Sample

Our sample for the prescreening survey consisted of 23,234 individuals. Of those who completed the prescreening survey, 500 individuals who qualified as having type 2 diabetes and being in a romantic relationship successfully completed the survey. Of the 500 individuals who participated in the study, 236 were male and 264 were female. Participants ranged in age from 21 to 74 years (M = 42 years, SD = 11.82 years). A majority of participants reported their race as white (67.8%), with 15.2% identifying as Asian, 8.2% as African American, 7.8% as Indian, 4.8% as Native American, and 0.6% as other. A majority of participants were married (64.6%), and others were monogamously dating (23%), engaged to be married or to enter a civil union (9.8%), or in a civil union (2.6%).

The average time since type 2 diabetes diagnosis was 5.03 years (SD = 5.86 years). In addition, most participants (74.4%) reported that they were diagnosed with type 2 diabetes after they were already romantically involved with their partner. A majority of participants actively managed their type 2 diabetes (98.4%), which included daily blood glucose monitoring (58.2%), diet and exercise (78.2%), oral medication (71.8%), long-acting insulin treatment (21.2%), and rapid-acting insulin treatment before meals (14.8%). A majority of participants also experienced complications or comorbid conditions as a result of their type 2 diabetes condition (96.4%), with blood pressure changes (51%), high cholesterol (37.2%), and nerve disease (34.6%) being most frequently reported within the sample.

Measures and Analyses

The broader survey for this study included demographic questions and a variety of closed-ended, Likert-type scale items that have been analyzed and reported elsewhere (Leustek & Theiss, Reference Leustek and Theiss2018). For this investigation, participants responded to an open-ended question asking them to describe their communication with a romantic partner about their illness. The open-ended question stated, “Information can sometimes be kept private from romantic partners for various reasons. In the space below, please describe the topics or information about your type 2 diabetes diagnosis that you keep private or avoid discussing with your romantic partner.” Participants were given a text box to respond to this question, and were given unlimited time and space to complete their answer.

All 500 responses were analyzed using content analysis to explicate the emergent themes embedded within the data. Our analytical approach was based in grounded theory through the utilization of the constant comparative method (Glaser, Reference Glaser1978). A research team consisting of two independent coders carefully reviewed the open-ended responses. First, the research team read through the open-ended responses to familiarize themselves with the dataset. Next, open and axial coding processes were used to look for larger themes in the data (Corbin & Strauss, Reference Corbin and Strauss2015). Open coding allowed the research team to explore the emergent and descriptive themes that were dominant within the data, and the axial coding process helped the research team organize the open codes into a hierarchical schema of more dominant themes. This analysis resulted in eight major themes regarding topic avoidance for individuals with type 2 diabetes in romantic relationships.

Using the eight major themes as a codebook, the research team went back through the responses and coded each response with a specific theme. Responses that included multiple answers or contained instances of more than one theme were unitized and separated as individual codes. A total of N = 512 units of analysis were observed in order to answer RQ1. We used Cohen’s κ to calculate the intercoder reliability between the independent coders. The reliability between coders for each subset of data ranged from ƙ = 0.82 to ƙ = 0.89. After all of the coding was complete, disagreements between the coding team were resolved through discussion with the first author.

Health and Wellness

The first theme described topic avoidance related to health, weight management, food consumption, sugar levels, and the overall guilt associated with not adhering to lifestyle changes necessary to manage the illness (14.9% of thematic units). For example, one participant (male, age 37) stated, “I’m sometimes not completely honest about how well I’m managing things. If I haven’t been good about my diet or getting exercise I won’t volunteer that information and sometimes actively hide it. I know I should do better; I feel like at that point it doesn’t accomplish much to have another person disappointed in me.” Partners also mentioned that issues relating to health and wellness might also influence their relationship in addition to health concerns, such as one participant (female, age 46) stating, “I always eat more when I’m eating alone than I do when I am with him. I snack way too much at night and to my knowledge, he doesn’t know I do that when I’m not with him. I am around 30 pounds overweight and he was too, until he got ill around the beginning of this year. Because of his illness, he has dropped down to around his ideal weight. This makes me very insecure and I’m afraid he may start looking for someone ‘closer to his size.’” Participants with responses in this theme described trying to hide or trivialize issues associated with their diet, conceal any cheating they do on their exercise or diet regimen, and avoid discussing their illness with their partner because they feel guilty about their health choices or fearful of what their partner might think. Another participant (male, age 42) stated that he often succumbed to his cravings for sweet foods, but avoided telling his partner because of the potential fallout in their relationship, stating, “I sometimes hide what I eat and do not tell her the carb ratio. I tend to do this behind her back from time to time, mostly when I get cravings for sweets and she is usually unaware. I make up for it by exercising more, but I do not share this info with her for the sake of not upsetting her.”

Symptoms/Complications

The second theme described topic avoidance related to symptoms that are associated with complications arising from type 2 diabetes (13.6% of thematic units). In this theme, participants emphasized not wanting to talk about the specifics of their symptoms, such as nerve damage, body odor (i.e., bad breath, strong urine scent, etc.), loss of hearing, loss of eyesight, blood pressure changes, yeast infections, and overall pain. One participant (male, age 26) mentioned not wanting to discuss symptoms with his partner, stating that he did not want to her to know “how bad the pain I get in my liver and feet is. I don’t want her to worry about me 24/7 or feel like I’m some kind of burden to her and think she has to treat me like my diagnosis.” Participants indicated that discussing these symptoms could be embarrassing or an indicator that they were not properly managing their illness. Another participant (female, age 31) mentioned the day-to-day issues she faced related to her symptoms, and how she avoided certain topics to prevent her husband from worrying that her illness had progressed, stating, “I try not to discuss days when I have horrible fruity breath from my diabetes, and I don’t mention my fears to him concerning whether or not that little nick from shaving my legs is healing too slow or not. My feet are often a little dry, so I wear socks a lot to hide them.” Other participants said they avoided discussing symptoms with their partner because it could worry them or make them feel anxious about their prognosis, such as one participant (male, age 41) who stated, “I sometimes don’t tell my wife when my hands and feet are tingling … I figure this is due to my blood-glucose becoming too high, and I don’t want her to worry.”

Maintaining Privacy Boundaries

The third theme described topic avoidance resulting from the desire to keep information about the illness private (11.6% of thematic units). Participants mentioned wanting to keep information private because disclosing it might upset or burden their partner. Discussing specifics of the illness could make communication awkward with their partner or shift some of the responsibility for controlling the illness onto their partner. For example, one participant (male, age 32) stated, “I try to avoid bringing stuff up in general, because I feel bad about the fact that I don’t take care of myself enough. When I think 10 or 20 years down the line, if I go blind, and I need her help, she’d be upset with me because I didn’t take care of myself the way I should have now. I feel like a burden towards her.” In addition, some participants felt that keeping information private created a healthier relational environment, with few sources of stress and anxiety. One participant (female, age 52) described how she tries to mention only more serious issues pertaining to her illness, stating, “I generally don’t tell him about any wounds I get on my lower legs. He is overly sensitive about this issue because an aunt of his lost both of her lower legs due to diabetes and he gets too obsessive and overbearing about this particular issue. I would tell him if I felt I had a wound or skin condition that needed emergency medical attention.” Other participants with responses in this theme described feeling like their illness was “my problem, not my partner’s,” and wanted to keep some autonomy in the management of their illness, such as one participant (male, age 45) stating, “I keep it all private. It is my condition and not hers, thus my concern and not hers. I am a man and deal with my own problems as well as the problems of my loved ones.”

