abstract: Chronic illness can be a stressful experience that requires coping and support. In the last twenty years, Shared Medical Appointments (SMAs) were developed in U.S. healthcare as a response to the rising rates and challenges of chronic disease management. Due to the infancy of the SMA model, however, little is known or understood about the benefits of group medical care for patients. To date, scholars have not explored or systematically observed the communicative aspects of the SMA model. Communal coping, a theoretical framework that foregrounds group interaction and communication, offers a pragmatic lens for exploring how patients collectively cope with the stressors of chronic illness in the context of SMAs. Using qualitative methods, I conducted participant observation of SMAs at a Veterans Affairs hospital to analyze the communicative, transactional nature of communal coping as it unfolded among heart failure patients, family members, and providers in context. I also conducted interviews with SMA attendees. Analysis is based on 56 hours of fieldwork and 14 hours of interviews. Findings of this dissertation revealed group members who attended heart failure SMAs engaged in communal coping to manage the stressors of chronic illness. Group members moved through four primary phases of the communal coping process: (1) establish a communal coping orientation; (2) discuss shared stressors; (3) engage in cooperative action; and (4) practice communal reflexivity. Findings suggest patients become empowered by group interaction during SMAs as they move through each phase of the communal coping process. This dissertation also highlights various communicative strategies providers' use during SMAs to facilitate communal coping and group interaction. Theoretically, this dissertation expands upon existing knowledge of communal coping by exploring how individuals embody and socially construct the communal coping process. Specifically, this dissertation extends past models of communal coping with the addition of the communal reflexivity phase and through conceptualizing communal coping as a facilitated process of empowerment. Pragmatically, this research also offers insight to the benefits patients derive from attending SMAs, such as reduced feelings of stigma and isolation and improved motivation. / Dissertation/Thesis / Doctoral Dissertation Communication Studies 2015

É alta a prevalência de dor crônica em pacientes com câncer, que é comprovadamente associada ao sofrimento psicológico acentuado e muitas vezes não é adequadamente diagnosticada e tratada. Estudo que realizamos com 120 pacientes adultos em atendimento ambulatorial na Clínica de Dor do Instituto Nacional de Câncer, no Rio de Janeiro que demonstrou que os pacientes mesmo conhecendo o seu diagnóstico de câncer, não se sentiam informados sobre a doença e a dor oncológica a contento, o que trazia insatisfação com o tratamento recebido e maior exigência com os resultados do mesmo. Nosso estudo revelou, ainda, que o comportamento do profissional durante o atendimento pode ser percebido pelos pacientes como fator tanto de melhora como de piora da dor, sendo o comportamento atencioso do profissional muitas vezes mais valorizado pelos pacientes que a supressão da dor. Estes resultados suscitaram questões relativas à qualidade da interação entre médicos e pacientes, desenvolvidas nesta dissertação. Embora não sejam suficientemente investidas nem na relação médico-paciente, nem na educação e no treinamento profissional, as habilidades de comunicação do médico afetam diretamente o nível de informação e de satisfação do paciente, suas crenças e os resultados do tratamento. Ao longo do tempo a relação médico paciente vem mudando, deixando de ser tão centrada na doença e no médico, para