Abstract The aim of this thesis was twofold: firstly, to increase understanding about the user of health information; namely about differences of users´ characteristics of health information behaviour, and secondly, to contribute to the research on factors that could be used as bases to tailor health information. Health information behaviour was scrutinised as information needs and seeking and information use in particular. It was also studied in relation to individuals´ physical health status. More studies on information use are needed, because understanding individual characteristics in issues related to information use has been considered critical for promoting healthy behaviours. Moreover, the thesis addressed the gap in research on the relationship between health information behaviour and tailoring health information. The thesis consists of three empirical studies and a literature review. The empirical research environments were provided by an intervention study aiming to prevent type 2 diabetes among a high risk population and by a population-based study among military conscription aged men. The setting was the City of Oulu in Northern Finland with the University of Oulu and the Oulu Deaconess Institute as the main operators of the studies. The empirical data were collected through questionnaires as well as through physiological and biochemical measurements during years 2010 and 2011. The data were analysed with statistical methods. Moreover, a literature review of tailored interventions studies using a computer as the medium of delivery in the context of physical activity, nutrition and weight management, was conducted. The findings indicate differences in health information users´ characteristics related to their information use as such and in relation to the indicators of their physical health status. It is suggested that, for example, health information presentation could be tailored on the basis of found differences and different message strategies and tactics could be used for different kinds of individuals. In addition, in the literature review the biases of tailored intervention studies stood out as influential on their outcomes. The thesis contributes to the current field of research on both health information behaviour and tailoring health communication. Moreover, the findings can support the development of more effective health promotion programs and intervention studies. / Tiivistelmä Väitöskirjatutkimukseni tavoitteena on lisätä ymmärrystä terveystiedon käyttäjistä ja erityisesti heidän terveysinformaatiokäyttäytymiseensä liittyvistä ominaisuuksista. Tutkimukseni tuottaa tietoa tekijöistä, joita voidaan käyttää terveystiedon räätälöinnin lähtökohtana. Terveysinformaatiokäyttäytymistä tarkastelen tiedontarpeiden ja -hankinnan sekä erityisesti tiedon käytön näkökulmasta. Informaatiokäyttäytymistä tutkitaan myös suhteessa tiedon käyttäjän fyysiseen terveydentilaan. Tutkimukseni vastaa tarpeeseen tutkia tiedon käyttäjiä, sillä tiedon käyttöön liittyvien yksilöllisten ominaisuuksien ymmärtäminen on keskeistä terveyden edistämisessä. Väitöskirja tuottaa uutta tietoa myös informaatiokäyttäytymisen ja terveystiedon räätälöinnin välisestä suhteesta. Väitöskirjani käsittää neljä osajulkaisua: kolme empiiristä tutkimusta ja kirjallisuuskatsauksen. Empiiriset tutkimukset toteutettiin tyypin 2 diabeteksen ehkäisyyn tähtäävän interventiotutkimuksen (PreDiabEx) ja väestöpohjaisen tutkimuksen (MOPO) tarjoamissa tutkimusympäristöissä. Tutkimusten kohteina olivat miehet ja naiset, joiden riski sairastua tyypin 2 diabetekseen oli korkea sekä kutsuntaikäiset miehet. Tutkimukset toteutettiin Oulussa ja päätoteuttajia olivat Oulun yliopisto ja Oulun Diakonissalaitos. Empiirinen aineisto kerättiin kyselyillä sekä fysiologisilla ja biokemiallisilla terveydentilaa ilmaisevilla mittareilla vuosien 2010 ja 2011 aikana. Aineisto analysoitiin tilastollisesti. Kirjallisuuskatsauksessa analysoidaan fyysisen aktiivisuuden, ravitsemuksen ja painonhallinnan interventiotutkimuksia, joissa tarkastellaan terveystiedon räätälöinnin vaikuttavuutta silloin, kun tiedonvälitykseen käytetään tietokonetta. Empiiristen tutkimusten tulokset viittaavat siihen, että niin terveystiedonkäyttäjien ominaisuuksissa informaatiokäyttäytymisessä kuin sen suhteessa heidän fyysisen terveydentilaansa on eroja. Terveystietoa tulisikin esittää eri tavoin erilaisille ihmisille, muun muassa erilaisia viestistrategioita ja -taktiikoita käyttäen. Kirjallisuuskatsauksen tulokset lisäsivät ymmärrystä siitä, miten tutkimusasetelman vinoumat voivat vaikuttaa interventiotutkimusten tuloksiin.

