Focus

The crucial role of effective communication in medical care, disease prevention, health promotion, and all other efforts to improve health has gained increasing recognition in recent years. One mark of this new prominence is the inclusion of the health communication focus area in Healthy People 2010. The six major objectives in this rapidly developing field cross disciplinary boundaries in research, teaching, training, and practice. Each objective identifies a needed improvement in research or practice. Together they lay the groundwork for significantly more effective and accessible information for consumers, healthcare professionals, and healthcare organizations.

The objectives cover a range of topics including technology, health literacy, Web site content, and interpersonal skills. Although diverse in form and content, all promote people achieving better health by making accurate and appropriate information more available, accessible, and useful. A midcourse check shows that progress toward the objectives is already under way.

The following summarizes action plans that are the product of discussion and collaboration by subject matter experts from the field, including the Healthy People 2010 Health Communication Focus Area Workgroup (Communicating Health: Priorities and Strategies for Progress, U.S. Department of Health and Human Services, 2003).

Objective 11-1: Increase the Proportion of Households With Access to the Internet at Home

This objective identifies the Internet as a frequent source for health information, and the ability to go online from home makes it easier and more convenient for individuals of all ages to learn about their health.

The 2010 target is that 80 percent of American homes will have an Internet connection. At baseline in 2000, 26 percent of American households could connect to the Internet. By 2003, 55 percent of households were online. Progress toward the objective is quantified by change in the number of households with an established Internet connection and is measured approximately every 2 years by Computer and Internet Use Supplement to the Current Population Survey of the U.S. Census Bureau.

A number of factors influence whether households connect to the Internet. These include access to a dial-up or broadband connection and whether individuals who can go online at school, work, or elsewhere choose to have a computer of their own. The cost of maintaining the connection is a limiting factor for some 27 percent of the households earning less than $50,000 a year, especially when broadband is becoming the new norm.

Furthermore, merely having an Internet connection in the home does not necessarily indicate that it is useful for all or even any members of a household. Navigating the Internet requires adequate computer skills, ongoing technical support, and knowledge of how to find Web content of interest. In addition, households may limit Internet use to certain members. For example, parents may limit access to the Internet because they fear what their children will find online or employees who use a company computer at home may be prohibited from allowing family members access.

Home Internet use has broad implications for health. Individuals can use it to learn about conditions and lifestyle factors and manage their health care whenever they wish—day or night—not just when the computer at their community center, library, school, office, or other away-from-home facility is available. The so-called “digital divide” separates those who can effectively access the vast information resources in cyberspace and those who cannot. Public policies are needed to help more households connect to the Internet so that people do not have to rely on public venues. As an example of an effort to foster more home Internet connections, the National Cancer Institute (NCI) provides a wide range of online resources about the digital divide and approaches to overcoming it at www.dccps.cancer.gov/cancer_resources-digdivide.html#background.

Objective 11-2: Improve the Health Literacy of Persons With Inadequate or Marginal Literacy Skills

An individual’s ability to obtain information about health and the health system, to understand it, and to use it for getting needed health care and making wise health and healthcare decisions is called health literacy. Massive quantities of information are available to Americans about health, treatments, lifestyle factors affecting health, the policies of various payers, and much more. Because Americans must obtain their health care in a complicated system, people’s ability to understand and use information—their level of health literacy—can significantly affect their state of health. Individuals with low health literacy face obstacles when attempting to navigate the healthcare system and make wise health choices. This objective aims to help people improve their ability to deal with information about their health and health care.

Data from the Health Literacy Component (HLC) of the 2003 National Assessment of Adult Literacy (NAAL) will serve as measurement for this objective. The data are expected to become available in mid- to late 2006. The NAAL measures functional literacy in ordinary situations such as reading newspapers and filling out forms. The HLC measures health-related skills such as understanding instructions for taking medication and filling out a patient information form during an office visit. Other tested skills include identifying symptoms that require medical attention and understanding benefits covered by an insurance plan.

Numerous factors influence individuals’ ability to perform such tasks, and thus their level of health literacy. Whether or not the information that healthcare professionals and healthcare systems provide is in a form and at a level the consumer can understand is crucial. Equally important are individuals’ own knowledge of health and the healthcare system, as well as their ability to read and understand English—especially the technical vocabulary that healthcare professionals frequently use. Persons with low health literacy or limited English language skills, furthermore, often hesitate to ask for needed clarifications because they are ashamed of their inadequate abilities. Unfamiliarity with American culture also can stand in the way of understanding.

