11 Health Communication

Goal

Overview

For individuals, effective health communication can help raise awareness of health risks and solutions, provide the motivation and skills needed to reduce these risks, help them find support from other people in similar situations, and affect or reinforce attitudes.¹ Health communication also can increase demand for appropriate health services and decrease demand for inappropriate health services. It can make available information to assist in making complex choices, such as selecting health plans, care providers, and treatments.¹ For the community, health communication can be used to influence the public agenda, advocate for policies and programs, promote positive changes in the socioeconomic and physical environments, improve the delivery of public health and health care services, and encourage social norms that benefit health and quality of life.²

The practice of health communication has contributed to health promotion and disease prevention in several areas. One is the improvement of interpersonal and group interactions in clinical situations (for example, provider-patient, provider-provider, and among members of a health care team) through the training of health professionals and patients in effective communication skills.^{3, 4} Collaborative relationships are enhanced when all parties are capable of good communication.

Another area is the dissemination of health messages through public education campaigns that seek to change the social climate to encourage healthy behaviors, create awareness, change attitudes, and motivate individuals to adopt recommended behaviors.^{6, 9, 10} Campaigns traditionally have relied on mass communication (such as public service announcements on billboards, radio, and television) and educational messages in printed materials (such as pamphlets) to deliver health messages. Other campaigns have integrated mass media with community-based programs. Many campaigns have used social marketing techniques.

Increasingly, health improvement activities are taking advantage of digital technologies, such as CD-ROM and the World Wide Web (Web), that can target audiences, tailor messages, and engage people in interactive, ongoing exchanges about health.^{4, 11,} An emerging area is health communication to support community-centered prevention.¹² Community-centered prevention shifts attention from the individual to group-level change and emphasizes the empowerment of individuals and communities to effect change on multiple levels.

A set of Leading Health Indicators, which focus on key health improvement activities and are described in Healthy People 2010: Understanding and Improving Health, all depend to some extent on effective health communication. The promotion of regular physical activity, healthy weight, good nutrition, and responsible sexual behavior will require a range of information, education, and advocacy efforts, as will the reduction of tobacco use, substance abuse, injuries, and violence. For example, advocacy efforts to change prices and availability of tobacco and alcohol products have resulted in lower consumption levels. (See Focus Area 26. Substance Abuse and Focus Area 27. Tobacco Use.) Effective counseling and patient education for behavior change require health care providers and patients to have good communication skills. Public information campaigns are used to promote increased fruit and vegetable consumption (5-A-Day for Better Health!), higher rates of preventive screening (mammogram and colonoscopy), higher rates of clinical preventive services (immunization), and greater rates of adoption of risk-reducing behaviors (Back to Sleep and Buckle Up for Safety).

Health communication alone, however, cannot change systemic problems related to health, such as poverty, environmental degradation, or lack of access to health care, but comprehensive health communication programs should include a systematic exploration of all the factors that contribute to health and the strategies that could be used to influence these factors. Well-designed health communication activities help individuals better understand their own and their communities’ needs so that they can take appropriate actions to maximize health.

Issues and Trends

Communication occurs in a variety of contexts (for example, school, home, and work); through a variety of channels (for example, interpersonal, small group, organizational, community, and mass media) with a variety of messages; and for a variety of reasons. In such an environment, people do not pay attention to all communications they receive but selectively attend to and purposefully seek out information.⁸ One of the main challenges in the design of effective health communication programs is to identify the optimal contexts, channels, content, and reasons that will motivate people to pay attention to and use health information.

A one-dimensional approach to health promotion, such as reliance on mass media campaigns or other single-component communication activities, has been shown to be insufficient to achieve program goals. Successful health promotion efforts increasingly rely on multidimensional interventions to reach diverse audiences about complex health concerns, and communication is integrated from the beginning with other components, such as community-based programs, policy changes, and improvements in services and the health delivery system.^10, Research shows that health communication best supports health promotion when multiple communication channels are used to reach specific audience segments with information that is appropriate and relevant to them.⁶ An important factor in the design of multidimensional programs is to allot sufficient time for planning, implementation, and evaluation and sufficient money to support the many elements of the program. Public-private partnerships and collaborations can leverage resources to strengthen the impact of multidimensional efforts. Collaboration can have the added benefit of reducing message clutter and targeting health concerns that cannot be fully addressed by public resources or market incentives alone.

Research indicates that effective health promotion and communication initiatives adopt an audience-centered perspective, which means that promotion and communication activities reflect audiences’ preferred formats, channels, and contexts.⁶ These considerations are particularly relevant for racial and ethnic populations, who may have different languages and sources of information. In these cases, public education campaigns must be conceptualized and developed by individuals with specific knowledge of the cultural characteristics, media habits, and language preferences of intended audiences. Direct translation of health information or health promotion materials should be avoided. Credible channels of communication need to be identified for each major group. Television and radio serving specific racial and ethnic populations can be effective means to deliver health messages when care is taken to account for the language, culture, and socioeconomic situations of intended audiences.

