Women & Health, 55:297–313, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0363-0242 print/1541-0331 online DOI: 10.1080/03630242.2014.996725
Empowerment in the Process of Health Messaging for Rural Low-Income Mothers: An Exploratory Message Design Project LINDA ALDOORY, PhD Department of Behavioral & Community Health, School of Public Health, University of Maryland, College Park, Maryland, USA
BONNIE BRAUN, PhD, ELISABETH FOST MARING, PhD, and MILI DUGGAL, PhD Department of Family Science, University of Maryland, College Park, Maryland, USA
ROWENA LYNN BRIONES, PhD Department of Public Relations, Virginia Commonwealth University, Richmond, Virginia, USA
Rural, low-income mothers face challenges to their health equal to or greater than those of low-income mothers from urban areas. This study put health message design into the hands of low-income rural mothers. The current study filled a research gap by analyzing a participatory process used to design health messages tailored to the everyday lives of rural low-income mothers. A total of forty-three mothers participated in nine focus groups, which were held from 2012 to 2013, in eight states. The mothers were from different racial and ethnic backgrounds. Participants discussed food security, physical activity, and oral health information. They created messages by considering several elements: visuals, length of message, voice/perspective, self-efficacy and personal control, emotional appeals, positive and negative reinforcements, and steps to health behavior change. This study was innovative in its focus on empowerment as a key process to health message design. KEYWORDS
health messages, mothers, rural health
Received November 5, 2013; revised April 20, 2014; accepted May 6, 2014. Address correspondence to Linda Aldoory, PhD, Department of Behavioral & Community Health, School of Public Health, University of Maryland, Room 2367E, 2242 Valley Drive, College Park, MD 20742. E-mail: [email protected] 297
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INTRODUCTION As research and practice have indicated, rural low-income mothers continue to be priority health consumers, who use the health system more than their male counterparts and who engage as the primary caretakers of children and family (Varkey, Kureshi, and Lesnick 2010). In their role, rural lowincome mothers face unique challenges: there is a shortage of health care providers, the distance to travel to health services is often problematic, and rural families have less health insurance coverage compared to their urban counterparts (Egbert and Parrott 2001; Pistella, Bonati, and Mihalic 2000). The impact of this limited access to health care subsequently narrows possibilities for influencing health outcomes—but empowering rural mothers via health literate messages can potentially enhance decision-making by these women. The current study highlighted the voices of low-income rural mothers and brought empowerment into play as the mothers constructed health literate messages. The researchers conducted participatory action research to design salient health messages regarding physical activity. This article presents the findings that revealed factors in health messages that were important for rural low-income mothers and a model for empowering health message design targeting the audience.
LITERATURE REVIEW Empowerment Theory Empowerment has been defined in numerous ways, and involves the processes by which individuals gain perceived autonomy and confidence to achieve control over issues of concern to them (Balit 2004; Bergsma 2004; Egbert and Parrott 2001; Jensen 2002; Johnson, Worell, and Chandler 2005; Kar, Pascual, and Chickering 1999; Krummel, Humphries, and Tessaro 2002; Pistella et al. 2000; Porr, Drummond, and Richter 2006; Powe 2002; Rappaport 1987; Varkey, Kureshi, and Lesnick 2010). In health promotion, empowerment of women “is the key to successful programs for social change that affect the quality of life and health of poor and powerless families and communities” (Kar, Pascual, and Chickering 1999, 1433). Individual empowerment has been shown to include perceptions of personal control, a level of self-consciousness, self-efficacy, and an awareness of the problem and possible solutions (Bergsma 2004; Kar, Pascual, and Chickering 1999; Zimmerman 1995). Research has focused on two particular dimensions of empowerment, that of self-efficacy and perceived personal control (Auger, DeCoster, and Colindres 2008; Zimmerman 1995; Zimmerman and Warschausky 1998). Self-efficacy, a core construct in prevailing health behavior theories, is the perceived capability or mastery of skills required to perform a particular action (Bandura 1986). Perceived personal control
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is the belief in having the power to make decisions about one’s own life. According to Baur (2010), individuals often perceive a sense of control over their decisions “even when the decision is contrary to public health recommendations” (46). Chiles and Zorn (1995) argued that, to feel empowered, someone “must feel capable of competently performing the tasks of the job and believe that she has the authority or freedom to make the necessary decisions for performing the tasks of the job” (2).
Rural Women’s Empowerment and Health Research has shown that rural populations deal with greater health risks than urban populations as they also face disproportionately high poverty rates and low education levels (Cotter 2002; Gundersen 2006). Rural residents lack access to health care providers and limited numbers of providers (Campo et al. 2008; Hartley 2004). Other barriers to health are travel time to providers, few publicly funded health programs, and lack of health insurance coverage (Pistella et al. 2000). For rural mothers, some studies have illuminated several barriers that impact their sense of empowerment (Pistella et al. 2000; Ulbrich and Stockdale 2002). These include geographic isolation, fewer community organizations, less community infrastructure, and fewer public transportation resources (Pistella et al. 2000). Pistella and colleagues described a series of activities that promoted empowerment of rural women through involvement in the planning and assessment of prenatal care services. Their findings indicated that women who used mobile prenatal care and social work services were more likely to acknowledge barriers to prenatal care access. Authors found that access and use of the social work interventions increased the rural women’s empowerment “through increased self-efficacy and self-worth” (83).
Rural Women’s Health Communication While numerous studies on women’s empowerment exist in related fields, little precedence is available in rural health communication research to help us understand how empowerment plays out for low-income rural mothers (Mayer-Davis et al. 2004). Studies of rural women’s health indicated that self-efficacy beliefs could predict behavioral intent (Egbert and Parrott 2001; Krummel, Humphries, and Tessaro 2002; Maibach and Cotton 1995). Egbert and Parrott (2001) examined rural women’s self-efficacy to perform cancer detection practices, such as self-exams and mammography. They found that the women’s perceptions regarding cancer detection practices were strongly influenced by perceived knowledge and perceived barriers. Authors concluded, “Efforts in communication to enhance perceptions of self-efficacy
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depend upon what the specific topic is, and, at minimum, perceptions of confidence in one’s skills to perform a task, as well as one’s ability to marshal requisite cognitive and environmental resources to follow through on such skills” (230). Thus, self-efficacy was linked with personal control to achieve a desired health practice. Authors suggested that health messages make direct reference to the barriers that the target audience faced.
Participatory Action Research Rudd and Comings (1994) encouraged use of participant involvement in the development and production of the participants’ own learning materials. For rural mothers, research has shown that participation and engagement led to empowerment around health (Auger, DeCoster, and Colindres 2008; Balit 2004; Mayer-Davis et al. 2004; Pistella et al. 2000; Rudd and Comings 1994). Thus, communication strategies should “involve [rural women] in assessing the nature of the problem, defining priorities, formulating solutions and managing the processes of change” (Balit 2004, 70).
Research Questions Two research questions guided data collection and analysis for this study: Research Question 1 (RQ1): How do rural low-income mothers perceive their self-efficacy and personal control when faced with health decisions? RQ2: What components of health messages are important to rural lowincome mothers to address their perceived self-efficacy and personal control?
