Disenfranchising Talk Mediates the Relationship Between Social Determinants of Health and Wellbeing Outcomes for Women of Color Patients with Autoimmune Disease.

Autoimmune disease disproportionately afflicts women of color (i.e., Black/African American, Hispanic/Latina, Multiethnic-racial) of childbearing age. Social determinants of health (SDOH) and dismissive healthcare provider (HCP) interactions exacerbate these disparities in health outcomes for women of color with autoimmune disease. Guided by the theory of communicative (dis)enfranchisement, this study assesses whether disenfranchising talk (DT) mediates the relationship between SDOH (i.e., race/ethnicity, insurance status, income, employment, education, and sexual orientation) and health outcomes including patient satisfaction, overall well-being, and tangible social support for women of color with autoimmune disease. Findings affirmed the mediating role of DT, such that Multiethnic-racial patients and those with less insurance coverage and lower household income reported less tangible social support, poorer overall well-being, and lower patient satisfaction when they experienced HCP DT. We offer theoretical and practical implications.

"Saving us to Death": Ideology and Communicative (Dis)enfranchisement in Misapplications of the 2016 CDC Opioid Prescribing Guidelines.

Guided by the theory of communicative (dis)enfranchisement (TCD), this study interrogates how interactions in which chronic pain patients are force tapered from their prescribed opioids are constrained and afforded by the hegemonic ideologies. To interrogate the harms caused for chronic pain patients by ideological policies enacted by the Centers for Disease Control and Prevention and assess what communicative mechanisms reify and resist such ideologies, this research analyzes 238 posts authored by chronic pain patient Reddit users. Reflexive thematic analysis illuminated a hegemonic ideology of opiophobia, (im)material ramifications of (a) discrimination by doctors, and (b) political and legal interference; mechanisms of reification: (a) positioning suicide as a rational option, (b) advocating for the use of illicit substances, and (c) stopping opioids voluntarily; and mechanisms of resistance: (a) counter-organizing and (b) counter-generating knowledge. We offer theoretical implications for the TCD and practical implications for patients, providers, patient advocacy organizations, and policymakers.

Assessing the mediating role of disenfranchising talk on the well-being of female patients with chronic overlapping pain conditions.

OBJECTIVE: Disenfranchising talk (DT) occurs when health care providers discredit, silence, and stereotype patients. Although ample research has suggested associations among negative patient-provider interactions and poorer well-being, this study is the first to investigate the mediating role of patient-provider DT in exacerbating poorer pain-related health correlates. METHODS: Female patients living with chronic overlapping pain conditions (N = 348) completed a cross-sectional survey including measures of DT, pain severity, pain catastrophizing, and pain disability, as well as demographic information. Structural equation modeling in AMOS 29 assessed whether DT mediated the relationship between age, educational attainment, and sexual orientation (demographics), and pain severity, catastrophizing, and disability (pain-related health correlates). RESULTS: Structural equation modeling revealed that DT mediated the relationship between age, educational attainment, and sexual orientation on pain-related health correlates, such that younger and LGBQA+ patients and those with less educational attainment reported heightened pain severity, catastrophizing, and disability when they also reported DT. CONCLUSION: In contrast to scholarship assessing how demographics and pain-related variables influence patient-provider communication, this study instead investigated the mediating role of DT in pain-related health correlates. PRACTICE IMPLICATIONS: Providers should avoid discrediting, silencing, or stereotyping female chronic pain patients' pain to potentially avoid exacerbating pain-related health correlates.

The Untapped Power of "We Don't Know": Epistemological Humility in the Era of COVID-19.

The SARS-CoV-2 (COVID-19) pandemic introduced many challenges and nuances that have transformed medical practice and research. The uncertainty caused by COVID-19 led to inevitable challenges to patient-provider relationships. The ever-changing landscape of COVID-19 research and policy proved to be challenging for the medical community and patients. These challenges also exacerbated long-standing issues regarding patient-provider communication and trust. On the other hand, these challenges gave voice to a burgeoning patient advocacy community. Through social media, advocacy and patient organizing, patients harnessed their power and organized over challenges relating to COVID-19 fears and concerns, ramifications of "Long COVID," and much more. During this unprecedented pandemic, there was a realization that the science and research surrounding COVID-19 is evolving and that there may be a benefit to embracing the dynamic nature of research and the scientific process. We propose that providers and the medical community should consider epistemological humility, which acknowledges insufficiencies related to the state of medical knowledge with a sense of understanding and respect for not having all of the answers. We argue that there is untapped potential in saying, "We don't know" and explaining why. There is an implicit culture that providers should be responsible for knowing everything and solving every problem. Epistemological humility challenges this culture, and inherently gives credence and voice to patient perspectives. We assert that epistemological humility is necessity when addressing contemporary health challenges such as COVID-19.

