# ![](media/image1.wmf){width="2.3986111111111112in" height="2.2930555555555556in"} {#section .Chapter-#}

# 11 {#section-1 .Chapter-#}

# Health Communication

Lead Agency: Office of Disease Prevention and Health Promotion

### Contents {#contents .Heading-Special}

[Goal Page 11-3](#goal)

[Overview Page 11-3](#overview)

[Issues and Trends Page 11-5](#issues-and-trends)

[Disparities Page 11-9](#disparities)

[Opportunities Page 11-10](#opportunities)

[Interim Progress Toward Year 2000 Objectives Page
11-11](#interim-progress-toward-year-2000-objectives)

[Healthy People 2010---Summary of Objectives Page
11-12](#healthy-people-2010summary-of-objectives)

[Healthy People 2010 Objectives Page
11-13](#healthy-people-2010-objectives)

[Related Objectives From Other Focus Areas Page
11-18](#related-objectives-from-other-focus-areas)

[Terminology Page 11-19](#terminology)

[References Page 11-22](#references)

## Goal

**Use communication strategically to improve health.**

## Overview

Health communication encompasses the study and use of communication
strategies to inform and influence individual and community decisions
that enhance health. It links the domains of communication and health
and is increasingly\
recognized as a necessary element of efforts to improve personal and
public health.[^1]**^,^** [^2]**^,^** [^3] Health communication can
contribute to all aspects of disease\
prevention and health promotion and is relevant in a number of contexts,
including (1) health professional-patient relations, (2) individuals'
exposure to, search for, and use of health information, (3) individuals'
adherence to clinical recommendations and regimens, (4) the construction
of public health messages and campaigns, (5) the dissemination of
individual and population health risk information, that is, risk
communication, (6) images of health in the mass media and the culture at
large, (7) the education of consumers about how to gain access to the
public health and health care systems, and (8) the development of
telehealth applications.Error: Reference source not found**^,^**
[^4]**^,^** [^5]**^,^** [^6]**^,^** [^7]**^,^** [^8]**^,^** [^9]**^,^**
[^10]**^,^** [^11]

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.Error: Reference
source not found 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.Error: Reference source not found 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.Error: Reference source not found

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.Error: Reference source not
found**^,^** Error: Reference source not found 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.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found,\ Error:\ Reference\ source\ not\ found^**
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.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found,^** [^12]An emerging
area is health communication to support community-centered
prevention.[^13] 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.
![](media/image2.wmf){width="4.396527777777778in"
height="6.581944444444445in"}

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

The environment for communicating about health has changed
significantly. These changes include dramatic increases in the number of
communication channels and the number of health issues vying for public
attention as well as consumer demands for more and better quality health
information, and the increased sophistication of marketing and sales
techniques, such as direct-to-consumer advertising of prescription drugs
and sales of medical devices and medications over the Internet. The
expansion of communication channels and health issues on the public
agenda increases competition for people's time and attention; at the
same time, people have more opportunities to select information based on
their personal interests and preferences. The trend toward
commercialization of the Internet suggests that the marketing model of
other mass media will be applied to emerging media, which has important
consequences for the ability of noncommercial and public health-oriented
health communications to stand out in a cluttered health information
environment.

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.Error: Reference source not found 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.Error: Reference
source not found**^,^** [^14] 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.Error: Reference source not found 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.Error: Reference source not found 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.[^15] Examples include the targeted use of mass
media messages for adolescent girls at increased risk of smoking;[^16]
the tailoring of computer-generated nutritional information to help
individuals reduce their fat intake and increase fruit and vegetable
consumption;[^17] and a national telephone service for Spanish speakers
to obtain AIDS information as well as counseling and referrals.[^18]

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.[^19] 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.[^20]

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.Error: Reference
source not
found**^,\ Error:\ Reference\ source\ not\ found,\ Error:\ Reference\ source\ not\ found,^**
[^21] 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.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found^** 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.Error: Reference source not
found

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.Error: Reference source not
found 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.[^22] Numerous studies of provider-patient
communication support the connection among the quality of the
provider-patient interaction, patient behavior, and health
outcomes.[^23] 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.Error: Reference source not
found**^,^** [^24]**^,^** [^25]**^,^** [^26] 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

Often people with the greatest health burdens have the least access to
information, communication technologies, health care, and supporting
social services. Even the most carefully designed health communication
programs will have limited impact if underserved communities lack access
to crucial health professionals, services, and communication channels
that are part of a health improvement project.