METHOD We conducted focus groups and incorporated a participatory approach to design health messages with the participants as co-creators. In considering the health topics to address, we referred to Extension, which developed a project that provided insight into the specific health challenges faced by rural families (http://ruralfamiliesspeak.org/homepage.html). Oral health, food security, and physical activity emerged as priority issues (Braun et al. 2002; Mammen, Bauer, and Richards 2009; Simson and Braun 2007).
Sampling and Participants We recruited a purposive and convenience sample through help from the U.S. Department of Agriculture’s Extension Educators, who worked with
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local community organizations and Head Start programs to talk to women, post fliers, conduct interviews, and provide feedback on the project. The University’s Institutional Review Board approved the study protocol, and informed consent was obtained from all participants via written forms that were signed. The focus group sample was guided by what the dominant rural populations were in each state in the study: African Americans in Maryland and in North Carolina; Asian/Pacific Islanders in Hawaii; Latinas in Washington and in Iowa; Caucasians in Maryland, Massachusetts, and Tennessee; and Native Americans in South Dakota. This maximum variation strategy diversified voices included in the message design and highlighted the particular majority group within low-income rural areas of the states.
ELIGIBILITY CRITERIA All of the participants had to live in federally designated rural counties in the state, had to be 18 years of age or older (for purposes of Institutional Review Board designation of consenting adult), had at least one child under age 12 years living in their home, and were from households with incomes of 185 percent or less of the federal poverty line. Extension Educators used a screening questionnaire with each woman they recruited to assess eligibility. The eligibility and participation rate was over 90 percent, given the purposive, geographic, and economic contexts of the Extension sites where recruitment took place. A total of forty-three mothers from different racial and ethnic backgrounds participated in nine focus groups held in eight states from 2012 to 2013.
Data Collection Each focus group lasted approximately two hours and included refreshments and childcare. We used a four-phased procedure during the group sessions. First, each trained moderator built rapport and discovered how mothers made meaning of terms, such as health, control, and everyday life. Second, the moderator guided discussion of various examples and formats of health messages found in campaigns regarding one of two topics: dental health in six groups and food security in three groups. These two topics were used to ease into discussions about health messages because participants had higher self-efficacy about in-home tasks, such as those related to oral health and food behaviors. The third phase involved questions about perceived self-efficacy and personal control regarding oral health and food insecurity. The fourth phase engaged the mothers in participatory message development. The women spent the time creating messages addressing physical activity. Physical activity has been prevalent in recent campaigns that tout
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both minor and major activities that could be performed by rural mothers in their everyday lives (Krummel, Humphries, and Tessaro 2002; Mayer-Davis et al. 2004). Furthermore, overweight and obesity are critical health concerns among rural communities (Olson, Bove, and Miller 2007), so the topic of physical health was expected to resonate with rural mothers. In this phase, the moderators provided the mothers a brief review of the science behind physical activity. Then, participants made decisions about creating different messages as the moderator guided them using a sequence of open questions and tasks. The mothers addressed the following components of messages: length of message, voice/perspective, elements of self-efficacy and personal control embedded in message, emotional appeal, positive and negative reinforcements, and whether steps to health behavior change should be included in message. Moderators used a guide of open-ended questions and probes to help participants feel comfortable as they shared interpretations and personal narratives. We pilot tested the guide to ensure that the questions posed were salient for mothers and that the participatory approach was understandable and useful.
Data Analysis Moderators audio-recorded the focus groups and transcribed the audiotapes verbatim to analyze data. We analyzed data using elements of grounded theory by Corbin and Strauss (2008). Thus, three types of coding—open, axial and selective—were followed. First, researchers read through transcripts multiple times to identify an initial list of themes that answered the research questions. Then, they coded transcripts with the themes to highlight quotes that supported and illustrated each theme. Four researchers independently coded each transcript and discussed any discrepancies to reconcile the coding. This process allowed for new themes to be found and other themes to be discounted based on lack of evidence in the transcripts for them. Health messages resulting from the mother’s participatory process were compiled, and mothers’ opinions were analyzed on the effectiveness of the process and the selection of the messages. During the final coding phase, we applied comments and interpretations to theoretical relationships found in the themes and developed a model from the themes.
QUALITY CONTROL MEASURES At the end of each group, the moderator debriefed with participants, asking them for feedback on the process used to design the health messages. This member check allowed researchers to determine whether the participatory approach was useful. Along with the transcripts, each focus group had a note
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taker to record observations using a set of open-ended questions measuring participants’ demeanor at the beginning and end of the focus group, their level of attentiveness and involvement, their grasp of concepts, and any extenuating circumstances that might have affected the focus group. These “observers’ reports” helped determine the effectiveness of the participatory approach. Quality control was also measured via a procedure of external reviewing by ten scholars and practitioners familiar with the health topics who read the data analysis. The reviewers assessed whether the themes and subthemes aligned with quotes and answered the research questions.
RESULTS The age of participants’ children ranged from a few months to 12 years, and about half of the mothers were single. Participants in each of the groups did not know each other well, but had “seen” each other before in the community.
Everyday Life and Health Everyday life for all of the participants was a series of repetitive activities relating to childcare, housekeeping, part-time work outside the home, and social services. One mother said, “I don’t have time to make a monthly grocery list, let alone remember to take a shower in the morning.” Another woman commented, “My days are always hectic, I have to go somewhere I have to do something. . . .” The need for both time and gas to travel to their daily destinations typified everyday life for the mothers. One woman described a typical school morning with her children: “They cannot find their shoes, they can’t find their jackets, I’m trying to find everything, and with five of them, it’s hard!” Most of the mothers included in their listing of daily activities a few minutes of “quiet” time. This was labeled as such because that was when their children were sleeping, busy, or distracted by television and the mothers had time to fold laundry or wash dishes. This “quiet” time was decidedly not “free” time, though. As one participant put it, “I wouldn’t call it my free time, it’s more down time.”
RQ1: Perceptions of Self-Efficacy and Personal Control PERCEIVED PERSONAL CONTROL According to most of the mothers, to be “in control” was to be responsible for making a decision. When asked about being in control many mothers referred to time and schedules and feeling unable to make decisions when
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too many errands and activities needed to be completed. One quipped, “The schedule controls me.” Some participants expressed a lack of control over their children’s activities and their responsibilities as a mother. As one woman explained, “It’s rough being a single mom of four little ones . . . you’re always running, and every day I have an appointment. . . .” These women, however, perceived being in control when not in their mother role. One said, “I go to work, that’s my escape valve.” Another explained: I feel I have no control over half of my life. The kids are out of hand behavior-wise, but my work and cleaning jobs I have control over—I am on a set schedule, I don’t have to ask permission, I just go I do my thing, and I’m good. But with the kids, they don’t listen . . . and my husband is no help, he laughs. . . .
On the other hand, several participants perceived control when making decisions related to their children, but felt out of control when visiting health care workers or when hearing health information counter to what they “feel” or “know” is best. One mother responded, “There are some parts where you’re in control, how I dress my kids, but like some things are requirements, that you really have no choice, that you have to do.” In one focus group, all mothers agreed when one remarked, “You can’t always make the decisions about your kids when you have to depend on the medical profession.” Another participant explained that this was related to economic constraints: My control is more about money. My children are on [the state’s] children’s health insurance, but I had to cancel a doctor’s appointment because I didn’t have the money. For them its easy, and it doesn’t cost me anything.