Uncertainty

The fourth theme described topic avoidance related to the uncertainties surrounding the prognosis and severity of the illness (10.5% of thematic units). As one participant (female, age 47) stated, “I don’t discuss how worried I am about my future health or about how much of a financial burden this will impose on our family in the future. I also don’t tell him that I think I’m developing diabetic nerve damage.” Specifically, participants mentioned avoiding topics about their own personal fears and uncertainty about the expected course of their illness, their quality of life in the future, and unforeseen complications arising later in life. One participant (female, age 59) discussed that she worried about the uncertainty surrounding her long-term prognosis, stating, “I am 22 years older than my fiancé. So, I’m not eager to share with him a couple of potential extreme outcomes of diabetes that could happen, in time, if I’m not careful: blindness or amputation of a limb. I don’t want him to get the feeling that he could eventually have an invalid on his hands.” In addition, another participant (female, age 37) felt uncertain about the implications for her illness in the context of her relationship with her husband, stating “My fear is that he will leave me because I’m not able to do as much as I used to, like cooking all the meals, do the laundry, etc. I’m also afraid to talk about losing my life and what to do about my son if that happened. I know he would care for him, but it would be so much harder, and I don’t want to leave them.” Participants also noted that if they were to become incapacitated or pass away due to their illness, they were uncertain as to whether their partner or family would be provided for, both financially and emotionally.

Lack of Partner Support

The fifth theme described topic avoidance with regard to requests for social support, as participants predicted a negative or poor outcome as a result of their request (8.1% of thematic units). For example, one participant (male, age 35) expressed his frustration when trying to seek support from his partner, stating, “It doesn’t really matter, because she won’t listen to anything I say anyway – and in the unlikely event that she does listen, she usually forgets about it quickly so I can tell her anything and it is as if I kept it private.” Participants noted that they avoided seeking support when they felt their partner would be uninterested, not want to discuss the problem, or make disparaging remarks toward them. Another participant (female, age 45) mentioned that her partner seemed disingenuous when providing support, stating, “I don’t share much about how my condition effects [sic] me with my partner – he is simply in his own world or gives me an ‘I’m sorry’ and has no memory of it later. So I just don’t bother.” In addition, participants with responses in this theme also felt as though their requests for support would be unheard, or that their partner would not be able to handle the request. For example, one participant (female, age 60) stated, “We don’t really discuss anything having to do with my condition, because it typically turns into a one-sided conversation about what issues he has, and how I just don’t understand, so I keep mostly everything to myself.”

Sexual Intimacy

The sixth theme described topic avoidance surrounding sexual intimacy and sexual capabilities (5.7% of thematic units). Participants mentioned avoiding topics related to their sex drive, desirability, and sexual functioning. Participants described wanting to avoid discussion about sexual dysfunction issues, such as erectile dysfunction, and reproductive health issues, such as polycystic ovarian syndrome. In addition, partners also described avoiding topics related to changes in their sex drive and sexual desire. One participant (male, age 38) stated that he avoided topics about sex with his partner because he noticed a change in his sexual capabilities, stating, “I have kept the issue of intimacy very private – simply for the fact that it’s far and few in between right now so I know she has not noticed the gradual decrease in performance and or quality of intimacy as it is related to my diabetes.” Another participant (male, age 47) discussed his frustration about his partner conflating sexual dysfunction with relational interest and desire, stating, “It is difficult to discuss erectile dysfunction with my partner, because she tends to see things of that nature as me not loving her or desiring her enough.” Topic avoidance in this category was often driven by participants’ desire to avoid drawing attention to the loss of intimacy and eliciting concern from one’s partner, such as one participant (female, age 59) who stated, “I avoid discussing my lack of sex drive. Because the diabetes limits my sleep, I am often not interested in sex, but I do not tell him for fear he will worry about our sex life.”

Financial Risks

The seventh theme described topic avoidance about issues related to finance and cost of care for the illness (5.1% of thematic units). Participants mentioned not discussing the cost of medication or care because their partner was either unaware of the true cost, or they did not want to argue with their partner about money. For example, one participant (female, age 36) stated, “I did not inform him that I have developed lesions on the back of my eye because we do not have insurance for him to see his doctor for his eyes and he has needed new script for last three years! Also, my insurance only covers one visit to the eye doctor for me so telling would just add undue stress to our situation. Since it can’t be helped, why bring it up?” Participants also mentioned that when they had to forgo treatment, medicine, and procedures due to a lack of funds, they avoided mentioning it to their partner to prevent any additional stress about the topic. Another participant (female, age 45) discussed having trouble being able to afford regular blood sugar testing, stating, “I avoid talking to him about testing my sugar because we don’t have health insurance right now and he doesn’t grasp how expensive the test strips are and just gets impatient with me. I pretty much keep to myself concerning this with my partner.”

Open Communication

Notably, a relatively large number of participants indicated that they strive to remain open in communication with their partner rather than avoiding certain topics about their illness (19.6% of thematic units). Partners mentioned that open communication was important because their type 2 diabetes was a “team effort” to keep under control. Participants with responses in this theme specifically mentioned that they appreciated the deeper understanding their partner had as a result of their open communication. For example, one participant (female, age 53) stated, “I tell him pretty much everything. We’ve been doing this for a while now, he knows a lot about diabetes and isn’t afraid of it or of learning more about it, whether from me or other sources. He knows where my numbers fall and where on the scale they fall. I’m not obsessed about it, although it is part of every choice it seems, he kind of follows my lead. I can’t think of anything I don’t tell him – except my weight of course.” Often, participants mentioned that open communication was possible because their partner also had type 2 diabetes, or there was a close family member/friend who had type 2 diabetes. Another participant (male, age 62) mentioned that prior experiences from both partners regarding type 2 diabetes was a motivational factor for open communication, stating, “Oh gosh, we share everything … having witnessed the experience of diabetic members of both our families, we are quite motivated to beat this – as a team.”

