Journal of Applied Communication Research Vol. 36, No. 1, February 2008, pp. 17
A Multiple Discourse Approach to Health Communication: Translational Research and Ethical Practice Roxanne Parrott
Experiences with the pursuit of health communication research are discussed in terms of barriers and facilitators to conducting this work. These experiences are considered for generalizable principles relating to the conduct of translational research. The importance of acknowledging the values and agendas which underlie the pursuit of translational research is emphasized. The contributions of both qualitative and quantitative methodologies to pursuits of translational projects are acknowledged. Finally, the need for communication scholars to participate in interdisciplinary endeavors is advanced as a goal with benefits for sharing the field’s theory and research insights, and to expand our own knowledge about other disciplines. Keywords: Translational Research; Multiple Discourse Approach; Ethical; Behavior Adaptation Translational research yields more than simple application; instead, the most important criterion is whether research findings are implemented in ways that function as pathways to improve lives. Many communication scholars who teach and conduct research in the health communication sub-discipline of our field find this truth about translational research to be a primary motive for doing health communication work. I am no exception. It is noteworthy that the medical, behavioral, and communication sciences have achieved a state of knowledge where there is a foundation to translate research into practice to improve lives, as it is not so many years ago that this was not the case. The relative lack of translational research has been noted in the past, generating discussion about why this state of affairs occurred. A number of significant barriers to achieving translational research have Roxanne Parrott is Professor of Communication in Pennsylvania State University’s Department of Communication Arts and Sciences. Correspondence to: Department of Communication Arts and Sciences, Department of Health Policy and Administration, Pennsylvania State University, University Park, PA 16802, USA. Email:
[email protected] ISSN 0090-9882 (print)/ISSN 1479-5752 (online) # 2008 National Communication Association DOI: 10.1080/00909880701799345
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been identified, including academic settings that reward departmental efforts over interdisciplinary programs and a lack of resources to support translational research (Pober, Neuhauser, & Pober, 2001). These issues suggest several realities about the pursuit of translational research. Perhaps foremost, translational research often depends upon the willingness of researchers from different disciplines to collaborate. In these translational collaborative endeavors, academic communication scientists work with other ‘‘experts’’ to plan, implement, and evaluate research. They bring different strengths, perspectives, and weaknesses, highlighting the reality that current definitions of evidence may need to be examined. For example, in the mid 1990s, epidemiological evidence that farmers are at a higher risk of skin cancer than the average population contributed to the view that this particular situation could benefit from translational research, and requests for applications to conduct such work were disseminated. Similarly, epidemiological evidence indicated a higher-than-average risk of skin cancer among youth living in some coastal regions in the southeast part of the United States, again a situation in which translational research activities might lead to improved well-being. In both of these cases, I was invited as a communication scientist to be present among a group of collaborators in Georgia who were interested in the design of interventions which could improve lives. The skin cancer risks for farmers and for soccer-playing youth are examples of issues that would benefit from translational research, which would guide decisions to allocate societal resources toward such important issues. Translational research, as suggested by Pober et al. (2001), often requires such resources. The Georgia collaborators agreed with the conclusion that translational efforts were warranted, but very different views emerged about what the evidence suggested should take place to achieve the sought-after benefit. For example, in the case of the farmers, one perspective focused on the need for farmers to organize, obtain health insurance, and attend health screenings to detect skin cancer earlier when it is likely to be more treatable. Another perspective regarded the situation as one that required makers of farm equipment to provide cabs shielding farmers from intense exposure to harmful rays during work in the fields. Still another view maintained that farmers are selfreliant, engaging in innovations disseminated via agricultural extension agents and other social networks, including friends and family. All the views had some merit, but limited fiscal resources required that decisions among these had to be made. For health communication scholars and colleagues from other disciplines sitting at the translational research table, there must be some consensus about which evidence is most persuasive in pointing to viable intervention. Once that is collectively determined, it becomes appropriate to consider the relevance of communication. For example, a decision to focus on communication to change individual health attitudes and behavior leads to the application of different theories than a decision to focus on communication to increase parental participation in building children’s healthy habits, to promote policy change to increase access to health care, or to support efforts to develop new organizational forms. The choice made from among numerous alternatives suggests which communication theories, research, and practice may
