Abstract
In this study, the authors examined reactions of Latino adults with limited English proficiency (LEP) to a culturally and linguistically adapted depression fotonovela, titled “Secret Feelings.” Fotonovelas are popular health education tools that use posed photographs, text bubbles with simple text, and dramatic narratives to engage audiences and raise their awareness and knowledge about specific health issues. Four focus groups (N = 32) were conducted at an adult school program (e.g., GED classes). Content analysis was used to generate themes from transcripts and memos. “Secret Feelings” was viewed as an entertaining, engaging, and educational tool that helped combat stigma toward depression and its treatments in the Latino community. Despite learning about depression, participants reported they wanted more information about the causes of depression, the process of recovery, and felt that the story did not shift their apprehensions toward antidepressants. The findings suggest that “Secret Feelings” is a promising depression literacy tool for Latinos with LEP that can raise awareness and knowledge about depression and its treatments, reduce stigma toward depression and antidepressant medications, and model appropriate help-seeking behaviors.
Keywords: depression, Latino/Hispanic, focus groups, fotonovelas
Health information that integrates cultural and linguistic elements of the intended audience can enhance the acceptability and relevance of the information and its effectiveness in changing attitudes, social norms, and health behaviors (Kreuter & Haughton, 2006). Few studies have examined how culturally appropriate health communication tools are perceived by specific audiences, and little is known about how culturally adapted mental health information is accepted by language minorities, such as Latino adults with limited English proficiency (LEP). This study used focus group methodology to evaluate the reactions of Latinos with LEP to a culturally adapted depression fotonovela titled “Secret Feelings.” Fotonovelas are popular health education tools that use posed photographs, text bubbles with simple text, and dramatic stories to engage audiences and raise their knowledge about specific health issues (Valle, Yamada, & Matiella, 2006).
Many Latinos with depression do not seek or receive adequate care. Latinos are more likely than non-Latino Whites to underutilize services, discontinue treatments prematurely, and receive depression care that is poor in quality even after adjusting for differences in educational levels, mental health needs, health insurance, and socioeconomic status (Olfson, Marcus, Tedeschi, & Wan, 2006; Young, Klap, Sherbourne, & Wells, 2001). Disparities in mental health care between the general population and Latinos seem to be increasing (Blanco et al., 2007), and Latinos with LEP are at greater risk for experiencing these inequalities in care (Sentell, Shumway, & Snowden, 2007).
On top of structural barriers to depression care, stigma, lack of knowledge of depression, misconceptions about depression treatments, and cultural norms regarding help-seeking play an important role in how Latinos with LEP seek and engage in depression treatments (Cabassa, Hansen, Palinkas, & Ell, 2008; Cabassa & Zayas, 2007; Interian et al., 2010; Nadeem et al., 2007; Pincay & Guarnaccia, 2007). These individual-level factors are salient barriers among different Latino groups (e.g., Puerto Ricans, Mexicans, Cubans) and seem to exert a strong influence on care-seeking behaviors beyond other barriers to care (e.g., language, insurance status). To address these individual-level barriers, Latinos with LEP and their families need accessible and easy to understand information about depression and its treatments to make informed decisions about how to engage into care.
Linguistically and culturally adapted depression literacy tools, such as fotonovelas, that target person-level factors provide a viable strategy to help reduce disparities in depression care. Fotonovelas embed engaging visuals and educational messages within the context of an entertaining and culturally appropriate narrative that portrays characters in common everyday situations that the audience can identify with. The aim of this study was to evaluate the reactions that Latinos with LEP reactions to “Secret Feelings,” a depression fotonovela adapted for Latinos with LEP. Our evaluation focused on (a) what they liked and disliked about the fotonovela format, story line, and characters; (b) what they learned about depression and its treatments; and (c) how they would use this fotonoveala in their community.
Method
Participants
Participants were recruited from an adult school program that provides ESL and GED classes in Los Angeles, California. The school was selected because most of its students are Latino adults with low levels of education and LEP. The study protocol was approved by the appropriate institutional review board. Adult students 18 years or older and of Latino descent were eligible to participate. To recruit students, trained bilingual research assistants (RAs) conducted short presentations during regular class hours describing the study purpose and methods. Interested participants received an appointment card with the time/date and location of the focus group.
