Progress Review

Health Communication

April 19, 2007

In the eighth session in the second series of assessments of Healthy People 2010, ADM John O. Agwunobi, Assistant Secretary for Health, chaired a focus area Progress Review on Health Communication. He was assisted by staff of the lead agency for this Healthy People 2010 focus area, the Office of Disease Prevention and Health Promotion (ODPHP), as aided by staff of the Centers for Disease Control and Prevention (CDC). Also participating in the review were representatives from other U.S. Department of Health and Human Services (HHS) offices and agencies. In his opening statement to Progress Review participants, ADM Agwunobi noted that the critical importance of communicating health information clearly and effectively to the public had been amply demonstrated during such emergency situations as the hurricanes of recent years and the developing threat of pandemic influenza.

The complete text for the Health Communication focus area of Healthy People 2010 is available online at www.healthypeople.gov/document/html/volume1/11healthcom.htm. More recent data used in the Progress Review for this focus area’s objectives and their operational definitions can be accessed at wonder.cdc.gov/data2010. For comparison, the report on the first-round Progress Review (held on June 24, 2003) is archived at www.healthypeople.gov/data/2010prog/focus11/2003fa11.htm. The meeting agenda, tabulated data for all focus area objectives, charts, and other materials used in the Progress Review can be found at a companion site maintained by the CDC National Center for Health Statistics (NCHS): www.cdc.gov/nchs/about/otheract/hpdata2010/focusareas/fa11-healthcomm2.htm.

Data Trends

In an overview of data for the focus area, NCHS Director Edward Sondik observed that more than one in three adults in the United States (77 million people) lack a sufficient degree of health literacy to interpret an over-the-counter drug label, know when a child should receive a vaccine, or use a body mass index chart. While access to health information via the Internet is improving, disparities among population groups still persist. All objectives and subobjectives encompassed by the focus area are now measurable; at the beginning of the decade, only one objective was measurable. Of the nine objectives and subobjectives highlighted in the Progress Review, one surpassed its target, three improved, two showed little or no change, and three became measurable so recently as to have only baseline data at the time of the Progress Review. Dr. Sondik then presented a more detailed examination of particular objectives.

(Obj. 11-1): In 2003, 64 percent of the total U.S. population aged 18 years and older had access to the Internet in their home, compared with 57 percent in 2001. Among racial and ethnic populations for which data were available, the proportions with access in 2003 were as follows: Asians/Pacific Islanders, 72 percent; non-Hispanic whites, 70 percent; non-Hispanic blacks, 48 percent; Hispanics, 45 percent; and American Indians/Alaska Natives, 40 percent. Achieved level of education is an important determinant of home access to the Internet. In 2003, 78 percent of those with at least some college education had access, compared with 56 percent of high school graduates and 28 percent of those who had not completed high school. In 2001, 59 percent of people without disabilities had Internet access at home, compared with 42 percent of people with disabilities. The target is 80 percent.

(Obj. 11-2): In 2003, 12 percent of the total population aged 16 years and older were at a proficient level of health literacy, 53 percent were at an intermediate level, 22 percent were at a basic level, and 14 percent were below the basic level. (For a list of criteria used in determining assignments to these categories, go to the NCHS link referenced in the introduction and refer to slide 13 under Data Presentation.) Among racial and ethnic populations for which data were available, the proportions below the basic level were as follows: non-Hispanic whites, 9 percent; Asians/Pacific Islanders, 13 percent; non-Hispanic blacks, 24 percent; American Indians/Alaska Natives, 25 percent; and Hispanics, 41 percent. Among people aged 65 years and older, 29 percent were below the basic level. The proportion of people with disabilities that was below the basic level was 23 percent, compared with 10 percent of people without disabilities. By education level, 54 percent of people aged 25 years and older who had not completed high school were below the basic level, compared with 15 percent of high school graduates in that age range, and 5 percent of those in the age range who had at least some college education. At the time of the Progress Review, targets had not been determined for the two subobjectives—Obj. 11-2a (to increase the percentage of adults in the Proficient category) and Obj. 11-2b (to decrease the percentage of adults in the Below Basic category).

(Obj. 11-3): In baseline year 2005, 95 percent of HHS-sponsored health communication campaigns had included research conducted during program development (Obj. 11-3a—target, 100 percent); 81 percent included documentation and study during implementation (Obj. 11-3b—target, 89 percent); and 59 percent provided for measurement of campaign impact (Obj. 11-3c—target, 65 percent). These results are based on a sample of HHS-sponsored health communication campaigns.

(Obj. 11-4): In baseline year 2006, less than 10 percent of health-related Web sites disclosed the identity of the persons/organizations responsible for the site (Obj. 11-4a—target, 19 percent); 35 percent disclosed the purpose or mission and limitations of the site (Obj. 11-4b—target, 40 percent); less than 1 percent clearly differentiated between advertising and non-advertising content and stated editorial policy or authorship (Obj. 11-4c—target 10 percent); 75 percent disclosed their privacy/user protection policy (Obj. 11-4d—target, 80 percent); 59 percent provided a mechanism for user feedback (Obj. 11-4e—target, 64 percent); less than 1 percent disclosed the date of creation, update, or review of the health content displayed (Obj. 11-4f—target, 10 percent); and 24 percent met three or more of the preceding evaluation criteria (Obj. 11-4g—target, 29 percent). The foregoing data are the result of a survey of 102 health-related Internet sites. The overall aim of the objective is to increase the proportion of Web sites that provide information that can be used to assess the quality of the sites.