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.[^27] With communication technologies, the
disparity in access to electronic information resources is commonly
referred to as the "digital divide."[^28] 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.[^29] 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.[^30] 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.[^31] The 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.[^32] An estimated 75 percent of persons in the United States
with chronic physical or mental health problems are in the limited
literacy category.[^33] People with chronic 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.[^34]**^,^** [^35]

Although the majority of people with marginal or low literacy are white
native-born Americans,[^36] 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.[^37] 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.[^38]

### Opportunities

For health communication to contribute to the improvement of personal
and community health during the first decade of the 21st century,
stakeholders, including health professionals, researchers, public
officials, and the lay public, must collaborate on a range of
activities. These activities include (1) initiatives to build a robust
health information system that provides equitable access, (2)
development of high-quality, audience-appropriate information and
support services for specific health problems and health-related
decisions for all segments of the population, especially underserved
persons, (3) training of health professionals in the science of
communication and the use of communication technologies,\
(4) evaluation of interventions, and (5) promotion of a critical
understanding and practice of effective health communication.

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.[^39]**^,^** [^40]

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.

## Interim Progress Toward Year 2000 Objectives 

Health Communication is a new focus area for Healthy People 2010.

## Healthy People 2010---Summary of Objectives

### Health Communication {#health-communication-1 .Heading-Special-Sub}

**Goal:** Use communication strategically to improve health.

  ------------ -------------------------------------------------------------
  **Number**   **Objective Short Title**

  11-1         Households with Internet access

  11-2         Health literacy

  11-3         Research and evaluation of communication programs

  11-4         Quality of Internet health information sources

  11-5         Centers for excellence

  11-6         Satisfaction with health care providers' communication skills
  ------------ -------------------------------------------------------------

## Healthy People 2010 Objectives

11-1. Increase the proportion of households with access\
to the Internet at home.

**Target:** 80 percent.

**Baseline:** 26 percent of households had access to the Internet at
home in 1998.

**Target setting method:** Better than the best.

**Data source:** Computer and Internet Use Supplement to the Current
Population Survey, U.S. Department of Commerce, Bureau of the Census.

Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **Households, 1998**                           | **Internet Access\  |
|                                                | at Home**           |
+================================================+=====================+
|                                                | **Percent**         |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 26                  |
+------------------------------------------------+---------------------+
| **Race and ethnicity** (head of household)     |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | DNA                 |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | DNA                 |
+------------------------------------------------+---------------------+
| > Asian                                        | DNC                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DNC                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | DNA                 |
+------------------------------------------------+---------------------+
| > White                                        | DNA                 |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | 13                  |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | DNA                 |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | 19                  |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | 36                  |
+------------------------------------------------+---------------------+
| > Black or African American                    | 11                  |
+------------------------------------------------+---------------------+
| > White                                        | 30                  |
+------------------------------------------------+---------------------+
| **Gender** (head of household)                 |                     |
+------------------------------------------------+---------------------+
| > Female                                       | DNA                 |
+------------------------------------------------+---------------------+
| > Male                                         | DNA                 |
+------------------------------------------------+---------------------+
| **Family income level**                        |                     |
+------------------------------------------------+---------------------+
| > Poor                                         | DNA                 |
+------------------------------------------------+---------------------+
| > Near poor                                    | DNA                 |
+------------------------------------------------+---------------------+
| > Middle/high income                           | DNA                 |
+------------------------------------------------+---------------------+
| **Education level** (head of household)        |                     |
+------------------------------------------------+---------------------+
| > Less than high school                        | DNA                 |
+------------------------------------------------+---------------------+
| > High school graduate                         | 14                  |
+------------------------------------------------+---------------------+
| > At least some college                        | DNA                 |
+------------------------------------------------+---------------------+
| **Geographic location**                        |                     |
+------------------------------------------------+---------------------+
| > Urban                                        | 28                  |
+------------------------------------------------+---------------------+
| > Rural                                        | 22                  |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

Many health care organizations and public service agencies use the
Internet as one of their main channels for information delivery. Access
to the Internet and subsequent technologies is likely to become
essential to gain access to health information, contact health care
organizations and health professionals, receive services at a distance,
and participate in efforts to improve local and national health.Error:
Reference source not found**^,\ Error:\ Reference\ source\ not\ found^**
The integration of communication media means electronic access to health
information not only via computers but also with Web-enabled televisions
and telephones, handheld devices, and other emerging technologies.
Technical literacy, or the ability to use electronic technologies and
applications, will be essential to gain access to this information.

