Health information seeking behavior of young educated Hispanic women.
Abstract: Given the health disparities for Hispanic women, it is important to understand factors that influence health information seeking behavior. This study aimed to examine the extent to which educated Hispanic women seek out health information, sources used, and the factors that motivated health information seeking behavior. Focus groups were conducted with Latinas attending university. Results show they were not involved in regular health information seeking, resulting from beliefs that health outcomes were distant, coupled with the perception that certain behaviors were determined and reinforced by cultural practices. Results can be used to guide health communication development and future studies.
Article Type: Clinical report
Subject: Women (Health aspects)
Universities and colleges
Cardiovascular diseases
Diabetes
Authors: Suggs, L. Suzanne
Cowdery, Joan E.
Noll, Debra
Pub Date: 09/22/2010
Publication: Name: American Journal of Health Studies Publisher: American Journal of Health Studies Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 American Journal of Health Studies ISSN: 1090-0500
Issue: Date: Fall, 2010 Source Volume: 25 Source Issue: 4
Product: Product Code: 8220000 Colleges & Universities NAICS Code: 61131 Colleges, Universities, and Professional Schools SIC Code: 8221 Colleges and universities
Accession Number: 309069160
Full Text: BACKGROUND

The number of Americans who self identify as Hispanic has grown over the last several decades with a three-fold increase since 1980 (NCHS, 2006). As of 2007, 15% of Americans identified themselves as Hispanic with that number rising to over 20% for those under 18 years of age (CDC, 2008). As the population of Hispanic Americans increases so does the disproportionate burden they bear across many health indicators. Hispanic Americans have a higher prevalence of diabetes, heart disease, obesity, and stroke than Non-Hispanic white Americans, as well as disparities in many other health indicators (CDC, 2009; Flegal, 2002). For instance, Hispanic Americans under the age of 65 are more likely to be uninsured than Caucasian Americans (34.4% vs. 16.1%) (NCHS, 2006). At a theoretical level, these differences reinforce the proposition that cultural factors could be important for the design and distribution of health communication.

Assorted economic and policy factors have increased pressures on health systems to encourage greater amounts of individual control and accountability for personal health management. This requires people to have the skills, knowledge, literacy and resources necessary to obtain, understand, evaluate, and act on health information. Although health disparities between Hispanic and Non-Hispanic white Americans are well documented, there is a limited amount of research that focuses on young, urban, educated Hispanic women, in particular related to their health information seeking behaviors and the factors that influence them.

HEALTH INFORMATION SEEKING BEHAVIORS

Existing research exploring the health information seeking behaviors of minority populations indicates that notable patterns are emerging. Some research has found that race and ethnicity is related to less information seeking, but in all groups higher education levels are associated with a greater probability to seek health information (Stavri, 2001). Ribisl and colleagues (1998) examined how education and ethnicity are related to receiving health messages from print media and interpersonal channels, hypothesizing that less educated, higher cardiovascular disease (CVD) risk Hispanic and Caucasian men receive fewer messages than more educated men. The results showed that Hispanic and Caucasian men with lower educational attainment had higher levels of CVD risk factors, and received less health information from print media and interpersonal channels than those with higher educational attainment. Furthermore, less educated men from both ethnic groups reported less CVD knowledge, lower self-efficacy and lower motivation to reduce CVD risk factors than higher educated men.

In a study on views and preferences of Hispanics regarding diabetes education, Rosal, Goins, Carbone, & Cortes (2004) found that participants reported receiving and sometimes reading print information but that they did not always pay attention to it, nor did they consistently follow treatment recommendations. They also preferred small interactive talks such as group meetings when obtaining diabetes information. Talosig-Garcia and Davis (2005) examined the resources that minority women (African-American

and Hispanic) used after receiving a breast cancer diagnosis. Although most women in the study (81%) reported receiving information about breast cancer from their health care provider at the time of diagnosis, the majority of women (71%) indicated that they did not search for additional cancer-related information after their initial diagnosis. For those women who did seek out additional information, they reported going back to their doctor 30% of the time, utilizing print sources 19% of the time, and utilizing the Internet 13% of the time. Myrick (1996, 1998) found that culturally specific health communication about HIV and inclusion of minority voices in the administration and implementation of HIV programs have been found to be the most effective methods for prevention behavior.

