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Strategies for Diffusing Public Health Innovations Through Older Adults' Health Communication Networks

Posted on: Friday, 30 September 2005, 06:00 CDT

By Levy-Storms, Len

How to ensure that new programs and practices are spread and adopted.

Individuals across the world are using longer, mostly because of basic advances in public health such as sanitation and clean drinking water. In the United States, changes in lifestyle that include more health-promoting behavior are among the factors helping individuals to live longer. Because of the increasing numbers of people living longer, efforts to encourage such behavior requires a a shift from a focus on individuals in clinical settings to a focus on subpopulations within the community and society.

POPULATION HEALTH AND AGING

Two major developments in the twentieth century are important in a consideration of population health and aging. In health, the causes of population mortality shifted from acute, infectious diseases to chronic, noninfectious diseases. Thus, the basic public health notions of prevention have required revision. Although primary prevention avoids the pathological onset of disease, and secondary prevention delays the clinical onset of disease (German, 1995), the new prevalence of chronic conditions required a new emphasis on modifying health-related behaviors such as diet and exercise and screening for early detection of potential problems.

At the same time, the age distribution of the U.S. population has changed, with more individuals living longer, combined with decreasing fertility rates.

Combined, these epidemiological and demographic transitions present a significant challenge to those who wish to provide effective health promotion interventions. For example, the presence of existing diseases may distract healthcare providers and elders themselves from taking preventive measures (German, 1995). As more and more older adults live longer with chronic diseases, public health approaches mast go beyond the healthcare system to the community to prevent or delay chronic diseases.

The range of preventive health behaviors includes lifestyle practices such as exercise and eating habits as well as undergoing medically recommended procedures such as screening. Fifty percent of premature mortality is directly related to individual lifestyle factors and behaviors; a much lower percentage of premature mortality is related to genetic profiles or inadequate access to medical care (McLeroy and Crump, 1994). What is more, while preventive health behaviors play a substantial role in reducing the risk for premature death, the positive effects also reduce the risk for disability from chronic disease, even among older adults.

PROMOTING ADOPTION OF 'HEALTH BEHAVIORS'

What is the best means to promote adoption of these obviously valuable health behaviors given current population realities?

Traditionally, health educators have taken a "rational" model of behavior and decision making. According to that model, with the right information, elders will change their behaviors accordingly. Health education strategies from this standpoint, then, focus on the readability of health education materials, adding language and graphics to make material "culturally competent," and having the change agent be someone the target audience can identify with. While these are no doubt effective for some target audience members, the approach is incomplete in that it does not consider the larger social context of health behaviors.

The relational approach, on the other hand, adds perspective on the issue and inherently considers individuals and their reciprocal engagement within the larger social context (Green, 1984). That is, it is not just that the "change agent" is a credible source but that this person is well connected within the community and has influence over his or her peers. This situating of the change agent within the larger community in relation to others is directly in line with a public health perspective.

A RELATIONAL PERSPECTIVE

Public health researchers have increasingly begun to adopt a relational perspective on individuals' health behaviors and to study not just attributes of individuals but also their actual relations with other individuals with the underlying assumption that these relations influence their health behaviors. This approach explains individuals' variation in their health behaviors via their relations with others, because individuals who communicate with others tend to be more alike to these others than not (Rogers and Kincaid, 1981). In other words, individuals and their health communication networks are likely to engage in similar practices related to their health. A communication network is ". . . the pattern of friendship, advice, communication, or support that exists among members of a social system" (Valente, 1995, p. 31). Health communication networks can be defined in any number of ways, focusing on discussions about health in general or even specific aspects of health (e.g., breast cancer). Reach one of these individuals, change that individual's behavior, and you are likely to reach and change the behavior of many others.

Older people would benefit especially from a relational approach to health promotion. They face an increased risk of decreasing social relations as their friends and family also age, as some move away and some die. Although formal health networks potentially play an important role in health promotion and prevention, informal, lay social networks also potentially play an important, complementary role in encouraging elders to see their physicians and to follow up on their recommendations. Approaching health promotion among older people from a relational perspective will contribute toward maintaining their connectedness with social ties and capitalizing on how social ties affect their health behaviors.