Depression Fotonovela
“Secret Feelings” is a 30-page comic book-sized fotonovela, printed in Spanish and English at a Grade 4 reading level that tells the story of a Latino family coping with depression. The main educational messages embedded in the narrative are that (a) depression is a real and serious medical condition that affects a person's functioning; (b) people with depression should seek professional help; and (c) treatment for depression, such as antidepressant medications and therapy, are available and effective. The story aims to counteract common misconceptions about depression and its treatments found in the Latino community, particularly that depression is caused by personal weakness, that persons receiving mental health treatments are viewed as locos (crazy), and that antidepressant medications are addictive (Interian, Martinez, Guarnaccia, Vega, & Escobar, 2007).
The development of “Secret Feelings” is described elsewhere (Cabassa, Molina, & Baron, 2010). Briefly, this fotonovela is informed by a conceptual model that combines entertainment-education strategies (Singhal & Rogers, 1999) and concepts from the self-regulatory model of illness cognition (Cameron & Leventhal, 2003) and the theory of reasoned action (Sutton, 1998). To enhance the cultural relevance of the fotonovela we used characters that resembled Latino individuals, placed the plot of the narrative within a family conflict, and used common expressions and words relatable to our intended audience.
Data Collection
Four focus groups were conducted at an adult school program; two in Spanish and two in English. Before the focus groups, participants filled out a demographic questionnaire and were then provided a copy of “Secret Feelings.” They had approximately 20 minutes to read the fotonovela. One trained bilingual RA facilitated the group discussions using a focus group guide (see the appendix) and another bilingual RA served as the note taker. The guide included open-ended questions with follow-up probes designed to explore what participants liked and disliked about “Secret Feelings,” what they learned, and how they would use the fotonovela. All focus groups were audio-taped and lasted approximately 60 minutes.
Data Analysis
Frequencies and measures of dispersion were used to describe the sample. Focus group recordings were professionally transcribed and facilitators wrote memos summarizing their notes and observations. Content analytical strategies were used to generate themes from the transcripts and memos (Bernard, 2002). Briefly, two investigators (LJC and RA) who did not facilitate the focus groups independently listened to all focus groups recordings and read all transcripts. Each investigator then developed their own analytical memos noting prominent themes from within and across groups in order to identify shared participants' reactions, experiences, and opinions regarding “Secret Feelings.” The two investigators met several times to share their memos, discuss emerging themes and develop consensus around identified theme. Finally, a report was developed that described each of the extracted themes and shared with the entire investigator team for feedback to ensure that the analysis captured all major themes and that saturation had been achieved.
Results
Sample Characteristics
Participant characteristics are presented in Table 1. Participants' averaged age was 32.7 years (SD = 10.11). They were mostly male, single, divorced, or widowed, and their highest level of education was high school or below. All were foreign born—from Mexico, Guatemala, or El Salvador—and the majority had lived in the United States for at least 9 years or more. The majority reported speaking mostly Spanish at home and preferred to read in Spanish. A quarter reported having sought professional help in their lifetime for a mental health problem.
Table 1. Sample Characteristics (N = 32).
| Percentage | |
|---|---|
| Age in years (mean ± SD)a | 32.7 ± 10.11 |
| Gender (female)a | 35.5 |
| Marital status | |
| Married or living with a partner | 40.6 |
| Single, divorced, or widowed | 59.4 |
| Highest level of education completed | |
| Elementary (1st-6th) | 12.5 |
| Middle/junior high (7th-9th) | 28.1 |
| High school (10th-12th) | 43.8 |
| Some college | 9.4 |
| College graduate | 6.3 |
| Place of birth | |
| Mexico | 78.1 |
| Guatemala | 15.6 |
| El Salvador | 6.3 |
| Years lived in the United States | |
| 1-5 | 40.6 |
| ≥9 | 59.4 |
| Reading language preference | |
| English | 25 |
| Spanish | 75 |
| Language spoken at home | |
| Only English | 6.3 |
| Mostly English | 3.1 |
| English and Spanish equally | 31.3 |
| Mostly Spanish | 37.5 |
| Only Spanish | 21.9 |
| Lifetime use of professional help for mental health problem (yes) | 25 |
One missing value reported for this variable (n = 31).
Participants' Reactions to “Secret Feelings”
Participants reactions are organized around the following four domains: (a) what they liked about the fotonovela, (b) what they disliked, (c) what they learned about depression and its treatments, and (d) how they would use “Secret Feelings” (see Table 2).