Education, proficiency in English, and familiarity with American culture are not guarantees to adequate health literacy. In many cases, individuals with all these skills find the complexities of the healthcare system or of medical science overwhelming, especially when ill health and emotional stress add to the challenge of navigating complicated service bureaucracies and understanding obscure technical or bureaucratic terminology.

Low health literacy has broad negative implications for both individuals and the healthcare system. Persons with limited health literacy have poorer health outcomes and higher medical costs than those persons with adequate or high health literacy. Individuals who are less health literate make greater use of high-cost healthcare services, especially hospitalization. They are less likely to participate in regular screenings, and therefore are diagnosed in later stages of diseases. In general, they lack understanding of the importance of treatments and as a result comply more poorly with treatment regimens.

As part of the effort to improve health literacy, the Office of Disease Prevention and Health Promotion (ODPHP) has developed the Quick Guide to Health Literacy. Designed for Federal and state government employees, grantees and contractors, and community partners working in health care and public health, the guide provides key health literacy concepts as well as techniques for better health communication, examples of best practices, and suggestions for organizational improvement. All the information is presented in a format designed for quick and easy reference and can be easily downloaded from www.health.gov/communication/.

Objective 11-3: Increase the Proportion of Health Communication Activities That Include Research and Evaluation

Only through research and evaluation will the quality of health communication activities improve and knowledge of effective practices increase. Although the objective encompasses all types of health communication activities, the first step in measuring the objective is to assess public information campaigns at the U.S. Department of Health and Human Services (HHS); other types of activities, both public and private sector, may be assessed in the future. In the long term, research and evaluation should become accepted as standard elements of all communication programs. Measurement criteria for this developmental objective are under review and are expected to be released in mid-2006.

Convincing those in charge of communication activities to include systematic evaluation is challenging for several reasons. Many healthcare and public health professionals believe that the randomized clinical trial (RCT), the “gold standard” of medical research, is equally appropriate to other areas of investigation. The RCT model, however, with its focus on controlling all possible confounders in order to clarify cause and effect, is not always the most appropriate for communication research, which focuses on synergistic effects among varied messages, media, and contexts. The clear distinction between treatment and control groups so basic to the RCT is often impossible to maintain in communication studies, where other research approaches prove more practical and effective. Because communication research frequently concentrates on getting specific messages to particular audiences, results may not lend themselves to generalizations about best practices for the field at large.

In addition, evaluation activities frequently have to compete for dollars within limited budgets. Often funding the activity takes priority over research and evaluation. Federal agencies may have difficulty obtaining approvals for audience research.

Despite the impediments, the need for evaluation is increasing. Policymakers and program planners face growing pressure to demonstrate that interventions deliver value for money spent. The effectiveness of every kind of health intervention, including communication activities, has therefore become a growing concern.

Examples of how to include evaluation in communications programs are available in CDCynergy, a series of CD-ROMs developed by the Centers for Disease Control and Prevention (CDC) that presents a practical and systematic approach to planning and implementing health communication strategies. Along with extensive references and resources, the series provides illustrative case examples and guides users through the step-by-step process of researching the causes of the health problem relevant to a particular health campaign, determining the population to be reached, selecting an appropriate strategy, and developing and carrying out a communication plan, with evaluation as an integral component of each stage. In addition to the original disc with a basic course, the CDCynergy series includes a growing number of special editions devoted to particular health issues, such as diabetes, cardiovascular health, immunizations, and sexually transmitted disease. Information is available at www.cdc.gov/communication/cdcynergy.htm.

Objective 11-4: Increase the Proportion of Health-Related World Wide Web Sites That Disclose Information That Can Be Used To Assess the Quality of the Site

With increasing numbers of people turning to the Internet to learn about health, the need to assess the quality and currency of the information on Web sites becomes ever more acute. This objective seeks to answer this need by encouraging Web sites to provide the information that users need to make that evaluation. To measure this objective, there must be reliable estimates of both the number of health-related Web sites available on the Internet and the number of sites that disclose information that can be used to assess quality. The information that needs to be disclosed includes the identities of the Web site’s developers and sponsors; the site’s intended purpose, including advertising; the original sources of the site’s content; the means the site uses to protect the privacy and confidentiality of users’ personal information; how the site evaluates its impact on users; and how and how often information is updated. Measurement for this objective is under way. Data are expected to be released in mid-2006.