Magister Public Health - MPH / The aim of this study was to conduct an evaluation of the campaign implementation between 2009 and 2012, taking account of its implementation plan. This qualitative evaluation study employed a descriptive study design focusing on whether the programme components were being implemented as planned and whether any issues that have arisen, require attention. Key Informant Interviews were conducted with a purposive sample of 12 respondents drawn from the study population of people who were directly involved with the campaign, and a documents review was also conducted.

This dissertation reports on an exploratory study investigating the potential of recorded audio media (i.e. audiocassettes/CDs) as a method of health communication in South Africa. The investigation examines recorded audio media as an alternative to printed brochures. People need access to information in order to make informed decisions about their health. In South Africa, the high HIV/AIDS infection rate is a case in point. The literature review deals with the accessibility of information in terms of physical accessibility (whether the receiver can find, operate and use the communication medium); and semantic accessibility (whether the receiver understands the message disseminated via the medium). Through the review, it was discovered that, where necessary, information must then be repackaged from an inaccessible to an accessible and appropriate format. Factors like visual disabilities, low levels of literacy and low reading proficiency, can render printed information inaccessible. This study discusses and researches the feasibility of recorded audio media (audiocassettes/CDs) as an alternative to print-based brochures by means of a comparative literature review and empirical study. Selected HIV/AIDS brochures (developed by the Department of Health) and similar recorded audio messages were evaluated amongst the target audience in order to compare the comprehension of the messages, the accessibility and acceptability of both media forms. The study was conducted at four public health clinics, where individual structured interviews and focus group interviews were employed as data collection methods. The data was analysed by means of qualitative content analysis. The findings indicate the definite potential of the use of recorded audio media in health and HIV/AIDS communication, and should be explored further. The comprehension of the audio messages was better than that of the printed brochures indicating the semantic accessibility of the audio messages. The positive reaction of the research participants toward the recorded audio messages also indicates the acceptability of the medium. Incorporating audiocassettes into the media mix of HIV/AIDS and other development and/or health communication campaigns, will contribute to the overall effectiveness of the communication strategy. / Dissertation (MA (Development Communication))--University of Pretoria, 2008. / Information Science / unrestricted

Health communication has gained worldwide recognition as one of the most effective methods for tackling global health challenges; a conclusion that is supported by a range of studies showing generally positive results. Literature in the field has tended to focus on one of two perspectives: either individual behaviour change or a cultural/critical approach. This dissertation, which falls into the latter category, extends previous work on health communication and culture into a new context, namely Saudi Arabia. The thesis is motivated by two main research questions. First, how has culture influenced health communication in Saudi Arabia specifically in initiatives against illicit drug use and alcohol abuse? Second, how has this communication developed? At the heart of this study is the role of Saudi culture in health communication in an increasingly interdependent and connected world. The dissertation makes use of mixed qualitative data collection methods. Principally, it utilised semi-structured interviews with key officials and focus groups with young Saudis and health promoters in Saudi Arabia as well as attendance at and observation of health-communication events and permanent exhibitions as a subordinate method. The study reveals promising findings supporting the growing scholarly interest in the cultural dimension of health communication. It concludes that the key influence of the Saudi culture on health communication against substance abuse is Islamic beliefs about health, in particular those about substance abuse. These beliefs created a rejection of illicit drug abuse in Saudi society, thereby shaping a supportive environment for promotion