Internet availability in the home is an important indicator of equitable
access among population groups. An increasing number of people have
access to the Internet at work and public facilities, such as libraries
and community centers, but several limitations affect the use of online
health information and support in these settings. Some employers monitor
electronic mail and the types of sites visited by employees. Access in
public settings may be problematic because of privacy and
confidentiality concerns, and access may be needed during times when
these facilities are unavailable. Because of the potentially sensitive
nature of health-related uses of the Internet, access at home is
essential.

Although the proportion of people with access to the Internet has risen
dramatically since 1995, many segments of the population lack access,
such as low-income and rural households; persons with less education;
and certain racial and ethnic groups, such as African Americans and
Hispanics.Error: Reference source not found Internet access rates vary
considerably according to income. Only 11 percent of households earning
\$24,999 or less have access, whereas 19 percent are connected among
those earning \$25,000 to \$34,999; 30 percent have access among those
earning \$35,000 to \$49,999; and 52 percent of households with \$50,000
or greater in income have an Internet connection.Error: Reference source
not found Barriers to Internet access include cost, lack of services in
certain communities, limited literacy, lack of familiarity with
different technologies, and, especially for people with disabilities,
inaccessible formats that limit appropriate and effective technology
use. Initiatives to promote universal access to the Internet will
involve public and private sector stakeholders, particularly government
agencies and technology corporations.

11-2. (Developmental) Improve the health literacy of persons with
inadequate or marginal literacy skills.

**Potential data source:** National Adult Literacy Survey, 2002, U.S.
Department\
of Education.

Responses from the National Adult Literacy Survey indicate that
approximately 90 million adults in the United States have inadequate or
marginal literacy skills.Error: Reference source not found Written
information is not the only way to communicate about health, but a great
deal of health education and promotion are organized around the use of
print materials, usually written at the 10th grade level and above.
These materials are of little use to people who have limited literacy
skills.[^41] The result is that a very large segment of the population
is denied the full benefits of health information and services.

Closing the gap in health literacy is an issue of fundamental fairness
and equity and is essential to reduce health disparities. Public and
private efforts need to occur in two areas: the development of
appropriate written materials and improvement in skills of those persons
with limited literacy. The knowledge exists to create effective,
culturally and linguistically appropriate, plain language health
communications. Professional publications and Federal documents provide
the criteria to integrate and apply the principles of organization,
writing style, layout, and design for effective communication.Error:
Reference source not found**^,^** [^42] These criteria should be widely
distributed and used. Many organizations such as public and medical
libraries, voluntary, professional, and community groups, and schools
could offer health literacy programs that target skill improvement for
low-literacy and limited English proficient individuals. If appropriate
materials exist and people receive the training to use them, then
measurable improvements in health literacy for the least literate can
occur.

11-3. (Developmental) Increase the proportion of health\
communication activities that include research and\
evaluation.

**Potential data sources:** Sponsored survey of *Federal Register*
notices;\
Grantmakers in Health; National Health Council.

Effective health communication programs are built on sound research and
evaluation. Meaningful research and evaluation are not afterthoughts but
integral parts of initial program design. Research provides the ideas
and tools to design and carry out formative, process, and outcome
evaluations to improve health communication efforts, certify the degree
of change that has occurred, and identify programs or elements of
programs that are not working.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found^** Research and
evaluation systematically obtain information that can be used to refine
the design, development, implementation, adoption, redesign, and overall
quality of a communication\
intervention.[^43]**^,^** [^44]

Programs funded by Federal, philanthropic, and not-for-profit
organizations could be strengthened with requirements for a minimum set
of evaluation activities and specific measurements. The level of
research and evaluation required should reflect the costs, scope, and
potential impact (in terms of benefit or harm) of the communication
activity proposed. At a minimum, programs should be expected to conduct
appropriate audience testing for need, cultural and linguistic
competence, comprehension, and receptivity. Requirements and
specifications for evaluation could be set for grant-funded
communication programs and included in requests for funding proposals
and grant program guidelines as well as for programs directly funded and
implemented by public or private sector organizations by including
research and evaluation activities in their work plans.