This study is premised on the assumption that health information seeking is a health behavior that can be explained by health behavior theories such as the Health Belief Model (HBM) and the Theory of Planned Behavior (TPB). These widely used health behavior theories provide important propositions about the determinants of behavior change. They are complementary, yet conceptually distinct, and communication designed on the basis of these theories would be quite different. The Health Belief Model (Hochbaum, Rosenstock, Leventhal & Kegeles, 1950) holds that predisposing factors influence perceived severity, susceptibility, benefits, barriers, and self-efficacy and in turn, influence behavior. Cues to action then motivate someone to take action towards the behavior. Thus communication based on HBM would focus on increasing perceived susceptibility, severity, benefits, and self-efficacy while decreasing perceived barriers and providing cues to motivate change. The Theory of Planned Behavior (TPB) (Ajzen & Madden, 1986) hypothesizes that intention is the strongest predictor of behavior change. Intention is a function of an individual's attitude toward the behavior, perceived subjective norms, and both perceived and actual behavior control. Thus communication designed to improve positive attitudes about a health behavior, subjective norms, and perceived behavioral control should increase intention and result in behavior change.

Given the disproportionately high rates of diabetes, heart disease, stroke, HIV infection and breast cancer mortality found in Hispanic women, it is important to better understand the factors that influence health beliefs and personal health information seeking behavior (CDC, 2009; NCHS 2004; Office of Women's Health, 2006a,b,c,d). Therefore, the purpose of this study was to examine the extent to which young, urban, educated Hispanic women seek out health information, sources used, and the factors that motivated health information seeking behavior.

METHODS

A series of three focus group sessions was conducted with Hispanic women attending university in Boston Massachusetts. Sessions were held at a centrally located focus group facility just next to a stop on the subway. Eligibility criteria included being female, Hispanic/Latina, attending a Boston area university, and able to participate in a 2-hour focus group session conducted in English. The study was approved by the Human Subject Research Review Board at the principal investigator's university.

RECRUITMENT AND PARTICIPANT OVERVIEW

Several methods were used to recruit participants for the focus groups. Flyers were posted in many locations in Boston, including salsa dance studios, restaurants, beauty salons, health clinics and seven college campuses. Flyers were checked regularly by the research team and were replaced when the contact information tear-offs were gone. While the flyers had to be replaced frequently, due to the tear offs being taken, only one of the participants was recruited through this strategy. After three weeks of flyer posting, the recruitment strategy was expanded to include posting messages on the e-mail lists of Latino student organizations at all local universities and colleges. Every Boston area college or university with a Hispanic/Latino student organization (La Fuerza) listed on their Web site was sent an e-mail describing the study. The text of the e-mail was identical to that of the flyers. This proved to be most effective as 14 of the participants learned of the study through the e-mail. During the first two focus groups, participants were encouraged to promote the subsequent focus group session to their peers and this approach resulted in two additional participants.

Interested individuals contacted the project team prior to enrollment and were provided an overview of the study, their eligibility was determined, and they were scheduled for a focus group session. Approximately four days prior to each focus group, participants received telephone calls and e-mails to remind them of the upcoming sessions. Upon arrival to the focus group session, participants were provided a written overview of the study and an informed consent form, which they were required to read and sign in order to participate. Healthy refreshments were served and $30 incentive checks were mailed to participants after the sessions. The focus groups were moderated by a healthy looking, 35 year old, non-Hispanic white woman with substantial focus group facilitation experience. Each focus group was video and audio taped and transcribed by trained research assistants.