Framing Chronic Pain in U.S. News Coverage of the Opioid Epidemic (2012-2022).

Chronic pain, pain persisting longer than six months, afflicts 20% of the U.S. population and is the leading cause of disability. To manage pain, many chronic pain patients (CPPs) and healthcare providers turn to opioids, prescription medications that block pain signals and offer relief. However, in light of the U.S.' ongoing opioid epidemic, CPPs without a history of opioid use disorder (OUD) are facing increased stigma when seeking opioid medication. Further, many have been forced to taper their therapeutic dose due to updated Centers for Disease Control and Prevention prescribing guidelines in 2016 and 2022, with a range of (adverse) outcomes. Though research has explored experiences of chronic pain and OUD independently, few studies have explored how media coverage of the opioid epidemic has shaped representations, and resulting stereotypes, of CPPs. Guided by framing theory, this content analysis examines sources' characterization of CPPs amidst a decade of U.S. news coverage of the opioid epidemic (N = 492). Findings identify four dominant news frames, including two novel frames termed culpability and strategy, and elements (i.e., characters, significant events) that comprise these frames. When discussed, CPPs were ascribed the identity of a drug-seeking addict 82% of the time. Collectively, this study provides insight as to how news media coverage of the opioid epidemic influence(d) public perceptions of chronic pain (patients). Findings offer theoretical and practical implications for media outlets, policymakers, CPPs and healthcare providers, as well as highlighting how use of opioids for pain management does not equate to abuse of opioids.

"You are Telling the Story Yourself": Defining and Developing Narrative Pictorial Warning Labels.

Pictorial warning labels (PWLs) featuring narrative content are promising strategies for communicating health risks and motivating behavior change. The objectives of this study were to (1) identify what intrinsic features a PWL must have to be constructed as a narrative and (2) uncover in what ways narrative PWLs are perceived as being (in)effective. Seven online focus groups were conducted via Zoom with moderate and heavy drinkers (n = 30). Participants discussed a series of mockup PWLs designed to communicate the cancer risk of alcohol. The discussion revealed that a static image must include character, causality, and setting to help individuals construct the story. Specifically, the character should be discernible and believable so that individuals can infer risk information. Moreover, the connection between the image and text should imply a causal relationship between alcohol drinking and cancer risks. Lastly, there should be sufficient relevant background or context information. When discussing the label effectiveness, most participants thought narrative PWLs were more effective than graphic, non-narrative PWLs at informing consumers about the cancer risk of alcohol. Their reasoning included narrative PWLs (1) being easy to understand, (2) evoking curiosity and imagination, (3) eliciting sympathy for the character, (4) not causing aversion, and (5) increasing risk perceptions. This study contributes to the narrative persuasion research and offers practical implications for designing image-based narratives.

Developing Measures for and Testing the Theory of Communicative Disenfranchisement (TCD) in the Context of Chronic Pain.

The post-positivist articulation of the theory of communicative disenfranchisement (TCD) asserts that people subjected to disenfranchising talk (DT; talk that discredits, silences, and stereotypes) experience proximal consequences (PCs; reduced agency, perceived credibility, and ability to exercise rights and privileges) and make negative inferences about others' future interactional goals (negative goal inferences [NGIs]). Through the mediators of PCs and NGIs, DT is theorized to lead to more distal health and well-being outcomes. This article developed measures of DT, PCs, and NGIs to test the TCD's post-positivist model in the context of chronic pain. Items were developed and refined in a pilot study. Then, in two validation studies, exploratory and confirmatory factor analyses were conducted and health and well-being outcomes were assessed. Findings offer initial empirical support for the reliability and convergent, divergent, and predictive validity of the DT, PCs, and NGIs measures, as well as the model proposed in the post-positivist articulation of the TCD.

Shared Decision-Making Experiences of Couples with Inherited Cancer Risk Regarding Family Building.