(Obj. 11-5): In 2003, four Centers of Excellence met the criteria for the objective. By 2006, the total had increased to eight, the four newer ones being Centers of Excellence for Health Communication Research. This surpasses the target of six. All eight of the centers are federally funded, four by the National Cancer Institute/National Institutes of Health and four by CDC.

(Obj. 11-6): In 2004, 58 percent of patients aged 18 years and older reported that doctors or other healthcare providers always listened carefully to them, compared with 57 percent in 2000 (Obj. 11-6a—target, 64 percent); 59 percent reported that doctors or other healthcare providers always explained things so they could understand them, the same proportion as in 2000 (Obj. 11-6b—target, 65 percent); 61 percent reported that doctors or other healthcare providers always showed respect for what they had to say, compared with 59 percent in 2000 (Obj. 11-6c—target, 65 percent); and 49 percent reported that doctors or other healthcare providers always spent enough time with them, compared with 46 percent in 2000 (Obj. 11-6d—target, 52 percent).

Key Challenges and Current Strategies

In presentations that followed the data overview, the principal themes were introduced by Cynthia Baur, Director of the CDC Division of Health Communication and Marketing, and Linda Harris, Leader of the ODPHP Health Communication and e-Health Team. These agency representatives set the stage for discussions among Progress Review participants, identified a number of barriers to achieving the objectives, and discussed activities under way to meet these challenges, including the following:

• Although broadband access to the Internet is increasing, little information is available about why some people are not using the Internet and few new initiatives are in place to assist those Americans who cannot purchase access on their own.

• Numerous studies have shown that low health literacy is linked to poor health outcomes, such as higher rates of hospitalization, less frequent use of preventive services, and low adherence to treatment regimes.

• For the most part, policymakers, healthcare professionals, and public health leaders are not sufficiently aware of the critical nature of improved literacy as a condition to achieving healthcare and public health goals.

• The variety of funding mechanisms for health communication projects within and across HHS agencies hampers the ability to measure research and evaluation funding through easily identified tracking systems.

• To locate relevant information on the Internet, health information seekers must rely on search engines, which do not always return reliable results.

• The appropriate role for Government to ensure the public interest in Web site quality has not been identified.

• A 2007 Joint Commission report states that problems with provider-patient communication can increase risk for injury or death for those who require medical care.

• Although the literature suggests that patients are more satisfied when they have a more balanced and active role in healthcare decision-making and in their relationship with their doctor, a 2006 study found that patients are actually less active in medical consultations now than in the past.

• The Federal Communications Commission has the congressionally mandated goal to promote affordable access to robust and reliable broadband products and services for all Americans.

• In September 2006, the Surgeon General and ODPHP co-sponsored the Surgeon General’s Workshop on Improving Health Literacy. Based on evidence provided during the workshop, a plan to raise awareness and identify promising practices will be developed by the HHS Health Literacy Working Group.

• The HHS Administration on Aging and ODPHP are collaborating to provide Federal, state, Tribal, and local partners in the Aging Network a health literacy resource, Tools for Improving Health Literacy, which is available online and in CD format. It is designed to help professionals in aging care communicate with older adults at all literacy levels on issues such as long-term care and evidence-based disease prevention programs.

• The HHS Health Resources and Services Administration is developing an interactive, Web-based Health Literacy Training Program for its grantees.

• In a $40 million initiative to help narrow the gap between discovery and application and to reduce health disparities, the NIH National Cancer Institute is providing 5-year funding to four Centers of Excellence in Cancer Communications Research, each of which includes three or more individual, hypothesis-driven research projects.

• In recent years, the National Board of Medical Examiners implemented the U.S. Medical Licensing Examination, a communication and interpersonal skills component of the U.S. Medical License Exam. Also, the American Medical Association developed a continuing medical education course in health literacy.

Approaches for Consideration

Participants in the Progress Review made the following suggestions for public health professionals and policymakers to consider as steps to enable further progress toward achievement of the objectives for Health Communication:

• Include household Internet access and reasons why people do not have Internet access as standardized questions in all relevant HHS data collection activities.

• Develop instruments to assess levels of health literacy that are more sensitive to individual differences based on language, culture, and experience.

• Build a business case for improving health literacy based on cost savings to be realized from enhanced patient safety and increased compliance with instructions.

• Take steps to collect and analyze data on health literacy on a more systematic basis and to make it possible to do so at the state level.

• Identify and disseminate health literacy best practices, including guidelines, standards, outcome measures, and innovative approaches directed toward improvement.

• Seek to arrive at a national consensus on core competencies for health communication and on mechanisms for connecting research, practice, and clinical application.

• Encourage public education to alert Web site users to disclosure and quality criteria and standards, how to apply them, and how to interpret seal-of-approval programs and other disclosure mechanisms.

• To help create market advantage for quality in health information Web sites, collaborate with intermediaries, such as healthcare providers, teachers, social workers, and community leaders, encouraging them to disseminate information about trusted sites and helping them direct others to reliable health information.

• Encourage non-Federal sources of funding for the Centers of Excellence model.

• Make greater efforts to reduce barriers to good communication between healthcare providers and recipients of services that arise from shame, low income, limited education, advanced age, disabilities, cognitive incapacity, and cultural and linguistic differences on the part of the consumer.

• Explore ways of providing incentives, financial and otherwise, for healthcare providers to participate in communication skills training and to spend more time with patients and improve the quality of those interactions.

• Explore new mechanisms for engaging different segments of the public in the development and review of health content.

[Signed July 10, 2007]
ADM John O. Agwunobi, M.D., M.B.A., M.P.H.
Assistant Secretary for Health

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