Table 2. Summary of Participants Reaction to “Secret Feelings”.
| Audience Reaction Domains | Results |
|---|---|
| What they liked |
|
| What they disliked |
|
| What they learned |
|
| How they would use “Secret Feelings” |
|
What participants liked about “Secret Feelings”
Across the four groups, both male and female participants found the fotonovela interesting and educational. There was a consensus that the fotonovela provided information about a common problem that is not openly discussed in the Latino community, and many felt that few Latinos have access to this type of information about depression. “Secret Feelings” was viewed as an important educational tool that could help raise awareness about depression, open minds, and combat embarrassment and stigma. Participants reported that the fotonovela increased their knowledge about depressive symptoms and their confidence in helping those in needs, as exemplified by the following comment of this male participant, “now you know how to refer people if you see someone with these symptoms, you can help them.”
Participants also liked the fotonovela format for several reasons. The information presented was perceived as accessible, clear, and easy to understand. The story was described as funny, realistic, and “in a way that we can learn and be entertained.” Characters were described as resembling real Latino people and the story depicted a “typical Latino house.” For example, participants identified with the main character and how depression affected her daily functioning and family life. They mentioned how the story portrayed common issues within the Latino community surrounding depression, such as how depression can afflict both men and women even when they recognized gender differences in expressing depressive symptoms. For instance, participants discussed how crying may be more common among women, whereas getting angry or irritable is a more common expression of depression for men. They identified with the important role that family members and friends have in helping someone seek help and recover from depression. Overall, the comments by this female participant encapsulate what people liked about “Secret Feelings,” “it's a complete story because it defines symptoms and where to seek help. It's complete in a short amount of words.”
What participants disliked about “Secret Feelings”
There were several elements that participants disliked about the fotonovela. Many felt that using color photos in the body of the fotonovela and the question and answer pages instead of black and white pictures would be more attractive and help catch people's attention. Participants liked the colorful cover page and were expecting to find similar colors in the rest of the fotonovela. There was a consensus across the four groups that the story could be strengthened by including more details about how depression affected the main character's immediate and extended family.
It does mention a little about her daughter and husband but what about the rest of the family, like sister or brother. What are their reactions? I would want to see how her family is reacting to her depression. (Male participant)
Participants indicated that they wanted details about how the main character recovered from her depression and the story to be “more specific about solutions and options.” In part, because they felt treatments need to take into consideration people's preferences and needs in order to recover. They wanted to see how taking antidepressants and going to therapy helped the main character get better. Many felt that adding such details would strengthen the story, making it more compelling and informative.
Participants' views toward antidepressant medications were a major point of discussion across the four groups. There was a general level of distrust toward these medications. Despite the fact that all groups identified learning from the fotonovela that antidepressants are not addictive, they all expressed that the story fell short in convincing them of this message. The following quotes capture this level of doubt: “no estoy muy de acuerdo en el uso de anti-depresivos” (I'm not too sure about the use of antidepressants; male participant); “so maybe it's not addictive but to me, I feel it's kind of addictive” (male participant).
Interestingly, learning that depression is linked to biological mechanisms helped them understand why medications would be an option, but they still worried about the addictive properties of antidepressants. Addiction concerns permeated the discussion regarding antidepressant medications. The following views were given to explain addiction concerns: once you start taking these medications you cannot stop, you have to take more and more to get better, and they are addictive because they have to be controlled by the doctor. Furthermore, they expressed concerns regarding medication side effects and their unknown physical consequences. Some perceived that greater addiction risk correlated with longer period of use, type of medication, and a person's susceptibility to addiction because of their experiences with medications. In all, antidepressants were seen as “the last option” and as a temporary solution to numb the pain, as expressed by this female participant:
es dormir un dolor o dormir un sentimiento. Es lo que hace … mantenerse drogado todo el tiempo ” (It's putting to sleep a pain or putting to sleep a feeling. That's what it does … maintain someone drugged all the time”).
What they learned about depression and its treatments
Participants expressed that they learned how to identify and recognize depressive symptoms and realize that it's not a character flaw or that it means someone is crazy. Armed with this information, participants felt they were better equipped to help friends and relatives with depression. They reported learning that depression is a real and serious medical condition that has a biological basis and if untreated it could lead to a person hurting themselves or others. Participants talked about how the fotonovela stressed the importance of seeking help from doctors and other mental health professionals, as one male participant put it, “most important is to ask for help.” A related message discussed by a male participant is that acceptance is a prerequisite for seeking help.