When talking about their own health needs, most of the mothers agreed they felt in control because they were the ones making the decisions not to seek health care. While they understood the health risks in not caring for themselves, they either had no insurance or ability to pay out of pocket, no time, or prioritized their children’s health over their own. One mother noted: “My doctor called and said you missed your yearly checkup and I was like, oh, I did? Oops.” Another shared, “I don’t even have a doctor for myself, my daughter does.” One participant related her perceptions of control with her relationship status: For me, yeah, I need to go to the doctor, who’s going to watch the kids? My husband doesn’t feel it’s important enough for me to go and get it
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taken care of, so for me, I have no control. My children, you’re sick, you’re going [to a health practitioner].
PERCEIVED SELF-EFFICACY Most of the participants felt in control of decisions about a health task when they perceived themselves to be capable of performing that task. One said she was capable of getting her children to brush their teeth by taking control of tooth brushing time in her house: she brushes their teeth when they shower. Another stated, “I feel like I am better able to advocate and fight for services for my child than I am for myself.” A few of the participants noted that while they might not be in control of their physical health they are capable of doing something for their mental health. For example, a mother said, “When I feel like things are getting out of control, the first thing I do is turn on that TV and put on Spongebob, and everybody is happy while I go do some laundry, clean something, but that’s how I get myself to calm down.” Another participant described her sense of control as positive attitude on life: When I say I am in control of my life, I feel like I am because I am able to deal with different situations. I don’t have it as hard as many people do, so I have it pretty easy, I can deal with different situations.
Most of the references to self-efficacy pertained to health practices. One mother told a story about a time when her young son was “really sick,” and she took him to a practitioner who told her he had “just a cold.” She did not believe this because her instincts told her he was sicker than he would be if he had just a cold. She perceived herself capable of following through on her instincts and getting a second opinion. She took him to an emergency room, and there he was diagnosed with RSV (Respiratory Syncytial Virus): “Sometimes you have to think for yourself and not worry what the doctor is going to say. My kids are more important to me.” Two other participants who described themselves as obese talked about self-efficacy and physical activity, albeit as a lack of control over weight reduction. One described a workshop she attended that she felt increased her knowledge about healthy eating and an exercise plan. The other asserted that she did not think her weight problem was a result of what she ate: I just need to put more exercise in my life. I feel like I exercise so much with running around with my kids, but I guess it’s not the right exercise. So I try to run up and down my steps, and just try to do anything . . . I just want to lose weight and be more healthy so that I can live a longer life and be there for my kids. I’m always outside running around with my son and playing football with him.
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RQ2: Health Message Components Preferred All of the mothers agreed that it was “extremely” important for health messages to resonate with their everyday life and their role as mother. They argued that current health messages never address the chaos they face in their morning schedules, the constraints they deal with throughout their daily tasks, or the lack of control they feel when they must rely on health practitioners. All of the mothers proposed certain characteristics they wished to incorporate in health messages. Each characteristic proposed by most of the participants is summarized below. EMPATHY WITH
THE
EVERY DAY
All of the mothers wanted to create health messages that resonated with their everyday life demands by having the message express empathy and understanding of the mothers’ everyday constraints. One woman said, “I get up around five in the morning, and I have my computer time by myself until the kids get up. I let the chickens out. I feed the cat, the dog, the rabbit, and then I do breakfast with the kids.” Because the mothers believed that constraints prevented them from fulfilling health demands asked of them, having health messages acknowledge their challenges increased the mother’s attention toward the messages. A participant suggested having messages that understand her routine: “Hit the floor. I go take care of my basic needs, bathroom, and toothbrush, wash my face. Then I go get the kids up, stick them in the shower, very routine.” Most of mothers stated that many health care workers were insensitive to the daily constraints faced by rural low-income families when they communicated health and illness information. One mother became emotional when she described her feelings about a health care worker: For us, we’re struggling. . . . I work, my husband works. I struggle to keep gas in my car to get from point A to point B. So if you’re telling me, well you need to come back for a follow up after this H1N1 shot. You tell me why it’s so important, because are you going to put the gas in my car for me to come back?
PEER VOICE WITH EVIDENCE-BASED FACTS Most of the participants wanted a spokesperson in health messages who shared their identity as a rural mother. When discussing their opinions about the health messages presented to them on dental health, most of the mothers appreciated the “Mary” character in the messages, who was a mother like they were and, as the message conveyed, who dealt with chaotic child care responsibilities like them. These mothers wanted to hear from mothers like
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them in the health messages they received. As one woman put it, “You tend to listen to people that you know more than somebody you don’t know.” While most of the mothers preferred to have the spokesperson of their messages be a mother like themselves, many wanted the actual content of the messages to derive from authoritative and expert research. Thus, the “facts” would be presented via scientific and medical sources, such as a dentist or physician. Then, these facts would be shared or promoted via a rural mother’s persona. SMALL STEPS TOWARD HEALTH Most participants preferred health messages that included the specific steps necessary to accomplish the desired task, but only if the steps were easy and completed within a relatively brief time period. For example, with a dental health message for mothers of infants, several participants supported the inclusion of the following: “The best way to clean a squirmy baby’s teeth is to lie them down first with you near their head (or head in your lap) and wipe their gums gently with a clean cloth.” Furthermore, most of the mothers liked health messages that addressed perceived barriers in minor easy ways. For example, while food security was an issue for these low-income rural mothers, they noted that healthy foods did not last as long as unhealthy foods. As one participant said, “You buy it for a week, and next week you have to go again.” Most of the mothers wanted a message that offered a tip on how to shop healthy but cheaply. Another cost-related barrier occurred when all of the mothers took their children food shopping with them. All of the mothers wanted simple ways to avoid “taking your kids with you and have them wanting everything when they’re with you in the store.” POSITIVE VERSUS NEGATIVE OUTCOMES Most of the mothers wanted to hear positive outcomes that would result from their actions, rather than what would be negative outcomes from a lack of action. Similarly, the mothers desired statements about what to do rather than what not to do. One participant suggested “putting babies to sleep or feeding them at certain times” as routines to help control her life. These participants believed it was positive to state in a message that “it’s easy” to do the desired health action. One participant suggested, “To do the one easy thing to keep your baby’s teeth healthy, it’s easier than what you think it is . . . it’s not hard to do.” LENGTH VERSUS DETAIL Most of the participants wished for narrative in the message where a story is being told while also having direction to explain what to do. For example,
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most of the mothers created specific messages, such as “don’t leave the bottle in your baby’s mouth at night” and “don’t use a pacifier.” One said, “We’re busy, we don’t have time for a lot of words, we need to know the information that’s needed.” However, most of the participants were attracted to stories about mothers like them. One mother said her attention would only be gained with a story of a mother just like her while she recognized that this would take time to tell. At the conclusion of the mothers’ decisions, some final message examples were constructed. An example of a message that some of the participants developed was: Hi, I’m Mary and I have two very active kids. My doctor told me to be more active. He said it’s okay to break the activity into small amounts at a time like walking to get the mail or parking away from the store and walking. I have learned to be active with my kids. They have a lot of energy and going with them is a good way for all of us to spend time together. Now I feel calmer and it’s easier to deal with my kids too.
