Talking About Health; Why Health Communication Matters

How do different metaphors to define genes relate to understanding?

November 14, 2013

Many of the important messages about health include information about the role of genes for health. Genes matter. Behavior matters. Environments matter. The problem is how to communicate that genes do not absolutely determine health. This will be an important part of health communication for many decades to come.

Professor Celeste Condit wrote about how genes have been defined in her book, “The meanings of the gene” [http://www.amazon.com/The-Meanings-Gene-Heredity-Rhetoric/dp/0299163644].

Efforts to define genes often depend on the use of metaphor, explaining what a gene is in terms of something else that an audience is assumed to already understand. Many of these metaphors use “instruction” as a key component. Professor Rachel Smith and I decided to evaluate two of these instruction metaphors, one that defined genes as “a blueprint of our possibilities” and the other that defined genes in terms of “instructions” more generally. The abstract of the article to be published in February in the journal, Health Communication, appears at: http://www.tandfonline.com/doi/abs/10.1080/10410236.2012.729181#.UtLxv1OFeSo. The online article is at: DOI: 10.1080/10410236.2012.729181

Participants received a message about the role of genes for health for which the introduction varied the definition of a gene, and all other content was the same. Participants who read a message with the blueprint metaphor were more likely to believe that genes absolutely determine health and that genetic therapies are the effective means to address the role of genes for health. The instruction metaphor related to participants having stronger beliefs that genes make one more susceptible to disease but do not absolutely determine the onset of disease, and beliefs that we have some personal control over the role that genes have for our health.

These results support the importance of the metaphors used to define health and scientific terms. Just one exposure to a message that defines genes in different ways can have powerful effects on our attitudes about genes and health.

Patient-Centered Outcomes Research Institute News on My Birthday

September 10, 2013

Nothing I enjoy more than a walk along a creek or stream and gathering fall foliage. In this case, it is cattails. A great way to spend a birthday.

At the same time, an announcement came into my email about the approval of 114 million dollars to support patient-centered outcomes research. The Affordable Care Act introduced this new research institute as part of its overall mission. Each of us will contribute one dollar to the initiative as part of the plan to fund its activities. I am not yet sure why a new institute was needed in addition to the National Institutes of Health which often includes patient centered outcomes research. I haven’t heard any real public discussion about this new initiative to fund research. You can check it out here: http://www.pcori.org/about-us/how-were-funded/

I will continue to ponder the meaning of another institute as part of the Affordable Care Act and share any insights I gain. Please do the same.

“Your potassium level is low”–what fruits can do about this message from my doctor

August 23, 2013

Well, the annual check-up was mostly good news. My numbers were mostly good. 64 resting pulse. 120 over 78 for blood pressure. But then my doctor said, “Don’t you like fruit?” Huh?

“Your potassium is low. Don’t you like fruit?” I eat an apple almost every day, I say. He nods and says, “Eat more fruit.” OK. What kind? How much?

First, potassium–why is it important? I guess I could’ve asked but it seemed as if I was expected to know. And I knew I could find out online. Which I did. Let’s just say that potassium is very important. It is crucial for heart function and for muscle contraction.

There are lots of food sources of potassium but I did find a ‘top 10’ list of fruits at http://www.healthaliciousness.com/articles/high-potassium-fruits.php. Dried apricots are number 1 and bananas are on the list but much closer to the bottom. Prunes, raisins, dates, and figs are on the list as well. I guess I will try a little harder to get some more of these in my daily routine.

Jennifer Ohs talks about how older adults make medical decisions

March 14, 2013

I am using a new text in my undergraduate health communication course. The text is edited by Maria Brann, a professor at West Virginia University. It is called, “Contemporary case studies in health communication” and is published by KendallHunt, 2011. The text has a unique approach that is working well to spark discussion in my diverse undergraduate classroom. Each case in the book leaves out the conclusion to the case, so that the class can speculate on the possible endings. Then, as the instructor, I have access to the conclusions written by the case study authors and can share these with the class. We have lively debates about how a case is resolved versus other ways it might have gone. For example, the case that I will discuss with the class tomorrow was written by Dr. Jennifer Ohs, a professor at Saint Louis University. The case discusses medical decision-making and uses the example of an older woman who is deciding whether to have sinus surgery. It is a case used to illustrate problematic integration theory, which is the theory we are discussing in class this week, a framework for understanding proposed by Professor Austin Babrow who is a faculty member at Ohio University. The theory explains why communication may cause us to form judgments that a good outcome is highly unlikely, while a bad outcome is very likely. Other situations that are problematic to integrate with our experiences include situations in which communication makes two options seem to be equal, both in terms of how likely or unlikely they may be and/or how good or bad we judge outcome linked to the option. The case discusses how an older woman considers what her husband, son, and daughter have to say about the surgery, the role of prayer, a friend’s view, and the conversations that her usual doctor and the specialist who would conduct the surgery have with her. In the end, she decides not to have the surgery. It is a good decision for her as it turns out, because she later learns that she needs dental surgery, and having that surgery resolves the issues she was having with her sinuses as well. Of course, she did not know that when she made the decision. Rather she made her decision because her daughter did not offer to come and be with her, because she really wanted a second opinion and her husband would not like to have to drive to the city to see another specialist, and because her son had a similar surgery that did not improve his health much. These were weighed with the doctor’s advice to have the surgery and led to her choice. It will be interesting to see how the class views this case and the ideas they come up with for possible conclusions.

