21

Health, Culture, and Power

Understanding Women Audiences of Health Media

Linda Aldoory

Issues of health are integral to women's everyday lives, especially as women in Western societies continue to be socially constructed as primary healthcare givers and main consumers of healthcare (Bruhn, 1988; Majority of Women Control Health-Care Decisions, 1997; Thirlaway & Heggs, 2005). Women are more likely than men to seek out medical information and support for health problems (Fallows, 2005; Fox, 2005; Yanovitzky & Blitz, 2000). Women are in fact the “guardians of health,” for families and for society (Thirlaway & Heggs, 2005, p. 109).

This sociocultural burden of women being assigned the role of health guardian is reflected in mainstream media, niche media, and public health campaigns, which typically include pedagogic media messages designed to create awareness, change attitudes, and induce changes in audiences' behaviors and lifestyles. In particular, there is a large sector of specialty media that targets women's health issues, and federal and state funded public health campaigns that target female audiences. As women are more likely than men to rely on media sources when they seek health information (Fallows, 2005; Fox, 2005), the narratives of many media health messages reinforce stereotypical feminine traits, such as the natural inclination to care for others and the prioritization of dieting as a route to achieving beauty.

Research in health communication has subsequently increased its attention toward women as audience members of health media. Most of the scholarship, however, reveals allegiance to a traditional, biomedical paradigm that has long governed Western-based medicine and health science. This paradigm manifests itself in health communication research in a number of ways: through an isolation of cognitive variables; through lack of cultural context; through focus on individuals as agents accountable for their own actions; and through a denial of political, economic, and social hegemonic formations that confound individual decisions about health. However, a growing body of knowledge about female audiences has contributed to a better understanding of the complexities of message appeals and campaign design. Yet, while doing so, this scholarship has largely neglected the broader cultural factors and ideological contexts that constrain how women interpret, negotiate, or resist representations of the body and of health in public campaigns and in news media.

This chapter will attempt to address the gaps in cultural and ideological critique by offering a synopsis of recent research on women as health audiences and then by stipulating a set of premises that may help to strengthen the scope of future cultural and critical approaches to women as audiences of health media. First I offer definitions of relevant terms in health communication, and then I argue that the biomedical paradigm has reigned as the dominant conceptual approach to research on women, health, and the media. The chapter then outlines and reviews selectively examples of scholarly work that has examined the ways in which health media, news media, and communication campaigns target women. After this review, the chapter offers propositions for developing a theoretical approach that reflects women's standpoint and that contributes constructively to women's decision-making on health-related issues.

Definition of Terms

This chapter takes a social constructivist approach to health and health communication. Concepts such as “health” and “audience” can take on different meanings when considered in this manner and can be interpreted through the lenses of everyday contexts and of intersecting personal and social identities. Therefore, in order for readers to understand my use of terms such as “health,” “health media,” and “audience” in this chapter, I define these taken for granted terms before I proceed to my discussion of health, culture, and power.

First, the word “health” is used in this chapter as the World Health Organization has defined it: “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (WHO, 2010, p. 1). The “absence of disease” used to be the historical conceptualization of health; it is based on medical science, which isolated the physical body from the mind and spirit. While Western medical practice continues to focus on healing the body, international health organizations and the field of public health helped revise the meaning of health so as to make it include the essential roles of mental, spiritual, and social well-being. According to the WHO's 2010 Constitution, “the ability to live harmoniously in a changing total environment is essential” (p. 1).

Health, human illness, and disease are viewed here as socially constructed states of being. While human illness appears on the surface to be a set of universal conditions – physical and mental symptoms and problems – that all humans experience regardless of their location or culture, illness is simultaneously a private individual experience and a medically defined one, since it is ultimately identified with and felt by an individual (Bagley, 2001). At the same time, cultural norms and political systems also (re)constitute our foundational ideas of and assumptions about health and sickness. The process of aging and the process of giving birth, for example, are two natural human experiences that are medicalized and often defined as diseased. The traditional, biomedical perspective considers health as an organizing system of physiological and measurable signs of absence of disease – and the absence of disease is often defined on the basis of young, able-bodied male physiology. Thus, individualized experiences of aging and “symptoms” that coincide with menses and menopause are signs of a “diseased” physiology (Martin, 1987). Cultural norms create perceptions of blame, victimization, and lack of control for many who experience these types of physical states. In addition to health marginalization according to gender and age, there is also stigma against women of color, against the physically disabled, and against lesbian, transgendered, and bisexual women. Thus health and illness are far from being universal categories; instead they are negotiated within the context of women's intersecting identities and experiences of oppression and privilege and they are dependent on dominant biomedical definitions of healthy and sick in this country.

Discourses of health filter through professional (provider to consumer/patient), interpersonal (family, friends), social (community), and mediatized channels. This chapter focuses primarily on health media, which I define as media content that is intentionally designed to influence health outcomes in audiences. Health media in this chapter include campaign messages presented through television, posters, brochures, billboards, Internet, radio, and magazines; news coverage in print, broadcast, and web-based formats; and health messages produced on CD-ROM disks and video, comics, and songs designed for entertainment and education. I exclude messages in popular contexts that potentially have an impact on health attitudes and behaviors but are delivered without the producers' explicitly stated intentions. While such popular media are important to study in order to advance our knowledge of the subtle ways in which audiences register implicit messages concerning their bodies and states of sickness and health, this chapter limits its analysis to manifest, informative, and persuasive messages that are intentionally crafted to educate and to promote and attempt to change health outcomes.

The audiences that are intended for health media are conceived of as fragmented and more fluid than in past conceptions of audiences, which argued for a monolithic vision of social groups (Byerly & Ross, 2006; Livingstone, 2006). New technologies, such as user-generated web tools, have disintegrated any former notions of a collective mass of people who have similar habits and exhibit universal behaviors. Furthermore, feminist researchers' study of intersectionality has highlighted the inability to assume similar lifestyles only on the basis of one shared cultural identity. Livingstone (2006) suggested, however, that “the audience” should ideally be considered as a “relational or interactional construct” that offers a “shorthand way” of understanding how communication technologies create and facilitate the construction of imagined communities. Such a shorthand construct allows authors such as myself to simplify the real-world conditions of audiences for the purpose of analysis while they remain aware of the constraints and dangers that categories impose.

Research on women and their relation to personal health, medical institutions, and the media has relied largely on simplistic and problematic – linear, binary, and isolated from culture – approaches to the body, to disease, and to audiences' reception of cultural representations. I purposely limit the studies discussed and the interpretations offered to North American perspectives and medical institutions. Within these conceptual and geographic parameters, I will explain how health and healthcare systems, health media, and women consumers of healthcare are all embedded in power relations that inscribe Western health and women. I illustrate these power relations here by describing and critiquing previous research in health communication on women audiences.