Implications for Relationships

The results of this study point to some notable implications for close relationships. One notable finding was that many of the reasons for topic avoidance that emerged in this study suggest that the potential for embarrassment and shame encourages avoidance of certain topics. A growing body of research has looked at the effects of stigma on communication in relationships and the motivations couples have for disclosing health information (Della, Ashlock, & Basta, Reference Della, Ashlock and Basta2016). Type 2 diabetes has a unique set of stigmatized stereotypes that characterize the condition, such as individuals with type 2 diabetes being perceived as lazy, careless, overindulgent, lacking self-control, and making poor lifestyle choices (Schabert, Browne, Mosely, & Speight, Reference Schabert, Browne, Mosely and Speight2013), despite the fact that genetics and hereditary insulin resistance are important risk factors for the development of type 2 diabetes (Lyssenko et al., Reference Lyssenko, Jonsson, Almgren, Pulizzi, Isomaa, Tuomi and Groop2008). Thus, avoiding topics related to one’s illness that are perceived as stigmatizing, such as failures to comply with treatment, undesirable symptoms and complications, or unexpected sexual dysfunction, can help an individual save face in the eyes of a romantic partner.

The results also point to uncertainty as a driving force for topic avoidance about type 2 diabetes in romantic relationships. Some participants mentioned that they were uncertain about facets of their illness, such as their ability to manage the illness, control symptoms, or foresee their long-term prognosis. Although these issues specifically reflect illness uncertainty (Johnson Wright, Afari, & Zautra, Reference Johnson Wright, Afari and Zautra2009; Mishel, Reference Mishel1990), ambiguity about one’s health can reverberate into broader concerns about the well-being of one’s self or a relationship. Not surprisingly, then, a number of the themes of topic avoidance in this study reflected an unwillingness to discuss one’s health condition owing to uncertainty about how the illness might dampen a partner’s attraction, or enthusiasm for the relationship. Studies show that relational uncertainty encourages topic avoidance about a variety of issues (Knobloch & Carpenter-Theune, Reference Knobloch and Carpenter-Theune2004; Knobloch, Sharabi, Delaney, & Suranne, Reference Knobloch, Sharabi, Delaney and Suranne2015; Theiss & Estlein, Reference Theiss and Estlein2014; Theiss & Nagy, Reference Theiss and Nagy2013) and our results suggest that managing chronic illness may exacerbate some of these uncertainties.

Finally, a unique finding in this study was that a notable number of participants specifically mentioned avoiding support requests relating to their type 2 diabetes. Many participants noted that they wanted to request support from their partner, but felt that their partner either could not provide adequate support or did not want to provide adequate support, so they chose to forgo the request. When attempts were made to request support, partners wound up making superficial attempts to provide support, and others used communication tactics to either avoid or reverse the support request. Prior research has shown that self-efficacy about one’s ability to provide support can influence how an individual approaches a support request (Bodie, Burleson, & Jones, Reference Bodie, Burleson and Jones2012). Given the nuanced and technical nature of type 2 diabetes maintenance and complications, it may be that relational partners feel as though they do not possess the knowledge or skill to effectively support their partner. When individuals anticipate that a partner lacks the motivation or skills required to enact effective support, they may side-step sensitive issues to avoid the disappointment of receiving poor support.

Implications for Communication

Surprisingly, a sizable percentage of participants specifically mentioned that they rarely avoided topics with their partner and strived to communicate openly about their illness. One explanation for this finding may be that open communication is an important quality in a relationship in which one partner has a chronic health condition (Goldsmith, Reference Goldsmith, Afifi and Afifi2009). Open, honest, and direct communication about one’s illness can be beneficial for clarifying expectations between partners, coordinating actions and routines for a healthier lifestyle, and managing complicated treatments (Goldsmith et al., Reference Goldsmith, Miller, Caughlin and Beck2008). If topics such as symptoms, worries, lifestyle changes, and financial issues are openly discussed between partners rather than avoided, then the relationship can provide an important source of support and facilitation for managing type 2 diabetes. An alternative explanation for this finding is that participants failed to recognize the various issues that they avoid discussing with their partner out of an ideology of openness. Cultural expectations about relationships tend to favor open and honest communication between partners over secrecy or dishonesty. Thus, individuals in this study may have been motivated to characterize their relationship in such a way that reflected cultural norms equating openness with intimacy without considering the true complexities of their relational communication.

Although open communication is often idealized in representations of close relationships, there are certain conditions in which constant openness can be detrimental to establishing intimacy and connection between partners. Along these lines, many participants also noted that privacy boundaries were an important part of choosing whether to disclose certain information to their partner. Taken together, these findings point to a core dialectical tension for individuals with type 2 diabetes, such that they desire open communication with their partner about the illness, but also want to protect their privacy to prevent embarrassment and stigma. These competing desires can create quite a quandary. For example, individuals may want the privacy and autonomy that comes with managing their condition by themselves, but they may also feel as though they want their partner’s support and help in self-managing at home. Individuals may also feel as though they do not want to burden their partner with their self-care and worries about their condition, but may also feel overwhelmed and distressed trying to manage it alone. Thus, coping with chronic illness in the context of a close relationship requires that partners find an acceptable balance between openness and privacy.

Implications for Health

As previously mentioned, our results suggest that individuals with type 2 diabetes may be reluctant to request support from their romantic partner, despite the fact that social support can be an important component of managing chronic illness. Given that social support is a factor that has consistently been shown to have a positive association with wellness and self-management (Gallant, Reference Gallant2003), future research should look at the mechanisms of support efficacy in the context of type 2 diabetes. Whereas individuals with type 2 diabetes may feel comfortable seeking informational or tangible support to cope with their illness, such as researching treatment options or adhering to a healthy diet, requesting emotional and esteem support, such as reassurance from their partner or recognition for making difficult lifestyle changes, can be much more face-threatening. Thus, romantic partners can be most effective in providing support when they offer multifaceted messages that address both relational and health-based needs.

In addition, health care providers should be aware of the potential topics that individuals with type 2 diabetes might avoid discussing outside of a medical context. Communication about adherence to treatments and lifestyle changes may function differently between health care providers and romantic partners. Topics that patients may feel comfortable discussing and communicating about with their health care provider, such as health and wellness, symptoms/complications, sexual intimacy, or uncertainty, may be uncomfortable to discuss with romantic partners. As such, health care providers should be proactive in addressing the importance of involving romantic partners or family members in the management of their condition.

Limitations and Future Directions

This study was not without its share of limitations. First, given that participants responded to an open-ended survey question about topic avoidance, we were unable to probe their responses to achieve the level of detail that would be possible in an interview setting. A more interactive method of data collection would have provided for more depth in the responses. Next, our study only looked at sources of topic avoidance for type 2 diabetics in romantic relationships. As such, our findings were limited in highlighting any of the antecedents and consequences of topic avoidance in these relationships. In addition, given the cross-sectional nature of this study, we were unable to observe how prolonged avoidance of communication about health-related issues may have long-term implications for people’s health and well-being Future research may wish to consider how topic avoidance exists during certain stages of chronic illness (e.g., immediately after diagnosis, during management, after symptoms manifest) and how topic avoidance influences romantic relationships over time.