11-4. (Developmental) Increase the proportion of health-related World
Wide Web sites that disclose information that can be used to assess the
quality of the site.

**Potential data sources:** Health on the Net Foundation; Health
Internet Ethics (Hi-Ethics); Internet Healthcare Coalition.

With the rapidly growing volume of health information, advertising,
products, and services available on World Wide Web sites, serious
concerns arise regarding the accuracy, appropriateness, and potential
health impact of these sites.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found^** People are using the
Internet to look up information, purchase medications, consult remotely
with providers, and maintain their personal health records.
Approximately 70 million persons in the United States use the Internet
for health-related reasons,[^45] and the potential for harm from
inaccurate information, inferior quality goods, and inappropriate
services is significant. Many initiatives are under way to identify
appropriate and feasible approaches to evaluate online health
sites.Error: Reference source not found Professional associations are
issuing guidelines and recommendations,[^46]**^,^** [^47]**^,^** [^48]
Federal agencies such as the Federal Trade Commission are actively
monitoring and sanctioning owners of Web sites that are false or
misleading,[^49] and developers and purchasers of online health
resources are being urged to adopt standards for quality
assurance.Error: Reference source not found

To allow users to evaluate the quality and appropriateness of Internet
health resources, health-related Web sites should publicly disclose the
following essential information about their site:Error: Reference source
not found (1) the identity of the developers and sponsors of the site
(and how to contact them) and information about any potential conflicts
of interest or biases, (2) the explicit purpose of the site, including
any commercial purposes and advertising, (3) the original sources of the
content on the site, (4) how the privacy and confidentiality of any
personal information collected from users is protected, (5) how the site
is evaluated, (6) and how the content is updated. An additional mark of
quality which should be present in a Web site relates to the site's
accessibility by all users. Contents of the site should be presented in
a way that it can be used by people with disabilities and with low-end
technology.

11-5. (Developmental) Increase the number of centers for\
excellence that seek to advance the research and practice of health
communication.

**Potential data sources:** Health Communication Interest Group,
American Public Health Association; Society for Social Marketing;
Association of Schools of Public Health; Health Communication Divisions,
International Communication Association and National Communication
Association; NCI.

To enlarge the knowledge base of health communication and incorporate it
into health promotion practice, a research and training infrastructure
is needed to develop, model, and coordinate activities. For this
purpose, centers for excellence located in academic institutions,
national organizations, or research centers would be instrumental to
meet scientific and practical needs. The centers would be responsible
for an array of activities, such as (1) promoting the adoption of health
communication theories and practices in health care, disease prevention,
and health promotion initiatives, (2) developing and disseminating
quality standards, (3) coordinating initiatives to develop a consensus
research agenda, (4) developing systems to identify and assess health
communication research, (5) evaluating communication strategies,
messages, materials, and resources, (6) fostering networking and
collaboration among health communicators, health educators, and other
health professionals, (7) promoting health communication skills training
for health professionals, and (8) promoting research and dissemination
activities among specific population groups.

These centers should provide expert staff, model curricula with core
competencies in health communication and media technologies,
appropriately equipped media labs, research seminars, continuing
education and distance learning courses, and training and placement
programs to expand the pool of health communication professionals and
health professionals with communication skills. The centers also could
create databases that would catalog items such as formative and outcomes
research studies and reports and could partner with existing
governmental dissemination networks to make data publicly available.
Centers for excellence in health communication could be funded through
Federal grants, foundations, or private sector health care
organizations.

11-6. (Developmental) Increase the proportion of persons who report that
their health care providers have satisfactory communication skills.

**Potential data sources:** National Committee for Quality Assurance;
Behavioral Risk Factor Surveillance System (BRFSS), CDC, NCCDPHP;
National Health Interview Survey (NHIS), CDC, NCHS; industry surveys
(FIND/SVP, Nielsen, Jupiter Communications).