HOW INNOVATIONS ARE SPREAD AND ADOPTED

Diffusion theory, which addresses the means by which innovations are spread through a population and adopted over time, provides a way to conceptualize the spread and adoption of health behaviors as an interpersonal, social process. Although the theory can be used to study planned change, it originated as a theory of naturally occurring adoption of innovations in social systems. The study that characterized classic diffusion theory looked at the adoption of hybrid corn seed by farmers around the mid-1940s and found that neighboring farmers, rather than mass media, were the most effective in persuading other farmers to adopt this seed (Valente, 1995). It was this seminal research that established the diffusion of innovations over time as fundamentally a social process (Rogers, 1995). Four principles represent the essence of diffusion theory.

Principle 1: Innovations are anything new to a population. For the purposes of this review, health behaviors are conceptualized as innovations, because they may be considered a new lifestyle behavior for some subgroups of older people (Rogers, 1995). Preventive health innovations are especially open to social influence because the benefits are not immediate but occur sometime in the future.

Principle 2: Interpersonal influence peaks when the rate of adoption of an innovation in a population reaches a maximum.

Principle 3: The adoption of innovations occurs in stages. Adoption stages are reflective of an older person's use of an innovation at any particular time. Diffusion theory's innovation- decision stages are (1)knowledge, or learning about an innovation's existence; (2) persuasion, or forming a favorable attitude toward it; (3) decision, or taking steps that lead to using it; (4) implementation, or actually trying the innovation; and (5) confirmation, or repeated use of an innovation, which may also lead to discontinuation (Rogers, 1995).

Principle 4: Interpersonal influence mostly affects the later stages of adoption. Although diffusion formally refers to the spread of an innovation at the population level, it must be adopted at the individual level eventually. In recognizing the mechanisms of influence at two levels, it suggests the roles of hoth mass media (social system level) and interpersonal communication channels (individual level). External influences such as mass media may lead to increased awareness of innovations, hut interpersonal influences can he more important in adoption or utilization of innovations when thelarger subculture considers the innovation to be positive (Valente et al., 1997). Thus, external or mass media influence becomes less important and interpersonal influence more important at later stages in the adoption of innovations, because any uncertainty about using the innovation can be better alleviated through interpersonal ties than through mass media.

Figure 1

Example of a Diffusion Curve: Cumulative Proportion of Mammography Adopters Over 20 Years (N=260)

IMPLICATIONS FOR EFFECTIVE HEALTH PROMOTION TO OLDER ADULTS

Translating these above-mentioned principles of the diffusion of innovations into a public health strategy to promote health behaviors among the aging population requires four practical and promisingly effective steps, which can be illustrated with the example of one specific health behavior, mammography screening.

Step 1. Assess the prevalence of the target health behavior in relation to rime since first adoption in a defined subpopulation of older adults. The first step is to understand \when (e.g., the year) the target population began to engage in the focal health behavior through the present time (via self-report survey or medical record documentation, if possible). If the focus is on more than one health behavior, then separate assessments must be done for each. Previous research on health behaviors has shown that behaviors do not necessarily correlate with one another (Rakowski et al., 1987). A critical part of this step is to identify a subpopulation of older adults that engages in direct or related communications about the behavior, based on any number of criteria including geographical or organizational boundaries, ethnic groups, and age cohort. One example is the regulars at a particular beauty salon where a range of health-related conversations occurs (Solomon et al., 2004). With the assessment of the adoption of the focal health behavior among the target population over time, one can determine whether a mass media or interpersonal health communication channel is most appropriate.

Step 2. Define the target health communication channel. Mass media health communication channels may include television, radio, Internet, and periodicals. Mass media channels will be most appropriate for subpopulations of older adults who have low rates of adoption of health behaviors. In other words, the health behavior of interest has yet to "take off" (e.g, mammography screening among older Samoan women in Los Angeles during the years 1978 to 1988 in Figure 1). Other subpopulations of older adults that would benefit from mass media channels (at least initially) would be those who are socially isolated but have access to a medium like television.

Interpersonal health communication channels may include any aspect of social relationships among the target subpopulation of older adults. The focus for interpersonal health communication networks is to determine whom individuals talk to about health. For example, if the health behavior of interest is mammography screening, then women can be asked whom they talk to about breast cancer. This level of specificity may or may not be important, so one may simply ask with whom they discuss health matters. The important point is to distinguish the health communication networks from the larger, more nebulous social networks (Vaux, 1988), then, from this information determine who in this network is the most well- connected and influential (see Step 4 below).