Participants

Participants were 51 dyads (N = 102) that were college-aged friends in which one friend shared his or her mental illness information with the other. Disclosers identified as female (n = 32, 62.7%), male (n = 18, 35.3%), and one did not report sex; recipients identified as female (n = 32, 62.7%), male (n = 18, 35.3%), and one did not report sex. Discloser age ranged from 18 to 27 years (M = 20.68, SD = 1.76); recipient age ranged from 18 to 27 years (M = 20.68, SD = 1.76). Disclosers self-identified as white/Caucasian (n = 35, 68.6%), Asian (n = 12, 23.5%), Hispanic or Latino/a (n = 2, 3.9%), American Indian (n = 1, 2%), or black/African American (n = 1, 2%). Similarly, recipients self-identified as white/Caucasian (n = 35, 68.6%), Asian (n = 12, 23.5%), Hispanic or Latino/a (n = 2, 3.9%), American Indian (n = 1, 2%), or black/African American (n = 1, 2%). Disclosers were college students identifying as freshmen (n = 8, 15.7%), sophomores (n = 13, 25.5%), juniors (n = 9, 17.6%), seniors (n = 18, 35.3%), graduate level (n = 2, 3.9%), or other (n = 1, 2%). Recipients were college students identifying as freshmen (n = 8, 15.7%), sophomores (n = 13, 25.5%), juniors (n = 9, 17.6%), seniors (n = 18, 35.3%), graduate level (n = 2, 3.9%), or other (n = 1, 2%). Disclosers described that at the time of disclosure, recipients were friends (n = 46, 90.2%) or significant others (n = 4, 7.8%). Disclosers reported that they had known the recipient for varying lengths of time, including less than 1 year (n = 13; 25.5%), 1 year (n = 5; 9.8%), 2 years (n = 7, 13.7%), 3 years (n = 7, 13.7%), 4 years (n = 4, 7.8%), or more than 4 years (n = 14, 27.5%). Although the majority of pairs had been in the relationship for one year or less (n = 3, 62.8%) when disclosers shared their mental illness information, some pairs had been in the relationship for more than 4 years at the time of disclosure (n = 8, 15.7%).

Disclosers reported the following mental illness diagnoses: anxiety disorders (n = 15, 29%), depression (n = 14, 27%), attention deficit disorder (ADD) and/or ADHD) (n = 11, 22%), obsessive–compulsive disorder (n = 5, 10%), other (e.g., body dysmorphic disorder, epilepsy) (n = 6, 11%), bipolar disorder (n = 3, 6%), and borderline personality disorder (n = 3, 6%). Participants provided the details of their mental illness in an open-ended fashion and could report more than one illness. Because of this, percentages total greater than 100%. Category designations were made using the NAMI (2012) groupings for mental illness.

Procedure

On receiving university Institutional Review Board (IRB) approval, we recruited dyads for the study. Dyads were considered eligible if one member had a mental illness (i.e., discloser) and had disclosed his or her mental illness to the other member (i.e., recipient) within the past five years, if both members of the dyad were at least 18 years of age and college students, and if both members of the dyad considered the other to be a friend. For the purpose of this research, the term “friend” was used in the broadest sense, and participants themselves determined whether or not the recipient was classified as a “friend.”

One member of each dyad enrolled in the study through a university online research participation system. Once enrolled, participants received an email describing the study in greater detail; participants were asked to provide both their own and their partner’s email address, and their role as discloser or recipient. No details about specific mental health-related information were exchanged via email. After participants replied with contact information for both members of the dyad, researchers sent individual emails to disclosers and recipients with a web link to online surveys and unique identification codes. Once participants completed the survey online, participants received course credit (if applicable) and were entered into a drawing for a gift card.

Measures

Variables measured for both disclosers and recipients included closeness, recipient response (support, emotional reaction, reciprocity, topic avoidance), and interaction effectiveness (see Table 5.1 for correlations among study variables). We used SPSS 23 to generate descriptive statistics, create variables, and establish reliability. Composite scores were created by averaging responses of individual items, and variables were screened for normality and multicollinearity.

Preliminary Analyses

We initially conducted paired-sample t-tests to evaluate differences in discloser and recipient perspectives for study variables (see Table 5.2). Results revealed significant differences for college-friend disclosers and recipients in evaluations of topic avoidance and reciprocity. Disclosers (M = 5.06, SD = 1.50) reported that recipients provided greater reciprocity than did recipients (M = 3.97, SD = 0.79), t (48) = 5.63, p < 0.001. Disclosers (M = 2.08, SD = 1.45) reported that recipients were less avoidant and were more responsive than did recipients (M = 1.64, SD = 0.88), t (48) = 2.71, p < 0.01.

Substantive Analyses

Using path analysis in StataIC 14, analyses were conducted to examine relationships among both disclosers’ and recipients’ reports of (a) relational closeness, (b) recipient response, and (c) interaction effectiveness. More specifically, the data were analyzed using the APIM (Cook & Kenny, Reference Cook and Kenny2005). The APIM is “a model of dyadic relationships that integrates a conceptual view of interdependence in two-person relationships with the appropriate statistical techniques for measuring and testing it” (p. 101). By applying the APIM, researchers can calculate if a discloser’s reports of relational closeness have an effect on his or her own reports of interaction effectiveness (i.e., an actor effect), as well as on his or her friend’s (the recipient) reports of interaction effectiveness (i.e., a partner effect). Furthermore, we explored whether these effects are mediated by each individual’s perceptions of the recipient’s response (see Figure 5.1). Owing to small sample size (N = 48), three separate models were run, such that each model included only one recipient response variable (e.g., support, reciprocity, or topic avoidance).

Figure 5.1 Proposed APIM of dyadic mental health disclosure interactions.

Models were estimated using maximum likelihood. When appropriate, indirect effects were evaluated using the product of coefficients method, such that the path coefficient for the effect of the independent variable to the mediator is multiplied by the path coefficient for the effect of the mediator to the outcome (MacKinnon, Lockwood, Hoffman, West, & Sheets, Reference MacKinnon, Lockwood, Hoffman, West and Sheets2002). The standard error of the product was calculated using the delta method (Oehlert, Reference Oehlert1992). Significance of the indirect effect was used as evidence for mediation (i.e., the confidence interval must not contain zero). Model fit was assessed using the obtained chi-square (χ²), Confirmatory Fit Index (CFI), and root mean square error of approximation (RMSEA). Good model fit was determined when the χ² value was nonsignificant, CFI was above 0.90 (i.e., Bentler & Bonett, Reference Bentler and Bonett1980; Hu & Bentler, Reference Hu and Bentler1999), and RMSEA values were below 0.10 (Browne & Cudeck, Reference Browne, Cudeck, Bollen and Long1993). If model fit was originally poor, items with nonsignificant path loadings were removed until acceptable model fit was achieved. All models are represented in Figure 5.2.

Figure 5.2 Model testing actor, partner, and indirect effects for closeness, recipient response variables, and interaction effectiveness.