MEASURES AND ANALYSIS

A facilitator guide was developed that outlined a series of questions related to constructs from Health Belief Model (HBM) and Theory of Planned Behavior (TPB) (See Table 1). The discussions were structured around health information seeking behaviors and the factors that influence them. They were designed to ascertain the extent that participants sought health information, the sources they relied on, and the conditions that motivated information gathering. The questions were included in all of the focus groups, but presented in a manner that complemented the flow of the discussions rather than in a predetermined schedule. Participants told their stories about interactions with health delivery systems and factors that influenced their health seeking practices and health behaviors. Transcripts of each focus group were first prepared by one member of the research team, then checked for accuracy by a second researcher and subsequently verified and finalized by the lead author.

Focus group interview data were analyzed using the constant comparative method (Strauss and Corbin, 1998). The constant comparative method is a grounded theory methodology whereby data is broken down and conceptualized into key themes. The transcripts of the focus groups were independently read by two of the authors. Recurring themes emerged and were coded by both authors independently. The authors then met and compared their findings. Disagreements in coding were resolved through a dialog about the context, group dynamics, and nature of the story being told. Statements were then grouped into the themes, with some overlapping, and 100 percent consensus achieved on the key themes identified in the interview transcripts and the grouping of the data. Those excerpts that best illustrate these themes or strength of certain constructs are presented in the results section below.

RESULTS

PARTICIPANTS

A total of 17 Latinas attended the focus groups. The first session included seven participants and the others each had five. Participants self identified as second or third generation Hispanic/Latina with families predominantly from Puerto Rico, the Dominican Republic and Mexico. Other Latin American countries represented were: Costa Rica, Ecuador, Cuba, Argentina and Peru. All participants were undergraduate or graduate students, unmarried, with health insurance, as part of their parents' coverage. During the 2-hour sessions, participants generally contributed equally to the discussions, seemed interested in the discussion, and enthusiastically shared their opinions.

HEALTH INFORMATION SEEKING BEHAVIOR, ATTITUDES, AND BELIEFS

The starting point for each of the sessions focused on the type and amount of health information seeking. The most prevalent, unambiguous response from all participants was that they did not regularly seek health information. They were clear that they rarely thought about personal health concerns unless they experienced poor health. The following excerpts illustrate the theme that emerged from the sessions.

"I don't really think about health at all until I get very sick or something happens. "

"... we go to a party and we drink and we're not thinking oh I might like you know in the future you know ... I don't think like that and I've never actually gone online or done any research online on how much I drink, how it's going to affect me, or anything like that. "

Although health information seeking behavior was infrequent, the participants identified the sources they have used. Most turned to their parents and Google when they wanted health information. Some acknowledged that they liked having access to the Internet because they could do their own research and they appreciated the anonymity it provided them. They explained that they could research topics and not feel embarrassed or judged. While one person mentioned WebMD, most people agreed that Google was their number one online source.

"Google is my bestfriend, I like Google everything but I don't know, like "disease prevention" I don't think I ever typed that in. "

"I feel more comfortable because they don't know who I am, it's kinda like anonymous. "

When asked whom they trusted most for health information, most responded their "mother." However, this was not the case when it came to sex and sexual health. They all agreed that talking with their mothers about sex was off limits.

"[Me and my friends] cant really talk to them [our Moms] about sex. They have very strong beliefs like, [you] shouldn't, you know, have sex until you're married and stuff like that ... I think it's part of a Latin thing, I think it has a lot to do with like the religion aspect."

"sex is wasn't really spoken about with me and my parents. [They] didn't really openly talk to me about it. That's something that I think should be spoken about with your kids openly. It's a different time now and they definitely grew up in a different era. "

The participants reported little trust in doctors. Indeed, they reported that their families relied on prayer and religion to prevent and to cure illness rather than seeking out formal medical information or attention.

"I don't know to be honest with you. I've been wondering, do these doctors really know what they're doing sometimes? You know, you're not sure if the doctor is going to give you the right, accurate information"

"I feel every time I go, I say I have a pain in my arm, they look at my toe. You know, I just go there and I don't even listen to what they say"

Given that the participants did not consistently think about health or search for health information, we asked, "If you were told that you were at high risk for a certain disease, what would you want to know?" They responded quite quickly and emotionally with statements such as "everything" and "the truth". One asked "But what's high risk?"" which others agreed was an important question.

