About Zhiwen Xiao, Ph.D.: Zhiwen Xiao is an Associate Professor of Health Communication at the University of Houston’s Jack J. Valenti School of Communication. She is a prolific scholar who focuses on the interplay of health literacy, behavior change, and health outcomes in vulnerable populations, with a particular emphasis on patients with HIV/AIDS and individuals who are at risk of contracting the disease. She has researched how culture, public education, and interpersonal communication dynamics impact the use of condoms and other safe sex practices in China, and her findings have been published in journals such as Psychology, Health and Medicine, AIDS Care, Journal of Health Communication, AIDS Education and Prevention, and the International Journal of Sexual Health, among others. She has also conducted research on the impact that racism has on health care access, quality, and outcomes in the United States, and has conducted comparative analyses of how African Americans and Asian Americans experience health care and health care related discrimination. During the recent COVID-19 crisis she examined the mental health impact that the pandemic and its associated social and health care crises had on different sectors of the American population.

As an Associate Professor, Dr. Xiao teaches courses in health communication theory and research, health campaigns, health literacy, quantitative research methods, multicultural health communication, and more. She is also a Faculty Affiliate for the Women’s Studies Department at the University of Houston. She earned her Bachelor of Arts in English from Wuhan University, her Master’s in Mass Communication from Southern Illinois University at Carbondale, and her Ph.D. in Health Communication from the University of Kentucky.

Interview Questions

[MastersinCommunications.com] Could you elaborate on the classes you teach as an Associate Professor at the Jack J. Valenti School of Communication, as well as your areas of research expertise?

[Dr. Zhiwen Xiao] I’ve taught classes at both the undergraduate and graduate levels at the Jack J. Valenti School of Communication. The undergraduate classes include Introduction to Communication Theory, Health Literacy, Health Campaigns Principles, Multicultural Health Communication, and Research Methods; the graduate classes include Health Communication Theory and Research, Health Campaigns, Health Literacy, and Quantitative Research Methodology.

My research has primarily focused on the behavioral and social aspects of HIV/AIDS prevention and management among at-risk populations and people living with HIV/AIDS. I’ve explored how individual-level and social-level factors determine behaviors related to HIV/AIDS prevention and management. I’ve also examined how health communication influences such individual-level and social-level factors to promote desired health outcomes and behaviors among the populations studied.

Recently, I’ve expanded my research to examine the relationship between perceptions of racism and health, to test a comprehensive model of mental health under the pandemic from health and crisis communication perspectives, to investigate health literacy and health disparities among ethnic minorities in the US and how health literacy influence health-related information seeking behaviors.

[MastersinCommunications.com] May we have an overview of your past and current research interests in health communication? What drew you initially to researching sexual health practices amongst different communities in rural and urban China? What have been some of your principal findings?

[Dr. Zhiwen Xiao] As I mentioned earlier, my research has primarily focused on the behavioral and social aspects of HIV/AIDS prevention and management among at-risk subpopulations and people living with HIV/AIDS in China. Initially, injection drug use and commercial plasma collection were considered as the major routes of HIV infection in China, and not much attention was paid to sexual transmission. China has seen dramatic changes in attitudes toward premarital and extramarital sex since 1990s and majority of Chinese believe premarital sex is acceptable. Therefore, there has been a significant rise in unconventional sexual activity among Chinese people (e.g., engaging in sex earlier, having more casual and multiple partners).

In addition, commercial sex and MSM (men who have sex with men) have been becoming very much alive since 1990s. However, a lot of people did not have the idea of safer sexual behavior and did not use condoms adequately. Sexual transmission has therefore become a primary mode of HIV infection, and one which bridges HIV infection to the general population. At the time when I was still a Ph.D. student, the number of HIV infection cases was increasing significantly in China, especially among certain at-risk populations (e.g., college students, MSM, female sex workers), but research on behavioral aspects of HIV prevention (e.g., safer sex) was very limited. Meanwhile, my professors (such as Dr. Philip Palmgreen, Dr. Rick Zimmerman, Dr. Seth Noar) were conducting prominent and influential research on HIV prevention. These factors drew me to researching sexual health practices among at-risk Chinese populations.