Patients with hereditary cancer predisposition syndromes have a high likelihood of passing germline mutations to future offspring. Patients at risk for inherited cancer may not have started and/or completed building their families; thus, they must decide about having children and consider the possibility of passing on their germline mutation. Utilizing the Shared Decision Making (SDM) Model, this study explores family building decision-making communication processes in opposite-sex couples with inherited cancer risk (ICR). Fifteen couples completed two recorded, analogue discussions and dyadic interviews at two time points. Participants were recruited through social media and snowball sampling. The constant comparison method was utilized to thematically analyze the data. When couples discussed family building options (FBOs), several themes were identified: FBO risks, FBO considerations, genetic-related FBO logistics, and life FBOs logistics. When deliberating family building decisions, couples shared easy conversational topics (e.g. FBO options and potential child's cancer risk due to a genetic variant) and difficult/conflict-inducing topics (e.g. preparing for possibilities, parenting, emotions, finances, and timing). Last, couples self-reported primary and secondary FBOs. The findings of this study capture couples' decision-making communication process while considering their experiences. Clinicians and practitioners can utilize these findings to support couples' family building decisions considering their ICR.

Improving communication between women with vulvodynia and their romantic partners: insights and recommendations for practitioners.

BACKGROUND: Interactions among female patients with vulvodynia, their romantic partners, and clinicians are key to promoting positive health outcomes. Previous studies have investigated how the content of romantic partners' responses to expressions of pain are related to these outcomes. Yet, the content of patients' conversations and the appraisals of their difficulty remain unknown. AIM: This study offers guidance to clinicians counseling patients with vulvodynia by explicating the frequency and difficulty of various salient conversational topics. METHODS: Thirty-four women with vulvodynia completed a screener survey indicating the frequency and difficulty of conversational topics. Follow-up in-depth interviews were conducted with 26 women. A dominant partner response type was identified for each participant. RESULTS: Topics most often discussed, such as sex, were rated as among the least difficult to discuss. Most participants reported experiencing the facilitative partner response type, which promotes adaptive coping. CONCLUSION: Determining patients' perceived conversational difficulty and frequency is necessary to provide quality and efficient counseling to women with vulvodynia and their partners. Patients also experience partner response types. Therefore, clinicians must solicit subjective assessments of conversational difficulty when advising patients and their romantic partners.

Caring for Patients without Personal Protective Equipment (PPE): Material Conditions as Multidimensional Cascading Triggers for Resilience Processes.

Guided by communication theory of resilience (CTR), we analyze 453 narrative accounts by Reddit user healthcare workers (HCWs) of their experiences with COVID-19-related personal protective equipment (PPE) shortages between March and May 2020. Via thematic analysis and sensitized by CTR concepts, we examine PPE shortages as a disruptive trigger event that catalyzes the enactment of resilience processes. Findings problematize PPE shortages as material, discursive, and symbolic triggers and explore how HCWs communicatively construct resilience given PPE shortages. This study extends CTR by: (a) underscoring the multidimensional nature of disruptive trigger events, (b) distinguishing the temporal element in cascading trigger events during periods of sustained disruption, and (c) attending to the transformational processes within the adaptation-transformation dialectic with the inclusion of a sixth resilience process, critiquing and resisting the status quo. Critiquing and resisting the status quo interrelates to other resilience processes of maintaining and using communication networks, employing alternative logics, and affirming identity anchors. Practical implications are offered.

"It's All in Your Head": A Meta-Synthesis of Qualitative Research About Disenfranchising Talk Experienced by Female Patients with Chronic Overlapping Pain Conditions.

Interactions between female patients with chronic pain and their medical providers in which providers question or contest the "realness" or nature of their illness experience (e.g. "It's all in your head") have been reported extensively in the extant qualitative literature, particularly for poorly understood ("contested") chronic pain syndromes. Many terms have been offered to describe this talk (e.g. invalidating, dismissive), resulting in conceptual fragmentation and isolated silos of research which together report about one communicative phenomenon. To rectify this fragmentation, the present study offers a meta-synthesis which explores, analyzes, and integrates the findings of 82 qualitative interview studies representing the patient-provider communication experiences of 2,434 female patients living with one or more of 10 chronic overlapping pain conditions (COPCs). COPCs are costly, gendered, and poorly understood. From the meta-synthesis, three key concepts are identified: (1) Functions of disenfranchising talk: Discrediting, silencing, and stereotyping; (2) Effects of disenfranchising talk: Harmed agency, credibility; access to care, support, and resources; and perception of patient-provider relationship; and (3) Responses to disenfranchising talk: Submission, critique, and resistance. Findings confirm the centrality of gender in the experience of disenfranchising talk, underscore the need to adopt an intersectional approach to the study of this talk along additional axes of race and class, and offer heuristic value toward conceptually unifying research about female COPC patients' experiences of disenfranchising talk from providers.

"Having Pain is Normal": How Talk about Chronic Pelvic and Genital Pain Reflects Messages from Menarche.