activities against risky health behaviour. In addition, Islamic influence inspired the related regulations and laws in the kingdom. Islamic and local influences exert a powerful influence on the practical side of health communication in Saudi Arabia, including the content of messages, the appeal used to attract the specific audience, and the communication channels used to promote the campaigns. The study engages with four concepts constituting the Islamic model of health and illicit drug abuse: prohibition (haram), promotion (Da’wah), repentance and inclusiveness (Tawbah), and treatment and rehabilitation (Elaj). The study also examines controversial issues about health communication in the country, such as the predominance of top-down communication, the absence of participatory communication and cultural diversity. In short, a lack of innovation and creativity in delivering health communication messages. The study illustrates the major role the Saudi government has played in communicating health and substance abuse since the 1980s, when officials realised the need to modernise the means of communicating health and drug issues from mosque-based only to include modern methods such as televised campaigns, school-based programmes and hospital-based health education. Since then, government-led health communication initiatives have been well established in the kingdom. The dissertation is able to demonstrate a critical understanding of the reality of health communication against substance abuse in Saudi Arabia and make a range of recommendations to improve the efficacy of current policies and suggest new avenues for future research.

This dissertation reports on an exploratory study investigating the potential of recorded audio media (i.e. audiocassettes/CDs) as a method of health communication in South Africa. The investigation examines recorded audio media as an alternative to printed brochures. People need access to information in order to make informed decisions about their health. In South Africa, the high HIV/AIDS infection rate is a case in point. The literature review deals with the accessibility of information in terms of physical accessibility (whether the receiver can find, operate and use the communication medium); and semantic accessibility (whether the receiver understands the message disseminated via the medium). Through the review, it was discovered that, where necessary, information must then be repackaged from an inaccessible to an accessible and appropriate format. Factors like visual disabilities, low levels of literacy and low reading proficiency, can render printed information inaccessible. This study discusses and researches the feasibility of recorded audio media (audiocassettes/CDs) as an alternative to print-based brochures by means of a comparative literature review and empirical study. Selected HIV/AIDS brochures (developed by the Department of Health) and similar recorded audio messages were evaluated amongst the target audience in order to compare the comprehension of the messages, the accessibility and acceptability of both media forms. The study was conducted at four public health clinics, where individual structured interviews and focus group interviews were employed as data collection methods. The data was analysed by means of qualitative content analysis. The findings indicate the definite potential of the use of recorded audio media in health and HIV/AIDS communication, and should be explored further. The comprehension of the audio messages was better than that of the printed brochures indicating the semantic accessibility of the audio messages. The positive reaction of the research participants toward the recorded audio messages also indicates the acceptability of the medium. Incorporating audiocassettes into the media mix of HIV/AIDS and other development and/or health communication campaigns, will contribute to the overall effectiveness of the communication strategy. / Dissertation (MA (Development Communication))--University of Pretoria, 2007. / Information Science / MA / unrestricted