Note. N = 48; †p < 0.10, *p < 0.05, **p < 0.01, *** p < 0.001. For each set of results, the first result reflects support. Results for reciprocity are in bold. Results for topic avoidance are in italics. Results including R represent paths that were removed to improve model fit for the represented recipient response variable.

Discloser and Recipient Disclosure Evaluation

Examination of dyadic data allows for the comparison of how both dyadic partners contribute to an overall assessment. We first discuss similarities and then differences in how close college-student friends recall mental illness disclosure with special attention to interaction effectiveness and closeness.

Dimensions of Response

Magsamen-Conrad’s (Reference Magsamen-Conrad2014) dimensions of recipient response were designed to evaluate how individuals contemplating disclosure may anticipate others’ reactions. Other research has examined the relationship between these dimensions and disclosure outcomes such as disclosure intention, disclosure depth and breadth, and topic avoidance (Shields, Reference Shields2017; Venetis, Magsamen-Conrad, Checton, & Greene, Reference Venetis, Magsamen-Conrad, Checton and Greene2017). Within the ongoing cancer communication contexts (Venetis, Greene, Checton, & Magsamen-Conrad, Reference Venetis, Greene, Checton and Magsamen-Conrad2015), reciprocity more strongly influenced cancer patient and partner decisions to disclose. Among women contemplating disclosure of their eating disorder, all four anticipated response dimensions were correlated with disclosure intention, but when examined holistically within the DD-MM (Greene, Reference Greene, Afifi and Afifi2009), only reciprocity predicted disclosure intention. Interestingly, within this study context of mental illness disclosure, supportive responses, rather than returned openness and reciprocated sharing, predicted interaction effectiveness. Future research may examine how each of the four dimensions contributes to disclosure intention and retrospective disclosure evaluations.

Rather than four separate dimensions, this research supported three dimensions, given that support and emotional reaction loaded as a single factor. This may have occurred due to our limited sample size, the specific content, or the retrospective nature of recalling an event that had already occurred (i.e., Magsamen-Conrad’s framework is prospective). Perhaps what is most salient to college-student friends is that when sharing personal and potentially stigmatizing information with another, friends provide positive support. Furthermore, that support can be enacted in the form of listening, demonstrating concern, withholding judgment, and affective behaviors such as offering a hug. Future research should continue to explore these dimensions of recipient support.

Limitations and Future Research

As in all research, this investigation presents limitations. One includes the limited sample size. On a practical level, we were challenged to recruit friends in which one had shared their mental illness information with the other and both were willing to participate. This speaks to the nature of dyadic data and motivating two individuals to complete surveys, particularly as our participants are college students and not all were necessarily eligible for extra course credit. The reduced sample size encumbered the number of variables we could entertain in our models. We recognize that variables beyond relational closeness are likely to influence recipient response and could be investigated in future research. However, owing to our sample size, closeness provided a succinct, one-factor variable that has been theoretically supported as predicting how individuals disclose and react in disclosure (Afifi & Steuber, Reference Afifi and Steuber2009; Greene et al., Reference Greene, Magsamen-Conrad, Venetis, Checton, Bagdasarov and Banerjee2012). Despite this limitation, we are pleased with our findings that demonstrate the value of closeness in predicting various recipient responses and how those responses contribute to discloser and recipient evaluations of interaction effectiveness.

A second limitation includes recruiting individuals who consider each other to be friends. Although this approach served the purposes of the current investigation allowing for exploration of disclosure as a dyadic process, there is value in investigating how the relationships between closeness, response, and interaction effectiveness differ among relational partners, friends, and others who are less close. For instance, given the close quarters and frequent interaction of many college students (e.g., dorm life), individuals with mental illness may feel compelled to disclose before they are ready to do so and/or to individuals with whom they are not particularly close. Extensions to the current research could look to incorporate a range of relational types in examinations of dyadic disclosure processes (perhaps even individuals who are no longer friends). Further, disclosure and recipient expectations of recipient response (e.g., degree of support) may differ based on closeness, and these expectations of response may influence perceptions of interaction effectiveness.

A third limitation is the lack of diversity within the sample. Our decision to recruit on a single Midwestern university campus may have constrained the age range and racial diversity of our participants (primarily white/Caucasian), which limits generalizability. Although we did not ask participants for their hometown/country of origin, it is likely that most participants were from the Midwest, which may reflect a unique, regional perspective on mental illness. Attitudes toward and beliefs about mental illness differ across ethnicities, cultures, and countries (e.g., Abdullah & Brown, Reference Abdullah and Brown2011). Future research could replicate this study in a different US region and/or alter the study design so as to capture the role of cultural perspectives on mental illness.

Conclusion

The current research utilized APIM analyses to examine disclosers’ and recipients’ perceptions of the role of closeness, recipient response, and interaction effectiveness during disclosure interactions about mental illness. In terms of theory, results represent initial steps in how we might extend the boundaries of our current conceptualization of disclosure by incorporating both the discloser and the recipient. For instance, several disclosure models, including the DD-MM (Greene, Reference Greene, Afifi and Afifi2009) and RRM (Afifi & Steuber, Reference Afifi and Steuber2009), situate closeness in disclosure processes. The suggestion that closeness functions somewhat differently for disclosers compared to recipients (even though partners in this study evaluated their level of closeness with the other in similar ways) underscores the need to perhaps develop a complementary model that explains the disclosure process from the unique perspective of the recipient.

Practically speaking, results point to the importance of continuing to support college students with mental illness diagnoses in terms of how to manage health-related information. However, university administrators, mental health services, and other support initiatives should consider also supporting or providing information about mental health issues to the general student population. More specifically, the average college student is likely to receive a health-related disclosure, and current findings indicate that recipients who felt they were supportive evaluate the interaction as more effective. Educating college students about how best to be supportive may enhance their feelings of efficacy and, in turn, their evaluations of disclosure interactions. Ultimately, improving the disclosure experience so that both disclosers and recipients report satisfying experiences benefits both dyadic partners but likely has greater implications for the discloser. Supportive responses may reduce feelings of isolation, improve efficacy in further disclosures, and serve to strengthen dyadic closeness.

Participants and Procedures

Participants included 88 adults, ages 22–58 (M = 44.7; SD = 8.47) from a large Southwestern city. To participate, parents needed to speak English and have a child between the ages of 4 and 15 years. The majority of the participants were female (N = 80), and more than half of the sample identified as non-Hispanic and white (n = 58; 65.9%), followed by Hispanic or Latino/a (n = 11; 12.5%). About 50% (n = 43) of the participants indicated they felt the need to lose weight and/or were actively doing something to achieve that goal. Based on our recruitment efforts, which included advertising through a university-wide email, child development centers, preschools, and schools, it is not surprising that 22% of the participants reported having a graduate degree, and another 55% reportedly attended and/or graduated from a four-year institution. More than half (n = 57, 64.8%) fell within a normal body mass index (BMI) range (18.5–25). About 2% were underweight, 16 participants (18.2%) were overweight, and another eight participants (9.1%) were classified as obese.