Good provider-patient communication contributes to quality care and
improved health status. Patients' assessment of their providers'
communication skills is important for individuals with a usual source of
care as well as for those without, who may have less frequent contact
with the medical care system. Studies indicate that patients find
communicating with their health care providers difficult
**^Error:\ Reference\ source\ not\ found,^** [^50] and report that
providers do not give them enough information, even though they highly
value the information and want to know more.[^51] Clear, candid,
accurate, culturally and linguistically competent provider-patient
communication is essential for the prevention, diagnosis, treatment, and
management of health concerns.Error: Reference source not found**^,^**
[^52]

Effective communication underpins prevention and screening efforts at
the clinical level, when providers have the opportunity to engage in
one-on-one counseling and supply information that is culturally and
linguistically appropriate and delivered at the person's health literacy
level. Diagnoses and treatments require doctors to negotiate a common
understanding with patients about what is to be done. The quality of
provider-patient communication can affect numerous outcomes, including
patient adherence to recommendations and health status.[^53] Appropriate
information and communication with a provider not only can relieve
patients' anxieties but also can help patients understand their choices,
allow them to participate in informed decisionmaking, and better manage
their own health concerns.

## Related Objectives From Other Focus Areas

1\. Access

1-3. Counseling about health behaviors

1-12. Single toll-free number for poison control centers

2\. Arthritis, Osteoporosis, and Chronic Back Conditions

2-8. Arthritis education

3\. Cancer

3-10. Provider counseling about cancer prevention

4\. Chronic Kidney Disease

4-3. Counseling for chronic kidney failure care

5\. Diabetes

5-1. Diabetes education

7\. Educational and Community-Based Programs

7-2. School health education

7-3. Health-risk behavior information for college and university
students

7-5. Worksite health promotion programs

7-7. Patient and family education

7-8. Satisfaction with patient education

7-9. Health care organization sponsorship of community health promotion\
activities

7-10. Community health promotion programs

7-11. Culturally appropriate and linguistically competent community
health\
promotion programs

9\. Family Planning

9-11. Pregnancy prevention education

10\. Food Safety

10-5. Consumer food safety practices

12\. Heart Disease and Stroke

12-2. Knowledge of symptoms of heart attack and importance of dialing
911

12-4. Bystander response to cardiac arrest

12-8. Knowledge of early warning symptoms of stroke

13\. HIV

13-8. HIV counseling and education for persons in substance abuse
treatment

13-9. HIV/AIDS, STD, and TB education in State prisons

13-10. HIV counseling and testing in State prisons

16\. Maternal, Infant, and Child Health

16-7. Childbirth classes

16-13. Infants put to sleep on their backs

17\. Medical Product Safety

17-3. Provider review of medications taken by patients

17-4. Receipt of useful information about prescriptions from pharmacies

17-5. Receipt of oral counseling about medications from prescribers and\
dispensers

17-6. Blood donations

19\. Nutrition and Overweight

19-16. Worksite promotion of nutrition education and weight management

19-17. Nutrition counseling for medical conditions

23\. Public Health Infrastructure

23-2. Public access to information and surveillance data

24\. Respiratory Diseases

24-6. Patient education

25\. Sexually Transmitted Diseases

25-12. Responsible sexual behavior messages on television

26\. Substance Abuse

26-17. Perception of risk associated with substance abuse

27\. Tobacco Use

27-16. Tobacco advertising and promotion targeting adolescents and young
adults

## Terminology

(A listing of abbreviations and acronyms used in this publication
appears in Appendix H.)

**Accuracy:** Content that is valid and without errors of fact,
interpretation, or judgment.

**Advocacy:** Communication directed at policymakers and decisionmakers
to promote policies, regulations, and programs to bring about change.

**Availability:** Content (whether a targeted message or other
information) that is delivered or placed where the audience can access
it. Placement varies according to audience, message complexity, and
purpose---from interpersonal and social networks to billboards, mass
transit signs, prime-time TV, and radio and from public kiosks (print or
electronic) to the Internet.

**Balance:** Where appropriate, content that fairly and accurately
presents the benefits and risks of potential actions or recognizes
different and valid perspectives on an issue.

**Consistency:** Content that remains internally consistent over time
and also is consistent with information from other sources.

**Consumer health informatics:** Interactive health communication (see
below) focusing on consumers.

**Consumer health information:** Information designed to help
individuals understand their health and make health-related decisions
for themselves and their families.

**Cultural competence:** The design, implementation, and evaluation
process that accounts for special issues of select population groups
(ethnic and racial, linguistic) as well as differing educational levels
and physical abilities.

**Decision support systems:** Computer software programs designed to
assist diagnostic and treatment decisions. Examples include drug alert
notification systems, prompts to implement practice guidelines, and
health risk appraisals.