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inform an endeavor. In the case of farmers’ skin cancer risk, for instance, the decision was made to focus on their self-reliance. As a result of selecting this focus, we looked for ways to communicate how they could manage their own well-being when long hours of working in the sun could not be avoided. Collaboration with experts from other fields in the conduct of translational research persists across health communication activities. Doing so challenges researchers to develop sufficient knowledge in a particular content domain that may be outside of their area of communication expertise in order to collaborate. As I often say to graduate students who may be considering pursuing a degree in health communication, it requires training to be an expert in communication and also training to be competent in the knowledge domain broadly conceived of as ‘‘health.’’ In reality, participating in translational research as a health communication scholar often begins with a willingness to tackle new knowledge bases in the pursuit of research endeavors. For example, with the mapping of the human genome, an increase in efforts to communicate about the role of genes in health represents a tremendous opportunity for communication scientists to work with others to improve lives. Talking to others about the genome requires a complex vocabulary in a specialized area of health, and the ability to participate in these discussions differs markedly from having a vocabulary relating to skin cancer, for example. In collaboration with geneticists and genetic counselors, we have identified a need to understand how genetic risk messages are comprehended by lay audiences, especially those messages that depend upon the use of visual communication forms to substitute for verbal forms, which could be textual and/or interactional (Parrott, Silk, & Condit, 2003; Parrott, Silk, Dorgan, Condit, & Harris, 2005). The decades of research in communication science about evidence, including statistical evidence, together with knowledge about visual communication from a number of realms, contributed to this translational undertaking. In the process of directing our translational research toward lay audiences, we maintained a belief that information needed to be delivered in a comprehensible fashion to individuals who may use it to improve their lives, implicitly reflecting that the current delivery system suffered a deficit and suggesting that experts, including doctors and genetic counselors, could improve upon the ways in which they communicate the information. Translational research is not a value-free or agenda-free pursuit. Translational research reflects possible profit-making motives aligning with decisions to translate some research with greater rapidity than other research (Parrott, 1997, 2004). These motives sometimes advance the interests of individual health and well-being and sometimes do not. For instance, a public health message about sun protection is explicitly an effort to disseminate expert information derived about how sun exposure contributes to skin cancer. This message may also be part of a marketing effort to sell sunscreen. The profit motive forms a core thesis in our discussion about green tobacco sickness (Parrott & Polonec, 2007). The evidence that nicotine is absorbed through the skin of tobacco harvesters, causing them to be ill, has been available for decades. Despite this fact, there has been no emphasis on educating physicians about this reality, limiting the likelihood that doctors will discuss or
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diagnose the condition. There has also been no allocation of resources to disseminate information to tobacco harvesters. While society continues to sell tobacco products, those whose health may be harmed in efforts to produce these products have little concern directed toward their well-being. By comparison, those who choose to consume the products in the wake of decades of communication about likely subsequent health harms receive significant attention. People whose lives we may wish to benefit may have historical reasons to be suspicious of our endeavors, as illustrated by Tuskegee. We need to understand these views. For instance, efforts to identify when, where, and how communication may contribute to discrimination in realms associated with employment, insurance, and reproductive choice (Parrott, Silk, Dillow, et al., 2005) illustrate why individuals may understand information about the role of genes in health but still not act, even avoiding the disclosure of known health conditions within families. Thus, communication that promotes ‘‘knowing your family history’’ will face barriers to action if family members believe that having a known precondition limits the likelihood of employment or obtaining health insurance (Bernhardt, McClain, & Parrott, 2004). If ‘‘know your family health history’’ is to be promoted, communicating