South Africa is a heterogeneous society. It is a multilingual, multicultural country with more than eleven official languages. It is a country that also has big educational and economic inequalities. These differences are pertinent barriers that often obstruct communication, also and especially in health communication. This study addresses such a problem, by first exploring the effectiveness and/or appropriateness of existing schizophrenia information material The Alliance Programme which was produced in the USA for universal consumption and is currently used in the South African context. In the study the externally produced schizophrenia information material is adapted to fulfil in the specific needs and preferences of the audience targeted in this study. The study was conducted based on the assumption that people need to access information that is relevant, easy to understand and appropriate to them in order to make informed decisions about their health. This study was conducted at the Weskoppies hospital in Pretoria (South Africa) among Tshwana-speaking patients suffering from schizophrenia. The specific aim of this study was to communicate the information in such a way that this group could use it optimally. Since this empirical study’s main aim was to evaluate and adapt the Alliance Programme to make it more suitable for the South African context, a formative research design was implemented. Usability testing was chosen as the research method. Literature review, individual semi-structured interviews, focus group interviews and participant observation were employed as data collection methods. The data was analysed by means of qualitative content analysis. The findings of this study indicated that the adapted messages or information about schizophrenia did improve the patients’ reception of the information. It was then concluded in this study that messages or information should either be adapted or created to suit the needs of a specific audience. This study also recommended that in order to make sure information (about schizophrenia) is communicated effectively and/or appropriately to any group (of patients suffering from schizophrenia), a participatory communication design should be used. / Dissertation (MIS)--University of Pretoria, 2009. / Information Science / unrestricted

Background: Management of atrial fibrillation (AF) is complex and requires active patient engagement in shared decision making to achieve better clinical outcomes, greater medication adherence, and increased treatment satisfaction. Efficacy in patient-physician interactions is a critical component of patient engagement, but factors associated with efficacy in older AF patients have not been well-characterized. Methods: We performed a cross-sectional analysis of baseline data from the ongoing Systematic Assessment of Geriatric Elements in Atrial Fibrillation (SAGE-AF) study, a cohort study of older adults (age ≥ 65) with non-valvular AF and CHA2DS2-VASc score ≥ 2. Participants were classified according to their Perceived Efficacy in Patient-Physician Interactions (PEPPI-5) score (lower: 0-44; higher: 45-50). Logistic regression analysis was used to identify sociodemographic, clinical (AF type, AF treatment, medical comorbidities), and geriatric (cognitive impairment, sensory impairment, frailty, independent functioning) factors associated with lower reported efficacy. Results: Participants (n = 1209; 49% female) had a mean age of 75. A majority (66%) reported higher efficacy in their interactions with physicians. Lower efficacy was associated with persistent AF (adjusted odds ratio [aOR] = 1.52; 95% confidence interval [CI] = 1.13-2.04) and with symptoms of depression (aOR = 1.67; CI = 1.20-2.33) or anxiety (aOR = 1.40; CI = 1.01-1.94). Decreased odds of lower efficacy were observed in participants with chronic kidney disease (aOR = 0.68; CI = 0.50-0.92) and those classified as pre-frail compared to those classified as not frail (aOR = 0.71; CI = 0.53-0.95). Conclusion: Older patients with persistent AF or symptoms of depression or anxiety have decreased efficacy in patient-physician interactions. These individuals merit greater attention from physicians when engaged in shared decision making.

The research questioned the efficacy of standard biomedical information sharing and communication processes in ensuring rapid and reliable behavioural changes in the control of epidemics, especially in high-context cultures. Information processing arousals and behaviour change motivations are subject to the level of interactions in the extrinsic and intrinsic elements of an information. Following, epidemic control can only be successful if relevant elements of a system’s values, norms, beliefs and practices for information processing are superimposed on scientific communication to create shared meanings. An empirical research approach in grounded theory underscore the data collection of this research with the data analogy utilising the MAXQDA Analytics Pro software. Ebola behavioural changes were identified to be enabled by the functional properties of community mobilisation as a structure and process for meaning making and behavioural motivation. A contextual health communication model dubbed the ecological collegial communication model has been modelled for