“Aceptar es lo primero … porque si no lo acepta … no van a aceptar ayuda ” (The first thing is acceptance … because if you don't accept … you are not going to accept help).
“Secret Feelings” was viewed as a useful tool for helping someone with depression accept that they have a problem that requires professional help and that it provided concrete options of how and where to seek help. Lastly, participants indicated learning about anti-depressant medications, particularly that people need to take them as prescribed by their doctors, they need to talk with their doctors if they have any side effects, they need to consult their doctors before stopping the medications, and that it takes a few weeks for the medication to work.
How they would use “Secret Feelings”
Across all groups, participants reported that they would share the fotonovela with friends and relatives. “If someone tells you about these symptoms, you can share this [referring to the fotonovela] with the person … So I can say, “read it and let me know what you think” (male participant). Many felt that the comic book design of “Secret Feelings” made it a discreet tool that people could share with someone without the stigma of giving them a brochure that have the words depression or mental illness on the cover. Others commented that the fotonovela could be used as a non-threatening way to introduce the issue of depression with someone exhibiting symptoms without having to directly confront them.
Participants came up with a list of places and strategies to disseminate “Secret Feelings” in the community. Places of distribution included schools and parent associations, churches, beauty salons, barbershops, supermarkets, Spanish newspapers, public libraries, parks, waiting rooms in medical clinics, hospitals and dentist offices, bus stops, train stations, and anywhere people typically wait for services. They also liked the idea of adapting “Secret Feelings” to different mediums, such as a radio, television or video, and the Internet because it was a discrete way to obtain the information.
Discussion
Study findings affirmed that “Secret Feelings” was well accepted and provided useful information about a rarely discussed issue in the Latino community. This fotonovela was viewed as educational, entertaining, and easy to understand despite some preferring color photographs. Participants welcomed the mixture of an entertainment-educational format that presented a relatable story. They also expressed that the lessons learned from the fotonovela cultivated a sense of self-efficacy in recognizing depression in others and in themselves. The use of characters that resembled Latino folks and the soap opera narrative were perceived as an effective format to catch readers' attention and engage them in learning about a stigmatized topic.
These positive reactions toward “Secret Feelings” indicate that the narrative and content resonated with participants own experiences and enabled them to form a personal connection with the characters. These findings suggest that the entertainment-education strategies embedded in our fotonovela, including the use of a dramatic story with salient cultural themes and norms, development of characters that resembled our intended audience, and the use of attractive and entertaining visuals, seem to increase audience engagement and identification with the story and stir interpersonal communication about the fotonovela content. Audience engagement and identification as well as interpersonal communication are communication processes that help readers accept new information, challenge maladaptive social norms and beliefs, and allow them to consider new behavioral options (Ritterfeld & Jin, 2006; Sood, 2002). A recent model of culture-centric narratives in health promotion stipulates that these three communication processes mediate the relationship between culturally informed narratives and attitudinal and behavioral change (Larkey & Hecht, 2010). Our findings provide qualitative evidence that “Secret Feelings” through its impact on audience engagement and identification and interpersonal communication set the stage for attitudinal and behavioral change. Future studies are needed to test this mediational process.
The educational value of “Secret Feelings” was what participants appreciated most. Participants expressed a thirst for information about depression and its treatments, which were evident in both the value they placed on the lessons learned about depression and their desire for more details about the impact of depression on the family and the main character's recovery. Participants' desire for more details about treatment alternatives and explanations of possible causes of depression warrant expanding these topics within “Secret Feelings”. It highlights how the fotonovela can be viewed as a springboard to initiate a deeper conversation about depression and its treatments within Latino communities.
“Secret Feelings” was viewed as a welcomed tool to help combat stigma in the Latino community, particularly the pejorative belief that people with depression are viewed as locos (crazy), lazy, or weak (Interian et al., 2010). The fotonovela debunked these beliefs by presenting an alternative view of depression as a real and serious medical condition. “Secret Feelings” was perceived as a nonthreatening tool that could be shared with relatives and friends with depression and/or distributed at different community locations and adapted for various types of media outlets. Studies have found that fotonovelas have an extended life as people tend to discuss the content and lessons of fotonovelas with family members and friends and to pass them along to others in their social networks, thus increasing the potential impact and reach of these health education tools in the community (Valle et al., 2006).