that the information may not be used to discriminate as regards employment or health care insurance may need to accompany the message in order to increase the likelihood that families will talk about health and heritage. We have also examined how individual perceptions of government, for example, shape views about the possible benefits of human genetics research (Achter, Parrott, & Silk, 2005), and how religious faith may factor in to perspectives about a role of genes in health (Harris, Parrott, & Dorgan, 2004; Parrott, Silk, Krieger, Harris, & Condit, 2004). If genetic therapies are to be supported as a strategy to increase well-being, communication about them will probably need to be couched in language that does not make doctors who practice genetic therapy appear to be ‘‘playing God’’ for those whose belief systems align with this view. Organizational agendas sometimes coincide with, and at other times may become a barrier to, translational research efforts. In research which sought to improve parents’ satisfaction with the care that their hospitalized children received, for example, we found that the hospital rules aligned with expectations that parents would feed their children, should they need such assistance, and provide companionship as well as other tangible support relating to the child’s care (Adams & Parrott, 1994). However, there were no strategies in place to communicate these expectations to parents, which contributed to nurses’ job dissatisfaction and parents’ care dissatisfaction. We developed a simple poster to communicate expectations to parents, which was posted in the hospital rooms where pediatric patients stayed, contributing to improved satisfaction for parents and nurses. Some of our research has focused on organizational barriers that may prevent patients from following medical advice. Building on work that revealed significant relationships between physicians’ nonverbal behaviors and patients’ verbal disclosure of concerns associated with organizational barriers to compliance (Duggan & Parrott, 2001), business field representatives who attend to the social discourse realm have been found to build
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affiliation with prospective customers which contributed to obligation, rapport, and increased sales (Clark, Drew, & Pinch, 2003). Translational research reveals the symbiotic relationship between qualitative and quantitative methods. In redesigning aspects of the research enterprise to accomplish translation, the fourth pathway highlighted in Petronio’s explication (2007) of translational research, health communication scholars reveal that the relationship between qualitative and quantitative methods is not an either-or scenario. Both are necessary in the conduct of translational work. For example, the maxim ‘‘do not promote a health message into an environment which cannot support it’’ requires examination of what is necessary to act on a message and what elements are present or absent in the location where an intended audience lives. In formative research designed to examine the work and family lives of farmers living in rural south Georgia, we learned that farmers may avoid the use of sunscreen because pesticides stick to it (Parrott, Steiner, & Goldenhar, 1996). We also found that migrant farmworkers may be at risk of skin cancer linked to pesticide exposure because laundry lines hang next to agricultural fields which receive aerial spray from pesticides (Parrott, Wilson, Buttram, Jones, & Steiner, 1999). Thus, one of the usual messages associated with possible pesticide residue on agricultural workers’ clothing, which is to dry the laundry in the sun, allowing its ultraviolet rays to break down the residue, could have contributed to additional exposure via the aerial spray. Translational research involving communication scientists makes apparent that the efforts in this realm have moved communication as a discipline into prominent roles in policy, including positions that afford opportunities to participate in and have input into decisions which may provide sites for far-reaching influence. My own experiences contributed to a perspective which frames the meaning of translational research and health communication research specifically for me. This perspective emerged from a decade of research and field work into the Multiple Discourse Approach (MDA) to health communication (Duggan & Parrott, 2001; Parrott, 2004; Parrott, Huff, Kilgore, & Williams, 1997). The MDA was the backdrop against which we advanced a Behavior Adaptation Model (BAM) to guide the design and evaluation of community-based health campaigns (Parrott & Duggan, 1999; Parrott, Monahan, Ainsworth, & Steiner, 1998; Parrott & Polonec, 2007). The BAM acknowledges that we often cannot avoid behaviors that put our health at risk while maintaining our employment and/or pursuit of recreational activities. The BAM has guided others’ work in risk-information domains, considering, for example, the correlations between actual and perceived knowledge as predictors of cognitive processing of risk information (Johnson, 2005). Both the MDA and the BAM have contributed to several insights into translational research which guide my current pursuits of such work. In 1999, Carol Steiner*the Director of Georgia’s Cancer Control Program at the time*and I received a Linkages Award from the Council on Linkages between Academia and Public Health Practice in Washington, DC. The council gives the Linkages Award to representatives of public health agencies and institutions of higher learning selected as collaborative exemplars. The council represents the Association of