Disclosure of Web sites’ policies, practices, sources, and sponsors allows consumers to evaluate whether sites are likely to present information that is accurate, up to date, and unbiased. The ability to determine the trustworthiness of a Web site has grown in importance as more people make decisions based at least in part on what they learn from the Internet. By comparing the sites, users can pick those that seem most trustworthy and appropriate. Like the nutritional label on food packages, these disclosures do not tell consumers which sites to use but instead give them the tools to make their own educated choices. What Web sites do with personal information remains an issue of great significance to many users. Even cyber-savvy surfers often find sites’ stated privacy policies to be obscure.

healthfinder® is a gateway Web site linking consumers and professionals to more than 5,000 health information resources from over 1,500 health-related organizations since 1997. The site is managed by ODPHP through its National Health Information Center.

MEDLINEplus provides extensive information on more than 80 health conditions, including hundreds of links to other reliable online resources maintained by Government agencies and other organizations. As the world’s largest medical library, NLM is internationally recognized as a highly trustworthy source of health information. Beyond the library’s worldwide reputation, the site also has earned accreditation from URAC, an independent, nonprofit organization that establishes standards in a number of areas of health care. URAC grants accreditation based on Web sites’ polices of disclosure, linking, privacy, and security; its processes for developing content; and other characteristics. Some 300 health sites have gained URAC accreditation.

Objective 11-5: Increase the Number of Centers for Excellence That Seek To Advance the Research and Practice of Health Communication

Improving the base of knowledge about effective health communication requires research. In turn, that requires institutions to conduct investigations and train practitioners. Centers for Excellence in Health Communication are institutions that effectively pursue these ends, either in research centers, university departments, or other organizations. The target for 2010 is six Centers for Excellence.

A Center for Excellence in Health Communication is defined as an organization making a sustained and concentrated effort to advance the science and application of health communication. It draws on diverse disciplines and adds to knowledge about methods of developing communication-based interventions and applications that promote health and prevent disease. It also trains health communication professionals and fosters dissemination and use of health communication concepts and practices by members of other health professions. Centers for Excellence must have a critical mass of health communication researchers and training programs. NCI, which funds a network of Centers of Excellence in Cancer Communications and Research (CECCR), will continue collecting data to assess this objective for the Healthy People 2010 Final Review.

Since this objective was first reported in 2004, the Federal Government has funded three new health communication centers that may meet the criteria for Centers for Excellence. The John M. Eisenberg Clinical Decisions and Communications Science Center, in the Agency for Healthcare Research and Quality, works to improve communication of health research findings to consumers, clinicians, policymakers, and payers by both conveying information about research findings in ways appropriate to each of these audiences and conducting research into communication methods that will better explain new findings and speed their adoption in clinical practice. Under its Centers of Excellence in Health Marketing and Health Communication program, CDC also has funded the Southern Center for Communication, Health, and Poverty at the University of Georgia and the Center of Excellence for Health Communication and Marketing at the University of Connecticut.

NCI’s CECCR initiative, which typifies efforts to establish new Centers of Excellence in Health Communication, has thus far funded centers at the universities of Michigan, Pennsylvania, and Wisconsin–Madison and at Saint Louis University. Each involves a multidisciplinary group of researchers engaged in projects to discover new theories, methods, and interventions to bring information about cancer more effectively to both the public and healthcare professionals in the hope of reducing health disparities among citizens and disseminating new scientific knowledge as quickly as possible. In addition, these centers will train health communication researchers. Each center’s grant amounts to $10 million over 5 years.

In addition to Federal Government agencies, private funders such as foundations and healthcare organizations also can establish Centers for Excellence. Examples of non-Federal research centers include the Harvard School of Public Health Center for Health Communication, which has undertaken a number of projects, perhaps the best known of which engineered the introduction of the Scandinavian concept of the “designated driver” into the United States, making it a norm of American social life that the driver should avoid drinking. Another example is the Center for Communication Programs at the Johns Hopkins Bloomberg School of Public Health, which has a number of projects in countries around the world.

Objective 11-6: Increase the Proportion of Persons Who Report That Their Healthcare Providers Have Satisfactory Communication Skills

Speaking clearly and effectively with patients is a critical form of health communication. A growing body of evidence links the providers’ communication and interpersonal skills to important outcomes such as patients’ satisfaction, adherence to treatment regimens, and positive health indicators. Evidence shows that clear communication by physicians and interactions between patients and physicians also lead to better results for patients, including better health outcomes and higher rates of adherence to treatment regimens. Little research has been done, however, on patients’ communication skills and their role in the medical interaction.