"Everything. I would want to know what I had to do in order to lower my chances of getting the disease or what would be my steps next if I did get the disease. I would just want to know everything beforehand so I could act like on my own if anything happened. "

"I would like to know the truth because a lot of doctors sugar coat things"

During each focus group, participants were asked, "What do you see as the major concerns/ issues regarding health?" The primary attitude that emerged from all focus groups was apathy towards individual health. For the most part, participants believed they were healthy, although many wanted to lose weight. In terms of motivators to stay healthy, participants reported being motivated first and primarily by appearance, followed by being able to live a long life doing the things they enjoy.

"Appearance was the first thing the first thing that came to my mind but I think that what you're [another participant] saying is true. Like say later when we have our kids I want to be healthy to like go out and play with them, you know? So I guess in the long run yeah. But its not the first thing that comes to my mind since it's not anywhere near my life right now."

They did not focus on prevention and only acted on health issues in a reactive manner when they or someone they knew experienced illness. Another participant said "you know as long as you look good, people consider you healthy" The idea of appearance as a barometer of good or poor health was firmly rooted in the belief system of these participants.

SUBJECTIVE NORMS AND BARRIERS

In addition to the issues of frequency, trusted sources, attitudes and beliefs about health, much of participant stories focused around the role of perceived subjective norms (TPB) and perceived barriers (HBM) to good health. This included both culture and societal norms. When asked what factors influenced their beliefs about health and their health practices almost everyone, without hesitation, said "culture."

"Um, I'm not sure if this is true but it seems that sometimes it's like being Hispanic and just the Hispanic cultures are, some aspects of them are sort of in opposition to good health, you know because the food and the way it's cooked and the lifestyle in most Hispanic cultures it's more lax, smoking is more accepted, so it just seems like in order to be healthy, and this it could just be a perception, but it seems that it's a harder conscious effort. Sort of that you have to compensate for your culture. Like you know Hispanic people aren't as used [to] having like all those good habits"

"I definitely think that culture plays a huge role, in terms of health awareness within the family because it's just stuff that you don't talk about, like it's always kept on the hush, hush"

"I think with older, like the older generation think that if I don't think about it, nothing will bad will happen.... It's the same way with like AIDS, how you don't want to talk about it. So if you don't talk about it, it doesn't exist. "

Given the importance on "looking" healthy that was expressed by the participants early in each session, we asked about barriers to healthy diets and physical activity. Family and cultural social norms were identified as the primary barriers. They spoke about diet and weight in terms of the context of being Hispanic and claimed"... we don't eat as healthy as other cultures do.'" They explained how food was a prominent fixture in family and social gatherings: "food is like the center of the family." They also recounted how they ate too much food at family gatherings because it was insulting not to eat what was prepared. Moreover, they commented that much of the food was often high in fat and sodium, and portions were quite large.

"food is happiness and food is you know part of the family"

"I think it's, it's easier to try to eat healthier when you're away from home because you don't have your mom's cooking in your face all the time. Then when you do go home it's like I have to eat it because if I don't she'll take offense and say, 'oh, wait my cooking's not good enough?'"

"you know, the culture. The thing is they don't care that it's unhealthy. A lot of things, about our culture, you know the smoking, the high starch, high sodium food, we kind of come in at odds with what is accepted now and what is good for you, you know"

"And then like portion sizes like my mom is used to cooking for like a big family and then as people started leaving the house, um, she still cooks for a big amount of people. So it's always like more food is there so it's what you're accustomed to. "

Some referred to eating behavior as part of social norms beyond the family. For example, they referred to feeling social pressure to eat the way others around them do.

"And then I think also the other thing, I feel like I don't know how to describe it but it's almost like pressure to eat what everyone else is eating. Like if I'm there and everyone else is eating pizza, I feel weird if I'm just gonna sit there and not eat it or sit there with a salad."