Summary Four main message factors emerged from all of the participants’ discussions and decisions. First, most of the mothers in this study wished to have a combination of a spokesperson being a peer but with facts deriving from an authority. Second, most of the participants were inclined toward positive outcomes represented in message content rather than negative results of NOT doing a health behavior. Third, most of the mothers in this study were very adamant about wanting to hear stories and simple actions that they could incorporate into their everyday lives. Finally, all mothers in this study wanted messages that resonated with their hectic, constrained lives and wished to hear comments in messages that expressed empathy toward their busy lives. These four message factors comprised a “template” that could be applied by health practitioners seeking guidance in message design.
DISCUSSION A participatory approach was used to design health messages in a way that resonated with rural low-income mothers and to engage the mothers in designing health messages that had appeal to them. By asking the mothers about their perceived control and self-efficacy, the findings provided insight on how low-income rural mothers made meaning of empowering health messages and the role messages could play in their daily lives (Auger, DeCoster, and Colindres 2008; Chiles and Zorn 1995; Cosgrove 2002).
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The articulations of personal control from this study can be interpreted through the lens of negotiated transitions, between maternal role, employee role, and self-health. Some of the mothers in the study were in control with their children but out of control when health care workers intervened with health information. This finding was consistent with previous research (Varkey, Kureshi, and Lesnick 2010). For other participants, they were in control at work but out of control with their children. In either case, most of the participants felt they had little control over their own health care, due to institutional and environmental constraints. Many participants portrayed greater self-efficacy in knowing what to do for their children, and less self-efficacy in trying to reduce barriers to their own health care. Most of the mothers expressed perceived capability of taking care of children. Additionally, several women perceived themselves to be “in control” of their own health, either by not needing healthcare or by stating that they were consciously aware that they are not taking care of themselves. In other words, making the decision to not take care of oneself was to control/decide to have the health be bad. However, these same women discussed their feelings of inadequacy when faced with healthcare providers. Thus, these findings on personal control and self-efficacy revealed a complicated relationship between the two concepts that call for more research into their construction of empowerment for health decisions among rural low-income women. The findings contributed to the literature on empowerment and health messages in several ways. First, results offered support for incorporating message content that expressed empathy. Health messages should acknowledge the chaos with which the mothers dealt their everyday lives (Egbert and Parrott 2001) and the lack of control they felt when they had to rely on health practitioners. Second, the findings revealed a more complicated perspective on source credibility than originally assumed. Most of the participants required inclusion of both peer and authority sources, whereas the literature on sources typically suggests one or the other, depending on audience. The mothers in this study wanted health messages to include a peer spokesperson (another mother) who shared facts from an authority. Third, perhaps the main contribution of the study to the scholarly literature was the development of a model that integrates concepts from literature with the voices of participants and their message factors used to develop health messages. The model, named the Empowering Co-Creational Health Message Model (E-COHM Model)©, was constructed out of the mothers’ voices that guided this project, and therefore, its validity derived from the lived experiences that the rural mothers in this study had with health and communication (see Figure 1). The first section of the model outlines the concepts from empowerment theory applied to the target audience. Findings supported four aspects to psychological empowerment (Zimmerman 1995), that of self-efficacy and personal control, plus a self-consciousness that the
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FIGURE 1 Empowering Co-Creational Health Message Model (E-COHM Model©).
women illustrated and the awareness of the health problem and how to manage it. The second section highlighted the message features found through the participatory approach that were most important to the target audience. These five message components included empathizing with lived experiences, emphasizing small steps toward change, and framing outcomes as positive rather than negative. The final section of the model took the message features and created a template that can be used in health messages about topics, such as food security, physical activity, and oral health.
Study Limitations and Future Research While this project contributed to the body of knowledge in rural health, the study had limitations. First, the process of working with rural mothers on message design was fluid and often nonlinear; researchers gave up their own sense of control over the project as it evolved into a partnership endeavor. Second, researchers worked with dozens of moderators, note takers, and graduate assistants in eight different states, and this challenged the ability of researchers to control data collection and management procedures. Third, although researchers conducted quality control measures, the findings are at risk of social acceptability bias, and the sample lacked representativeness of the population of rural low-income mothers in each state, thus potentially limiting the generalizability of the findings. Several areas for future research emerged that relate to the E-COHM model and its usefulness. Researchers might test the health messages created here for their effects on awareness, knowledge, and behavioral intent. Studies are needed that explore different delivery channels to send messages. Other research might measure messages’ longitudinal impact on informed decision-making among rural mothers.
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CONCLUSION In conclusion, self-efficacy and personal control are fluid perceptions that helped the mothers in this study negotiate health decisions for themselves and, more so, for their children. The scholarly implications from this study are significant: researchers developed a model reflective of participatory message design of the E-COHM model, that could be tested and retested for its heuristic ability to determine whether empowerment might be both a process and an outcome of health message design for low-income rural mothers. The theory-based research on rural mothers and health messaging is sparse, and the model allows scholars a framework from which to continue studies in this area to advance our understanding of empowerment and its role in health communication. The study’s practical implications include the template of message factors at the end of the model, which could be a useful tool for health communicators. The voices of the rural mothers heard here illustrate that it is possible to develop procedures to co-create health messages with rural audiences that communicators are trying to reach. Through participatory models, such as the one proposed, communicators are more likely to develop health messaging that is culturally appropriate and meaningful to the everyday lives of their audiences.
FUNDING This project was supported by the Rural Health and Safety Education Competitive Program of the USDA Cooperative State Research, Education and Extension Service, grant number 2010-46100-21791. Partners include: University of Massachusetts, Amherst; Washington State University; University of Maryland Extension; Rural Maryland Council; Maryland Rural Health Association; University of Maryland School of Public Health, Herschel S. Horowitz Center for Health Literacy; and fourteen Rural Families Speak About Health state research teams.
REFERENCES Auger, S. J., M. E. DeCoster, and M. D. Colindres. 2008. Teach-with-stories method for prenatal education: Using photonovels and a participatory approach with Latinos. In Emerging perspectives in health communication, ed. H. M. Zoller and M. J. Dutta, 155–81. New York: Routledge. Balit, S. 2004. Listening to rural women. Journal of Development Communication 15(2):69–79. Bandura, A. 1986. Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice-Hall.