Health, Culture, and Power

Health is constituted within contexts of culture and power, and these contexts can sometimes direct audiences to produce meanings that uphold hegemonic constructions of race, gender, and class. Definitions and experiences of health and disease are also based in audiences' membership within given cultural or social orders, and dominant or normative ideologies of gender, nation, class, or ethnicity can guide our judgments of health and perceptions of symptoms (Thirlaway & Heggs, 2005). Arguing for the influence of gendered experiences, Bagley (2001) asserted, “A woman or man may experience an illness in a uniquely gender-specific manner” (p. 442). As Martin's (1987) classic study shows, some women viewed menstruation and menopause as “normal” aspects of womanhood; whereas the medical institutions defined menstruation and menopause as diseased states that required pharmaceutical treatment. Furthermore, Martin also found that women from different racial backgrounds and socioeconomic contexts constructed meanings of reproductive health differently. Cultural differences change how health and medicine are interpreted and then enacted upon in everyday life.

The Biomedical Paradigm

The definition of reproductive processes as medically symptomatic derives from the biomedical perspective that constitutes Western-based medical research and healthcare. The biomedical perspective (re)produces relations of power where federal, corporate, and medical authorities control the production of meaning about health in this country. There are several characteristics of the biomedical paradigm that suggest both formal and hegemonic control. First, the biomedical approach to science calls for empiricism, for detachment from what is being studied, and for a hierarchical research relationship between the expert researcher and the examined participant. This sets up a knower/known dichotomy that invests medical scientists, physicians, and healthcare organizations with power and frames the consumers of healthcare as inferior and passive. The normative legitimacy of medical power is illustrated in those situations where women who choose to make personal health decisions without consulting medical practitioners are cast as either naïve or willful, and sometimes as ignorant.

A second characteristic of the biomedical approach is its dismissal of the role of emotionality in health outcomes. Emotions are discredited as a biasing or polluting factor in “accurate” cognitive processing; at best, emotion has been conceptualized as “a heuristic, a mental shortcut, whereby people access their pool of positive and negative feelings towards an issue to guide judgment” (Thirlaway & Heggs, 2005, p. 108). Yet the medical erasure of the emotional context runs counter to the ways in which individuals and families who live with illness experience and grapple with emotions on a routine basis (Sharf & Vanderford, 2003). Mishler (1984) argued that there is ongoing conflict between the “the voice of medicine” and “the voice of the lifeworld” – where the lifeworld is viewed by medical practitioners as insubstantial to healthcare. Emotionality is a stereotype ascribed to women; thus women are rendered inconsequential by the biomedical paradigm.

A third characteristic of the biomedical paradigm is its emphasis on a pharmaceutical treatment of the physical body, which results in the body being medicalized and isolated into examined and potentially treatable parts. The focus is on the individual level of analysis, where, according to the paradigm, visible and measurable change of the body and of health can be monitored and observed. As a consequence, holistic views of health are ignored or minimized, and non-Western forms of healing are considered placebo agents, or even dangerous impediments to the patient's recovery. By extension, US medical institutions can devalue some communities' non-Western approaches to health and treatment as unscientific or outdated.

Finally, the biomedical paradigm constrains health practices through economic power relations (Sharf & Vanderford, 2003). Sharf and Vanderford explain the economic commodification of healthcare in the following terms: “Consumers purchase it, providers supply it, third-party payers and health care organizations manage it, and primary care practitioners coordinate and guard entry to more specialized modes of treatment” (ibid., p. 13). Both Condit (1994) and Turow (1989) have extended this argument to health communication, to suggest that doctors are considered the best authorities on health information because they do exert some control over what counts as expert knowledge and as critical economic resources. The professional and cultural capital of doctors, as the most elevated authorities on health and disease, gets further enhanced when audiences report that they are the most credible spokes-persons in health news and in public health campaigns.

In everyday life there is a confluence of the biomedical and the sociocultural “lifeworld” frames, and this confluence creates multiple and yet constraining views and practices of health and illness. Individuals experiencing illness negotiate their identities within healthcare's contested political and economic terrain in this nation. Knowledge production on, and interpretations of, treatments for illnesses manifest themselves along hegemonic racial, economic, and gender lines. The biomedical “norm” for being healthy consists, subtly and politically, in being white, thin, male, young, heterosexual, able-bodied, and financially secure. Communities of women and people of color are often marginalized by the medical environment as a result of such assumptions, which in turn shape the formulation of health standards.

I use the phrase medical environment here so as to include physician and hospital services, federally funded medical research, professional training and education, and related public health practices and research projects. I am referring to this collection of medically produced entities as an “environment” because racial, economic, and gendered marginalization does not always manifest itself openly in patients' conversations with healthcare practitioners; instead, subtle and sometimes hard to detect norms and values that lie beneath the taken for granted professional norms of medicine create the potential for women to be marginalized. If female health consumers internalize meanings of trivialization and lack of power in health contexts, then ultimately they may think and act in a manner that has a negative impact on their own health.

Health Media

The biomedical paradigm is reflected in health media, and in particular in media used for public health campaigns that attempt to change behavior, which is often the main goal of such campaigns (Sharf & Vanderford, 2003). Most campaigns assume a linear progression, in their audiences, from knowledge increase to attitude change, with the intent to change concretely a health outcome. Meta-analyses have indicated that behavior change is successful in only approximately 5 to 7% of all public health campaigns (Snyder & Hamilton, 2002; Derzon & Lipsey, 2002). Yet reliance on the biomedical paradigm continues to guide campaign planners toward the ongoing pursuit of behavior change and toward the use of a linear model of communication that removes media messages and media effects from historical and social contexts. Health campaigns need to reassess their organizational and long-term campaign priorities, re-examine their definitions of success, and consider seriously the roles that culture, power, and meaning-making play in shaping the contours of health.

Also, like healthcare, economic structures and power relations have an impact on health media (Sharf & Vanderford, 2003). The media overwhelmingly portray women's health issues from a middle-class perspective because medical and pharmaceutical establishments favor middle- to upper-income consumers, clients, and patients (Condit, 1994). Therefore health images in news, campaigns, and popular media tend to mirror middle-American lifestyles and problems. The channels selected tend to be those that imply access via economic resources: while posters in bus shelters continue to be a tactic for urban segments of campaign populations, Internet and cell phone technologies are the predominant mode regardless of the age or socioeconomic status of the audience targeted.

One example of this derives from my own experiences as a campaign consultant. A team of researchers completed extensive, in-depth research about audiences of over 65-year-old adults in the United States and about their media use and preferences. We found that, while Internet use was increasing among this population, over 80% of the older adults did not use the Internet, and the majority of these people did not wish to use Internet or did not have access to computers. The research we conducted revealed that older adults preferred to use television and to receive newsletters from hospitals, appreciated American Association of Retired Persons (AARP) materials sent to their homes, and wanted printed materials to be in large text for easier reading. The media planning team subsequently hired by the client was given all these research details, and the team still proceeded to create a media campaign of Internet sources for the audience of older adults. Channels included paid advertisements on Facebook and in online newspapers. Regardless of the older adults' lack of access and desire – and we found many of them to be economically limited, too – the media team wished to prove to the client that their funding made a large impact on today's interactive web environment. The economic drive behind the client and the media team's work superseded the cultural and economic criteria that defined the target audience.