Progress toward this objective is measured by the Medical Expenditure Panel Survey (MEPS) of the Agency for Healthcare Research and Quality. Four survey items that are part of the MEPS compose the measurement for this objective. The objective seeks the following by 2010: 64 percent of individuals will report that their healthcare providers always listen carefully to them; 65 percent will report that their healthcare providers always explain things understandably; 65 percent will report that their healthcare providers always show respect for what they say; and 52 percent will report that healthcare providers always spend sufficient time with them. In 2003, the responses were 58 percent, 60 percent, 61 percent, and 49 percent, respectively.

By measuring patients’ assessments of their physicians’ communication skills, responses may actually measure patients’ satisfaction with their providers rather than specific communication skills. Ideally, a measure would assess particular skills according to predetermined criteria. Questions in MEPS also do not distinguish the communication skills of members of the various healthcare professions. Instruments should be developed that measure the differences in communication skills that a provider may need depending on his or her role (i.e., physician versus nurse versus physician assistant). More sensitive assessments of the effects of limited health literacy and behavioral differences on the communications skills of both patients and providers also are needed.

Although interviews are central to medical practice and physicians perform thousands over their careers, the training that they receive in communication skills varies widely in content and length, with some medical students receiving only a few hours of instruction and others following organized programs of 40 or more hours.

To improve clinicians’ ability to communicate well with all Americans, the HHS Office of Minority Health has developed National Standards for Culturally and Linguistically Appropriate Services in Health Care. The 14 principles, available at www.omhrc.gov/templates/browse.aspx?lvl=1&lvlID=3, are primarily intended for healthcare organizations but also are appropriate for use in individual practices. Other efforts to help health professionals improve their communication skills include A Family Physician’s Practical Guide to Culturally Competent Care, sponsored by Professional Education Services Group, Science Applications International Corporation, and Astute Technology and supported through unrestricted monies from the HHS Office of Minority Health. The guide is available at http://cccm.thinkculturalhealth.org/.

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Resources

Communicating Health: Priorities and Strategies for Progress, developed by the Office of Disease Prevention and Health Promotion, provides detailed discussion of the background and issues related to the six health communication objectives in Healthy People 2010 at http://odphp.osophs.dhhs.gov/projects/HealthComm/.

Making Health Communication Programs Work (“The Pink Book”), created by the National Cancer Institute, provides detailed guidance in planning, developing, carrying out, and evaluating health communication programs. It is available online and also can be ordered free in hard copy at www.cancer.gov/pinkbook/page1.

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Activities

The Quick Guide to Health Literacy, prepared by the Office of Disease Prevention and Health Promotion (ODPHP), is a quick and easy reference, filled with facts, definitions, tips, checklists, and resources. The guide’s fact sheets provide a basic overview of health literacy concepts. They also offer strategies for improving the usability of health information and health services through communication, knowledge-building, and advocacy. Examples of health literacy best practices are included. The Quick Guide materials are intended to be user-friendly and action oriented. They can be easily reproduced, either individually or as an entire unit. For more information, visit the ODPHP Web site, www.health.gov/communication.

The Health e-Technologies Initiative, a national program supported by the Robert Wood Johnson Foundation, evaluates promising new interventions and seeks to provide the evidence base and knowledge required to build better eHealth programs. The initiative’s Web site is home to a Resource and Communications Center that promotes evidence-based eHealth research and features the Health e-Bytes editorial column, an extensive eHealth literature library, a media center, and a collaboration community. The site also includes information on research tools and resources, a Health e-Technologies Fact Sheet, links, and information on relevant events and conferences. The center is open for use by researchers, policymakers, developers of eHealth applications, and the general public as well as grantees. In addition, the initiative is cosponsoring a Harvard Medical School Continuing Medical Education course titled “Patient-Centered Computing and eHealth: State of the Field.” For more information, visit www.hetinitiative.org/.

The Health Communication Initiative is a nationwide campaign sponsored by the American College of Physicians Foundation. The focus of the initiative is to improve health outcomes by improving health communication. The initiative includes health communication projects; sponsorship of health communication conferences; a patient-centered health literacy program; an Information Rx project with the National Library of Medicine providing physicians with tools to refer patients to accurate and trustworthy health information on the Internet; and HEALTH TiPS, which are 4” x 6” cards containing important information patients need to know to manage their chronic conditions. To learn more about the initiative, visit http://foundation.acponline.org/healthcom/abouthci.htm.

Consumer Health: An Online Manual contains information on a variety of topics including evaluating health Web sites, consumer health information on the Web, health literacy, and Web page design. It was prepared by the National Network of Libraries of Medicine, South Central Region. The manual is available at
http://nnlm.gov/scr/conhlth/manualidx.htm.

