍREZ
    ​Associate Profesor
    ​Public Health Communication

    sramirez37 at ucmerced dot edu

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