centrar-se mais no doente como um ser integral, o que implica no reconhecimento, pelo médico, de saberes diferentes dos seus e de que o seu saber não constitui uma verdade absoluta a ser acatada pelos demais. Apesar de bem-vindas, estas mudanças trazem uma certa confusão nos papéis a serem desempenhados por médicos e pacientes e dificuldades aos médicos de lidarem com as diferenças, com as queixas subjetivas dos pacientes, com as emoções destes e as suas próprias. Se hoje é esperado que os pacientes sejam participativos, corresponsáveis por seus tratamentos e recuperação e que se deem conta do poder que eles têm, individual e coletivamente, espera-se que os médicos sejam estudiosos, bem informados, experientes, sinceros, empáticos, sensíveis, atenciosos, compassivos, perspicazes, bem treinados, hábeis em compartilhar informações e decisões com os pacientes, compreendendo o que estes querem e o que não querem e ajudando-os a expressar suas crenças, preferências e receios, disponibilizando tempo suficiente para isso. Tantas expectativas terminam por trazer conflitos que só poderão ser resolvidos com a melhoria da comunicação entre médicos e pacientes, num esforço de ambas as partes. / The high prevalence of chronic pain in patients with cancer, which has been proven to be associated with intense psychological suffering, is frequently not adequately diagnosed and treated. The author undertook a study at the Pain Clinic of the National Cancer Institute in Rio de Janeiro, involving 120 adult patients, where even those who were aware of their cancer diagnosis did not feel sufficiently informed about the disease and the oncologic pain. This situation brought on dissatisfaction with the treatment received and more demands as to results. The study revealed, nevertheless, that the professionals behavior during the consultation could be perceived by the patients as a factor improving or worsening the pain. tese results have raised questions regarding the quality of the interaction between doctors and patients, which were discussed in this paper. In fact, the professionals considerate behavior was many times more valued than the actual suppression of pain. In spite of the inexistence of sufficient investment either in the doctor-patient relationship, or in the education and training related to that issue, the doctors communication abilities affect directly the level of information of the patient, as well as his satisfaction, beliefs and even results of the treatment. The doctor-patient relationship has changed over time, no longer presenting itself centered on the disease and the doctor, to center itself more on the patient as an integral being, which entails the doctors recognition that there are expertises other than his own and that his expertise does not constitute the absolute truth that will apply to others. Although welcome, these changes bring about a certain confusion of roles to be played out by doctors and patients. Doctors face difficulties when dealing with certain differences, with the patients subjective complaints, their emotions as well as the doctors own. If it is expected today, that patients be participative, co-responsible for their treatments and recovery, conscious of their own power, individually and collectively, it is also expected that doctors be studious, wellinformed, experient, sincere, empathic, sensitive, attentive, compassionate, shrewd, well trained, skillful in sharing informations and decisions with patients, understanding what they want, what they dont want, and helping them express their beliefs, preferences and concerns, allocating time enough for this. All these expectations can end in conflicts that may be resolved with an improvement in communication between doctors and patients in an effort from both sides.