Clean Your Hands Campaign

February 19, 2013

The World Health Organization — WHO — has long promoted hand-washing as an important way to reduce the risk of spreading infections. While we all can reduce the risk by washing our hands, we may also assume that healthcare workers would be among the people most likely to practice hand-washing. Apparently not. A study designed to increase hand-washing among healthcare works cites evidence that compliance with the practice is just 25-40%. The article appears online in PLOS ONE [ a publication of PLOS [ http://www.plos.org/] an organization designed to make peer-reviewed medical research accessible in less time and with less cost than more traditional approaches to publishing scientific results. The research led by Chrsitopher Fuller, “The Feedback Intervention Trial (FIT) — Improving Hand-Hygiene Compliance in UK Healthcare Workers A stepped Wedge Cluster Randomised Trial”, conducted the study in 60 locations that included 16 acute hospitals and 44 general medical wards or acute elderly care sites. All sites were already participating in the “Clean Your Hands” campaign. This campaign includes placing alcohol hand-rub at patient bedsides, using posters and other educational materials to encourage workers to clean their hands. an audit and feedback on compliance was cinluded at least once every six months, so workers knew that the behavior is expected and would be evaluated. The FIT focused on goal-setting for and rewarding of handwashing behavior as an additional compoment to the national campaign.

A significant increase in hand-washing occurred with the FIT, with more change in the 16 intensive therapy units than in the other sites — achieving 13-18% change versus 10-13% change, ranging about 60% to nearly 80% compliance. The improvement declined over time. There were difficulties associated with implementing the protocol, including that the trial place extra responsibilities on some ward staff, who did not receive additional training beyond the initial introduction to the intervention and were not monitored after the initial observation of their placement of materials bedside. To increase the likelihood that such a campaign would be successful over time, the authors recommend that the tasks be integrated into the role of some employees and audited regularly as part of job performance. As for me, I will be watching to be sure healthcare workers wash their hands. And I will do the same.

Taking Healthcare Into Your Own Hands Guest Post by Bill Paquin

January 24, 2013

Debates about the federal health care overhaul aside, one truth has emerged from the recent national discussion about the health care and insurance industries. In the end, we are all responsible for our own individual health.

Now, that sounds obvious, but it’s not necessarily how we’ve lived for half-a-century, in a world where many peoples’ employers covered whatever malady might strike them. Without the financial stress of paying ‘a la carte’ for anything from stitches to a coronary stent, there was less pressure on the individual to take preventative action to protect their health. When an issue arose, you went to the doctor, and that was that.

With far fewer employers offering comprehensive health care, and those that are moving to high deductible plans that put the burden of paying for small accidents and illnesses back on the individual, personal health care has become much like other commodities, where shoppers find the best price and only purchase what they need.

Whether you’re self-employed or a full time employee living with a high deductible plan as your sole coverage, remember these guidelines to help you navigate the ever-changing system:

Get in Shape

If wanting to look and feel your best never motivated you to eat the right foods and exercise, perhaps saving big money at the doctor will. Obesity accounts for more health maladies than any other condition, from type II diabetes to heart problems. By keeping your weight in check, you’ll need fewer trips to the doctor. When you’re feeling great, your wallet will thank you.

Read the Fine Print of Your Insurance Plan

Every insurance plan is different, and finding out that a test or doctor’s visit isn’t covered after you’ve already gone can be an unexpected roadblock in our budget. Read your plan, understand the terminology, and ask questions about cumulative costs of any tests and procedures before agreeing to them. Of course, don’t forgo necessary care, but do seek out the best options and decide ahead of time, if possible, if you plan to reach your deductible or not.