Women and Health

Historically, women have been oppressed by the biomedical assumptions guiding Western healthcare. As explained earlier, the medical profession treats women's natural reproductive processes as states of disease needing biomedical treatment. Also, the stereotypes of emotionality and mental instability have led physicians to prescribe tranquilizing drugs and anti-depressants to more women than men (Nussbaum, Ragan, & Whaley, 2003). Women report experiencing more health problems and seeking out healthcare more frequently than men. However, one study found that, although women asked more questions than men, healthcare providers gave shorter and less technical answers to women's questions (ibid., p. 194). Gabbard-Alley (1995) stated that, “although women spend more time involved in communication acts in health contexts, for whatever reasons, their concerns are taken less seriously than are those of men” (p. 39).

However, as explained earlier, women are typically ascribed the caregiver role within the context of family and of societal norms (Thirlaway & Heggs, 2005). In interviews with mothers about family food choices, De Bourdeaudhuij (1997) found that women felt a responsibility to keep everyone in the family healthy and satisfied with the food provided. This type of “unpaid caregiving” is distinctly gendered. Culturally prescribed gender norms assume that women from all types of racial, ethnic, geographic, and class backgrounds hold ideals of nurturance, compassion, and self-sacrifice (Gahagan, Loppie, Rehman, Maclellan, & Side, 2007). Whether accepted or contested, women often adopt the role of unpaid caregiver, even within expansive kinship networks (Gahagan et al., 2007, p. 48).

Women seek out health information more than men, and they do so through media sources (Warner & Procaccino, 2007). Recent studies have shown that women are more likely to go online to seek health information, and that women who are online mostly look for health and medical information and want support for health and personal problems (Fallows, 2005; Fox, 2005; Warner & Procaccino, 2007). These studies do not contextualize consumer-seeking behavior within cultural, economic, or social contexts: perhaps women online have greater access to computers because their class position affords them access to capital, professional employment, and transportation; or perhaps unemployed women have more spare time to think about healthcare and to seek out information online. Questions of identity, cultural perspective, and economic constraints are significant factors that influence women's exposure to and reception of health media. Current research, however, has restricted explanations for women's meaning making to certain isolated cognitive variables. Some research projects such as my own have begun to engage with questions of culture and power in this area, but there are very few other studies that attempt to offer a holistic critique or to engage with women's interpretations deeply enough to account for health media's varied intersections with and impact on society.

Women as an Audience of Health Media

The research on female audiences of health media reflects the dialectical tension between the biomedical paradigm and a sociocultural perspective, where both simultaneously facilitate and constrain research designs and interpretative approaches. On the one hand, scholars have increasingly attended to cultural sensitivity, racially and ethnically diverse participant groups, and marginalized and underserved populations of women. Studies have offered greater understanding of how women with different identities and from different cultural communities make meaning of various forms of health media through the lenses of race, class, and everyday experiences of illness and disease. However, current-day studies continue to focus on woman's accountability for behavior change, and few researchers analyze the effects of medicalization on women's bodies and minds. There is limited analysis of the power relations in play that benefit medical and economic interests while constraining women's choices; and the racial and gender hegemony of the medical and media systems are rarely interrogated.

The body of knowledge on women as a health audience is too large to be summarize completely or described in detail in this chapter. What I do here instead is to present some themes that characterize the research published in this country; and I limit the search to the last 15 years. These themes help illuminate the gaps in understanding that will be critiqued in the conclusion of this chapter. For each theme, I include a description of one or two representative studies that have been published since 2000.

Formative Research with Female Audiences

There have been some published articles that report formative research findings, which became the basis for developing health campaigns (Bull, Cohen, Ortiz, & Evans, 2002; Doyle et al., 2006; Lindsey et al., 2007). Focus groups reveal women's opinions and responses that are then mined to design slogans, posters, or other health messages.

In Bull and colleagues' (2002) study, focus groups were used to investigate opinions about female condoms in order to develop a female condom promotion campaign in Denver, Colorado. The authors stated that the participants were “women” aged between 14 and 25. They reported that these participants were of varied racial identity, although race was invisible in the description of findings and interpretations. Researchers first used some of the women's opinions about female condoms to design posters that were subsequently shared with focus groups for feedback. Findings suggested that the participants wanted direct statements about female condoms making sex less worrisome than male condoms do, because female condoms allow women to have more control over their sexuality and reproductive functions. This study represented a rigorous and systematic model for focus group methodology, because researchers held focus groups with women at three separate time periods during the development of campaign messages: before launching the design, during the campaign, and afterwards, for final revisions. The voices of the women were implemented through visual and textual elements of the final campaign materials. However, there was no explanation for why young and older adolescents were defined as adult women and included in women's discussions of sexual intercourse, unprotected sex, and condom use. The reader is led to believe that the participants were sexually active; but there was no interrogation of the power relations within the family and in the more private partner contexts that regulate sexuality.

Health Messages as Cues for Individual Cognitions

The largest group of studies on women and health media tests the impact of mediatized messages on individual cognitions (Hether, Huang, Beck, Murphy, & Valente, 2008). Scholars believe that psychological factors can be linked to behavioral intent, increasing the likelihood of behavior change, which is the primary goal of the health messages examined in this research. Dependent measures include knowledge, attitudes, intent to engage in requested behavior, and sometimes actual behavioral outcomes. This cognition-to-behavior link guides the theories that dictate the selection of independent variables for researchers to measure in their assessments of a media campaign's outcomes. The popular theories in health communication are the same ones that prevail in the research on women audiences: social cognitive theory, the health belief model, and the theory of reasoned action/planned behavior (Airhihenbuwa & Obregon, 2000; Freimuth, 1995). This group of health communication studies does not interrogate the influence of institutional factors and gendered norms on women's health-related choices and practices.

For example, Hether and colleagues (2008) analyzed findings from a panel survey (of repeat survey-takers from a research company's email list). The survey had an 8% response rate; the participants were 92% white, 69% married, and 66% had a close family member or a friend with cancer. Thus a somewhat select group of women responded to a questionnaire about their knowledge, attitudes, and behavioral intentions following the viewing of a breast cancer survivor's story. The study's “most important contribution” was the finding that watching two breast cancer stories on television had greater effect on knowledge, attitudes, and behavioral intention than watching only one breast cancer story (Hether et al., 2008, p. 820). Authors did not critique the intersectional identities and cultural experiences that may have led this particular group of women to feel that watching two stories had greater salience for the person than watching just one.