Participants signed up online or by phone to participate in a one-on-one interview conducted by one of the researchers. Interviews were conducted in a private and quiet space to elicit honest and thorough responses. Each interview took about 45 minutes and was audio recorded and transcribed for analysis. Following the interview, participants completed an online questionnaire pertaining to their own health, their children’s health, and closed-ended items about perceived communication behaviors.

Plan of Analysis

Data analysis began with a constant comparative technique (Strauss & Corbin, Reference Strauss and Corbin1990) that was used to identify themes across the interviews and fine-tune the definition of each category (Glaser & Strauss, Reference Glaser and Strauss1967). A subsample of the transcripts (20%) was coded by the authors, and Cohen’s kappa was calculated for intercoder reliability (Stroud & Higgins, Reference Stroud, Higgins, Sloan and Zhou2011). After intercoder reliability was achieved, the entire set of transcripts was analyzed by one coder to explore the presence of the themes and to identify exemplar quotations. The interview protocol focused on where parents received health and weight management information, what they may perceive as healthy behaviors, how they communicate this information to their children, and difficulties or barriers they perceive in communicating and implementing these healthy behaviors for their children.

Overall Health Schema

When specifically prompted about health behaviors for themselves or for their children, asking, “What do you perceive to be physical activity?” or “What is nutrition?,” parents often provided traits of health. Traits refer to the way parents characterized health to themselves and their families, and included concepts such as importance, definitions of health, and features of health. Traits of health were mentioned 69 times by parents. Many mentions of traits included the notion that health is important. For example, “I think good health is important and everyone should strive for it.” For some, parents simply defined what health is to them and their families: “I believe that health is about balance. It’s important what we eat, think, exercise, stress, and reducing toxins in our environment and food. I believe living green is an important step in being healthy.”

Another example of how parents characterized health by providing definitions and features of health included the outcomes of health: “Without good to excellent health, anyone’s life will not be optimal and life expectancy will be reduced.” Many parents also spoke of food as fuel, that food has a purpose and allows you to feel good. Similarly, parents wanted to teach their children that exercise and food are not punishments or rewards. This became especially true when there was a fear that later in life, their children may not choose a healthy lifestyle or may view exercise and activity as a chore. Parents mentioned their ability to influence choices, and therefore do so by expressing the notion that exercise can be fun, that choosing the apple over cake is a good choice. For example:

Although some parents spoke generally of health definitions and features, others spoke specifically to their children and the goal they have for them:

At the same time, many parents freely provided recommendations for good health. Many parents noted they were “very conscious about just reviewing the food I am taking and kind of assessing whether it is a good choice or bad choice” when it came to their own health. When it came to how to help shape their children’s health and to what physical activity and nutrition are, parents provided numerous recommendations. Many of them kept to their version of the USDA recommendations, including portion sizes, types of food to eat, time to exercise, and so on. As mentioned previously, health was often spoken about as balance and, therefore, some parents indicated that in addition to the guidelines, it is acceptable to treat yourself, or for a child to be a child now and then: “And I was just going to say it’s always a balance because I wanted to have childhood food and things that taste good to them, but I want to also make sure they are getting what they need.” In addition to recommendations based on USDA standards, many parents also believed that where the food came from was more important than the composition of food consumption. For example, they focused primarily on eating organic foods, and spoke less on the ratio of fruits and vegetables to meats and starches. This included foods with no genetically modified organisms (GMOs) or chemicals and no processed foods, only foods with organic and pronounceable ingredients.

Last, there was a difference in how parents spoke about strategies for health behaviors for themselves and how they spoke about health behaviors for their children. Parents often seemed to perceive there was an obligation to work out, to go to the gym, or to go for a run. In other words, they framed it as “working out” (N = 79 compared to N = 27 for mentioning the gym or runs for children). However, for their children, activity and food were about fun and enjoyment (N = 51). That is, children played sports, took dance classes, or went on walks with the family. Children were brought along on grocery shopping trips and helped make dinner as a form of entertainment. Parents reported on the children’s extracurricular activities as forms of exercise, and made the activities fun for their children rather than a chore.

Sources of Health Information

The second theme that emerged revolved around characteristics of health information sources. Parents mentioned intentionally finding sources (N = 85), such as searching online or consulting family and friends, or mentioned unintentionally coming across health information sources (N = 42), such as on social media. Within the theme of intentional sources, parents mentioned signing up for listservs or actively collecting information on social media outlets. For example, one parent commented, “I have Pinterest boards, I’ll save recipes on there. I’ll find something that I think would be applicable for their lunch later. I don’t know if I go and look for it, but I am actively collecting it.” Similarly, parents mentioned intentionally picking up pamphlets or articles from medical offices or the children’s school. For example, “I read the school hand outs of what activities my child does at school and complement this with outside activities to ensure he is getting enough exercise.” Another parent mentioned the various information sources sought, as well as intentionally picking up a pamphlet, “News, talk shows, internet, reading magazines, podcasts. Anywhere really. When I see a brochure or pamphlet in a medical office, I usually take it and read it immediately.”

The second way parents mentioned sources of information are through unintentional sources such as those shared on social media, or when media outlets posted announcements. Facebook, Instagram, and Pinterest were often mentioned as social media outlets on which friends, family, or professionals they “follow” share health information that participants happen to see while on these outlets. For example, “Most recently, I’ve really gotten interested in getting exercise tips and nutrition/food tips through Pinterest, as there is a greater variety of ideas on this website. However, seeing results from my friends who are using specific workouts or making special recipes are much more reliable sources than online resources.” Another parent mentioned, “I usually just find information on the internet, a lot of times I like to look at news my friends post on Facebook.”

The sources parents reported were also distinguishable by whether they were mediated by technology. Of those who mentioned any form of mediated sources, 20 participants identified a formal mediated source, while 32 mentioned an informal mediated source. Formal mediated sources included government sponsored websites, such as the Centers for Disease Control and Prevention (CDC), or large corporations that publish health information, such as WebMD. Informal mediated sources included social media and blogs. For example, one participant said, “I like fitness blogs because these women are moms just like me so I enjoy reading their advice and about their experience.” In addition to general blogs, participants turned to blogs written specifically by other parents or moms. However, participants seemed to have different opinions about blogs, with some believing blogs are more valid accounts of information because these fellow mothers have similar experiences, while others “take it with a grain of salt.”

There were 44 mentions of formal face-to-face, or nonmediated, sources, such as doctors, and 22 mentions of informal face-to-face sources, such as friends and family. For example, “Of course we read information in the newspaper about the healthy diets and what kids will eat and are continually working toward a healthier lifestyle. Mostly we just visit with other parents and friends about new ideas for cooking, snacking, and rewarding our children without totally indulging all of the time.”