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Mammen, S., J. W. Bauer, and L. Richards. 2009. Understanding persistent food insecurity: A paradox of place and circumstance. Social Indicators Research 92:151–68. doi:10.1007/s11205-008-9294-8 Mayer-Davis, E. J., A. M. D’Antonio, S. M. Smith, G. Kirkner, S. L. Martin, D. Parra-Medina, and R. Schultz. 2004. Pounds off with empowerment (POWER): A clinical trial of weight management strategies for black and white adults with diabetes who live in medically underserved rural communities. American Journal of Public Health 94:1736–42. doi:10.2105/AJPH.94.10.1736 Olson, C. M., C. Bove, and E. Miller. 2007. Growing up poor: Long-term implications for eating patterns and body weight. Appetite 49:198–207. doi:10.1016/j.appet.2007.01.012 Pistella, C. L. Y., F. A. Bonati, and S. L. Mihalic. 2000. Rural women’s perceptions of community prenatal care systems: An empowerment strategy. Journal of Health & Social Policy 11:75–87. doi:10.1300/J045v11n04_05 Porr, C., J. Drummond, and S. Richter. 2006. Health literacy as an empowerment tool for low-income mothers. Family & Community Health 29:328–35. doi:10.1097/00003727-200610000-00011 Powe, B. D. 2002. Promoting fecal occult blood testing in rural African American women. Cancer Practice 10(3):139–46. doi:10.1046/j.1523-5394.2002.103008.x Rappaport, J. 1987. Terms of empowerment/exemplars of prevention: Toward a theory for community psychology. American Journal of Community Psychology 15:121–48. doi:10.1007/BF00919275 Rudd, R. E., and J. P. Comings. 1994. Learner developed materials: An empowering product. Health Education & Behavior 21:313–27. doi:10.1177/ 109019819402100304 Simson, E., and B. Braun. 2007. Oral health among rural, low-income families: Implications for policy and program. Accessed March 23, 2015. http://sph.umd.edu/sites/default/files//files/OralHealthAmongRuralLowIncomeFamilies2-7-07.pdf Ulbrich, P. M., and J. Stockdale. 2002. Making family planning clinics an empowerment zone for rural battered women. Women & Health 35:83–100. doi:10.1300/J013v35n02_06 Varkey, P., S. Kureshi, and T. Lesnick. 2010. Empowerment of women and its association with the health of the community. Journal of Women’s Health 19:71–76. doi:10.1089/jwh.2009.1444 Zimmerman, M. A. 1995. Psychological empowerment: Issues and illustrations. American Journal of Community Psychology 23:581–99. doi:10.1007/ BF02506983 Zimmerman, M. A., and S. Warschausky. 1998. Empowerment theory for rehabilitation research: Conceptual and methodological issues. Rehabilitation Psychology 43:3–16. doi:10.1037/0090-5550.43.1.3
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Empowerment in the Process of Health Messaging for Rural Low-Income Mothers: An Exploratory Message Design Project LINDA ALDOORY, PhD Department of Behavioral & Community Health, School of Public Health, University of Maryland, College Park, Maryland, USA
BONNIE BRAUN, PhD, ELISABETH FOST MARING, PhD, and MILI DUGGAL, PhD Department of Family Science, University of Maryland, College Park, Maryland, USA
ROWENA LYNN BRIONES, PhD Department of Public Relations, Virginia Commonwealth University, Richmond, Virginia, USA
Rural, low-income mothers face challenges to their health equal to or greater than those of low-income mothers from urban areas. This study put health message design into the hands of low-income rural mothers. The current study filled a research gap by analyzing a participatory process used to design health messages tailored to the everyday lives of rural low-income mothers. A total of forty-three mothers participated in nine focus groups, which were held from 2012 to 2013, in eight states. The mothers were from different racial and ethnic backgrounds. Participants discussed food security, physical activity, and oral health information. They created messages by considering several elements: visuals, length of message, voice/perspective, self-efficacy and personal control, emotional appeals, positive and negative reinforcements, and steps to health behavior change. This study was innovative in its focus on empowerment as a key process to health message design. KEYWORDS
health messages, mothers, rural health
Received November 5, 2013; revised April 20, 2014; accepted May 6, 2014. Address correspondence to Linda Aldoory, PhD, Department of Behavioral & Community Health, School of Public Health, University of Maryland, Room 2367E, 2242 Valley Drive, College Park, MD 20742. E-mail: [email protected] 297
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INTRODUCTION As research and practice have indicated, rural low-income mothers continue to be priority health consumers, who use the health system more than their male counterparts and who engage as the primary caretakers of children and family (Varkey, Kureshi, and Lesnick 2010). In their role, rural lowincome mothers face unique challenges: there is a shortage of health care providers, the distance to travel to health services is often problematic, and rural families have less health insurance coverage compared to their urban counterparts (Egbert and Parrott 2001; Pistella, Bonati, and Mihalic 2000). The impact of this limited access to health care subsequently narrows possibilities for influencing health outcomes—but empowering rural mothers via health literate messages can potentially enhance decision-making by these women. The current study highlighted the voices of low-income rural mothers and brought empowerment into play as the mothers constructed health literate messages. The researchers conducted participatory action research to design salient health messages regarding physical activity. This article presents the findings that revealed factors in health messages that were important for rural low-income mothers and a model for empowering health message design targeting the audience.
LITERATURE REVIEW Empowerment Theory Empowerment has been defined in numerous ways, and involves the processes by which individuals gain perceived autonomy and confidence to achieve control over issues of concern to them (Balit 2004; Bergsma 2004; Egbert and Parrott 2001; Jensen 2002; Johnson, Worell, and Chandler 2005; Kar, Pascual, and Chickering 1999; Krummel, Humphries, and Tessaro 2002; Pistella et al. 2000; Porr, Drummond, and Richter 2006; Powe 2002; Rappaport 1987; Varkey, Kureshi, and Lesnick 2010). In health promotion, empowerment of women “is the key to successful programs for social change that affect the quality of life and health of poor and powerless families and communities” (Kar, Pascual, and Chickering 1999, 1433). Individual empowerment has been shown to include perceptions of personal control, a level of self-consciousness, self-efficacy, and an awareness of the problem and possible solutions (Bergsma 2004; Kar, Pascual, and Chickering 1999; Zimmerman 1995). Research has focused on two particular dimensions of empowerment, that of self-efficacy and perceived personal control (Auger, DeCoster, and Colindres 2008; Zimmerman 1995; Zimmerman and Warschausky 1998). Self-efficacy, a core construct in prevailing health behavior theories, is the perceived capability or mastery of skills required to perform a particular action (Bandura 1986). Perceived personal control
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is the belief in having the power to make decisions about one’s own life. According to Baur (2010), individuals often perceive a sense of control over their decisions “even when the decision is contrary to public health recommendations” (46). Chiles and Zorn (1995) argued that, to feel empowered, someone “must feel capable of competently performing the tasks of the job and believe that she has the authority or freedom to make the necessary decisions for performing the tasks of the job” (2).
Rural Women’s Empowerment and Health Research has shown that rural populations deal with greater health risks than urban populations as they also face disproportionately high poverty rates and low education levels (Cotter 2002; Gundersen 2006). Rural residents lack access to health care providers and limited numbers of providers (Campo et al. 2008; Hartley 2004). Other barriers to health are travel time to providers, few publicly funded health programs, and lack of health insurance coverage (Pistella et al. 2000). For rural mothers, some studies have illuminated several barriers that impact their sense of empowerment (Pistella et al. 2000; Ulbrich and Stockdale 2002). These include geographic isolation, fewer community organizations, less community infrastructure, and fewer public transportation resources (Pistella et al. 2000). Pistella and colleagues described a series of activities that promoted empowerment of rural women through involvement in the planning and assessment of prenatal care services. Their findings indicated that women who used mobile prenatal care and social work services were more likely to acknowledge barriers to prenatal care access. Authors found that access and use of the social work interventions increased the rural women’s empowerment “through increased self-efficacy and self-worth” (83).