**Evidence base:** Relevant scientific evidence that has undergone
comprehensive review and rigorous analysis to formulate practice
guidelines, performance measures, review criteria, and technology
assessmentsError: Reference source not found for telehealth
applications.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found^**

**Formative research:** Assesses the nature of the problem, the needs of
the target audience, and the implementation process to inform and
improve program design. Formative research is conducted both prior to
and during program development to adapt the program to audience needs.
Common methods include literature reviews, reviews of existing programs,
and surveys, interviews, and focus group discussions with members of the
target audience.

**Health communication:** The art and technique of informing,
influencing, and motivating individual, institutional, and public
audiences about important health issues. The scope of health
communication includes disease prevention, health promotion, health care
policy, and the business of health care as well as enhancement of the
quality of life and health of individuals within the community.[^54]

**Health education:** Any planned combination of learning experiences
designed to predispose, enable, and reinforce voluntary behavior
conducive to health in individuals, groups, or communities.[^55]

**Health literacy:** The degree to which individuals have the capacity
to obtain, process, and understand basic health information and services
needed to make appropriate health decisions.Error: Reference source not
found (See also *Literacy.*)

**Health promotion:** Any planned combination of educational, political,
regulatory, and organizational supports for actions and conditions of
living conducive to the health of individuals, groups, or communities.

**Interactive health communication:** The interaction of an individual
with an electronic device or communication technology to access or
transmit health information or to receive guidance on a health-related
issue.Error: Reference source not found

**Internet:** A worldwide interconnection of computer networks operated
by government, commercial, and academic organizations and private
citizens.

**Literacy:** The ability to read, write, and speak in English and to
compute and solve problems at levels of proficiency necessary to
function on the job and in society, to achieve one's goals, and develop
one's knowledge and potential.[^56]

**Medical informatics:** A field of study concerned with the broad range
of issues in the management and use of biomedical information, including
medical computing and the study of the nature of medical information
itself.[^57]

**Outcome evaluation** (sometimes called impact evaluation)**:**
Examines the results of a communication intervention, including changes
in awareness, attitudes, beliefs, actions, professional practices,
policies, costs, and institutional or social systems.

**Patient communication:** Information for individuals with health
conditions to help them maximize recovery, maintain therapeutic
regimens, and understand alternative approaches. Patient communication
includes educational resources, provider-patient communication, and,
increasingly, peer-to-peer communication.

**Process evaluation:** Monitors the administrative, organizational, or
other operational characteristics of an intervention. Process evaluation
includes monitoring the dissemination of communication products to
intended users (whether gatekeepers or audiences) and audience members'
exposure to a message. For an interactive health communication
application, process evaluation may include testing how the application
functions.

**Reach:** Information that gets to or is available to the largest
possible number of people in the target population.

**Reliability:** Content that is credible in terms of its source and is
kept up to date.

**Repetition:** Delivery of and access to content continued or repeated
over time, both to reinforce the impact with a given audience and to
reach new generations.

**Risk communication:** Engaging communities in discussions about
environmental and other health risks and about approaches to deal with
them. Risk communication also includes individual counseling about
genetic risks and consequent choices.

**Social marketing:** The application of marketing principles and
techniques to program development, implementation, and evaluation to
promote healthy behaviors or reduce risky ones**.**[^58]**^,^** [^59]

**Tailoring:** Creating messages and materials to reach one specific
person based on characteristics unique to that person, related to the
outcome of interest, and derived from an assessment of that
individual.Error: Reference source not found

**Targeting:** Creating messages and materials intended to reach a
specific segment of a population, usually based on one or more
demographic or other characteristics shared by its members.Error:
Reference source not found

**Telehealth:** The application of telecommunication and computer
technologies to the broad spectrum of public health, medicine, and
health.

**Telemedicine:** The use of electronic information and communication
technologies to provide clinical care across distance.Error: Reference
source not found

**Timeliness:** Content that is provided or available when the audience
is most receptive to, or in need of, the specific information.

**Underserved:** Individuals or groups who lack access to health
services or information relative to the national average. The
underserved population may include residents of rural, remote, or
inner-city areas; members of certain racial and ethnic groups;
socioeconomically disadvantaged persons; or people with disabilities.

**Understandability:** Reading or language level and format (including
multimedia) appropriate for a specific audience.

**World Wide Web (Web):** An international virtual network composed of
Internet host computers that can be accessed by graphical browsers.

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