All cognitive theories in health communication attest to the relevance of self-efficacy for behavior change. Self-efficacy is the perceived confidence that one can successfully engage in the behavior requested in the health message. Self-efficacy can be linked to understandings of empowerment and control, and therefore it can be an important construct in the study of women audiences. Some authors argue that self-efficacy is a significant predictor of disease prevention and of detection behaviors among women (Allen, Sorensen, Stoddard, Colditz, & Peterson, 1998; Anderson & McMillion, 1995; Lipkus, Biradavolu, Fenn, Keller, & Rimer, 2001; Prentice-Dunn, Floyd, & Flournoy, 2001; Stein, Fox, Murata, & Morisky, 1992). One study found that – according to the categories used by the authors – “Hispanic women” were more likely than “white women” to believe that they can do nothing to prevent getting heart disease (Christian, Rosamond, White, & Mosca, 2007). Another study found that perceived social norms can influence self-efficacy; when women perceived greater social acceptance of a behavior, their self-efficacy in performing that behavior increased (Egbert & Parrott, 2001). These general findings were not analyzed in the context of racial and class hegemony, which defines health practices in this country; however, the results do offer an opportunity for questions to be posed about hegemony and the role of culture in mediating perceptions of self-efficacy.

Women and Health News

Research on women as audiences of news about health risk examines interpretations of risk probabilities and the impact of spokespersons as legitimate presenters of safety information. One study examined how 170 women employed by a large corporation interpreted risk probability in a news article (Thirlaway & Heggs, 2005). Findings showed a wide variety of responses in how the women described their own risk after reading the article. A few reinterpreted the health risk in quantifiable phrases and did not articulate an emotive response. Some used words such as “frightening” and “concerning,” others responded with guilt, and still others restated the facts without expressing any obvious opinion or attitude. Only 20% of participants reported intent to change some behavior; and the reasons given for not changing behavior reflected resistance toward the media, toward “expert” opinion, and toward “science” and “statistics” (p. 114). The authors concluded that “experiential contexts” were filters for the women's responses to the health risk news.

Studies of spokesperson impact have revealed a gendered context for how women make meaning out of risk news. Siegrist, Cvetkovich, and Gutscher (2001) found that women had less trust in news spokespersons who were authorities than men did, and that women gave less support for government officials′ decisions not to investigate a high-risk event. In another study we explored how women interpreted news about the safety risk concerning a food supply; and we did this through 23 in-depth individual interviews (Vardeman & Aldoory, 2008b). When news texts were shared with the participants, we found that, initially, the latter expressed concern for loved ones rather than for themselves. Regardless of whether one was a parent or not, a participant articulated meaning within her perceived role of caregiver; as one participant said, “it's just this like guilty feeling because you're supposed to be the one providing the nutrients.” Most of the participants expressed distrust of the federal and medical organizations represented in the news; they did not believe that government and medical spokespersons prioritized the needs of female consumers over the governmental goals of reputation or organizational profit. However, in the face of high risk, the participants felt compelled at least to attempt to take the protection measures suggested in the news.

Our study also explored whether experiential and cultural characteristics in spokespersons enhanced the salience of news for individual participants. The majority of participants preferred spokespersons in risk news to be similar to them not only in terms of physical and demographic characteristics, but also in terms of familial context and risk susceptibility. For example, a female spokesperson shown to be empowered within the formal system of government and within the system of science increased participants' perception of legitimacy and salience of the messages in relation to the health threat. One participant said: “If it's a woman spokesperson talking about it, and she seems really passionate about the issue [. . .] then I look at them like, ‘Wow! They're in a position of power.’” Additionally, when the spokesperson transmitted a sense of involvement and susceptibility, this heightened the participant's emotional response to news about the threat and increased the salience of this news for her. Perhaps the spokesperson's vulnerability to the health risk lowered her control over the situation, and participants perceived this state as balancing the relations of power between them and that person; this in turn heightened the audience's sense of legitimacy of the message, since it was not coming from a distant or neutral “third-party” representative who would not understand vulnerability to a risk that may impact women.

The participants also shared the constraints they had perceived in processing meaning and in deciding on a course of action after their exposure to the news. The primary barrier was the perception of limited alternatives to the food in question. “Tell us what we can do without stopping feeding our kids yogurt and cheese and milk that they live on everyday. Give us some other practical suggestions [. . .].” Some women had limited media access and did not trust alternative media outlets. Another barrier to action was the prioritization of other health threats in their everyday lives. Finally, race and ethnicity also played a role for the women of color in the study. The participants represented a diverse group – with respect to age, race, and ethnicity. The women of color expressed greater concern about the health risks communicated in the news and a desire to change their food behaviors to reduce the risk; but they also communicated less self-efficacy in their perceived ability to do what was being asked of them in the safety messages of the news.

A second study of pregnant women, nursing women, and women with young children as audiences of health messages explored how these women construct meaning in a contested media environment that targets them as high-risk audiences (Vardeman & Aldoory, 2008a). The study was conducted around the news coverage of methylmercury levels in fish (FDA & EPA, 2004). The new FDA (Food and Drug Administration) and EPA (Environmental Protection Agency) guidelines were issued just three years after a different set of federal guidelines on eating fish; this fact, together with variations in health risks according to type and amount of fish, and together with a simultaneous promotion of benefits from fish consumption, created a situation where the news environment relating to fish consumption represented conflicting and confusing messages. The setting for our study was this contested news terrain: rather than examine just one news story as a static textual unit, we sought to replicate the natural media environment about fish consumption at the time. News media tended to report the risks without a historical perspective, which added to the contradictions. The media offered a prime environment, designed to explore how women from federally defined high-risk groups made meaning out of risk news and its messages. Actual news articles from local and regional newspapers were introduced to six focus groups conducted across three Mid-Atlantic states – in an eastern shore community, in a suburb, and in an urban city. Eastern shore groups offered a perspective from women whose livelihoods depended on the fishing industry.

Most of the women were already aware of the contradictory nature of messages about eating fish safely. To articulate their understandings of the risk messages in the study, participants compared the conflicting information to their current knowledge and past experiences. Many of the pregnant women and women with small children expressed confusion about the risk, because they perceived it to be directly related to their caregiving ability and they sensed a loss of control that affected their efficacy. The confusion was accompanied by feelings of concern, fear, anxiety, and guilt about whether they could eat fish or feed it to their families. Even though the benefits of eating fish continued to be touted in the news, the women's purposeful avoidance of any fish offered them a way to regain control in an ambiguous health context, which they perceived as having a direct impact on their identity as caregivers. For women living in fishing economies, there was skepticism about the media, the government, the fish packing industry, and the environmental groups. These participants did not believe that the warnings were based on fact – they perceived their source as having a low credibility rate, or they did not think that enough facts had been offered in the news to support the idea of there being a real risk. These women survived on sales of fish throughout the region; they told stories of resistance against the regulatory efforts of state agencies. The women negotiated their struggles within contested relations of power with their husbands and economic providers, and with what they perceived to be a controlling government and constraining activist groups. Their oppositional readings of the health message also illustrated their belief that the media were primarily representatives or “voices” of the government.