The last source parents mentioned is unique, as the source was themselves. Participants often commented on the fact that they mostly rely on their own experiences, such as their education, health background, and familial upbringing. For example, one mother said, “I don’t search for most nutritional advice until there is a serious medical problem, I trust what I have tried myself and what is time-tested to be healthy but taste great or feel great.” Similarly, another parent mentioned her education and that she thinks diet and exercise information should be personal, “I personally feel like … I’m well educated about it I don’t really feel like I need anybody to tell me. It’s just kind of being a person when you should just exercise and eat right. But really, I don’t feel like I need an outside source to come in to tell me what my child should or should not be doing.”

Information Assessment

Whether the information was sought out intentionally or it was stumbled upon unintentionally, parents assessed information on many dimensions. When deciding whether or not to accept the information, parents examined the source based on credibility or trustworthiness, their own common sense, whether it aligned with their own beliefs and ideas of truth, the usefulness, and the topic. The most often cited rationale for paying attention to information was the topic at hand, and therefore the usefulness of the material (N = 10). Parents mentioned information surrounding weight loss, nutrition, and physical activity as the primary topics they pay attention to. This was likely influenced by the prompt of the study and preceding questions in the interview. For example, one mother spoke about weight loss: “Weight loss as I’m like most other women, and always looking to lose a pound or two.”

The most cited rationale for embracing information either intentionally or unintentionally sought out was credibility and overall trustworthiness (N = 24). One participant indicated, “I am most likely to pay attention to messages that come from those that I trust. For example, my doctor, trainer, or friends who have a high interest in health.” Others indicated that information based on scholarly or scientific research was the only type of information they trusted, “[I trust] positive and scientific information in messages because they relay the information that I know to be true, but also imply the science behind what it supports to provide evidence.” Parents also paid attention to social media and news sources when presented with information about health. They indicated that the pure frequency of the information, or even the amount of “likes” something has on Facebook, would warrant the information as credible and a worthwhile read.

Despite being exposed to the same information, and frequently, by way of the news or social media, some parents remained steadfast in their distrust:

Communicating to Children

When asked how they communicated these schemas and perspectives of what they considered good or healthy nutrition and physical activity, parents gave a variety of responses. We were able to separate the majority of responses into two main forms of communication: indirect and direct. Direct communication, outright conversations about nutrition and physical activity, was mentioned only 31 times by parents. These were concerted efforts by parents to talk to their children about physical activity and nutrition, and though they may not have sat down with their children to have a conversation, they did talk directly. The overall tones of conversations were reportedly more casual or conversational: “I just stay conversational. I don’t sit them down and have a talk about it. It’s just part of our lifestyle … . I verbally reinforce, just calling attention to what we’re eating. Not in a way that is obnoxious. Just part of our normal conversation.” Many of the conversations occurred while doing something else, or while partaking in the behavior together (e.g., dinner time, grocery shopping), using it as an opportunity. For example, one parent commented that her strategies depend on the situation:

The direct verbal communication also took the form of education about physical activity and nutrition. For example, parents felt that while eating dinner, they could talk about food choice and portion size:

Another mother discussed the idea of balance and moderation when discussing eating habits, and encouraged her daughter to collaborate in the cooking process in order to instill positive behaviors for the future:

Similarly, parents used direct communication to encourage or suggest to their children to be physically active. For example, “Well, if we are at home, I just suggest that they go outside and play for a while.” Others specifically engaged in physical activity with their children, and used the opportunity to talk about what activity can do for the body or why people should be active.

More often, parents indicated they use indirect communication with their children. Indirect verbal communication was the least used form (N = 14), as once parents started talking about certain behaviors, they began to talk about them in more detail, which then fell into the direct communication category. For example: “I make it a part of meal conversations. If I’ve cooked pasta, for example, and he asks for simple pasta with butter, I will suggest a tomato sauce. Or if we go out for sushi, I suggest that he eat a few edamame.” Nonverbally, we saw indirect communication in the form of modeling behaviors and accessibility of resources. Modeling behaviors have been found to be amongthe most effective ways to encourage healthy behaviors in children (Hamilton & White, Reference Hamilton and White2010); however, the literature often does not pay attention to whether these behaviors are intentional or occur by happenstance. The results here show that many parents purposely modeled healthy behaviors for their children (N = 45). For example, one parent commented on the importance of modeling: “It is important to model healthy behaviors otherwise my child gets mixed messages and is less likely to follow healthy habits if I don’t.” Another example of this involved the importance of both parents modeling healthy behaviors:

Other parents purposefully engaged in healthy behaviors with their children, partaking in the activity, or involving their children in their own activity (e.g., making dinner). For example, “For exercising, my daughter and I like to be active all the time. We dance around when we’re getting dressed and making food in the kitchen, we take walks to nearby parks where we can play.” More often than not, parents engaged in multiple forms of indirect communication, including modeling and talking indirectly about the behavior they were engaging in. For example, the parent in the following vignette mentions going grocery shopping together, planning out meals, and encouraging better choices of food via outcome, without directly saying why healthier options are a better choice (e.g., protein makes you stronger).

We also saw indirect nonverbal communication in the form of controlled accessibility (N = 48). Controlled accessibility was often portrayed in the form of packing lunches, not having certain foods in the house, or enrolling children in schools where healthy eating is required (e.g., schools that have a set list of food parents can pack for their child). For example:

Concerning exercise, controlled accessibility took the form of making sports, classes, and exercise (often labeled as “play time”) readily available. This included parents providing the funds to put their children through these activities, having equipment at home, and driving/showing up to practices, games, and recitals.

Barriers to Healthy Behaviors

Despite the desire to communicate positive weight management practices to their children, parents experienced a number of perceived barriers to both their own and their children’s healthy eating and physical activity. Barriers are the reasons why parents reported they did not implement, or believed it was difficult to encourage, the behaviors they perceive to be healthy. Some parents also reported perceiving these barriers as related to their ability to communicate the need for these behaviors. Many parents mentioned time, accessibility, and money as the primary reasons why they and their family members have trouble eating healthy or meeting the recommended physical activity requirement during the week.

First, time was the most frequently mentioned perceived barrier for both physical activity and healthy eating behaviors. In fact, it was mentioned 76 times throughout the interviews, even when the interviewers did not prompt parents to think about barriers. Parents talked about full schedules, random changes in schedules, and exhaustion. For example, one parent wrote, “Random conflicts popping up keep me from exercising sometimes. Exhaustion from our busy lifestyles can also be a barrier.” These specific examples of barriers often surfaced in the context of physical activity, which was often discussed as a time commitment that required changing clothes, going somewhere to exercise, coming back, showering, and then changing clothes again. For example, “I feel my time is limited. Or not even so limited, but the free time I have is not conducive to getting on by. So maybe my free time is at nine o’clock at night, my kids are in bed, and I can’t leave the house. So I can’t go walk the dogs then, so I’ve missed that window.” Time restrictions also overlap into their children’s lives. Although many parents mentioned their children engaging in sports or dance rather than “working out,” they continued to speak about time as a barrier, especially because many children need to be driven to these activities and parents wanted to show support.