Culture was also portrayed as a barrier to physical activity. They thought it prohibited them from physical activity and felt that it was not normal to see Hispanics at the gym.

"in terms of exercise, I feel like Hispanic women are not expected to be outdoors or do sports. It's for the guys"

"I played a lot of sports in high school and they [parents] were like 'do you know what are you doing? Water polo? Girls don't play water polo.'"

"Hispanic, as, as us Latinas, I don't see a lot of us involved, you know like in the [Boston] marathon, or even at the gym were I work I can count the Latinas that go there."

In addition to specific behavioral barriers, cultural factors fostered perceptions of health that differed from prevailing societal norms. The participants observed disconnect between mainstream norms promoted in the mass media and cultural norms.

For example, they suggested that being a little heavy can be viewed positively. Indeed, they indicated that Jennifer Lopez was a good role model for delivering health information to Hispanics, but noted the disconnect with cultural and main stream norms:

"but they're always crackin on her butt. Like it's a bad thing, when in Hispanic culture it's like cool."

"My mom is obese, my dad is obese. Um, it's just a normal part of [Latin culture]."

They also expressed that even though cultural norms suggest more full figured sized, there was also a disconnect within the Hispanic media. The following excerpt best represents the discussion:

"Talking about Hispanic media though I think when you think about TV that's true. That if you look at Hispanic shows, like Sabado Gigante. I mean girls, they're always in bikinis and things like that so that's why I think image is... I mean it's in other cultures too, but I don't know maybe it's a little more dominant. Like girls are the sex symbols on Hispanic TV".

It is also worth noting that some participants had difficulty in labeling people with what they perceived as negative health labels, even in terms of cultural norms. For example, the woman who described her parents as obese, paused, seemingly thought about what she just said and then added "... I mean my mom and my dad they're not that fat, but, they're still

PERCEIVED BEHAVIORAL CONTROL, SUSCEPTIBILITY, AND SELF-EFFICACY

Other themes that emerged included the role of perceived behavioral control (TPB), perceived susceptibility (HBM), and self-efficacy (TPB, HBM). Participants felt that much of their health status and practices was determined by cultural factors outside their control. At the same time, there were some things they had control over. They had a very low perceived susceptibility of disease, yet felt they had the skills and resources necessary to find good health information if there was a cue to action.

Participants believed that they could prevent some diseases and illnesses, but it was not an issue that took up much thought or effort. They understood that their current health habits would have long-term consequences (like smoking and drinking), but since they had not been affected yet, they simply did not think about it.

"we don't think about what's gonna happen to us like ten-fifteen years from now, because were healthy now and you know were so young that we don't need to even think about it."

"I guess the problem being so young is that they're not, I mean, you don't think about that because it's not you and it's not your parents and it's not your friends. So, I guess that it's ignorance, you know, that's lack of education maybe. But it's also like how do you make people think about a condition they don't have?"

Time was frequently mentioned as another factor beyond their control. One comment was representative of this concern: "it's a lot easier to eat a slice of pizza when you're running out the door than to sit and have a salad." In addition to time, they also talked about peer norms when eating.

"I mean it's just easier to eat take-out pizza than it is to, like sit there and spend you know ten minutes or whatever, eating a salad. "

We explored participants' thoughts about their self-efficacy to access to the resources necessary to be healthy. They had high self-efficacy that they could access what they needed, but lacked the motivation, related to a low perceived susceptibility, to do so.

"Yeah the resources are there, you just have to use them"

"I think you have the choice to like go a safer path as far as preventing diseases. I mean as far as like do you smoke cigarettes or do you not, that's a choice"

We asked participants if they desired greater access to health technologies or programs. Many mentioned wanting to have access to a nearby gym. However, when others pointed out that students had access to the campus athletic facilities, the conversation returned to their lack of motivation. Many participants agreed that they needed a personal trainer who would "yell at them" to get them to workout at the gym. However, they did not identify any technologies or programs that would benefit them.