Again, the participants described certain barriers that prevented them from engaging in safe fish consumption. First there was a lack of available realistic options to eating fish. Related to this was the lack of details in the news about everyday practices that would enable one to decide about fish and amounts of fish. As one woman asked: “How are we to know when we go to the store which fish come from waters that are subject to a mercury advisory?” Next, other health risks took priority in these women's busy everyday lives. And, finally, low self-efficacy led women to believe there was nothing they could do about the problem.

Medically Underserved Women Gain Some Attention

Fortunately, the past few years reveal a trend toward more studies with medically underserved women, who traditionally had been invisible in health communication research. Medically underserved populations have limited access to health facilities, quality healthcare, and health insurance. The phrase “medically underserved” has replaced the phrase “hard to reach” in public health discourse, in attempts to acknowledge the role of institutional and medical constraints that keep at-risk populations from seeking healthcare. While some women consciously resist a mainstream medical environment and are “hard to reach” by health workers and by health messages, women who are medically underserved typically desire access to affordable quality healthcare, and they do seek accurate health information in order to make sound health decisions (Wathen, 2006). Women already face gendered norms that trivialize their personal health concerns; in the case of medically underserved women, additional racial, ethnic, or sexual marginalization occurs.

Research on these communities of women has focused on health topics such as breast cancer and Acquired Immune Deficiency Syndrome/Human Immunodeficiency Virus (AIDS/HIV) and has emphasized one broad racial, ethnic, or geographic category – for instance Hispanic women, African American women, rural women – in the analysis of research participants (Anderson & McMillion, 1995; Egbert & Parrott, 2001; Meana, Bunston, George, Wells, & Rosser, 2001; Stein, Fox, & Murata, 1991). While increasing, the number of studies of marginalized women is significantly lower than the number of studies that rely on convenience samples of white middle-class women. Some recent studies do not publish any demographics or identities of the research participants. Due to this ongoing invisibility of identity in the research, I take more time here to furnish greater detail from the few studies that have highlighted the voice of marginalized audiences of women.

There have been a few studies investigating Latino populations and their perceptions of health messages. One such study investigated “Hispanic” (labeled as such by the researchers) women's preferences for receiving breast health information (Oetzel, DeVargas, Ginossar, & Sanchez, 2007). Hispanic women are at greater risk of breast cancer than of any other cancer, and yet they are significantly less likely than other black and white women to engage in early detection methods such as self-examination or mammography. “Availability of health care and health insurance are the major structural barriers to cancer screening in Hispanic populations” (Oetzel et al., 2007, p. 224). The authors used a convenience survey of 176 women, most of whom identified themselves as Mexican American, and these women indicated English as their preferred language. Almost two thirds of the participants were married, had at least some college education, and held private health insurance (18 participants had Medicare/Medicaid, and 29 reported no health insurance). Findings indicated that the women who valued the element of interdependence with others in their life used a variety of sources of information about breast cancer screening. Women who identified with both traditional Hispanic culture as well as US cultural values used media channels as well as family sources for breast cancer screening. Those women who did not identify either with a traditional form of Hispanic culture or with US culture responded to fear appeals in health messages and resisted expert spokespersons. While cultural identity was measured via quantitative items that did not provide in-depth meaning to cultural cues, Oetzel and colleagues (2007) did allow for greater variation in the ways in which culture should be considered. Rather than rely on simplistic measures of attitudes, the authors included more nuanced characteristics such as ethnic identity, self-image, perceived assimilation with US culture, and relational connectedness.

More studies have been done with black women as health audiences than with other women of color; and, again, studies in this country have prioritized AIDS/HIV and breast cancer. Frisby (2002), for example, recruited a convenience sample of 92 “African American women” (the label used by the researcher) from a “Northeastern metropolitan area” to complete a questionnaire about breast cancer and mammograms (p. 494). African American women have a lower incidence rate of breast cancer but a higher mortality rate. Frisby argued that “early detection would significantly reduce morbidity and mortality numbers of African American women” (p. 489). The sample of women varied by age, income, and level of education, although the findings were not analyzed according to these intersectional identities. The author summarized the findings into five conclusions: (1) the women held negative thoughts of death and fear relating to breast cancer; (2) they typically thought of campaigns and products such as the pink ribbon; (3) they did not have knowledge of the causes or risks of breast cancer; (4) they desired “rational” advertising appeals, which communicate causes and risks; and (5) the women wished to see “role models” of African American women who survived breast cancer and subsequently led productive lives (p. 500). Frisby's conclusions support the findings reported in studies of white women and in studies of female participants whose identities remained invisible in the published articles. With breast cancer information women tend to react negatively the first time round, and they desire someone who looks like them to be represented in the messages. To extend the findings on women and breast cancer, a discussion is needed about black women's higher mortality rate in the context of a medical hegemony that privileges white women, and also in the context of cultural and intersectional identities that may help explain why women do not find that campaign messages are salient for them – or why they even fail to expect salience at all.

Kreuter and Haughton (2006) conducted a quasi-experimental study to assess the usefulness of cultural tailoring on African American women and their cancer prevention knowledge and practices. The authors selected four cultural constructs they believed to be salient for African American women: religiosity, collectivism, racial pride, and time orientation. For the women in the treatment groups, cancer-related knowledge and prevention behaviors increased when messages were tailored so as to speak not only to the women's cultural cues, but also to their sense of self-efficacy, motivation, and other cognitive characteristics. Graphics and text for the tailored magazines were developed with the extensive participation from African Americans (the authors did not specify if these participants were female).

There have been a few studies that focus on Asian American women as audiences of breast cancer prevention campaigns (Jenkins et al., 1999; Sun, Zhang, Tsoh, Wong-Kim, & Chow, 2007). Asian American women have a higher mortality rate than African American and white women, although the prevalence rate of breast cancer is lower among them. Asian American women have the second lowest breast cancer screening rate among all ethnic groups in the United States (Sun et al., 2007). In their study, Sun and colleagues found that Chinese-language public service announcements on radio increased breast cancer knowledge and related health practices. In this convenience sample of Asian women, results also indicated that respondents with an education above high school and women from Hong Kong showed a superior ability to recall breast health guidelines from media messages. Again, while this research was important by giving a voice to an invisible sector of marginalized women, the findings do not really illuminate the “lifeworld” experiences of participants. These experiences may help scholars distinguish specific factors such as higher education and spokesperson demographics, which may affect the ways in which different groups of women perceive health messages.

Offering a Context for Women and Health Media

There have been very few reception studies of women as consumers of health media that have included critiques of the social and cultural norms that have an impact on how women accept, negotiate, or resist health messages in the media (Grodin, 1991; Press & Cole, 1995; Simonds, 1992). Over the last 10 years, however, scholars have made some tentative progress in this area of research. In earlier projects I did attempt to take a cultural approach in order to explore the ways in which women made meaning out of health media. One study examined a media environment rather than a media text as a unit of analysis (Aldoory, 2001). Additionally, I did not impose any one health topic for discussion with the 50 women who participated in focus groups and individual interviews; I let the women formulate their primary health concerns, and I allowed them to take the lead in discussing and debating these concerns. The groups were set by similar race, class, sexual orientation, age, educational level, and professional status (ibid.). For example, one focus group comprised women who identified as African American and as Caribbean American, employed, married, and in their forties. Another focus group consisted of women in their forties who identified themselves as lesbian and labeled themselves “working class” and white. I made an effort to pay greater attention to the impact of intersectional identities on women's engagement with health and medical issues.