My early-stage research has focused on the effects of individual differences and social contextual variables on HIV preventive and safer sex behaviors (such as condom use) and sexual communication among diverse Chinese populations, including Chinese college students, Chinese men who have sex with men (MSM), Chinese female sex workers (FSWs), and Chinese migrants. I have also investigated the impact of sexual revolution on the HIV epidemic among Chinese women. Some of the primary findings of these studies include: positive attitudes, social norms, and self-efficacy are significant predictors of condom use among Chinese college students, and social norms regarding condom use are a stronger predictor of condom use than positive attitudes towards condom use; sexual communication about condom use and HIV/STDs prevention is associated with condom use among MSM; exposure to HIV/AIDS prevention information delivered by various mass media outlets (such as radio, street posters and the Internet) is associated with sexual communication about HIV or condom use with sexual partners among female sex workers; and sexual communication mediates the effects of self-efficacy regarding condom use among homosexually and heterosexually active migrant men and women in Beijing, China.

These studies underscore the importance of including components that promote positive attitudes towards condom use, positive social norms regarding condom use, safer sex self-efficacy, and sexual communication in HIV prevention interventions for various at-risk Chinese populations. These studies have been published by AIDS Care; AIDS Education and Prevention; Psychology, Health and Medicine; Journal of Health Communication; International Journal of Sexual Health; and other journals.

I conducted systematic or meta analyses on some of the HIV prevention intervention programs conducted in China. For example, the meta-analysis study published by AIDS Patient Care and STDs (2012) included a total of 26 programs and the systematic review study published by the International Journal of Public Health (2013) included a total of 45 programs. The studies found that in China, many HIV prevention interventions have successfully reduced HIV risk-related outcomes; however, the majority of the interventions included in the studies were not based on theories and did not report conducting formative research or process evaluation. These two meta- or systematic analysis studies also found that those interventions that reported the conduction of formative research and process evaluation, that were peer-led, that used pretest-posttest control group design, and that combined nonmedia channels, printed, and visual materials, were more likely to report positive impact on condom use behavior among target audiences. These studies point to important future directions for both research and practice in HIV prevention efforts in China.

Later my research has been expanded to the area of HIV management among Chinese people living with HIV/AIDS by investigating their disclosure of HIV infection status, coping, social support, HIV-related stigma, depression, quality of life, and the factors that influence their adherence to antiretroviral therapy from a health communication perspective. These studies bring to the fore the fact that psychological interventions are greatly needed for Chinese people living with HIV/AIDS and these interventions should focus on providing emotional, informational, social, and appropriate functional support, and reducing or eliminating stigmas relating to HIV in order to encourage people living with HIV/AIDS to implement effective coping strategies such as active support seeking, acceptance, and direct action. These studies can be seen in AIDS Care; Psychology, Health and Medicine, and others.

Recently, I’ve been conducting research to examine the relationship between the perceptions of racism and health among African Americans and Asian Americans and compare the differences between the two groups and within each group. I’ve also been investigating how health literacy and crisis efficacy influence COVID-19 related mental health. In addition, I’ve been studying health literacy among ethnic minorities in the US and Americans’ health-related information seeking behaviors.

[MastersinCommunications.com] Much of your research concerns the intersection of social norms, family dynamics, health communication programming, and AIDS prevention and management. What communication strategies and methods have you found to be the most effective when designing and implementing sexual health care interventions?

[Dr. Zhiwen Xiao] Communication strategies and methods that focus not only on individual factors, but also on interpersonal/family dynamics will be more effective when designing and implementing sexual health care interventions. My research found strengthening parent-child communication is very important in preventing adolescents’ risky behaviors. Parent-based interventions can focus on enhancing parent communication skills that reflect what is conceivable, what is open to discuss, what types of messages adolescents might view as important for their parents to convey, and how to operate open discussions with their children. Effective intervention programs can employ personal examples that the targeted parents can easily relate to or influential figures who have high credibility among the targeted parents to demonstrate how they effectively communicate with their children.

On the other hand, children-based intervention programs can assist young people in mastering and developing communication skills and self-efficacy by providing them coping strategies such as how to voluntarily approach their parents to discuss sexual behaviors, and how to deal with the potential punishments from parents or possible emotional outrages of parents when sensitive topics or problems have been discussed or disclosed. Since adolescents are heavy media users, using an entertainment-education strategy, that is, combining entertainment with parent-child communication education in the mass media such as television, DVDs, and movies, could therefore be an effective way of improving young people’s communication skills and communicative self-efficacy.