STRATEGIES TO PROMOTE HEALTH INFORMATION SEEKING BEHAVIOR

Finally, the participants were asked to make recommendations for strategies to promote health among Hispanics. Again, culture emerged as a dominant theme. They said that the messages needed to be delivered from a Hispanic person of the same gender. They suggested using churches, high schools, doctor offices, and e-mail, especially for college students, but there was widespread agreement that the most effective source would be television. In particular, they predicted that messages incorporated into Spanish language soap operas would be most effective.

"La Enamorada. Oh my God. It's like a big thing. My mom is hooked on it."

"The soap operas. They go on for hours. "

"I watched one a soap opera, a Spanish soap opera, and I loved that one, and as a matter of fact, the girl who played it she's Puerto Rican. She played a woman who is dying of AIDS. She had full-blown AIDS. She died of AIDS. And I was like, Wow, man I could, I could, you know, and it's true."

They suggested that Hispanic celebrities such as Jennifer Lopez, Eva Longoria, and Shakira were good role models for Hispanic women and message delivered by them would be well received. The participants advised that young Latinas, including college students, should be one of the initially targeted groups.

"if we want to see a real change in the community it has to start with like, our age, so that our children, learn, and eat, adopt our daily routines, of exercising, of living healthier lives. I don't want to say that it's too late but it might be too late to change how they [our parents] live,"

"yeah, that's the problem, all these diseases do exist and you can't keep your mouth shut about them to be honest with you. I mean I think if people would open up and talk about them more you know, basically people aren't paying enough attention to adequate healthcare, you know"

At the conclusion of each focus group, the moderator shared some health statistics related to obesity, health screening, and diabetes among Hispanic women. Most of the participants were unaware of this information and they expressed a sense of shock at the disparities experienced by Hispanic women. Some were dismayed by their lack of knowledge and indicated that they might do some research on Google to learn more about disease prevention. We did not follow-up with them to see if they did.

DISCUSSION

The results demonstrated the salience of several constructs from each of the theories included in the study; TPB: Perceived behavioral control, Subjective norms, and Attitudes; HBM: Perceived Susceptibility, Barriers, and Cues to Action. The focus group participants were unequivocal that they rarely engaged in health seeking activities until the onset of poor health (cue to action). The participants had a sense of distance from the negative consequences of unhealthy behaviors (perceived susceptibility). This finding was not entirely surprising as previous research shows that Hispanic women are not typically driven by health information needs as normal part of daily life unless motivated by specific personal concerns and the same holds true for college students (Courtright, 2005; Rosal, Goins, Carbone & Cortes, 2004). Limited information seeking may exacerbate health problems such as those reflected in existing health disparities.

Culture was specifically identified as a primary determinant in establishing norms about health and was particularly important in three different contexts: family, diet and popular culture, although there are cross cutting pressures arising from culture. This study, as well as other research, suggests that family has a strong impact on health behaviors and reinforced cultural norms and expectations (Carbone et al, 2007). Interestingly, the participants in this study were skeptical that parents could modify their health behavior, but younger people were more likely to do so especially if appropriate mass media health campaigns were implemented. At the same time, their most trusted source of information was their mothers, thus making it unlikely that change will occur among Hispanic women unless mothers are part of the change process.

Participants revealed that sports and physical activities were not prioritized as an activity for them because of culture and gender role expectations. Generally, Hispanic women are less physically activity than non-hispanic whites (Herrera, 2004; NCHS, 2006). Participants reinforced the problem of family events where food was a central focus. Traditional Hispanic diets are high in calories, sodium, complex carbohydrates, and saturated fat, which increase the risk of obesity and diabetes (Syracuse, 2006).

The importance attributed to popular culture, such as telenovelas, is also consistent with recent research. Wilken and colleagues (2007) found that inserting both a story line about breast cancer and concurrent public service announcements, using an actress from the program, was linked to increased calls to a cancer hotline and greater knowledge about breast cancer information among viewers. In another instance, calls to an HIV hotline number increased after a soap opera displaying an HIV storyline (Kennedy, O'Leary, Beck, Pollard & Simpson, 2004).