Rural Women’s Health Communication While numerous studies on women’s empowerment exist in related fields, little precedence is available in rural health communication research to help us understand how empowerment plays out for low-income rural mothers (Mayer-Davis et al. 2004). Studies of rural women’s health indicated that self-efficacy beliefs could predict behavioral intent (Egbert and Parrott 2001; Krummel, Humphries, and Tessaro 2002; Maibach and Cotton 1995). Egbert and Parrott (2001) examined rural women’s self-efficacy to perform cancer detection practices, such as self-exams and mammography. They found that the women’s perceptions regarding cancer detection practices were strongly influenced by perceived knowledge and perceived barriers. Authors concluded, “Efforts in communication to enhance perceptions of self-efficacy
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depend upon what the specific topic is, and, at minimum, perceptions of confidence in one’s skills to perform a task, as well as one’s ability to marshal requisite cognitive and environmental resources to follow through on such skills” (230). Thus, self-efficacy was linked with personal control to achieve a desired health practice. Authors suggested that health messages make direct reference to the barriers that the target audience faced.
Participatory Action Research Rudd and Comings (1994) encouraged use of participant involvement in the development and production of the participants’ own learning materials. For rural mothers, research has shown that participation and engagement led to empowerment around health (Auger, DeCoster, and Colindres 2008; Balit 2004; Mayer-Davis et al. 2004; Pistella et al. 2000; Rudd and Comings 1994). Thus, communication strategies should “involve [rural women] in assessing the nature of the problem, defining priorities, formulating solutions and managing the processes of change” (Balit 2004, 70).
Research Questions Two research questions guided data collection and analysis for this study: Research Question 1 (RQ1): How do rural low-income mothers perceive their self-efficacy and personal control when faced with health decisions? RQ2: What components of health messages are important to rural lowincome mothers to address their perceived self-efficacy and personal control?
METHOD We conducted focus groups and incorporated a participatory approach to design health messages with the participants as co-creators. In considering the health topics to address, we referred to Extension, which developed a project that provided insight into the specific health challenges faced by rural families (http://ruralfamiliesspeak.org/homepage.html). Oral health, food security, and physical activity emerged as priority issues (Braun et al. 2002; Mammen, Bauer, and Richards 2009; Simson and Braun 2007).
Sampling and Participants We recruited a purposive and convenience sample through help from the U.S. Department of Agriculture’s Extension Educators, who worked with
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local community organizations and Head Start programs to talk to women, post fliers, conduct interviews, and provide feedback on the project. The University’s Institutional Review Board approved the study protocol, and informed consent was obtained from all participants via written forms that were signed. The focus group sample was guided by what the dominant rural populations were in each state in the study: African Americans in Maryland and in North Carolina; Asian/Pacific Islanders in Hawaii; Latinas in Washington and in Iowa; Caucasians in Maryland, Massachusetts, and Tennessee; and Native Americans in South Dakota. This maximum variation strategy diversified voices included in the message design and highlighted the particular majority group within low-income rural areas of the states.
ELIGIBILITY CRITERIA All of the participants had to live in federally designated rural counties in the state, had to be 18 years of age or older (for purposes of Institutional Review Board designation of consenting adult), had at least one child under age 12 years living in their home, and were from households with incomes of 185 percent or less of the federal poverty line. Extension Educators used a screening questionnaire with each woman they recruited to assess eligibility. The eligibility and participation rate was over 90 percent, given the purposive, geographic, and economic contexts of the Extension sites where recruitment took place. A total of forty-three mothers from different racial and ethnic backgrounds participated in nine focus groups held in eight states from 2012 to 2013.
Data Collection Each focus group lasted approximately two hours and included refreshments and childcare. We used a four-phased procedure during the group sessions. First, each trained moderator built rapport and discovered how mothers made meaning of terms, such as health, control, and everyday life. Second, the moderator guided discussion of various examples and formats of health messages found in campaigns regarding one of two topics: dental health in six groups and food security in three groups. These two topics were used to ease into discussions about health messages because participants had higher self-efficacy about in-home tasks, such as those related to oral health and food behaviors. The third phase involved questions about perceived self-efficacy and personal control regarding oral health and food insecurity. The fourth phase engaged the mothers in participatory message development. The women spent the time creating messages addressing physical activity. Physical activity has been prevalent in recent campaigns that tout
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both minor and major activities that could be performed by rural mothers in their everyday lives (Krummel, Humphries, and Tessaro 2002; Mayer-Davis et al. 2004). Furthermore, overweight and obesity are critical health concerns among rural communities (Olson, Bove, and Miller 2007), so the topic of physical health was expected to resonate with rural mothers. In this phase, the moderators provided the mothers a brief review of the science behind physical activity. Then, participants made decisions about creating different messages as the moderator guided them using a sequence of open questions and tasks. The mothers addressed the following components of messages: length of message, voice/perspective, elements of self-efficacy and personal control embedded in message, emotional appeal, positive and negative reinforcements, and whether steps to health behavior change should be included in message. Moderators used a guide of open-ended questions and probes to help participants feel comfortable as they shared interpretations and personal narratives. We pilot tested the guide to ensure that the questions posed were salient for mothers and that the participatory approach was understandable and useful.
Data Analysis Moderators audio-recorded the focus groups and transcribed the audiotapes verbatim to analyze data. We analyzed data using elements of grounded theory by Corbin and Strauss (2008). Thus, three types of coding—open, axial and selective—were followed. First, researchers read through transcripts multiple times to identify an initial list of themes that answered the research questions. Then, they coded transcripts with the themes to highlight quotes that supported and illustrated each theme. Four researchers independently coded each transcript and discussed any discrepancies to reconcile the coding. This process allowed for new themes to be found and other themes to be discounted based on lack of evidence in the transcripts for them. Health messages resulting from the mother’s participatory process were compiled, and mothers’ opinions were analyzed on the effectiveness of the process and the selection of the messages. During the final coding phase, we applied comments and interpretations to theoretical relationships found in the themes and developed a model from the themes.
QUALITY CONTROL MEASURES At the end of each group, the moderator debriefed with participants, asking them for feedback on the process used to design the health messages. This member check allowed researchers to determine whether the participatory approach was useful. Along with the transcripts, each focus group had a note
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taker to record observations using a set of open-ended questions measuring participants’ demeanor at the beginning and end of the focus group, their level of attentiveness and involvement, their grasp of concepts, and any extenuating circumstances that might have affected the focus group. These “observers’ reports” helped determine the effectiveness of the participatory approach. Quality control was also measured via a procedure of external reviewing by ten scholars and practitioners familiar with the health topics who read the data analysis. The reviewers assessed whether the themes and subthemes aligned with quotes and answered the research questions.
RESULTS The age of participants’ children ranged from a few months to 12 years, and about half of the mothers were single. Participants in each of the groups did not know each other well, but had “seen” each other before in the community.
Everyday Life and Health Everyday life for all of the participants was a series of repetitive activities relating to childcare, housekeeping, part-time work outside the home, and social services. One mother said, “I don’t have time to make a monthly grocery list, let alone remember to take a shower in the morning.” Another woman commented, “My days are always hectic, I have to go somewhere I have to do something. . . .” The need for both time and gas to travel to their daily destinations typified everyday life for the mothers. One woman described a typical school morning with her children: “They cannot find their shoes, they can’t find their jackets, I’m trying to find everything, and with five of them, it’s hard!” Most of the mothers included in their listing of daily activities a few minutes of “quiet” time. This was labeled as such because that was when their children were sleeping, busy, or distracted by television and the mothers had time to fold laundry or wash dishes. This “quiet” time was decidedly not “free” time, though. As one participant put it, “I wouldn’t call it my free time, it’s more down time.”