My research also underscored the importance of including components that promote sexual communication between sexual partners, for example, increasing frequency and effectiveness of sexual communication and teaching partner communication skills in HIV/STIs prevention interventions for at-risk populations. My research suggests that HIV/STIs prevention programs may benefit from promoting sexual partners’ willingness to engage in sexual communication and assertiveness in sexual communication. In addition, my research found that communication strategies that facilitate sexual partners to increase the feeling of obligation to inform HIV status and to overcome the fear of rejection caused by disclosure of HIV status would promote voluntary HIV disclosure between sexual partners and positive coping with the disease.

Communication strategies and methods that focus on community factors and cultural/social norms will also be more effective when designing and implementing sexual health care interventions. For example, interventions that focus on providing emotional, informational, and appropriate functional social support from communities and families as well as those that aim to increase accessibility and availability of preventive screening tests and preventive methods will be more likely to increase sexual well-being. In addition, communication strategies that strive to eliminate/reduce HIV- or sexual health-related social/cultural stigma and to change some cultural beliefs/social norms (e.g. women should not negotiate protective behaviors, unsafe sex is more enjoyable) might be more effective in increasing sexual well-being. Health is a global phenomenon and a culturally dependent concept. Culture affects health-related behaviors, which in turn affects health outcomes. I believe culturally relevant, sensitive and competent strategies are a “must” to have in health communication.

[MastersinCommunications.com] What methodologies do you employ in your investigation of health communication and health behaviors? Do you use primarily qualitative research, quantitative research, or a mixture of both?

[Dr. Zhiwen Xiao] I use both quantitative and qualitative research methods. For quantitative research studies, I have conducted cross-sectional surveys and utilized different statistical techniques such as structural equation modeling (SEM), multiple regression analysis, ANOVA tests, MANOVAs, mediation analysis, and t-tests/chi-square tests. For example, in the study which investigated social support, depression and quality of life among people living with HIV in Guangxi, China, a survey was administered among 3002 participants and structural equation modeling (SEM) was used to test the conceptual model. In addition, I’ve been conducting randomized controlled trials to develop and test a couple of interventions recently.

For qualitative research studies, I’ve conducted focus groups, in-depth interviews, and content/textual analyses. For example, in the study that was trying to understand perceptions of obesity among African American women, photovoice and in-depth interviews were employed to document, reflect, and communicate perceptions and experiences regarding obesity among a group of African American women.

I think there are challenges in each stage of conducting research with human beings. For example, deciding on a relevant research topic, finding an appropriate theoretical rationale, proposing innovative research questions and hypotheses, selecting a research site and acquiring access to the site, recruiting study participants, building trust and rapport with participants, getting local institutions to support and participate, cleaning and dealing with data, employing the most sufficient and appropriate study design and statistical techniques–these are all challenging but important work items to accomplish.

There are a lot of techniques and strategies we can use to deal with these challenges. For instance, we can use gatekeepers, word of mouth, snowballing, token of gifts, face-to-face meetings/discussions, among others, to recruit and retain participants. To build trustful relationships with participants, we need to provide participants with adequate information about the researchers and the study, and we need to ensure they understand what the study is about and what their rights are for participation. We also need to make sure that the researchers are not perceived just as some irrelevant outsiders or “experts” by participants. Sometimes we also want to build partnership with local communities or organizations during the research process. Partnership can help us recruit and retain participants, and solve problems that we encounter in the process. Some of my research studies would not have been able to be implemented if our research team did not build a trustful partnership with local CDCs in China. Lastly, attending research methodology workshops regularly is a good way to update knowledge and skills and tackle challenges in research.

[MastersinCommunications.com] How has your research informed your teaching in areas such as health campaign development, multicultural health communication, health communication research, and health literacy?

[Dr. Zhiwen Xiao] Based on previous research studies (e.g., Noar, 2006) and my own systematic and meta analyses, interventions that are theory-based, peer-led and culturally sensitive, that conduct formative research (e.g., preproduction research and production research/pretesting) and process evaluation, that do meaningful audience segmentation, that use appropriate targeting and tailoring approaches, that employ multiple media outlets plus interpersonal communication, that use a sophisticated outcome evaluation design, and that tackle both individual and societal level factors, might be more likely to be successful.