Step 3. Identify the stage of the focal health behavior. Some health behaviors are more complex than others, but a number of options are available to identify the diffusion stage. For example, before a woman can decide to obtain a mammogram, she must be aware that she needs one. In becoming aware, she may develop a favorable or unfavorable attitude toward the behavior, depending on whether she thinks it is worthwhile. Further, the woman must have access to a healthcare facility or mobile van that performs mammograms and, usually, a physician's referral. Finally, obtaining one mammogram is not enough; women must have regular mammograms for them to be effective in the early detection of breast cancer. So, to be considered truly adopted, the mammography must be employed repeatedly. The same is true for many other health behaviors such as engaging in exercise and eating a healthy diet.

Another factor related to determination of the stage of adoption is the information available, since acquisition of knowledge and development of attitudes are potential precursors to the actual behaviors. In one study (Levy-Storms and Wallace, 2003), a combination of time between first and last use of mammography as well as knowledge and attitudes toward it were used to "stage" women, that is, determine their stage of adoption.

Both first year and most recent year of adoption were used as part of algorithms based on diffusion theory's innovation-decision stages to assign women to three mutually-exclusive groups: (1) "implementation and confirmation" stages, in which the woman had had a recent mammogram (either a first mammogram within the past five years or a recent one within the past two years; if not, (2) the "decision" stage, wherein she planned to have a mammogram in the future. Women who did not fall into these two categories were coded as being in the (3) "knowledge and persuasion" stages. All five innovation-decision stages were collapsed into these three groups in this study for analytical purposes, but they could be kept separate for the design and evaluation of health promotion campaigns in practice.

A staging approach could even be applied to differentiate subpopulations of older adults who are nonadherent, that is, do not engage in a behavior such as mammography. Another study did categorize women according to their level of nonadherence: (1) never, (2) lapsed (had a mammogram two or more years ago), or (3) due (one to two years ago) (Levy-Storms, Bastani, and Reuben, 2004). In this latter study, then, women's knowledge and attitudes were not directly factored into the staging algorithm. Staging, then, can be tailored to the behavior of interest and the study's focus.

Regardless of the exact approach taken to staging a health behavior, the point is that staging will allow a more sensitive strategy for health promotion because moving the target population through the early stages may be considered as progress even if the later stages (that is, repeated engagement in the health behavior) is the ideal. Of course, behavior is not always linear, so individuals may even skip stages.

Step 4. Promote the health behavior using a combination of mass media and opinion leaders. In most situations, health promotion of health behaviors will include a combination of mass media and interpersonal health communication channels. Thus, the issue is how much effort for each is necessary. Depending on where subpopulations of older adults fall into stages of behavior change, those promoting the behavior change should use either mass media or interpersonal health communication channels. The mammography example illustrates two important factors to consider related to the strengths and weaknesses of combined approaches.

Communication strategies to promote the adoption of mammography screening have used a variety of means, from brochures to lay peers. Strategies using lay peers, lay health workers, and community role models have had more success in improving mammography screening behaviors among minority women than those strategies using only print media (Suarez, Nichols, and Brady, 1993), a finding that suggests the importance of interpersonal interaction in promoting mammography screening. An important factor within health communication channels is who is doing the talking. For example, one program. Tell A Friend, effectively increased use of mammography among low-income women 40 years of age and older because it asked the women to nominate ten friends whom they would call and encourage to have a mammogram (Calle and Miracle-McMahill, 1994).

Another study strongly supports the importance of connections between women. This study found that formal and informal health communication networks influenced recent use of mammography screening, but women who had the strongest connections within their health communication networks additionally influenced other women's future intention to use mammography screening (Levy-Storms and Wallace, 2003). The difference between these "connected" women and other peer-based health promotion models is that the former were identified based on direct nominations from other women in their churches who were also in the study. However, identifying connected women based on nominations can be time consuming, and no one way exists to identify these opinion leaders. Another approach would be to just "ask around" to find people who have a reputation as opinion leaders.