Although time was mentioned frequently in the context of physical activity, it was also a perceived barrier for parents concerning healthy eating. Time was a major issue for parents, as balancing a family and the schedule of each person is difficult; Therefore, in that experience, the time it takes to grocery shop, cook, and clean dishes was perceived as difficult to fit in on a daily basis. One parent mentioned, “It is hard because sometimes we have very busy days where it is just easier to stop and get Whataburger on the way home.” Additionally, when parents did manage to include physical activity into the schedule, adopting healthy eating, also, became a time issue. For example:

One parent mentioned she does not perceive any barriers, because healthy living is a priority in their house: “None really, there are many options to choose from for sports and physical activity you just have to make it a priority.” We therefore considered parents’ making these behaviors a priority and their motivation to do so as a component of time. This subtheme was mentioned an additional 32 times by parents both in the sense that barriers were not perceived because parents made healthy behaviors a priority, and in the context of parents who did not necessarily make these behaviors a priority and chose an alternative. One parent mentioned her biggest fear was that her family just does not prioritize these healthy behaviors: “It requires time and energy and I worry my family does not prioritize working out.”

Second, parents mentioned the accessibility of healthy foods and physical activity as a perceived barrier to engaging in weight management practices. This theme is defined by the inability of parents to find the foods they believe to be healthy. Often, parents characterized accessibility as the inability to easily find or consume non-GMO, organic, or natural foods. Accessibility of nutritious food was also mentioned in relation to the ease of their families’ accessibility to unhealthy food. For example, “Well my concern for her is school lunches. I know that she’s not getting the healthiest things there because it’s made for an army.” This affected the entire family as well, especially when eating out: “Eating out is a concern because I don’t know what they have back there. And things that I think may be scratch is actually a frozen or bagged product.”

Accessibility also frequently referred to an individual’s health. Health issues (e.g., chronic illnesses, diabetes, bad knees) are cited as rationales for why adopting a healthier diet or engaging in physical activity are limited for themselves or for their child. For example, “I have problems with my knee and foot that limits my ability to exercise. And there are no barriers that I can think of that would prevent my child from participating in sports. It is something that he thoroughly enjoys, and couldn’t imagine taking him out of them.” A few parents mentioned the development of health issues (e.g., eating disorders) as a rationale for allowing their children to behave in a particular manner. For example, “I have always been concerned about my children ever having eating disorders, as they are very present in today’s society, especially at a young age. This is why I’ve always been open to them eating whatever they want, but also teaching them about the importance of healthy eating and exercise.” Similarly, safety was cited as an accessibility issue. A family’s neighborhood safety (e.g., crime that may be present) or daylight savings time (e.g., night taking away from the amount of time available to go outside) contribute to parents feeling uncertain about their children or themselves going outside to engage in activity. For example:

Last, and probably most consistent with previous family communication literature, money was the third most prevalent barrier mentioned by participants. Parents referenced the cost of healthy food, gym memberships, or organized sports as a barrier to their own and their children’s regular diet and exercise habits. For example, one parent stated, “I would definitely say one of the biggest barriers about healthy eating is the cost. Food that is better for you is typically more expensive, and my family can’t afford to make sure we’re buying ONLY healthy food.”

Practical Implications

This study provides insight into the way parents seek out and consequently communicate weight management practices, including nutrition and physical activity. The results of this study provide an opportunity to develop stronger, theory-based health interventions targeting parents and the healthy upbringing of their children that incorporate both direct and indirect communication strategies. Moreover, this study provided insight into the differences in how parents vary in their perspectives of health (e.g., fruits and vegetables are healthy, versus the need to be organic) and their ideas of how to communicate this to their children. Interventions targeting parents may help in streamlining what is healthy for children, dispelling myths, and explicating the pros and cons of organic food. The results of this exploration, along with that of future research, will allow us to understand fully what types of messages help promote healthy behaviors. Not only does this research help with parent–child communication, but it also provides guidance for health care providers in talking to their patients’ parents about the best mode of communication to prevent children from being another statistic. Thus, the results of this study, in conjunction with past research, argue for more targeted health promotion tactics that also encourage talk, in conjunction with indirect tactics such as modeling, social control, and positive controlled accessibility.

Limitations and Future Research

Although this study aims to make unique contributions to communication and health scholarship, there are limitations. First, this study relied primarily on a university population. Therefore, many of our participants were of higher socioeconomic status, with 36% of them making more than $150,000 per household. Many of our participants (67%) identified as white or Caucasian and, on average, our parents were of normal weight range. By reaching out to a broader population, the data could be more generalizable, which could provide insight into the way different demographics vary in their communication. However, what does make our population more generalizable is that our population met the national average of overweight or obese children, at just over one third. Additionally, we had a broad range of parents, ages 22–58 years (M = 44.73), and children ranging the full 5–15 years (M = 11.23).

There is room to expand on this research in the future. For one, research should collect data from children about how they perceive the information that is being shared – what do they know? How do they make sense of it? How does it influence their decisions at lunch or at a friend’s house? Exploring the other side of the communicative process will allow researchers to better understand not only how children perceive the communication and therefore act on it, but what motivates children in a positive way to partake in healthier behaviors. Understanding children’s perceptions of communication can help us better shape messages from parents and health care providers without crossing the fine line that may push a child into unhealthy behaviors.

Furthermore, Li, Li, Guan, Ma, and Cui (Reference Li, Li, Guan, Ma and Cui2015) identified ten hotspots for research on health information seeking behavior, and three of the major areas are understanding adult health information seeking via mobile phone and its apps, attitudes and trust in online sources, and utilization of social media by parents. Future research should focus specifically on how parents obtain their health information “online” by specifying if it is through social media, applications, or traditional online research. This would be an interesting intersection for technology and health information seeking behaviors, to identify factors that influence credibility and retention of health information. For example, a few of the parents in our study mentioned the articles on social media that are titled with numbers, such as “10 Ways Blueberries Increase Health.” One parent mentioned not trusting these sources, while another mentioned she liked the streamlined version of this health information. Taking this a step further, it would be advantageous to investigate if preferential differences in health information influence parents’ subsequent communication with their children. It is possible that parents may be more likely to discuss health information with children when it comes from a more simplistic source. As demonstrated in the present chapter, unintentional information seeking consisted of these types of articles on Facebook or Twitter, so this may be an avenue for future research.

Clearly, this project only begins to scratch the surface of our understanding of the parent–child dyad’s communicative processes about weight management practices. Though the research on parent–child communication and health seems to be thorough, there are pieces missing. We aimed to start to fill that gap through a thorough examination of actual messages and communicative efforts. Future research connecting quantitative and qualitative data, as well as dyadic data, will continue to provide a more thorough understanding to help build stronger health promotion messages for parents through mass media and patient–parent–provider communication.