epidemiological control as the output of the research. Specific to the methodology, a systematic qualitative and data analysis process in grounded theory was adopted for conducting the research and the dissertation writing. Commencing the process was the identification and analysis of the problem from the perspectives of the challenges to the Ebola communication management. This was comprehensively identified from the fundamentals of the process of communication to the communication itself and was assessed from the motivational factors underlying the behaviours within which the rationality of the behaviours could be understood for their inflexibility to change or their insensitivity to the Ebola messages. The mediations of the behavioural motivators in the cognitive processes to information processing were considered for their intrinsic and extrinsic values to arouse information processing and persuade change. To explore the interface between communication and culture in cognitive processes of information processing and decision making, literatures on behavioural theories, including anthropological theories from which the processes and determinants of behavioural enactment are predicted were reviewed in chapters two to four. Intention (also used interchangeably in this dissertation as motivation) was unanimously construed as proximal in determining behaviours in the literatures. However, intention was also construed to have linkages with other factors in the determination of behaviours.:Dedication ii Declaration iii Acknowledgements iv Table of contents v List of figures vi List of photos vii List of matrices vii List of tables vii List of appendices viii Abbreviations ix 1 Communication and culture of the 2014/2015 West Africa Ebola outbreak 1 1.1 Introduction 1 1.2 Conceptualisation of the research problem – the key factors of the Ebola outbreak 4 1.2.1 Structural violence 7 1.2.2 Communication deficiency 10 1.2.3 Cultural models (values and practices 20 1.2.3a Death and funerals 21 1.2.3b Caregiving 26 1.2.3c Reliance on traditional healers 31 1.3 Research objectives 37 1.4 Definitions 38 1.5 Questions formulation and research questions 42 1.6 Justification 52 1.7 Conclusion 58 2 Theoretical frameworks consistent with the 2014/2015 Ebola outbreak health communication approaches – A discourse 59 2.1 Introduction 59 2.2 Psychological/behaviour science models 60 2.2.1 Health belief model 61 2.2.2 Protection motivation theory 64 2.2.3 Theory of planned behavior /reasoned action 71 2.2.4 Social cognitive theory / social learning theory 76 2.3 Summary 79 3 Information processing/communication theories 81 3.1Introduction 81 3.2 Elaboration likelihood model 81 3.3 Activation model 86 3.4 Narrative theory and entertainment education 88 3.5 Summary 95 4 Ecological theories / framework 97 4.1 Introduction 97 4.2 The PEN-3 Model 98 4.2.1 Health education (cultural identity)100 4.2.2 Cultural appropriateness of health behavior (cultural empowerment) 101 4.3 Bioecological theory 103 4.4 Developmental process of Bronfenbrenner’s model in the framework of the 2014/2015 Ebola outbreak 108 4.5 Theoretical framework of this dissertation 119 5 Research process and methodologies 125 5.1 Introduction 125 5.2 Justification of the research methodology 128 5.3 Overview of Monteserrado County 134 5.4 Techniques/procedures 137 5.4.1 Archival materials/documents 138 5.4.2 Ethnographic/observations 139 5.4.3 Key informants/in-depth interviews 142 5.4.4 Focus group discussions 143 5.5 Data analysis 146 5.5.1 Codes 147 5.5.2 Qualitative analysis employed in the research 152 5.6 Role of the researcher 153 5.6.1 Origins of the project 153 5.6.2 The discourse - philosophical worldview 156 5.6.3 Concluding thoughts 157 6 Data analysis: cultural practices, health and communication in the Liberian context 160 6.1 Introduction 160 6.2 Ethnicity and religion 162 6.3 Social organization 171 6.4 Aspects of death and burial practices 179 6.5 Concept of health and health care 186 6.6 Communication and information sharing approach in Liberia 193 6.6.1Traditional communication and the town crier in Liberia 195 6.6.2 Contribution of Crusaders for Peace 201 6.6.3 Development of overarching Ebola communication messages 206 6.7 Conclusion 210 7 Data analysis: Socio-cultural patterns in Ebola perceptions, content of messages and behavioural outcomes 212 7.1 Introduction 212 7.2 Parent codes – summative description and discussions 214 7.3 Understanding the socio-cultural patterns in Ebola knowledge and behaviours: Perceptions of Ebola transmissions 226 7.4 Content and nature of Ebola messages in perceptions and behaviours 237 7.5 Conclusion 276 8 Data analysis: Understanding the