RQ1: Perceptions of Self-Efficacy and Personal Control PERCEIVED PERSONAL CONTROL According to most of the mothers, to be “in control” was to be responsible for making a decision. When asked about being in control many mothers referred to time and schedules and feeling unable to make decisions when
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too many errands and activities needed to be completed. One quipped, “The schedule controls me.” Some participants expressed a lack of control over their children’s activities and their responsibilities as a mother. As one woman explained, “It’s rough being a single mom of four little ones . . . you’re always running, and every day I have an appointment. . . .” These women, however, perceived being in control when not in their mother role. One said, “I go to work, that’s my escape valve.” Another explained: I feel I have no control over half of my life. The kids are out of hand behavior-wise, but my work and cleaning jobs I have control over—I am on a set schedule, I don’t have to ask permission, I just go I do my thing, and I’m good. But with the kids, they don’t listen . . . and my husband is no help, he laughs. . . .
On the other hand, several participants perceived control when making decisions related to their children, but felt out of control when visiting health care workers or when hearing health information counter to what they “feel” or “know” is best. One mother responded, “There are some parts where you’re in control, how I dress my kids, but like some things are requirements, that you really have no choice, that you have to do.” In one focus group, all mothers agreed when one remarked, “You can’t always make the decisions about your kids when you have to depend on the medical profession.” Another participant explained that this was related to economic constraints: My control is more about money. My children are on [the state’s] children’s health insurance, but I had to cancel a doctor’s appointment because I didn’t have the money. For them its easy, and it doesn’t cost me anything.
When talking about their own health needs, most of the mothers agreed they felt in control because they were the ones making the decisions not to seek health care. While they understood the health risks in not caring for themselves, they either had no insurance or ability to pay out of pocket, no time, or prioritized their children’s health over their own. One mother noted: “My doctor called and said you missed your yearly checkup and I was like, oh, I did? Oops.” Another shared, “I don’t even have a doctor for myself, my daughter does.” One participant related her perceptions of control with her relationship status: For me, yeah, I need to go to the doctor, who’s going to watch the kids? My husband doesn’t feel it’s important enough for me to go and get it
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taken care of, so for me, I have no control. My children, you’re sick, you’re going [to a health practitioner].
PERCEIVED SELF-EFFICACY Most of the participants felt in control of decisions about a health task when they perceived themselves to be capable of performing that task. One said she was capable of getting her children to brush their teeth by taking control of tooth brushing time in her house: she brushes their teeth when they shower. Another stated, “I feel like I am better able to advocate and fight for services for my child than I am for myself.” A few of the participants noted that while they might not be in control of their physical health they are capable of doing something for their mental health. For example, a mother said, “When I feel like things are getting out of control, the first thing I do is turn on that TV and put on Spongebob, and everybody is happy while I go do some laundry, clean something, but that’s how I get myself to calm down.” Another participant described her sense of control as positive attitude on life: When I say I am in control of my life, I feel like I am because I am able to deal with different situations. I don’t have it as hard as many people do, so I have it pretty easy, I can deal with different situations.
Most of the references to self-efficacy pertained to health practices. One mother told a story about a time when her young son was “really sick,” and she took him to a practitioner who told her he had “just a cold.” She did not believe this because her instincts told her he was sicker than he would be if he had just a cold. She perceived herself capable of following through on her instincts and getting a second opinion. She took him to an emergency room, and there he was diagnosed with RSV (Respiratory Syncytial Virus): “Sometimes you have to think for yourself and not worry what the doctor is going to say. My kids are more important to me.” Two other participants who described themselves as obese talked about self-efficacy and physical activity, albeit as a lack of control over weight reduction. One described a workshop she attended that she felt increased her knowledge about healthy eating and an exercise plan. The other asserted that she did not think her weight problem was a result of what she ate: I just need to put more exercise in my life. I feel like I exercise so much with running around with my kids, but I guess it’s not the right exercise. So I try to run up and down my steps, and just try to do anything . . . I just want to lose weight and be more healthy so that I can live a longer life and be there for my kids. I’m always outside running around with my son and playing football with him.
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RQ2: Health Message Components Preferred All of the mothers agreed that it was “extremely” important for health messages to resonate with their everyday life and their role as mother. They argued that current health messages never address the chaos they face in their morning schedules, the constraints they deal with throughout their daily tasks, or the lack of control they feel when they must rely on health practitioners. All of the mothers proposed certain characteristics they wished to incorporate in health messages. Each characteristic proposed by most of the participants is summarized below. EMPATHY WITH
THE
EVERY DAY
All of the mothers wanted to create health messages that resonated with their everyday life demands by having the message express empathy and understanding of the mothers’ everyday constraints. One woman said, “I get up around five in the morning, and I have my computer time by myself until the kids get up. I let the chickens out. I feed the cat, the dog, the rabbit, and then I do breakfast with the kids.” Because the mothers believed that constraints prevented them from fulfilling health demands asked of them, having health messages acknowledge their challenges increased the mother’s attention toward the messages. A participant suggested having messages that understand her routine: “Hit the floor. I go take care of my basic needs, bathroom, and toothbrush, wash my face. Then I go get the kids up, stick them in the shower, very routine.” Most of mothers stated that many health care workers were insensitive to the daily constraints faced by rural low-income families when they communicated health and illness information. One mother became emotional when she described her feelings about a health care worker: For us, we’re struggling. . . . I work, my husband works. I struggle to keep gas in my car to get from point A to point B. So if you’re telling me, well you need to come back for a follow up after this H1N1 shot. You tell me why it’s so important, because are you going to put the gas in my car for me to come back?
PEER VOICE WITH EVIDENCE-BASED FACTS Most of the participants wanted a spokesperson in health messages who shared their identity as a rural mother. When discussing their opinions about the health messages presented to them on dental health, most of the mothers appreciated the “Mary” character in the messages, who was a mother like they were and, as the message conveyed, who dealt with chaotic child care responsibilities like them. These mothers wanted to hear from mothers like
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them in the health messages they received. As one woman put it, “You tend to listen to people that you know more than somebody you don’t know.” While most of the mothers preferred to have the spokesperson of their messages be a mother like themselves, many wanted the actual content of the messages to derive from authoritative and expert research. Thus, the “facts” would be presented via scientific and medical sources, such as a dentist or physician. Then, these facts would be shared or promoted via a rural mother’s persona. SMALL STEPS TOWARD HEALTH Most participants preferred health messages that included the specific steps necessary to accomplish the desired task, but only if the steps were easy and completed within a relatively brief time period. For example, with a dental health message for mothers of infants, several participants supported the inclusion of the following: “The best way to clean a squirmy baby’s teeth is to lie them down first with you near their head (or head in your lap) and wipe their gums gently with a clean cloth.” Furthermore, most of the mothers liked health messages that addressed perceived barriers in minor easy ways. For example, while food security was an issue for these low-income rural mothers, they noted that healthy foods did not last as long as unhealthy foods. As one participant said, “You buy it for a week, and next week you have to go again.” Most of the mothers wanted a message that offered a tip on how to shop healthy but cheaply. Another cost-related barrier occurred when all of the mothers took their children food shopping with them. All of the mothers wanted simple ways to avoid “taking your kids with you and have them wanting everything when they’re with you in the store.” POSITIVE VERSUS NEGATIVE OUTCOMES Most of the mothers wanted to hear positive outcomes that would result from their actions, rather than what would be negative outcomes from a lack of action. Similarly, the mothers desired statements about what to do rather than what not to do. One participant suggested “putting babies to sleep or feeding them at certain times” as routines to help control her life. These participants believed it was positive to state in a message that “it’s easy” to do the desired health action. One participant suggested, “To do the one easy thing to keep your baby’s teeth healthy, it’s easier than what you think it is . . . it’s not hard to do.” LENGTH VERSUS DETAIL Most of the participants wished for narrative in the message where a story is being told while also having direction to explain what to do. For example,
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most of the mothers created specific messages, such as “don’t leave the bottle in your baby’s mouth at night” and “don’t use a pacifier.” One said, “We’re busy, we don’t have time for a lot of words, we need to know the information that’s needed.” However, most of the participants were attracted to stories about mothers like them. One mother said her attention would only be gained with a story of a mother just like her while she recognized that this would take time to tell. At the conclusion of the mothers’ decisions, some final message examples were constructed. An example of a message that some of the participants developed was: Hi, I’m Mary and I have two very active kids. My doctor told me to be more active. He said it’s okay to break the activity into small amounts at a time like walking to get the mail or parking away from the store and walking. I have learned to be active with my kids. They have a lot of energy and going with them is a good way for all of us to spend time together. Now I feel calmer and it’s easier to deal with my kids too.