An important limitation uncovered by our evaluation was that “Secret Feelings” fell short in convincing participants that antidepressants are not addictive. The fotonovela included information about how antidepressants help people with depression, how these medications should be taken, and used several authority figures, such as a primary care doctor and pharmacist, to stress that these medications are not addictive. Although these strategies helped our participants learn about antidepressants, they were not effective at shifting readers' concerns about antidepressants.
Addiction concerns about antidepressant medications are common among Latinos (Interian et al., 2010) and are linked to delays in seeking help, treatment dropout, and lack of medication adherence (Ayalon, Areán, & Alvidrez, 2005; Lanouette, Folsom, Sciolla, & Jeste, 2009; Lewis-Fernández, Das, Alfonso, Weissman, & Olfson, 2005). The addiction concerns reported by our participants parallel those reported in previous studies (Cabassa et al., 2008; Interian et al., 2007; Pincay & Guarnaccia, 2007) and suggest that for some Latinos antidepressants are tied to fears of dependency, loss of control, physical harm, and beliefs that these medications make people numb, drugged, and unable to function. Improvements to “Secret Feelings” should focus on expanding the content of antidepressants with more targeted messages that address these common concerns. Given that misconceptions of antidepressants are prevalent among Latinos, an information-based approach, such as our fotonovela, may not be sufficient to change people's perceptions of antidepressants. Combining “Secret Feelings” with other interactive approaches, such as one-to-one or group discussions with health care professional or trained peer health workers may be more appropriate to help shift these common concerns.
Several study limitations need to be considered. Reactions to the fotonovela may not be generalized to other Latino groups as our sample was constrained to one adult education program in Los Angeles, California. Future studies are needed to corroborate these findings with other Latino groups. The exploratory nature of this study prevented us from examining causal relationships between exposure to “Secret Feelings” and changes in attitudes and behaviors. Results from this study generated hypotheses of how this fotonovela may set the conditions for attitudinal and behavioral changes that can then be tested using experimental designs.
Implications
“Secret Feelings” was found to be engaging, educational, and provided information about depression in an entertaining format. Future studies are needed to test the causal relationships between exposure to our fotonovela and lasting changes in attitudes, stigma, and help-seeking behaviors and to identify communication processes that mediate these relationships. Future versions of “Secret Feelings” should incorporate participants' suggestions for using color photographs and expanding the story line to include other family members, more information about recovery from depression and to counteract misconceptions that antidepressants are addictive. This fotonovela can be used by community health workers, doctors and/or mental health providers to initiate a dialogue with Latino clients about depression and its treatment and engage them in seeking help for this disabling condition. “Secret Feelings” is a promising depression literacy tool that can raise awareness and knowledge about depression and its treatments, reduce stigma toward depression and antidepressant medications, and model appropriate help-seeking behaviors.
Acknowledgments
Authors' Note: This work was supported in part by the New York State Office of Mental Health Policy Scholar Grant (PI: Cabassa); NIH Grant L60 MD001850-02 (PI: Cabassa); a University of Southern California Neighborhood Outreach Grant (PI: Baron), grants from L. A. Care Health Plan, AmerisourceBergen, Takeda Pharmaceuticals North America, Inc and an educational grant from Eli Lilly and Company.
Appendix.
Focus Group Questions.