The focus groups revealed that individuals adopt multidimensional approaches to health that may seem contradictory. Taken as a whole, the participants were only periodically interested in seeking health information, yet in these moments they used interpersonal and web-based sources, although they recommended using more mass-media channels. Essentially they displayed both dimensions of health consciousness that have been associated with information seeking efforts. As Dutta-Bergamn (2004) reported, mass media sources such as TV and radio were typically used by non-health oriented individuals and interpersonal and web-based sources were characteristic of health-oriented people.

LIMITATIONS

The qualitative methods used in this study provide rich, detailed information, however there were several limitations that should be noted. In terms of the substantive content, a number of topics were not included. We did not collect any survey-based data about health status, health care utilization, or other salient individual factors that would have established a useful context for the analysis. Furthermore, the focus groups did not take account of interest or recall of social marketing or health communication campaigns. This would have been useful to explore because campaigns are seen as important vehicles to distribute information and promote healthy lifestyle choices (Maibach & Holtgrave, 1995; Rimal, Flora & Schooler, 1999; Zimmerman et al., 2007). However, since there was no doubt that the participants conducted very little personal health research, it is unclear whether this line of questioning would have been fruitful

IMPLICATIONS FOR RESEARCH AND PRACTICE

Focus groups with educated, urban Hispanic women attending university ascertained the extent that they sought health information, the sources used, and the factors that motivated information gathering. Interestingly, the participants were not involved in any type of regular or systematic health information gathering nor did they prioritize these activities. This resulted from several factors that instilled beliefs that health outcomes were distant (low perceived susceptibility), coupled with the perception that the specific health behaviors such as proper nutrition and physical activity were for the most part determined and reinforced by cultural practices largely beyond the participants' control (subjective norms and perceived behavioral control). Many challenges exist when people do not seek out information as part of an overall integrated approach to health and wellness. This is a unique and puzzling dilemma that will require a variety of study approaches and careful operationalization of theory based constructs.

It is evident that culture plays a large role as it was both embraced and blamed for health, health behaviors, attitudes and thought processes. Despite this, culturally specific health disparities persist and suggest that health promotion efforts are not achieving their intended goals. Therefore, additional research should look further into the antecedents of health information seeking, especially amongst friends and family. As mother-daughter relationships are important, these partnerships may prove to be a vital foundation to facilitate health or illness. In terms of popular culture or entertainment education, it would be useful to examine the depth of knowledge and understanding that can be transferred and whether different health topics or entertainment are amenable to this form of communication.

The need for enhanced health communication is prompted by the changing nature of health care that places much greater reliance on individual responsibility. Hispanic women bear the burden of higher rates of several diseases relative to women in other ethnic and racial groups. Yet, educated Hispanic women in this study had low perceived susceptibility to disease. While this is to be somewhat expected among college age students, this demographic group has a known risk for poorer health, associated with lifestyle and knowledge seeking behaviors, is educated and has access to resources. Thus, this trend is reversible and preventable, if the knowledge and motivation is in hand. The results can be used to inform health promotion and disease prevention programming efforts in terms of content, delivery channels, and participant recruitment.

Health promotion and communication experts should consider culture, in addition to behavioral factors, when designing messages, campaigns, and programs. Messages and delivery channels need to be targeted and perhaps tailored to the specific needs of Hispanic university women. For example, communication efforts about weight should consider that Hispanic cultural norms suggest being overweight is positive (Council of Latino Agencies, 2002). Therefore, when addressing issues of weight management and weight related co-morbidities with this population, it may be important to focus on healthy weight and the benefits of diet and exercise rather than being obese or too heavy. Participants' conceptualization of health as "looking good" suggests that efforts need to be undertaken to persuade people to adopt a deeper interest (or even some interest) in health as a way of life with no specific start or end point. In the absence of affordable, widespread individualized health counseling or coaching it may be worthwhile to develop systems that leverage communication technologies. For example, as the vast majority of college students have mobile phones, individual, biometric-based communication systems using mobile phones could provide an effective and economical platform to deliver tailored messages to relatively large numbers of users.