Summary Four main message factors emerged from all of the participants’ discussions and decisions. First, most of the mothers in this study wished to have a combination of a spokesperson being a peer but with facts deriving from an authority. Second, most of the participants were inclined toward positive outcomes represented in message content rather than negative results of NOT doing a health behavior. Third, most of the mothers in this study were very adamant about wanting to hear stories and simple actions that they could incorporate into their everyday lives. Finally, all mothers in this study wanted messages that resonated with their hectic, constrained lives and wished to hear comments in messages that expressed empathy toward their busy lives. These four message factors comprised a “template” that could be applied by health practitioners seeking guidance in message design.
DISCUSSION A participatory approach was used to design health messages in a way that resonated with rural low-income mothers and to engage the mothers in designing health messages that had appeal to them. By asking the mothers about their perceived control and self-efficacy, the findings provided insight on how low-income rural mothers made meaning of empowering health messages and the role messages could play in their daily lives (Auger, DeCoster, and Colindres 2008; Chiles and Zorn 1995; Cosgrove 2002).
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The articulations of personal control from this study can be interpreted through the lens of negotiated transitions, between maternal role, employee role, and self-health. Some of the mothers in the study were in control with their children but out of control when health care workers intervened with health information. This finding was consistent with previous research (Varkey, Kureshi, and Lesnick 2010). For other participants, they were in control at work but out of control with their children. In either case, most of the participants felt they had little control over their own health care, due to institutional and environmental constraints. Many participants portrayed greater self-efficacy in knowing what to do for their children, and less self-efficacy in trying to reduce barriers to their own health care. Most of the mothers expressed perceived capability of taking care of children. Additionally, several women perceived themselves to be “in control” of their own health, either by not needing healthcare or by stating that they were consciously aware that they are not taking care of themselves. In other words, making the decision to not take care of oneself was to control/decide to have the health be bad. However, these same women discussed their feelings of inadequacy when faced with healthcare providers. Thus, these findings on personal control and self-efficacy revealed a complicated relationship between the two concepts that call for more research into their construction of empowerment for health decisions among rural low-income women. The findings contributed to the literature on empowerment and health messages in several ways. First, results offered support for incorporating message content that expressed empathy. Health messages should acknowledge the chaos with which the mothers dealt their everyday lives (Egbert and Parrott 2001) and the lack of control they felt when they had to rely on health practitioners. Second, the findings revealed a more complicated perspective on source credibility than originally assumed. Most of the participants required inclusion of both peer and authority sources, whereas the literature on sources typically suggests one or the other, depending on audience. The mothers in this study wanted health messages to include a peer spokesperson (another mother) who shared facts from an authority. Third, perhaps the main contribution of the study to the scholarly literature was the development of a model that integrates concepts from literature with the voices of participants and their message factors used to develop health messages. The model, named the Empowering Co-Creational Health Message Model (E-COHM Model)©, was constructed out of the mothers’ voices that guided this project, and therefore, its validity derived from the lived experiences that the rural mothers in this study had with health and communication (see Figure 1). The first section of the model outlines the concepts from empowerment theory applied to the target audience. Findings supported four aspects to psychological empowerment (Zimmerman 1995), that of self-efficacy and personal control, plus a self-consciousness that the
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FIGURE 1 Empowering Co-Creational Health Message Model (E-COHM Model©).
women illustrated and the awareness of the health problem and how to manage it. The second section highlighted the message features found through the participatory approach that were most important to the target audience. These five message components included empathizing with lived experiences, emphasizing small steps toward change, and framing outcomes as positive rather than negative. The final section of the model took the message features and created a template that can be used in health messages about topics, such as food security, physical activity, and oral health.
Study Limitations and Future Research While this project contributed to the body of knowledge in rural health, the study had limitations. First, the process of working with rural mothers on message design was fluid and often nonlinear; researchers gave up their own sense of control over the project as it evolved into a partnership endeavor. Second, researchers worked with dozens of moderators, note takers, and graduate assistants in eight different states, and this challenged the ability of researchers to control data collection and management procedures. Third, although researchers conducted quality control measures, the findings are at risk of social acceptability bias, and the sample lacked representativeness of the population of rural low-income mothers in each state, thus potentially limiting the generalizability of the findings. Several areas for future research emerged that relate to the E-COHM model and its usefulness. Researchers might test the health messages created here for their effects on awareness, knowledge, and behavioral intent. Studies are needed that explore different delivery channels to send messages. Other research might measure messages’ longitudinal impact on informed decision-making among rural mothers.
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CONCLUSION In conclusion, self-efficacy and personal control are fluid perceptions that helped the mothers in this study negotiate health decisions for themselves and, more so, for their children. The scholarly implications from this study are significant: researchers developed a model reflective of participatory message design of the E-COHM model, that could be tested and retested for its heuristic ability to determine whether empowerment might be both a process and an outcome of health message design for low-income rural mothers. The theory-based research on rural mothers and health messaging is sparse, and the model allows scholars a framework from which to continue studies in this area to advance our understanding of empowerment and its role in health communication. The study’s practical implications include the template of message factors at the end of the model, which could be a useful tool for health communicators. The voices of the rural mothers heard here illustrate that it is possible to develop procedures to co-create health messages with rural audiences that communicators are trying to reach. Through participatory models, such as the one proposed, communicators are more likely to develop health messaging that is culturally appropriate and meaningful to the everyday lives of their audiences.
FUNDING This project was supported by the Rural Health and Safety Education Competitive Program of the USDA Cooperative State Research, Education and Extension Service, grant number 2010-46100-21791. Partners include: University of Massachusetts, Amherst; Washington State University; University of Maryland Extension; Rural Maryland Council; Maryland Rural Health Association; University of Maryland School of Public Health, Herschel S. Horowitz Center for Health Literacy; and fourteen Rural Families Speak About Health state research teams.
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