motivators of Ebola behaviours – an analytical interrelationships model perspective 278 8.1 Introduction 278 8.2 Patterns of Ebola behaviours 279 8.3 Conclusion 317 9 Decoding: the interface between culture and communication in the Ebola communication management 319 9.1 Introduction 319 9.2 Contextual elements of effective communication – the interface 321 9.3 Cognitive heuristics to “…protect yourself…” 336 9.4 Processes of moderations of “protect yourself” in cognitions 339 9.5 Conclusion 343 10 Theoretical and conceptual inferences from empirical data and framework for a culturally appropriate communication 344 10.1 Introduction 344 10.2 Research questions 344 10.3 Epidemic control: The cultural model framework to persuasive communication for epidemic management 359 10.3.1 The composite conceptual analytical elements of the model 364 10.3.1a Model definition and assumptions 365 10.3.1b The ECCM – the interactive elements of a system 367 10.3.1c Pattern of communication in the ECCM 371 10.3.2 Summary 374 10.4 Processes of how to apply the ECCM 375 10.5 Limitations of the model 382 10.6 Conclusion 383 11 Conclusions and recommendations 385 11.1 Introduction 385 11.2 Key conclusions 385 11.3 Implications 387 11.3.1 Policy framework implications 387 11.3.2 Theoretical implications 390 11.4 Further research 393 11.4.1 Approach to communication 393 11.4.2 Cultural dynamics 396 11.4.3 Health perceptions 398 11.4.4 Ebola orphans and victims 398 11. 5 Research limitations 399 References 401

Background: Despite consensus guidelines, only about half of at-risk relatives in families with Hypertrophic Cardiomyopathy (HCM) undergo clinical screening and even fewer undergo predictive genetic testing, leaving those unscreened at risk for sudden cardiac death. The use of qualitative inquiry to examine family communication and complex factors influencing uptake of screening may inform interventions to increase uptake and prevent sudden cardiac death. Purpose: The purpose of this study was to describe the engagement of at-risk relatives in family screening for HCM. Specific Aims: The specific aims were to (1) Describe the experience of communication of genetic risk of HCM in families with a causative variant for HCM; (2) Use the Theory of Engagement to identify facilitators and barriers to family screening in families with a causative variant for HCM; and (3) Identify strategies to increase uptake of clinical screening and predictive genetic testing in families with a causative variant for HCM. Framework: The Theory of Engagement, adapted from McAllister, was used as an initial framework for the study. Methods: A qualitative descriptive design with purposive and snowball sampling was used and data were analyzed using qualitative content analysis. Results: The overarching theme of Bringing Genetic Risk to the Foreground was comprised of three major themes: Cues to Action, Preferences for Knowledge and Gateways to Screening, reflecting factors that affect engagement with genetic risk and family screening throughout the lifespan. Conclusions: Integrated longitudinal care and access to genetic specialists are needed for patients and families with a causative variant for HCM.

Objectives: 1) To evaluate the impact of an interprofessional blended learning course on pharmacy and medical students’ communication skills; 2) To compare pre- and post-course communication skills across cohorts. Method: Pharmacy (N = 57) and medical (N = 67) students enrolled in a required Communication Skills for Health Professionals course completed asynchronous online modules and face-to-face standardized patient interview sessions over the course of 1 semester. Students completed pre- and post-course objective structured clinical examinations with standardized patients and were evaluated by trained faculty using the validated Common Ground Instrument. Communication skill domains evaluated on a 1 to 5 scale included: rapport building, agenda setting, information management, active listening, addressing feelings, and establishing common ground. Nonparametric statistical tests were used to examine paired pre-/post-course domain scores within professions and pre- and post-course scores across professions. Results: Performance in all communication skill domains increased significantly for pharmacy and medical students (p valuesImplications: The blended learning Communication Skills for Health Professionals course improved students’ interpersonal communication skills across multiple domains. Fostering communication skill development in medical and pharmacy students could improve the extent to which future health care professionals engage in patient-centered communication.