The primary health concerns varied a great deal; they included heart disease, diabetes, menopause, eating disorders, breast cancer, and Medicaid. While some of these concerns, like menopause and hormone replacement therapy, were directly connected to being female, others related to conditions that have been socialized as feminine, such as eating disorders. Race, ethnicity, class, and sexuality played an integral role in how the participants decoded health messages, and pregnancy and motherhood also influenced participants' attitudes toward their bodies. The women's personal experience of health problems and their beliefs about the medical establishment were relevant to their interpretations of health messages. Finally, source credibility and beliefs about mainstream media were used to decode health messages. For participants who reflected the type of woman targeted by mainstream health messages, there was a great deal of personal relevance and comprehension of health messages. This greater acceptance of mediated health messages in everyday life by the women of US dominant/mainstream race and class would ultimately enable increased attention to and improved opportunities for health. Participants from cultural groups that are underserved by medical institutions and by media did not attend to mainstream health messages in the same way. Thus many of the women in the study did not see themselves reflected in health media messages – not even after they acknowledged the attempts that health organizations and media campaigns had made to advance public awareness of health-related problems and concerns. For the lesbian women in the study, no attempts have been made to address their health needs; in fact these women documented hostility from gynecologists and other health practitioners who prioritized reproductive health and issues of fertility.

For these women, message reception was a process by which primary health concerns were negotiated and integrated into everyday life over time – each media message discussed by participants was not perceived distinctly, but rather was considered in the context of greater meaning related to a given health concern. Participants cognitively connected and compared health messages, accepting some meanings and rejecting others, within the contexts of their self-ascribed identity, cultural norms, motherhood and pregnancy, opinions about the source and media in general, and experiences with health, illness, and medical environments. As other scholars have asserted, the participants negotiated the meaning of a health concern at a broad and cumulative level rather than at the level of some particular isolated message (van Zoonen, 1994; Wathen, 2006).

An Agenda for Research on Women as Audiences, of Health Media

This chapter reflected on some recent research that examined women as audiences of health messages and illustrated some themes found in the work conducted in the United States. Overall, there has been a lot of research on female audiences of health media, but very little of it has placed culture and gender at the center of analysis. While many of the studies offer contributions to understanding women in their capacity as audiences, others reveal gaps that leave invisible the cultural factors, gender norms, and power relations governed by medicine, government, and media institutions, all of which affect the way women create meaning out of health messages. Furthermore, while intersectionality has become important in critical studies and in feminist media research, it is virtually absent in the study of women as audiences of health news and health campaigns.

I outline below certain theoretical premises and new directions that can take into account and help explain the different responses of women to health media and shed light on the various factors that influence the meanings that women ascribe to representations. These premises should be considered intellectual moments designed to pose new questions and to propel future research that can support, extend, or elaborate upon the current state of knowledge on female audiences of health media. I hope that the agenda I propose below will lead to further development of research and to a burgeoning of theory-building in the area of gender, media, culture, and health communication.

Negotiated Meaning of Health

Through the lenses of power, culture, identity, and hegemony, women construct negotiated and often troubling meanings for health, illness, and disease. I like to believe that, ultimately, mediatized health messages can make an impact on women's health, and certainly most of the research in this area directs attention toward women's health outcomes – for instance increasing regularly scheduled mammography, performing breast self-exams, and using condoms consistently and correctly. However, given the negotiated contexts, I argue that there can be several other “outcomes” that represent worthy pursuits and are in need of further research. Goal-directed health media could attempt to increase the following: the salience of a health issue at personal level; the ability to use health-related information; confidence in making decisions about health; and an awareness of power structures and constraints that hinder good health. Future research on female audiences needs to explore these outcomes of meaning rather than outcomes of behavior, so that media messages might be better directed at women's everyday lives.

Negotiated Media Environment

As van Zoonen (1994) has suggested, women go beyond an individual health text and broaden their negotiated meanings to the larger context of a health issue, which includes understandings of media and of the healthcare industry. What is actively negotiated over time is not the meaning given to one text, but rather the meaning of a given phenomenon, such as breast cancer, and its role in a woman's life. There is limited research in this broader area of audience reception, but such studies might offer contributions to understanding how women interpret health and their identity as a healthy person. Health messages are seldom interpreted in a vacuum; the overall media environment, culture, community, and society all create meaning for women, even at the moment when a woman interprets a single health message within this larger context. Therefore examining the broader media context is important to understanding how women interpret particular health messages in the media.

Intersectionality as an Analytical Lens

Women's intersecting personal identities shape meanings that health messages have for them (Glenn, 1999; Valdivia, 1995; Zinn & Dill, 1996). There has been a dearth of studies in health communication focusing on the interconnected experiences of women as gendered and raced subjects. Intersectionality assumes that women's identities are always expressed and defined by the interwoven and inseparable categories of race, gender, class, and sexuality. A commitment to understanding intersectionality creates research that is more complex, more realistic, and more sensitive to cultural contexts, all of which are significant for studying women as audiences of health media. Additionally, an intersectional approach complicates matters related to oppression and resistance, as these relate to audiences of, and to potential actors in, health. According to Weber (2001), a woman can “occupy both dominant and subordinate positions and experience advantage and disadvantage” because of race, class, gender, and/or sexuality (p. 105).

Constraints as Lived Reality

Women filter interpretations of health media through prisms of perceived constraints that create their lived realities and limit the success of health media focused on behavior change. Yanovitzky and Blitz (2000), through secondary analysis of national data, found that, while both interpersonal and mediated communication were important in motivating women to seek mammograms, mass media were particularly important for women who did not have regular access to a physician, while the physician's advice was more important for those women who did (p. 129). Women may perceive constraints that are invisible to health care practitioners, or that are trivialized by the medical establishment in this country. Exploring the differing sets of constraints that women have would not only increase the potential for greater access to health information, but might also empower some women in their health decision-making and in their relationship with the healthcare system (Brown, Carroll, Boon, & Marmoreo, 2002; Wathen, 2006).

Caregiver Role

The sociocultural role of caregiver, ascribed to women in this country, creates for women a perspective through which they can view health messages. The caregiving perspective is not exclusive to mothers and pregnant women. While mothers and pregnant women may have a heightened hegemonic sense of caring for their children, the caregiving role impacts women who care for older parents, who make doctors' appointments for partners and husbands, and who care for siblings and friends, often in healing ways. In the research I conducted about risk news, young women expressed concern about their parents and boyfriends. “Unpaid caregiving” is a social burden that some women accept and endure as a form of additional stress, which lowers their own health status, while other women ignore or even resist the caregiving role – and then they have to face family, organizational, and societal criticism and disdain for their rejection of nurturing behaviors. Health media reflect this cultural stigma through images of women caring for others and being the ones responsible for visits made to healthcare practitioners. Health media research should explore how women see themselves in this role and how the burdens of caregiving influence their interpretations of health messages and of decision-making about health.