No presente estudo utiliza-se a Teoria das Representações Sociais, iniciada por Serge Moscovici, ao publicar a obra La Psychanalyse son image et son public em 1961. Para o autor, as representações sociais são originadas a partir das definições de linguagem e comunicação configurando-se em uma conexão de idéias, metáforas e imagens mentais em constante dinâmica, sendo sustentadas pela comunicação. Essa perspectiva teórica se propõe a entender como os indivíduos e grupos sociais compreendem o mundo, sua realidade e as circunstâncias nas quais se comunicam, compartilham idéias, ações, crenças, ideologias e interagem entre si e com os outros. Este estudo tem como objetivo compreender como os indivíduos constroem e reconstroem os conceitos e as práticas de saúde, as relações estabelecidas entre saúde e doença e como caracterizam as práticas tradicionais de saúde existentes na comunidade negra de Itamatatiua - Maranhão. No que se refere à metodologia utilizou-se os principíos da etnometodologia aliados à etnografia, com o intuito de perceber os modos de dizer e fazer saúde na comunidade. Mediante pesquisa de campo verificou-se que os itamatatiuenses vivem um momento de transição social, política e econômica que vem se repercutindo nas práticas de saúde. A manutenção e utilização de praticas tradicionais de saúde, que envolvem chás, ervas de giraus, emplasto, garrafadas, benzimentos e curandeirismo continua a ser observada, coexistindo com as práticas institucionais do Programa de Saúde da Família. As construções simbólicas em torno da saúde estabelecem relações complexas em uma rede que envolve o momento de transmissão oral; a promessa de saúde e a fé em Santa Teresa; questões territóriais que se traduzem em título de cidadania quilombola e melhoria de qualidade de vida; cultura da cerâmica como base econômica; transição alimentar com a entrada no mercado de consumo dos alimentos industrializados; modo de vida, na maior parte das vezes, harmonioso; relações conflituosas entre os múltiplos saberes em interação, que envolve o conhecimento reificado institucionalizado e o conhecimento popular. Concluí-se que através da oralidade as experiências práticas de saúde das gerações antepassadas se consolidaram e hoje se colocam em paralelo as práticas institucionalizadas governamentais e privadas, constituindo um conjunto de representações características dessa comunidade. / In the present study, we have used the Theory of Social Representations, initiated by Serge Moscovici, when he published the work La Psychanalyse son image et son public, in 1961.For the author, social representations are derived from the definitions of language and communication in setting up a connection of ideas, metaphors, and imagery in a constant dynamics, and being sustained by communication. This theoretical perspective proposes to understand how individuals and social groups understand the world, their reality, and the circumstances in which they communicate, share ideas, actions, beliefs, ideologies, and interact among themselves and with others. This study aims to understand how individuals construct and reconstruct the concepts and practices of health, the relations between health and disease, and how to characterize the traditional health practices existing in the black community of Itamatatiua - Maranhão. Regarding the methodology, we have used the principles of ethno-methodology allied to ethnography, in order to understand the ways of saying and doing health in the community. The field research revealed that people from Itamatatiua live a moment of social, policy, and economic transition that have been reverberating in health practices. The maintenance and use of traditional health practices, which involve teas, seedbed herbs, plasters/patches, potions, blessings, and faith healings continue to be observed, coexisting with the institutional practices of the Family Health Program. The symbolic constructions around health establish complex relationships in a network that involves the time of oral transmission; the promise of health and faith in Santa Theresa; territorial issues that translate into quilombola citizenship title and improved quality of life; ceramic culture as the economic base; dietary transition with the entry of processed foods in the consumption market; way of life, in most cases, harmonious; conflicting relations among multiple knowledge in interaction, which involves the institutionalized reified knowledge and popular knowledge. We conclude that, through oral speech, health practices of past generations have consolidated and currently are placed in parallel with governmental institutionalized and private practices, constituting a set of characteristic representations of this community.