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State and Territorial Health Officials (ASTHO) and the National Association of County and City Health Officials (NACCHO). Lessons about translational research that Carol Steiner and I learned in our collaborations (Parrott & Steiner, 2003) increased our commitment to such work and contributed to my invitation to serve on the Institute of Medicine’s committee which wrote the report Who Will Keep the Public Healthy? Educating Public Health Professionals for the 21st Century (Gebbie, Rosenstock, & Hernandez, 2003). That service led to a nomination, appointment, and four years of service as a member of the Institute of Medicine’s Board on Population Health and Public Health Practice. These service roles affirm the reality that translational research insights, in part, come from the act of doing and the course of knowing. It is, thus, valuable to include efforts to understand and support the role of communication science in translational research in our discipline’s national and international organizations. References Achter, P., Parrott, R., & Silk, K. (2005). Minority opinion in human genetic research. Politics and the Life Sciences, 23, 6066. Adams, R., & Parrott, R. (1994). Pediatric nurses’ communication of role expectations to parents of hospitalized children. Journal of Applied Communication Research, 22, 3647. Bernhardt, J. M., McClain, J., & Parrott, R. L. (2004). Online health communication about human genetics: Perceptions and preferences of Internet users. CyberPsychology and Behavior, 7, 728735. Clark, C., Drew, P., & Pinch, T. (2003). Managing prospect affiliation and rapport in real-life sales encounters. Discourse Studies, 5, 531. Duggan, A. P., & Parrott, R. L. (2001). Physicians’ nonverbal rapport-building behaviors and patients’ talk about the subjective component of illness. Human Communication Research, 27, 299311. Gebbie, K., Rosenstock, L., & Hernandez, L. (Eds.) (2003). Who will keep the public healthy? Educating public health professionals for the 21st century. Washington, DC: National Academies of Sciences Press. Harris, T., Parrott, R., & Dorgan, K. (2004). Talking about human genetics within religious frameworks. Health Communication, 16, 105116. Johnson, B. B. (2005). Testing and expanding a model of cognitive processing of risk information. Risk Analysis, 25, 631650. Parrott, R. (1997). Encouraging sunscreen use. Journal of Cosmetics and Toiletries, 112, 94. Parrott, R. (2004). Emphasizing ‘communication’ in health communication. Journal of Communication, 54, 751787. Parrott, R., & Duggan, A. (1999). Using coaches as role models of sun protection for youth: Georgia’s ‘‘Got Youth Covered’’ project. Journal of Applied Communication, 27, 107120. Parrott, R., Huff, T., Kilgore, M., & Williams, M. (1997). A peer discussion of physicians’ communication competence. Southern Medical Journal, 90, 709719. Parrott, R., Monahan, J., Ainsworth, S., & Steiner, C. (1998). Communicating to farmers about skin cancer: A behavioral adaptation model. Human Communication Research, 24, 386409. Parrott, R., & Polonec, L. (2007). Preventing green tobacco sickness in farming youth: A behavior adaptation approach. In K. B. Wright & S. D. Moore (Eds.), Applied health communication: A sourcebook (pp. 341359). Cresskill, NJ: Hampton Press. Parrott, R., Silk, K., & Condit, C. (2003). Diversity in lay perceptions of the sources of human traits: Genes, environments, and personal behaviors. Social Science and Medicine, 56, 10991109.
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Parrott, R., Silk, K., Dillow, M., Krieger, J., Harris, T., & Condit, T. (2005). The development and validation of tools to assess perceptions of genetic discrimination and genetic racism. Journal of the National Medical Association, 97, 980991. Parrott, R., Silk, K., Dorgan, K., Condit, C., & Harris, T. (2005). Risk comprehension and judgments of statistical evidentiary appeals: When a picture is not worth a thousand words. Human Communication Research, 31, 423452. Parrott, R., Silk, K., Krieger, J. R., Harris, T., & Condit, C. (2004). Behavioral health outcomes associated with religious faith and media exposure about human genetics. Health Communication, 16, 2946. Parrott, R., & Steiner, C. (2003). Lessons learned about academic and public health collaborations in the conduct of community-based research. In T. L. Thompson, A. M. Dorsey, K. Miller, & R. L. Parrott (Eds.), Handbook of health communication (pp. 637650). Mahwah, NJ: Lawrence Erlbaum Associates, Inc. Parrott, R., Steiner, C., & Goldenhar, L. (1996). Georgia’s harvesting healthy habits: Formative evaluation. Journal of Rural Health, 12, 291300. Parrott, R., Wilson, K., Buttram, C., Jones, K., & Steiner, C. (1999). Migrant farmworkers’ access to pesticide protection and information: Cultivando buenos habitos campaign development. Journal of Health Communication, 4, 4964. Petronio, S. (2007). JACR commentaries on translating research into practice: Introduction. Journal of Applied Communication Research, 35, 215217. Pober, J. S., Neuhauser, C. S., & Pober, J. M. (2001). Obstacles facing translational research in academic medical centers. The Federation of American Societies for Experimental Biology, 15, 23032313.