CONCLUSION

The study examined and reported factors that influence health information seeking behavior, sources used, and the factors that motivated health information seeking behavior of young, educated Hispanic women. It is apparent that just making information available is not a sufficient catalyst for health behavior change. Overall, this study highlights a serious quandary in terms of being able to cultivate the attention of people who have not sought and have no plans to seek health information. Therefore, we are left with the questions; How do we engage people who are not part of the conversation? How do we make the conversation more attractive?

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L. Suzanne Suggs, PhD, CHES

Joan E. Cowdery, PhD

Debra Noll, MA

L. Suzanne Suggs, PhD, CHES, is Assistant Professor, Faculty of Communication Sciences, Institute of Public Communication and Education, Universita della Svizzera italiana, Via G. Buffi 13, CH 6900 Lugano, (p) +41.058.666.4484, (f) +41.058.666.4647, E-mail: suggs@suggs.info. Joan E. Cowdery, PhD, is Associate Professor, Health Education, School of Health Promotion & Human Performance, Eastern Michigan University, 319A Porter, Ypsilanti, MI 48197. E-mail: jcowdery@emich.edu. Debra Noll, MA, is the Communication Associate, Health Communication Department, Health Resources in Action, 95 Berkeley Street, Suite 208. Boston, MA 02116. E-mail: dfnoll@gmail.com
Table 1. Focus Group questions

Question                                     Theoretical construct

What do you see as the major concerns/       TPB: Attitudes/beliefs
  issues regarding health? For               HBM: Perceived
  yourself? For your family?                 susceptibility
For people
Do you believe that you can                  TPB: Attitudes/beliefs,
  prevent certain                            Perceived
  diseases? If no: Why?
If yes: In what ways/How? Do                 behavioral control
  you seek out
  information about preventing them?
What factors influence your belief           TPB: Attitudes/beliefs/
  system about health?                       Subjective Norms
What motives, if any, do you have            HBM: Cues to action/
  for trying to stay healthy or              benefits
  prevent disease or manage diseases
  you may already have?
What roles do family members play            TPB: Subjective Norms
  in Disease prevention? What
  roles do friends play? What roles
  do health providers play?
What role does your family play in           TPB: Subjective Norms
  your beliefs
  about health and
  disease prevention?
Do you believe that you have what            TPB: Perceived
  you need to:                               Behavioral Control
  stay healthy?                              HBM: self-efficacy
prevent disease? manage disease?
Did you know that the prevalence of          HBM: Perceived
  diabetes, heart disease, obesity,          susceptibility
  and stroke is higher for Hispanic
Americans than in Whites? Why
  do you think this is the case?
If you were told that you were at            HBM: Perceived
  high risk for a certain disease, what      susceptibility,
  would you want to know?                    Cues to action
What types of things make it                 HBM: Perceived
  difficult for you to eat healthy? To       barriers
  maintain a healthy weight?
What barriers prevent you from: Regular      HBM: Perceived
  activity/exercise?                         barriers
What are some of the barriers /problem       HBM: Perceived
  you have when needing to                   barriers
find trustworthy health information?
Do you have ideas on how to minimize or      HBM: Perceived barriers/
  remove those barriers?                     Cues to action
What are they? How would you do that?
Where do you go for information regarding    TPB: Behavior
  health/health concerns?
Why do you choose those approaches?          HBM: Behavior
What do you like/dislike
  about these sources? Do you trust          TPB: Attitudes
  theses sources?
Does the information you get seem
  relevant?
Where would you like Health Information      TPB: Behavior
  to be available?                           HBM: Behavior
Are there certain technologies or            TPB: Behavior
  programs that you wish you had             HBM: Behavior
  access to? Want to change? Use more
  or less of?
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