abstract: Smoking prevalence has been a significant issue in China. This present study investigates family influences on the smoking behaviors of highly-educated Chinese youths (HECY) and explores whether family factors work as distal factors in the revised framework of the theory of planned behavior. Convenience sampling and snow-ball sampling have been utilized to select participants from highly-educated Chinese youth population who are students studying in colleges or universities and people who recently graduated from Chinese colleges or universities with Bachelor's and/or Master' degrees. This study relies on quantitative methodologies to analyze the data from the participants' responses to online cross sectional surveys with SPSS. This present study has determined that family influences do contribute to the smoking behaviors of highly-educated Chinese youths. In addition to examining the proximal factors (highly-educated Chinese youths' attitudes toward smoking, self-efficacy and social norms of smoking) in the model of the theory of planned behavior, this current study has examined the following distal factors: (1) parental communication about smoking, (2) communication about smoking among siblings, (3) parents, siblings and/or cousins' attitudes toward smoking, and (4) smoking behaviors of parents, siblings and/or cousins. / Dissertation/Thesis / Masters Thesis Communication Studies 2014

Trata-se de um estudo transversal de natureza compreensiva. Teve como objetivo discutir os aspectos comunicacionais da relação enfermeiro-usuário na atenção básica, tendo em vista o princípio do vínculo. Teve como base as produções científicas sobre comunicação terapêutica em saúde. O método utilizado foi a triangulação de métodos. O processo compreendeu três momentos distintos: no primeiro, a aplicação do Inventário de Problemas Éticos na Atenção Primária à Saúde (IPE-APS) para uma primeira visão dos enfrentamentos e conflitos nas relações entre os enfermeiros e usuários, e que serviu para a triagem das unidades/sujeitos para a etapa seguinte; no segundo, a observação do atendimento de enfermagem com base em um roteiro sobre os aspectos comunicacionais (verbais e não-verbais); e no terceiro, entrevista aberta, com as enfermeiras cujo atendimentos foram observados, na sequência da observação. A análise permitiu evidenciar o uso da comunicação terapêutica pela enfermeira através da utilização de seus elementos como a empatia, a escuta receptiva, respeito e o acompanhamento do paciente em suas reflexões discutidos no marco teórico desta pesquisa. Em vista do que foi percebido nas condutas das enfermeiras, desvela-se que a comunicação deve ser percebida como base para o cuidar em enfermagem mas, entretanto, por alguns momentos, é apenas entendida como algo inerente à prática e como processo mútuo de troca de informações técnicas a fim de estabelecer um plano terapêutico ao paciente. / It is a comprehensive research that aimed to discuss communicational aspects of primary-care patient-nurse relationship, focusing on bond and therapeutic communication. Data collection used a triangulation of methods with distinct stages: (i) application of the Inventory of Ethical Problems in Primary Health Care (IPE-APS) to an overview of ethical issues in nurse-patient relation and to select the services and nurses for observation of nursing care actions. The observation focus was communication aspects (verbal and nonverbal) during the care action. After observation, nurses should talk about their communication in the action. The analysis used the elements of therapeutic communication: empathy, receptive listening, respect and accomplish of patients in their thoughts, feelings, fear, and believes. The results pointed out that the nurses realize the importance of communication for their actions, however, they consider it inherent to nurse practice and as an exchange of technical information to get patients accomplish to treatments.

This study presents the process of creating a performance ethnography of my family’s narratives about familial chronic illness and disability. I label this process performing narrative medicine. By documenting and granularly analyzing the process of my performance ethnography, the following chapters provide a step-by-step discussion of how families communicate about chronic illness/disability through storytelling and humor, and how/what performance does as a method, metaphor and object of study to further our current communicative practices and understandings of chronic illness and disability in families. I argue that performing narrative medicine is a heuristic for families living with chronic illness and disability, and a method that may be used and applied outside the context of my own family. The chapters in my dissertation directly address the following questions: How does my performance work as embodied knowledge to gain greater understanding of the lived experience of familial disability/chronic illness? How does the use of humor as a communicative construct, and performance ethnography work as a practice of “performing narrative medicine?” What are our scholarly stakes in performing narrative? How too might binding narrative medicine to performance inform how we do qualitative research? How do the respective motions of narrative medicine and research practices/principles of performance ethnography converge and cross-fertilize each other? Does a work like narrative medicine endow storytelling and performance with a consequentiality? This performance ethnography of familial disability and chronic illness contributes to understandings of families dealing with chronic illness/disability, extends narrative medicine as a theoretical construct, and speaks to a long tradition of the practice of performance ethnography. Overall, performing narrative medicine reveals the underlying communication competencies at work in families living with chronic illness and disability. Through the use of humor and performance as a communication practice, I reveal the power of empathy. The power in realizing our own human capacities to relate to one another across differences, and continue the work of “living well.” This dissertation emphasizes the power of performance to constitute alternative ways of performing and understanding familial chronic illness, by emphasizing the work of creating, implementing and studying performance.

Parents of seriously ill children are charged with making complicated medical decisions, and many of those decisions are made during their children’s hospitalizations. As medical staff seek to support parents, it is important for them to understand what resources parents are drawing upon for decision-making. This project explored parental decision-making by examining the following research questions: RQ1: What resources do parents draw upon to make medical decisions for their seriously ill children? RQ2: How do parents enact their spiritual or religious frameworks in clinical settings when faced with medical decisions for their seriously ill children? Methods of research included ethnographic observation of a pediatric palliative care team and semi-structured interviews with twenty parents and grandparents of seriously ill children. Analysis of the interview data brought out three main themes: the role of spirituality for parents of seriously ill children, the ways parents perceive spiritual conversations with hospital personnel, and the role of spirituality for parents making difficult decisions. A case study is presented as an exemplar of complex decision-making, and the author offers her personal narratives of parenting a seriously ill child. The author suggests new directions for practitioners based on a constitutive approach to communication in which practitioners and parents work together to build towards an understanding of the child’s illness. The findings from this study contribute to the current understanding of families with seriously ill children and should shape medical education in a way that will benefit the next generation of professional care providers as they seek to meet the needs of children and their families.