Chronic pelvic and genital pain conditions (CPGPCs) often go undiagnosed and untreated in women for years after symptom onset. This is due, in part, to communication challenges experienced by patients such as difficulties describing pain and the stigmatized nature of CPGPCs. However, studies have yet to explore how early messages about menstruation, a context similar in its stigmatized and painful nature, may contribute to undertreatment and diagnostic delays for adult women experiencing CPGPCs by normalizing pelvic and genital pain when they are young girls. Guided by critical feminist theorizing (CFT) and sensitized by an existing typology of negative messages communicated by mothers to daughters about menstruation, this study analyzes interviews with 17 women with CPGPCs to explore how features of negative messages about menstruation (i.e., information restriction and omission) appear and recur in women's descriptions of their later CPGP experiences. Findings suggest that early life talk about menstruation forms a communicative precedent for young girls which later constrains how they talk about CPGP in adulthood. Findings also problematize early-life communication about menstruation, which normalizes women's pain, and suggest connections to outcomes (e.g., diagnostic delays) for women with CPGPCs. Theoretical and practical implications are offered. Limitations and future directions are described.

Feasibility, acceptability, and outcomes of a pilot intervention facilitating communication about family building between patients with inherited cancer risk and their partners.

Objective: This study reports the feasibility, acceptability, and outcomes of a longitudinal, communication pilot intervention for patients with inherited cancer risk and their partners. Methods: Couples were recruited through social media and snowball sampling. At Time 1 and 2, 15 couples completed a structured discussion task about family building concerns and decisions, followed by an online post-discussion questionnaire and dyadic interview to provide feedback about the experience. Interview data were analyzed to assess outcomes using applied thematic analysis. Results: Participants reported the intervention created an opportunity for honest disclosure of family building goals and concerns. Participants also stated the structured nature of the discussion task was useful and did not cause additional stress. The intervention ultimately aided at-risk patients and their partners to realize their concordant concerns, discover/confront discordant concerns, and mutually agree upon next steps. Conclusions: This pilot intervention is feasible and acceptable. Furthermore, it offers a framework to facilitate effective communication about family building between patients with inherited cancer risk and their partners. Innovation: This intervention is the first conversational tool designed for at-risk patients and their partners.

Information versus influence: An analysis of educational, relational, and identity rewards present in direct-to-consumer prescription drug advertising.

BACKGROUND: Pharmaceutical companies have rationalized rapid increases in spending on direct-to-consumer advertising (DTCA) by highlighting the educational potential that such efforts have for patients. Others have argued that profits and influence, not educational benefits, are the true motivators for the expansion of DTCA. It is critical that pharmacists be aware of the content of direct-to-consumer advertisements to best counsel patients on proper medication expectations. OBJECTIVES: This study investigated the ways in which drug information is being presented to patients and whether such rewards may act as a form of education regarding a greater emphasis on the product or the condition the drug is designed to treat. METHODS: This study conducted a content analysis of 60 broadcast prescription drug advertisements appearing over a 12-week primetime programming period across 4 major news networks to determine which types of educational, relational, and identity rewards were present across the textual, verbal, and visual modalities. RESULTS: Findings indicated a greater overall presence of relational and identity rewards than educational rewards. Most of the educational rewards served to promote a particular drug rather than educate consumers about a condition. There was a statistically significant relationship between reward type and modality, such that there were greater relational and identity rewards within the visual modality and greater educational rewards in the textual modality than expected. CONCLUSION: Findings showed that educational rewards in the service of promoting a particular drug were included more than 2.5 times as often as educational rewards about the condition treated. This lack of information about the condition suggests that DTCA may be aiming to increase profits by encouraging conversation between patients and providers about the advertised medications. As a result, a patient may demonstrate an increased desire to discuss a particular drug with a pharmacist or a provider rather than discussing information about the condition itself.

Female U.S. Military Veterans' (Non)Disclosure of Mental Health Issues with Family and Friends: Privacy Rules and Boundary Management.

Grounded in communication privacy management (CPM) theory, this study explores the criteria female U.S. military veterans rely on when creating privacy rules regarding (non)disclosure of their mental health information with others as well as how female veterans manage privacy boundaries. Interviews with a diverse sample of 78 female veterans recently diagnosed with PTSD revealed examples of all five criteria for privacy rules proposed by CPM theory and illustrate how factors such as military culture, trauma, and risk/benefit assessments are interconnected. Female veterans also altered their boundary linkages, permeability, and control in response to tensions between revealing and concealing mental health information. Findings suggest the potential utility of drawing connections between tensions that motivate concealing/revealing and boundary management operations and highlight the need to further develop and evaluate programs such as peer support counseling within the Department of Veteran Affairs where female veterans can serve as support resources for their peers.