|
References
- Ayalon L, Areán P, Alvidrez J. Adherence to antidepressant medications in Black and Latino elderly patients. American Journal of Geriatric Psychiatry. 2005;13:572–580. doi: 10.1176/appi.ajgp.13.7.572. [DOI] [PubMed] [Google Scholar]
- Bernard HR. Research methods in anthropology: Qualitative and quantitative approaches. 3rd. Walnut Creek, CA: AltaMira Press; 2002. [Google Scholar]
- Blanco C, Patel SR, Liu L, Jiang H, Lewis-Fernández R, Schmidt AB, Olfson M, et al. National trends in ethnic disparities in mental health care. Medical Care. 2007;45:1012–1019. doi: 10.1097/MLR.0b013e3180ca95d3. [DOI] [PubMed] [Google Scholar]
- Cabassa LJ, Hansen MC, Palinkas LA, Ell K. Azúcar y nervios: Explanatory models and treatment experiences of Hispanics with diabetes and depression. Social Science & Medicine. 2008;66:2413–2424. doi: 10.1016/j.socscimed.2008.01.054. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Cabassa LJ, Molina GB, Baron M. Depression Fotonovela: Development of a depression literacy tool for Latinos with limited English proficiency. Health Promotion Practice. 2010 doi: 10.1177/1524839910367578. Advance online publication. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Cabassa LJ, Zayas LH. Latino immigrants' intentions to seek depression care. American Journal of Orthopsychiatry. 2007;77:231–242. doi: 10.1037/0002-9432.77.2.231. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Cameron LD, Leventhal H. The self-regulation of health and illness behaviour. London, England: Routledge; 2003. [Google Scholar]
- Interian A, Ang A, Gara MA, Link BG, Rodriguez MA, Vega WA. Stigma and depression treatment utilization among Latinos: Utility of four stigma measures. Psychiatric Services. 2010;61:373–379. doi: 10.1176/appi.ps.61.4.373. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Interian A, Martinez IE, Guarnaccia PJ, Vega WA, Escobar JI. A qualitative analysis of the perception of stigma among Latinos receiving antidepressants. Psychiatric Services. 2007;58:1591–1594. doi: 10.1176/appi.ps.58.12.1591. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Kreuter MW, Haughton LT. Integrating culture into health information for African American women. American Behavioral Scientist. 2006;49:794–811. [Google Scholar]
- Lanouette NM, Folsom DP, Sciolla A, Jeste DV. Psychotropic medication nonadherence among United States Latinos: A comprehensive literature review. Psychiatric Services. 2009;60:157–174. doi: 10.1176/appi.ps.60.2.157. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Larkey L, Hecht M. A model of effects of narrative as culture-centric health promotion. Journal of Health Communication. 2010;15:114–135. doi: 10.1080/10810730903528017. [DOI] [PubMed] [Google Scholar]
- Lewis-Fernández R, Das AK, Alfonso C, Weissman MM, Olfson M. Depression in US Hispanics: Diagnostic and management considerations in family practice. Journal of the American Board of Family Practice. 2005;18:282–296. doi: 10.3122/jabfm.18.4.282. [DOI] [PubMed] [Google Scholar]
- Nadeem E, Lange JM, Edge D, Fongwa M, Belin T, Miranda J. Does stigma keep poor young immigrant and U.S.-born Black and Latina women from seeking mental health care? Psychiatric Services. 2007;58:1547–1554. doi: 10.1176/ps.2007.58.12.1547. [DOI] [PubMed] [Google Scholar]
- Olfson M, Marcus SC, Tedeschi M, Wan GJ. Continuity of antidepressant treatment for adults with depression in the United States. American Journal of Psychiatry. 2006;163:101–108. doi: 10.1176/appi.ajp.163.1.101. [DOI] [PubMed] [Google Scholar]
- Pincay IEM, Guarnaccia PJ. “Its's like going through an earthquake”: Anthropological perspectives on depression among Latino immigrants. Journal of Immigrant and Minority Health. 2007;9:17–28. doi: 10.1007/s10903-006-9011-0. [DOI] [PubMed] [Google Scholar]
- Ritterfeld U, Jin S. Addressing media stigma for people experiencing mental illness using an entertainment-education strategy. Journal of Health Psychology. 2006;11:247–267. doi: 10.1177/1359105306061185. [DOI] [PubMed] [Google Scholar]
- Sentell T, Shumway M, Snowden L. Access to mental health treatment by English language proficiency and race/ethnicity. Journal of General Internal Medicine. 2007;22(Suppl. 2):289–293. doi: 10.1007/s11606-007-0345-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Singhal A, Rogers E. Entertainment-education: A communication strategy for social change. Mahwah, NJ: Lawrence Erlbaum; 1999. [Google Scholar]
- Sood S. Audience involvement and entertainment-educations. Communication Theory. 2002;12:153–172. [Google Scholar]
- Sutton S. Predicting and explaining intentions and behavior: How well are we doing? Journal of Applied Social Psychology. 1998;28:1317–1338. [Google Scholar]
- Valle R, Yamada AM, Matiella AC. Health literacy tool for educating Latino older adults about dementia. Clinical Gerontologist. 2006;30:71–88. [Google Scholar]
- Young AS, Klap R, Sherbourne CD, Wells KB. The quality of care for depressive and anxiety disorders in the United States. Archives of General Psychiatry. 2001;58:55–61. doi: 10.1001/archpsyc.58.1.55. [DOI] [PubMed] [Google Scholar]