To help physicians provide better patient care, the American Academy on Physician and Patient has designed doc.com, an interactive learning resource for healthcare communication, which contains 40 multimedia-rich interactive online modules featuring role-modeling of communication skills. Topics include communicating in specific situations and communicating with colleagues. To learn more about the modules, visit www.physicianpatient.org/.

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In the Literature

Interactive Health Communication Applications for People With Chronic Disease by M.E. Burns et al. The Cochrane Library Issue 1, 2006. John Wiley & Sons Ltd.
This study reviewed computer-based programs known as Interactive Health Communication Applications (IHCAs), which combine health information with online peer support, decision support, or help with behavior change, to determine the impact of such programs on people with chronic disease. The study found largely positive effects of IHCAs on users.

The CIS Model for Collaborative Research in Health Communications: A Brief Retrospective From the Current Generation of Research by A.C. Marcus et al. Journal of Health Communication 10(Suppl 1):235-245, 2005.
The National Cancer Institute’s Cancer Information Service (CIS) provides an example of how a service organization dedicated to health communications also can serve as a laboratory for research. The authors describe CIS efforts in health communication research, suggesting that other service organizations follow the CIS model for collaborative research to improve health communications.

Reducing the Digital Divide for Low-Income Women With Breast Cancer: A Feasibility Study of a Population-Based Intervention by D.H. Gustafson et al. Journal of Health Communication 10(Suppl 1):173-193, 2005.
This article describes a feasibility test for the National Cancer Institute’s Cancer Information Service (CIS) to provide access to an Internet-based system to improve quality of life for rural, underserved breast cancer patients. The authors propose a model for how CIS telephone and partnership program services could disseminate information and support systems, thereby also helping to close the digital divide separating low-income women from the resources they need to manage their cancer.

Health Literacy: A Prescription To End Confusion by Institute of Medicine, Committee on Health Literacy. Washington, DC: National Academies of Science, 2004.
This report examines the effects of limited health literacy and provides recommendations for improving health literacy. These recommendations include what individuals can do to improve their health literacy skills and manage their care better, steps providers and healthcare systems must take, as well as what educators, employers, and community organizations must do. The report calls for multidisciplinary research on health literacy.

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Meetings

56th Annual Conference of the International Communication Association. Dresden, Germany. Visit www.icahdq.org/conferences/confregistration.asp. June 19–23, 2006.

Health Literacy: The Foundation for Patient Safety, Empowerment, and Quality Health Care. Rosemont, IL. Sponsored by the Joint Commission on Accreditation of Healthcare Organizations and Joint Commission Resources. Visit www.jointcommission.org/PublicPolicy/health_literacy.htm. June 26–27, 2006.

Critical Issues in eHealth Research Conference: Toward Quality Patient-Centered Care. Bethesda, MD. Visit www.hetinitiative.org/sub-resources/res-upcoming_events_awards.html. September 11–12, 2006.

CDC’s 2006 National Health Promotion Conference: Innovations in Health Promotion: New Avenues for Collaboration. Atlanta, GA. Visit www.cdc.gov/cochp/conference/index.htm. September 12–14, 2006. (Includes sessions on health policy and communications.)

The Third Health Information Technology Summit. Washington, DC. Visit www.hitsummit.com/. September 25–27, 2006.

4th Annual Public Health Information Network Conference. Atlanta, GA. Visit www.cdc.gov/phin/conference/06conference. September 25–27, 2006.

National Prevention Summit: Prevention, Preparedness, and Promotion. Washington, DC. Registration and abstract information will be posted as it becomes available at www.healthierus.gov. October 26–27, 2006.

American Public Health Association 134th Annual Meeting: Public Health and Human Rights. Boston, MA. Visit www.apha.org/meetings/. November 4–8, 2006.

92nd Annual National Communication Association Convention. San Antonio, TX. Visit www.natcom.org/nca/Template2.asp?bid=4216. November 16–19, 2006.

Fifth Annual National Health Communication Conference: Moving Toward Real Solutions: Advances To Address Low Health Literacy. Washington, DC. Visit http://foundation.acponline.org/healthcom/locationmap.htm. November 29, 2006.

Plain Language 6th International Conference. Amsterdam, The Netherlands. Visit www.plainlanguagenetwork.org/news/. October 11–14, 2007.

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The mission of the Office of Disease Prevention and Health Promotion (ODPHP) is to provide leadership for disease prevention and health promotion among Americans by stimulating and coordinating prevention activities. Prevention Report is a service of ODPHP. This information is in the public domain. Duplication is encouraged.