Communication Work About Chronic Unexplained Pain.

This essay draws upon Donovan's conceptualization of "communication as work" to explicate types of communicative work undertaken by the authors - two patients with vulvodynia, a poorly understood chronic genital pain condition - during patient-provider interactions prior to diagnosis. Uniquely positioned as patients-turned-scholars, we extend the rich construct of "communication work" by narrating the types of communicative work undertaken ourselves as patients communicating within a stigmatized health context for which a clear diagnosis is often ambiguous or unable to be reached. Donovan notes that conditions with a high degree of uncertainty and ambiguity have the capacity to shift the nature of talk. This brief essay illustrates the ways in which the nature of patient-provider communication work is shifted by the ambiguity of this health context. Theoretical and practical implications are briefly offered.

Addressing Health Disparities in America: Analysis of Community Health Improvement Plans.

BACKGROUND: Healthy People 2020 has made achieving health equity one of its overarching goals; another goal is increasing the number of accredited local agencies that have Community Health Improvement Plans (CHIPs). Community Health Improvement Plans are meant to serve agencies as guiding documents for multiple years. OBJECTIVES: This study investigates the prevalence with which health disparities are addressed within CHIPs and the specific health disparities targeted by these objectives. METHODS: Researchers analyzed 4,094 objectives from CHIPs of 280 local Public Health Accreditation Board (PHAB)-accredited and nonaccredited public health agencies in the United States. RESULTS: Despite the PHAB's focus on addressing health equity, not all PHAB-accredited agencies addressed health disparities (85.4% of CHIPs analyzed). However, more accredited than nonaccredited agencies (73.9%) contained at least one objective focused on health disparities. DISCUSSION: Findings indicate that if health equity is truly a goal of national initiatives, agencies' planning documents (e.g., CHIPs) can do a better job addressing commonly ignored populations.

The Vulvar Vernacular: Dilemmas Experienced and Strategies Recommended by Women with Chronic Genital Pain.

This manuscript uses Goldsmith's (2004) normative model of social support to explore conversations women have with a romantic partner about vulvodynia. Twenty-six women with vulvodynia participated in semi-structured interviews in which they described conversational goals, discussed challenges, and offered advice to others managing vulvodynia. As this study was concerned with interactions with romantic partners both present and past, women with vulvodynia, not their partners, were the targets of recruiting efforts. Two key communicative dilemmas emerged from the data analysis: (a) I need to talk to you, but I can't, and (b) I want to be honest, but not too honest. These dilemmas represent ambiguity about the causes and duration of pain and the implications that being unable to have pain-free intercourse has for their relationships and identities as women. Three strategies, communicative practices for managing dilemmas, also emerged: (a) reframe the illness, (b) refocus the relationship, and (c) redefine intimacy. The theoretical and practical implications of this research are socially situated within timely conversation about women, their bodies, and their roles.

Tracking Success: Outputs Versus Outcomes-A Comparison of Accredited and Non-Accredited Public Health Agencies' Community Health Improvement Plan objectives.

With funding for public health initiatives declining, creating measurable objectives that are focused on tracking and changing population outcomes (i.e., knowledge, attitudes, or behaviors), instead of those that are focused on health agencies' own outputs (e.g., promoting services, developing communication messages) have seen a renewed focus. This study analyzed 4094 objectives from the Community Health Improvement Plans (CHIPs) of 280 local PHAB-accredited and non-accredited public health agencies across the United States. Results revealed that accredited agencies were no more successful at creating outcomes-focused objectives (35% of those coded) compared to non-accredited agencies (33% of those coded; Z = 1.35, p = .18). The majority of objectives were focused on outputs (accredited: 61.2%; non-accredited: 63.3%; Z = 0.72, p = .47). Outcomes-focused objectives primarily sought to change behaviors (accredited: 85.43%; non-accredited: 80.6%), followed by changes in knowledge (accredited: 9.75%; non-accredited: 10.8%) and attitudes (accredited: 1.6%; non-accredited: 5.1%). Non-accredited agencies had more double-barreled objectives (49.9%) compared to accredited agencies (32%; Z = 11.43, p < .001). The authors recommend that accreditation procedures place a renewed focus on ensuring that public health agencies strive to achieve outcomes. It is also advocated that public health agencies work with interdisciplinary teams of Health Communicators who can help them develop procedures to effectively and efficiently measure outcomes of knowledge and attitudes that are influential drivers of behavioral changes.