People identified as such appear to be more effective at reaching women in comparison to a process that targets all women equally with a less directed message. And, although the simplest strategy would be to target the opinion leaders with the message and hope for dissemination, it would be prudent to recruit them to a program in which they could be trained to disseminate the message formally through their informal relations. The key point is to think of the opinion leaders as potential catalysts of behavior change. Each of the aforementioned examples found that some degree of interpersonal contact enhanced their intervention's effect on mammography screening behaviors among otherwise hard-to-reach populations, possibly because women seek the advice of other women before talking to a professional.

CONCLUSION: THINK RELATIONALLY

Humans are social beings, and social relationships affect health. Aging and health are social phenomena and require public health strategies that make use of social relationships. Although the recommendation from this review is to combine mass media and interpersonal health communication channels, the emphasis is on the latter. Far fewer studies have taken an approach based on an interpersonal health-communication channel. Yet, many older people will have heard of the variety of public health innovations that promote "healthy" behaviors, so the challenge will be less to inform them and make their attitudes favorable than it will be to get them to repeatedly engage in the health behavior. Understanding and then mobilizing social relationships among connected groups of individuals to promote healthy behaviors promises to be a more effective strategy than strategies that target specific groups of individuals with little or no regard for their social relationships.

REFERENCES

Calle, E. E., and Mirade-McMahill, H. L. 1994. "Personal Contact from Friends to Increase Mammogaphy Usage? American Journal of Preventive Medicine 10(6): 361-66.

German, P. S. 1995. "Prevention and Chronic Disease in Older Individuals." I\n L. A. Bond, S. J. Cutler, and A. Grams, eds., Promoting Successful and Productive Aging (Vol. XVI, pp. 95-108). Thousand Oaks, Calif.: Sage.

Green, L. W. 1984. "Health Education Models." In J. D. Matarazzo, S. M. Weiss, J. A, Herd, N. E. Miller, and S. M. Weiss, eds., Behavioral Health: A Handbook of Health Enhancement and Disease Prevention (pp. 181-98). New York: John Wiley & Sons.

McLeroy, K. R., and Crump, C. E. 1994. "Health Promotion and Disease Prevention: A Historical Perspective." Generations (Spring): 9-16.

Levy-Storms, L., and Wallace, S. P. 2003. "Use of Mammography Screening among Older Samoan Women m Los Angeles County: A Diffusion Network Approach." Social Science and Medicine 57(6): 987-1000.

Levy-Storms, L., Bastani, R., and Reuben, D. B. 2004. "Predictors of Different Levels of Non-adherence to Mammography Screening: Implications for Interventions." Journal of the American Geriatrics Society 52: 768-73.

Rakowski, W. R., et al. 1987. "Correlates of Preventive Health Behavior in Late Life." Research on Aging 9(3): 331-55.

Rogers, E. M., and Kincaid, L. 1981. "Communication Network Analysis." In E. M. Rogers, ed., Communication Networks. New York: Free Press.

Rogers, E. M. 1995. Diffusion of Innovations. 4th ed. New York: Free Press.

Solomon F. M., et al. 2004. "Observational Study in Ten Beauty Salons: Results Informing Development of the North Carolina BEAUTY and Health Project." Health Education and Behavior 31(6): 790-807.

Suarez, L., Nichols, D. C., and Brady, C. A. 1993. "Use of Peer Role Models to Increase Pap Smear and Mammogram Screening in Mexican- American and Black Women." American Journal of Preventive Medicine 9(5): 290-6.

Vaux, A. 1988. Social Support: Theory, Research, and Intervention. New York: Praeger.

Valente, T. W, Jato, M., and van der Straten, A. 1994. "Social Network Influences on Contraceptive Use among Women in Traditional Associations." Paper presented at the 122nd annual meeting of the American Public Health Association, Washington, D.C.

Valente, T. W. 1995. Network Models of 'the Diffusion of Innovations. Cresskill, N.J.: Hampton Press.

Valente, T. W., et al. 1997. "Social Network Associations with Contraceptive Use among Cameroonian Women in Voluntary Associations." Social Science and Medicine 45(5): 677-87.

Len Levy-Storms, Ph.D., M.P.H., is assistant professor, Department of Social Welfare and Department of Medicine/Geriatrics, and associate director, Anna and Harry Borun Center for Gerontological Research, University of California, Los Angeles.

Copyright American Society on Aging Summer 2005

Source: Generations

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