Also, my research findings suggest that minority racial/ethnic groups (e.g., Korean and Vietnamese Americans/immigrants) report significant differences in health literacy and such significant racial/ethnic disparities in health literacy are associated with racial/ethnic disparities in self-perceived health status and utilization of health care services. Therefore, interventions should consider the health literacy skills of target audiences (e.g., whether target audiences understand intervention messages)

My research has informed my teaching. I assign my students to read my research studies and other research publications. Also, I require students to conduct research-oriented projects. When I teach my health campaigns class, I ask my students to conduct research and analysis on a case of health communication campaign based on the above principles. I also ask them to develop and evaluate a health campaign by applying the above principles. For my health communication theory and research class, students are required to research a specialized area of health communication of interest to them. This assignment helps students explore their research skills, including reviewing, analyzing, and synthesizing the existing literature on a particular topic, developing innovative research questions and hypotheses pertaining to health communication in practice, and applying advanced research methods to a study that they propose, design, implement, and present.

For my health literacy class, students are required to develop a tri-fold educational brochure on a health problem. Students need to apply the principles mentioned above and the brochure should be written at the 8th grade reading level or lower. Students are also required to propose a field-testing plan (i.e., a plan on how to pre-test the efficacy of the brochure). Students enjoyed the course projects, because they got to conduct field research and apply class concepts beyond the classroom.

[MastersinCommunications.com] How do you see the field of health communication (and more specifically sexual health communication) evolving in the coming years, both within the United States and internationally?

[Dr. Zhiwen Xiao] I agree with other scholars (such as Beck, Thompson, Rimal) in the field of health communication and public health that the scholarship of health communication has established credibility and visibility in the broader communication discipline both within the United States and internationally. A lot of students and faculty are attracted to the field of health communication. And health communication scholars have been exploring and employing communication strategies to address health problems and improve health education and promotion. Also, a lot of health professionals recognize the importance of health communication in their practice. I had a lot of students (both undergraduate and graduate) who were from the medical field or health-related organizations. They have started to employ effective health communication skills or strategies to interact with patients or clients. Some of them have started to revise health communication materials for their organizations.

The field of health communication is gaining recognition nation-wide and internationally because the field emphasizes the use theories of communication and behavior change to guide practice. However, there are challenges–for example, misinformation shared online and among the public–that future health communication scholarship needs to address. Also, scholars in health communication need to become more prominent and influential in social and health care policy.

According to Thompson, a famous scholar in Health Communication, nearly 75% of the published articles focused on AIDS/HIV/safer sex in the first 5 years of Health Communication, one of the two flagship journals in the field of health communication. However, a systematic analysis study of the articles published by the journal from 1989 to 2010 found that only 6.2% of all articles focused on AIDS/HIV/safer sex, indicating sexual health communication might have drawn much less attention from researchers in the field of health communication between 1989 and 2010. To get a better sense about how many studies have focused on sexual health communication since 2010, I did a quick search in the database of Academic Search Complete. I perceive research on sexual health communication has been more active internationally than within the United States in the past decade.

The United States is one of the developed countries that rank top in rates of sexually transmitted infections and diseases. However, there are only 18 states in the US that require sex education to be medically accurate; 39 states and the District of Columbia mandate sex education and/or HIV education [but only 28 states and the District of Columbia mandate both sex education AND HIV education], and only 19 states require inclusion of information on condoms or contraception (Data from the Guttmacher Institute). These facts indicate research on sexual health communication is still greatly needed.

[MastersinCommunications.com] May we have an overview of the University of Houston’s Master of Arts in Health Communication program and how the mission of this program intersects with your mission as a scholar, instructor, and advocate of health communication?

[Dr. Zhiwen Xiao] Health communication is a rich, multidisciplinary area of study. Our graduate program equips health communication students with practical and theoretical knowledge to examine how individuals and communities define health and illness as well as how they prevent, control and manage diseases and promote health.

Our courses include Health Communication Theory & Research, Communication in Healthcare Contexts, Communication & Crisis Across Lifespans, Health Campaigns, Health Literacy. Our curriculum features a comprehensive approach to health delivery and promotion. Students who chose to pursue a graduate degree with our program gain knowledge in various subjects, including: patient-provider communication, social marketing and communication campaigns on health-related behavioral change, cultural influences on health meanings and treatment preferences, health citizenry and health literacy, communication within healthcare organizations, risk and crisis management, the influence of narrative and interactive media — including e-health and telemedicine — on public understanding and health promotion.

My mission as a scholar, instructor, and advocate of health communication equipment my students with theoretical, practical, and adaptable knowledge and skills that can support students’ professional practice and career growth.

Thank you, Dr. Xiao, for your fascinating discussion of your research in sexual health education and health communication!