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? 

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? 

Back from a wonderful trip to San Antonio - what an honor to have been selected to participate in a Grantwriting Workshop along with my dear friend Dr. Deanna Kepka and my new friends, Dr. Crystal Lumpkins, Dr. Cynthia Mojica, Dr. Penny Flores, and Dr. Alan Holden. Deanna and I were friends and postdocs at NCI together. She is a real superstar in the world of cervical cancer prevention and disparities and I am in awe of her commitment, work ethic, and ability to balance the enjoyment of life with the hard work of being on the tenure track. 

Many thanks to Dr. Amelie Ramirez, whose research and career I have admired since graduate school, her entire staff, and the NCI's Center to Reduce Cancer Health Disparities, for making this workshop possible. Dr. Ramirez is an example of a mentor who may not have known the role she has played in my life: A role model whose very existence and research trajectory paved the way for my own. 

A very special thanks to our instructor, Dr. Alan Kristal, whose direct, no-holds-barred style of feedback was exactly what I needed. 

The week was intense, although we did manage to sneak out for two amazing dinners on the San Antonio Riverwalk! I returned exhausted but intellectually refreshed and recommitted to building a program of research that makes a difference. Peace and courage to all to keep up the good work!

The segment below was featured on Univision's Health Week / Semana de la Salud on Tuesday, August 26, 2014. Watch below or go to the website to view the rest of the videos featuring challenges to eating healthfully - exacerbated by the drought - faced by vulnerable communities in California's Central Valley.