Deep Cultural Meanings Help Improve Salience

Health campaigns that use only outward appearances of racial, ethnic, and language sensitivity will likely draw attention from the target audiences of women, but they will not necessarily result in personally meaningful considerations made by the women. Kreuter and Haughton (2006) examined the usefulness of Hall's (1984) “levels of culture” and Resnicow, Baranowski, Ahluwalia, and Braithwaite's (1999) “deep structure of culture,” and they found that an integration of surface-level and entrenched or deep cultural meanings creates greater personal relevance for women. One scholarly move toward including deeper structures of culture in health messages has entailed involving indigenous cultural members as co-designers and partners in the development of health messages. Research has shown that this, along with participatory action research, produces greater behavioral motivation as an effect of health campaign messages (Kreuter & Haughton, 2006).

Conclusion

While research on women as health audiences has increased, the scholarship continues to reinforce the assumptions of the biomedical paradigm: for instance the isolation of cognitive variables from their contexts and the disavowal of the power relations that structure the individuals' reception of representations in health media – and hence their involvement in, and their decision-making about, vital healthcare issues. The growing body of knowledge about female audiences has increased sensitivity about marginalized groups of women, and it has also contributed to a better understanding of message appeals and campaign design. Yet it still neglects broader cultural factors and ideological contexts that constrain how women consume and interpret narratives of health in media texts.

The research agenda proposed in this chapter emerges out of a critical review of existing work on women's interpretations of health messages and on the various contextual factors and structural constraints that impinge upon audiences' abilities to make sense of the numerous explicit and implicit messages concerning health that they receive from different media technologies, media genres, and media sources. Future research can thus begin to address more vigorously the topic of health media in relation to gender and culture, and to build what will hopefully be a robust cultural theory. Such a theory should germinate out of empirical work that centers on the voices of the women who make health decisions that have an impact on their everyday lives and on the lives of their families and societies.

REFERENCES

Airhihenbuwa, C. O., & Obregon, R. (2000). A critical assessment of theories/models used in health communication for HIV/AIDS. Journal of Health Communication Supplement, 5(1), 5–16.

Aldoory, L. (2001). Making health communications meaningful for women: Factors that influence involvement. Journal of Public Relations Research, 13, 163–185.

Allen, J. D., Sorensen, G., Stoddard, A. M., Colditz, G., & Peterson, K. (1998). Intention to have a mammogram in the future among women who have underused mammography in the past. Health Education and Behavior, 25(4), 474–488.

Anderson, R. B., & McMillion, P. Y. (1995). Effects of similar and diversified modeling on African American women's efficacy expectations and intentions to perform breast self-examination. Health Communication, 7(4), 327–343.

Bagley, G. (2001). The television text: Spectatorship, ideology, and the organization of consent. Critical Studies in Media Communication, 18(4), 436–451.

Brown, J. B., Carroll, J., Boon, H., & Marmoreo, J. (2002). Women's decision-making about their health care: Views over the life cycle. Patient Education and Counseling, 48, 225–231.

Bruhn, J. G. (1988). Life-style and health behavior. In D. S. Gochman (Ed.), Health behavior: Emerging research perspectives (pp. 71–86). New York, NY: Plenum Press.

Bull, S. S., Cohen, J., Ortiz, C., & Evans, T. (2002). The POWER campaign for promotion of female and male condoms: Audience research and campaign development. Health Communication, 14, 475–491.

Byerly, C. M., & Ross, K. (2006). Women and media: A critical introduction. Oxford, UK: Blackwell.

Christian, A. H., Rosamond, W., White, A. R., & Mosca, L. (2007). Nine-year trends and racial and ethnic disparities in women's awareness of heart disease and stroke: An American Heart Association national study. Journal of Women's Health, 16, 68–81.

Condit, C. M. (1994). Hegemony in a mass-mediated society: Concordance about reproductive technologies. Critical Studies in Mass Communication, 11, 205–230.

De Bourdeaudhuij, I. (1997). Perceived family members' influence on introducing healthy food into the family. Health Education Research, 12, 77–90.

Derzon, J. H., & Lipsey, M. W. (2002). A meta-analysis of the effectiveness of mass-communication for changing substance-use knowledge, attitudes, and behavior. In W. D. Crano & M. Burgoon (Eds.), Mass media and drug prevention: Classic and contemporary theories and research (pp. 231–258). Mahwah, NJ: Lawrence Erlbaum Associates.

Doyle, P. A., Bird, B. C., Appel, S., Parisi, D., Rogers, P., Glaros, R., Brandt, N., Barber, V., Salmon, C. A., & Birkhead, G. (2006). Developing an effective communications campaign to reach pregnant women at high risk of late or no prenatal care. Social Marketing Quarterly, 12, 35–50.

Egbert, N., & Parrott, R. (2001). Self-efficacy and rural women's performance of breast and cervical cancer detection practices. Journal of Health Communication, 6(3), 219–233.

Fallows, D. (2005). How women and men use the Internet. Washington, DC: Pew Internet & American Life Project. Retrieved May 1, 2006, from http://www.pewinternet.org

FDA, & EPA. (2004, March). What you need to know about mercury in fish and shellfish. Retrieved September 21, 2005, from http://www.cfsan.fda.gov/~dms/admehg3.html

Fox, S. (2005). Health information online. Washington, DC: Pew Internet & American Life Project. Retrieved May 1, 2006, from http://www.pewinternet.org

Freimuth, V. S. (1995). Mass media strategies and channels: A review of the use of media in breast and cervical cancers screening programs. Wellness Perspectives, 11(2), 79–106.

Frisby, C. M. (2002). Messages of hope: Health communication strategies that address barriers preventing black women from screening for breast cancer. Journal of Black Studies, 32, 489–505.

Gabbard-Alley, A. S. (1995). Health communication and gender: A review and critique. Health Communication, 7, 35–54.

Gahagan, J., Loppie, C., Rehman, L., Maclellan, M., & Side, K. (2007). “Far as I get is the clothesline”: The impact of leisure on women's health and unpaid caregiving experiences in Nova Scotia, Canada. Health Care for Women International, 28, 47–68.

Glenn, E. N. (1999). The social construction and institutionalization of gender and race: An integrative framework. In M. M. Ferree, J. Lorber, & B. B. Hess (Eds.), Revisioning gender (pp. 3–43). Thousand Oaks, CA: Sage.

Grodin, D. (1991). The interpreting audience: The therapeutics of self-help book reading. Critical Studies in Mass Communication, 8, 404–420.