An audience-centered perspective also reflects the realities of people’s everyday lives and their current practices, attitudes and beliefs, and lifestyles. Some specific audience characteristics that are relevant include gender, age, education and income levels, ethnicity, sexual orientation, cultural beliefs and values, primary language(s), and physical and mental functioning. Additional considerations include their experience with the health care system, attitudes toward different types of health problems, and willingness to use certain types of health services. Particular attention should be paid to the needs of underserved audience members.

Targeting specific segments of a population and tailoring messages for individual use are two methods to make health promotion activities relevant to audiences.¹³ Examples include the targeted use of mass media messages for adolescent girls at increased risk of smoking;¹⁴ the tailoring of computer-generated nutritional information to help individuals reduce their fat intake and increase fruit and vegetable consumption;¹⁵ and a national telephone service for Spanish speakers to obtain AIDS information as well as counseling and referrals.¹⁶

Interventions that account for the cultural practices and needs of specific populations have shown some success. For example, a breastfeeding promotion program among Navajo women that was based on investigations of their cultural beliefs about infant feeding practices showed increased rates of breastfeeding.¹⁷ Similarly, an intervention that used the novela, a popular form of Latino mass media, to reach young people and their parents sought to improve parent-youth communication in Hispanic families and to influence the adolescents’ attitudes about
alcohol.¹⁸

Advances in medical and consumer health informatics are changing the delivery of health information and services and are likely to have a growing impact on individual and community health.^{3, 4, 11, 19} The convergence of media (computers, telephones, television, radio, video, print, and audio) and the emergence of the Internet create a nearly ubiquitous networked communication infrastructure. This infrastructure facilitates access to an increasing array of health information and health-related support services and extends the reach of health communication efforts. Delivery channels such as the Internet expand the choices available for health professionals to reach patients and consumers and for patients and consumers to interact with health professionals and with each other (for example, in online support groups).

Compared to traditional mass media, interactive media may have several advantages for health communication efforts. These advantages include (1) improved access to personalized health information, (2) access to health information, support, and services on demand, (3) enhanced ability to distribute materials widely and update content or functions rapidly, (4) just-in-time expert decision support, and (5) more choices for consumers.^{4, 21} The health impact of interactivity, customization, and enhanced multimedia is just beginning to be explored, and already interactive health communication technologies are being used to exchange information, facilitate informed decisionmaking, promote healthy behaviors, enhance peer and emotional support, promote self-care, manage demand for health services, and support clinical care.

Widespread availability and use of interactive health communication and telehealth applications create at least two serious challenges. One is related to the risks associated with consumers’ use of poor quality health information to make decisions. Concerns are growing about the Web making available large amounts of information that may be misleading, inaccurate, or inappropriate, which may put consumers at unnecessary risk. Although many health professionals agree that the Internet is a boon for consumers because they have easier access to much more information than before, professionals also are concerned that the poor quality of a lot of information on the Web will undermine informed decisionmaking. These concerns are driving the development of a quality standards agenda to help health professionals and consumers find reliable Web sites and health information on the Internet. An expert panel convened by the U.S. Department of Health and Human Services describes high quality health information as accurate, current, valid, appropriate, intelligible, and free of bias.⁴

The other challenge is related to the protection of privacy and confidentiality of personal health information. The personal privacy and the confidentiality of health information are major issues for consumers, and these concerns are magnified when information is collected, stored, and made available online.⁴ As the availability and variety of interactive health applications grow, consumer confidence about developers’ ability or intent to ensure privacy will be challenged. In the near future, personal health information will be collected during both clinical and nonclinical encounters in disparate settings, such as schools, mobile clinics, public places, and homes, and will be made available for administrative, financial, clinical, and research purposes. Although public health and health services research may require de-identified personal health information, policies and procedures to protect privacy will need to ensure a balance between confidentiality and appropriate access to personal health information.

The trend of rapidly expanding opportunities in health communication intersects with recent demands for more rigorous evaluation of all aspects of the health care and public health delivery systems and for evidence-based practices.²⁰ Numerous studies of provider-patient communication support the connection among the quality of the provider-patient interaction, patient behavior, and health outcomes.²¹ As the knowledge base about provider-patient interactions increases, a need becomes apparent for the development of practice guidelines to promote better provider-patient communication. Additional evidence about the process of health information-seeking and the role of health information in decisionmaking also is needed. Health communication campaigns could benefit as well from more rigorous formative research and evaluation of outcomes. Expected outcomes should be an important consideration and central element of campaign design. As health communication increasingly involves electronic media, new evaluation approaches are emerging.^{4, 22, 23, 24} Given the critical role that communication plays in all aspects of public health and health care, health communication and outcomes research should become more tightly linked across all health communication domains.