The Zika virus is associated with the devastating birth defect microcephaly, and while a vaccine was not yet available in early-2017, several were under development. It is imperative to identify effective communication strategies to promote uptake of a new vaccine, particularly among women of reproductive age. Moreover, though the Zika outbreak has received much social media attention, little is known about these conversations on Instagram. The purpose of this dissertation, therefore, was to understand current Zika-focused communication on Instagram and to inform effective communication strategies to promote future Zika vaccine uptake intent. The study aims were: (1) explore Zika conversations on Instagram; (2) determine effective message characteristics to increase Zika vaccine uptake intent; and (3) explore salient demographic, healthcare, and psychosocial factors related to Zika vaccine uptake intent. A content analysis of 1,000 Zika-focused Instagram posts, found that these messages primarily focus on perceived threat constructs, yet they elicited little engagement. In addition, 10% of all Instagram posts mentioned conspiracy theories, and these messages elicited high engagement. A 2x2 online experiment tested the effect of message framing and visual type on Zika vaccine uptake intent. The 339 participants – all women of reproductive age – each were exposed to one of four messages (gain vs. loss-framed, and infographic vs. photo). There was no interaction effect of framing and visual type (p=.116), nor main effect of either framing (p=.185) or visual type (p=.724) on vaccine uptake intent. When testing the effect of these variables on those known to be predictors of behavioral intent, gain-framed messages were associated with higher subjective norms, perceived benefits, and self-efficacy. Data from the same online survey was used to examine whether demographics, healthcare-related variables, and psychosocial variables predict Zika vaccine uptake intent. Attitude (p<.001), subjective norms (p=.002), perceived benefits (p=.001), self-efficacy (p=.031), perceived susceptibility (p=.030), and cues to action (p=.020) were predictive of higher Zika vaccine uptake intent, as was being African-American (p=.042). In summary, messages promoting the Zika vaccine should be designed to complement the high perceived threat of Zika while activating positive social norms and perceived benefits in order to allow the public to respond efficaciously.

A qualitative approach was used to explore the influence of mass media campaigns on Black women’s perceptions of breast cancer. The primary purpose of this study was to address the high breast cancer mortality rate among young Black women, thus informing strategies to increase awareness of risk and encourage prevention activities. Black women have higher incidence rates before age 45 and are more likely to die from breast cancer at every age. Although the breast cancer mortality variance has been linked to socioeconomic status, studies have shown that differences in cancer knowledge and beliefs persist even when educational and socioeconomic measures are statistically controlled. Because little is known about how various ethnic group members form ideas about breast cancer in the U.S., semi-structured interviews were conducted with 27 Black women between the ages of 30 and 40 to determine their knowledge and beliefs about breast cancer, as well as their personal perceptions of susceptibility to being diagnosed with breast cancer, in order to illuminate the interplay of culture and health belief systems on participants’ understanding of breast cancer messaging. To explore the potentially complex dynamics involved in how young Black women come to construct meanings about breast cancer, a theoretical framework that coupled Cultural Models Theory with the Risk Perception Attitude framework was used to address how health campaigns influence the behaviors and breast cancer detection experiences of Black women. Findings from the study revealed that young Black women’s perceptions of breast cancer are primarily driven by personal experiences, as opposed to mass media influences. The Black women in this study had a lack of knowledge of risk and prevention factors and did not perceive themselves to be affected by breast cancer due to their young age. In spite of cultural taboos against discussing health issues with family and friends, the women in this study tended to take responsibility for their health and were proactive in seeking and acting on health information.

This project examines user-generated health narratives through corpus analysis of 246 reviews posted on Midwestern Hospital’s Yelp page. Understanding how different stakeholders act and interact within online health communities models a shift in new conceptions of health, and provides evidence of health ecologies’ ability to determine patient perceptions of care. Documents produced by users in these health communities represent health narratives comprised of a user’s health experience, that user’s treatment perceptions, and the community’s perceptions of the user’s experience. Author uses corpus methods to interpret user trace data and rhetorical moves embedded in health narratives. Findings suggest that users who interact with the Yelp community produce different health narratives than less engaged users. Understanding how different stakeholders act and interact within online health communities models a shift in new conceptions of health, and provides evidence of health ecologies’ ability to determine patient perceptions of care.