Hall, E. (1984). The dance of life: The other dimension of time. Garden City, NY: Anchor.

Hether, H. J., Huang, G. C., Beck, V., Murphy, S. T., & Valente, T. W. (2008). Entertainment-education in a media-saturated environment: Examining the impact of single and multiple exposures to breast cancer storylines on two popular medical dramas. Journal of Health Communication, 13, 808–823.

Jenkins, C. N., McPhee, S. J., Bird, J. A., Pham, G. Q., Nguyen, B. H., Nguyen, T., Lai, K. Q., Wong, C., & Davis, T. B. (1999). Effect of a media-led education campaign on breast and cervical cancer screening among Vietnamese–American women. Preventive Medicine, 28, 395–406.

Kreuter, M. W., & Haughton, L. T. (2006). Integrating culture into health information for African American women. American Behavioral Scientist, 49, 794–811.

Lindsey, L. L. M., Hamner, H. C., Prue, C. E., Flores, A. L., Valencia, D., Correa-Sierra, E., & Kopfman, J. E. (2007). Understanding optimal nutrition among women of childbearing age in the United States and Puerto Rico: Employing formative research to lay the foundation for national birth defects prevention campaigns. Journal of Health Communication, 12, 733–757.

Lipkus, I. M., Biradavolu, M., Fenn, K., Keller, P., & Rimer, B. K. (2001). Informing women about their breast cancer risks: Truth and consequences. Health Communication, 13(2), 205–226.

Livingstone, S. (2006). The changing nature of audiences: From the mass audience to the interactive media user. In A. N. Valdivia (Ed.), A companion to media studies (pp. 337–359). Oxford, UK: Blackwell.

Majority of women control health-care decisions. (1997, Summer). Merck Media Minutes, 1.

Martin, E. (1987). The woman in the body: A cultural analysis of reproduction. Boston, MA: Beacon Press.

Meana, M., Bunston, T., George, U., Wells, L., & Rosser, W. (2001). Influences on breast cancer screening behaviors in Tamil immigrant women 50 years old and over. Ethnicity and Health, 6(3/4), 179–188.

Mishler, E. G. (1984). The discourse of medicine. Norwood, NJ: Ablex.

Nussbaum, J. F., Ragan, S., & Whaley, B. (2003). Children, older adults, and women: Impact on provider-patient interaction. In T. L. Thompson, A. M. Dorsey, K. I. Miller, & R. Parrott (Eds), Handbook of health communication (pp. 183–204). Mahwah, NJ: Lawrence Erlbaum Associates.

Oetzel, J., DeVargas, F., Ginossar, T., & Sanchez, C. (2007). Hispanic women's preferences for breast health information: Subjective cultural influences on source, message, and channel. Health Communication, 21, 223–233.

Prentice-Dunn, S., Floyd, D. L., & Flournoy, J. M. (2001). Effects of persuasive message order on coping with breast cancer information. Health Education Research, 16(1), 81–84.

Press, A. L., & Cole, E. R. (1995). Reconciling faith and fact: Pro-life women discuss media, science and the abortion debate. Critical Studies in Mass Communication, 12, 380–402.

Resnicow, K., Baranowski, T., Ahluwalia, J., & Braithwaite, R. (1999). Cultural sensitivity in public health: Defined and demystified. Ethnicity and Disease, 9, 10–21.

Sharf, B. F., & Vanderford, M. L. (2003). Illness narratives and the social construction of health. In T. L. Thompson, A. M. Dorsey, K. I. Miller, & R. Parrott (Eds), Handbook of health communication (pp. 9–34). Mahwah, NJ: Lawrence Erlbaum Associates.

Siegrist, M., Cvetkovich, G., & Gutscher, H. (2001). Shared values, social trust, and the perception of geographic cancer clusters. Risk Analysis, 21, 1047–1053.

Simonds, W. (1992). Women and self-help culture: Reading between the lines. New Brunswick, NJ: Rutgers University Press.

Snyder, L. B., & Hamilton, M. A. (2002). A meta-analysis of US health campaign effects on behavior: Emphasize enforcement, exposure, and new information, and beware the secular trend. In R. C. Hornik (Ed.), Public health communication: Evidence for behavior change (pp. 357–384). Mahwah, NJ: Lawrence Erlbaum Associates.

Stein, J. A., Fox, S. A., & Murata, P. J. (1991). The influence of ethnicity, socioeconomic status, and psychological barriers on use of mammography. Journal of Health and Social Behavior, 32(2), 101–113.

Stein, J. A., Fox, S. A., Murata, P. J., & Morisky, D. E. (1992). Mammography usage and the health belief model. Health Education Quarterly, 19(4), 447–462.

Sun, A., Zhang, J., Tsoh, J., Wong-Kim, E., & Chow, E. (2007). The effectiveness of utilizing Chinese media to promote breast health among Chinese women. Journal of Health Communication, 12, 157–171.

Thirlaway, K. J., & Heggs, D. A. (2005). Interpreting risk messages: Women's responses to a health story. Health, Risk and Society, 7(2), 107–121.

Turow, J. (1989). Television and institutional power: The case of medicine. In B. Dervin, L. Grossberg, B. J. O'Keefe, & E. Wartella (Eds.), Rethinking communication, Vol. 2: Paradigm exemplars (pp. 454–473). Newbury Park, CA: Sage.

Valdivia, A. N. (1995). Feminist media studies in a global setting: Beyond binary contradictions and into multicultural spectrums. In A. N. Valdivia (Ed.), Feminism, multiculturalism, and the media: Global diversities (pp. 7–29). Thousand Oaks, CA: Sage.

van Zoonen, L. (1994). Feminist media studies. Thousand Oaks, CA: Sage.

Vardeman, J. E., & Aldoory, L. (2008a). A qualitative study of how women make meaning of contradictory media messages about the risks of eating fish. Health Communication, 23(3), 282–291.

Vardeman, J. E., & Aldoory, L. (2008b). How women make meaning of their shared involvement with spokespersons in news about bioterrorism. Media Report to Women, 36(2), 15–22.

Warner, D., & Procaccino, J. D. (2007). Women seeking health information: Distinguishing the web user. Journal of Health Communication, 12, 787–814.

Wathen, C. N. (2006). Health information seeking in context: How women make decisions regarding hormone replacement therapy. Journal of Health Communication, 11, 477–493.

Weber, L. (2001). Understanding race, class, gender and sexuality: A conceptual framework. Boston, MA: McGraw-Hill.

WHO (World Health Organization). (2010). Constitution of the World Health Organization. Retrieved February 23, 2010, from http://apps.who.int/gb/bd/PDF/bd47/EN/constitution-en.pdf

Yanovitzky, I., & Blitz, C. L. (2000). Effect of media coverage and physician advice on utilization of breast cancer screening by women 40 years and older. Journal of Health Communication, 5, 117–134.

Zinn, M. B., & Dill, B. T. (1996). Theorizing difference from multicultural feminism. Feminist Studies, 22, 321–331.