Because national data systems will not be available in the first half of the decade for tracking progress, one subject of interest concerning health communication is not addressed in this focus area’s objectives. Representing a research and data collection agenda for the coming decade, the topic covers persons who report being satisfied with the health information they received during their most recent search for such information. Health-conscious consumers increasingly are proactive in seeking out health information. Individuals want information about prevention and wellness as much as about medical problems. Public health and the medical community share an interest in promoting—and sustaining—informed decisions for better health. Surveys suggest that people want to get health

information from a professional and that counseling by health professionals can be effective both in reducing lifestyle risks and supporting self-management of chronic diseases like diabetes. (See Focus Area 1. Access to Quality Health Services and Focus Area 7. Educational and Community-Based Programs.) However, diminished time in clinical visits and some clinicians’ discomfort with open communication work against optimum information exchange. In addition, many people want information to be available when and where they need it most. Health information should be not only easily accessible but also of good quality and relevant for the needs of the person. The increasing use of the Internet as a source for health information will require greater awareness of the importance of the quality of information.

Disparities

Research indicates that even after targeted health communication interventions, low-education and low-income groups remain less knowledgeable and less likely to change behavior than higher education and income groups, which creates a knowledge gap and leaves some people chronically uninformed.²⁵ With communication technologies, the disparity in access to electronic information resources is commonly referred to as the “digital divide.”²⁶ The digital divide becomes more critical as the amount and variety of health resources available over the Internet increase and as people need more sophisticated skills to use electronic resources.²⁷ Equitably distributed health communication resources and skills, and a robust communication infrastructure can contribute to the closing of the digital divide and the overarching goal of Healthy People 2010 to eliminate health disparities.

Even with access to information and services, however, disparities may still exist because many people lack health literacy.²⁸ Health literacy is increasingly vital to help people navigate a complex health system and better manage their own health. Differences in the ability to read and understand materials related to personal health as well as navigate the health system appear to contribute to health disparities. People with low health literacy are more likely to report poor health, have an incomplete understanding of their health problems and treatment, and be at greater risk of hospitalization.²⁹The average annual health care costs of persons with very low literacy (reading at the grade two level or below) may be four times greater than for the general population. An estimated 75 percent of persons in the United States with chronic physical or mental health problems are in the limited literacy category. People withchronic conditions, such as asthma, hypertension, and diabetes, and low reading skills have been found to have less knowledge of their conditions than people with higher reading skills. ^{, 30}

Although the majority of people with marginal or low literacy are white native-born Americans,³¹ changing demographics suggest that low literacy is an increasing problem among certain racial and ethnic groups, non-English-speaking populations, and persons over age 65 years. One study of Medicare enrollees found that 34 percent of English speakers and 54 percent of Spanish speakers had inadequate or marginal health literacy.³² As the U.S. population ages, low health literacy among elderly people is potentially a large problem. Nearly half of the people in the elderly population have low reading skills, and reading ability appears to decline with age. A study of patients 60 years and older at a public hospital found that 81 percent could not read and understand basic materials such as prescription labels and appointments.³³

Opportunities

A national health information infrastructure (NHII) provides a framework that stakeholders can use to communicate with each other and to transform data into useful information on multiple levels. Efforts are under way throughout the world to develop integrated national and global health information infrastructures to support health improvements. In the United States, the National Committee on Vital and Health Statistics (NCVHS) is advising the Secretary of Health and Human Services and Congress on the health information needs of the country. The NCVHS defines NHII as all of the technologies, standards, applications, systems, values, and laws that support individual health, health care, and public health. Issues related to technical standards, privacy and confidentiality, and regulatory guidelines are being addressed by the public and private sectors. ^{, 34}

The infrastructure makes it possible for people not only to use health information designed by others but also to create resources to manage their own health and to influence the health of their communities. For example, community groups could use computers to gain access to survey information about the quality of life in their neighborhoods and apply this information to create an action plan to present to local elected and public health officials. Information is a critical element of informed participation and decisionmaking, and appropriate, quality information and support services for all are empowering and democratic.

As patients and consumers become more knowledgeable about health information, services, and technologies, health professionals will need to meet the challenge of becoming better communicators and users of information technologies. Health professionals need a high level of interpersonal skills to interact with diverse populations and patients who may have different cultural, linguistic, educational, and socioeconomic backgrounds. Health professionals also need more direct training in and experience with all forms of computer and telecommunication technologies. In addition to searching for information, patients and consumers want to use technology to discuss health concerns, and health professionals need to be ready to respond. To support an increase in health communication activities, research and evaluation of all forms of health communication will be necessary to build the scientific base of the field and the practice of evidence-based health communication. Collectively, these opportunities represent important areas to make significant improvements in personal and community health.