Ask Questions About Cost

It’s somewhat engrained in our culture to follow ‘doctor’s orders.’ But if the doctor suggests a further test or procedure, don’t hesitate to ask about the costs. Oftentimes there may be an alternative that better fits your budget. [or the constraints of your insurance]

Use In-Network Doctors

Insurance providers typically have a network of ‘preferred’ providers, and finding a doctor within this list can mean significant savings. Also remember that you never have to stick with the first doctor you find — search around until you find a provider you relate to and trust. And if you’re starting from scratch, your provider’s network list is a good place to begin your search.

Keep Track of Your Health Expenditures

Although tax write-off eligibility for health care expenses may be slightly altered in 2013 at the national level, you’re still likely entitled to a tax break if you have significant health-related costs in your budget. Save every receipt and keep track of any expense that’s health related to report on your tax forms.

Start a Health Savings Account

People with a high-deductible health insurance plan are eligible to begin an HSA, which lets account holders deposit pre-tax dollars into a fund specifically for their own health care. This money can be used for doctor’s visits and procedures and count against your deductible, but can be written off of income taxes. Best of all, an HSA means you’ll already have money set aside when an emergency arises.

Research What Ails You

In the past, doctors have advised patients not to trust what they read online. Fortunately, reputable providers like the Mayo Clinic now offer comprehensive, accurate information about health issues and diseases on the internet. Understanding your symptoms and diagnoses is integral to making smart financial decisions about your own health care.

Choose Generic Medications

Doctors may prescribe a name brand medication . Most doctors, however, will be responsive to your inquiries about less expensive, generic alternatives. Of course, ensure that the drug you are prescribed is safe and effective, but oftentimes a generic medication may be exactly the same as the well-known name brand manufacturer.

When it comes to paying for care, individuals are more responsible than ever for their own health. Remember, the buck ultimately stops with you.

About the Author

As the CEO of Vertical Health, patient care advocate http://www.billpaquin.com Bill Paquin works to convey accurate health information to consumers. He operates web sites including http://www.diabeticlifestyle.com, http://www.endocrineweb.com and other sites focused on improving patient care associated with endocrine disorders. Bill is a husband and father, and writes about improving patient care in our healthcare system.

Health Communication, Health Literacy, and the Affordable Care Act

November 8, 2012

If you are like me, you imagine a time when you will be less ‘scheduled’. This has been a time of being over-scheduled in the past half dozen weeks. I have a pile of topics I want to discuss relating to communicating about health. And too little time to do so.

One of the topics that keeps coming through my piles relates to an article written by Stephen A. Sommers and Roopa Mahadevan that was commissioned by The Institute of Medicine–IOM–and published in October 2010. I came across it when preparing to talk about health literacy and health communication with my undergraduates last year. It has been shuffling about on my desk since then. Today is finally the day I will share my thoughts about it.

First, the relationship between health literacy and health communication that I discuss with my undergraduates in a ‘designing health messages’ course is two-fold. On the one hand, low levels of health literacy, meaning the audience is unlikely to understand many health and science terms or be able to use math and statistics to make decisions–suggests that health communicators, whether they are public health program planners or medical doctors, should adapt their communication so that it will be understood, and informed decisions can be made based on an accurate understanding. A great deal of health communication message design research and practices focuses on this effort, working to assure that knowledge gaps do not become wider between more and less educated audiences, for example.

The second issue related to health communication and health literacy relates to efforts to improve health literacy. In other words, how could we communicate to motivate someone with low levels of health literacy to become excited about learning more vocabulary and applying more statistics in making choices about health?

Addressing both health literacy issues in health communication is the ethical thing to do. Knowing that someone does not understand health vocabularies or may be embarrased to ask questions when they do not understand places a responsibility on the health communicator to adapt. Knowing that high levels of health illiteracy uniformly exist in the U.S. suggests that health communicators ought to be involved with improving the situation across the many contexts for talking about health.

Stephen A. Sommers and Roopa Mahadevan open their paper with the statement that the Affordable Health Care Act does not address low health literacy directly. BUT–they assert–the law cannot be successful unless national efforts strive to address low health literacy. Health literacy is mentioned in the ACA in relation to research dissemination, shared decision-making, medication labelings, and workforce development. “All four suggest the need to communicate effectively with consumers, patients, and communities in order to improve the access to and quality of health care” (p. 6).

So there we have it. If we are to achieve the aims associated with the ACA, including improving the population’s health and bringing health care costs under control, we will only achieve these aims through communication that adapts to and accommodates low levels of health literacy while motivating citizens to improve their health literacy.

Health communication and IOM paper findings about how to discuss medical evidence

September 26, 2012

I have talked often about the importance of evidence to guide our informed decisions about health. A new paper from the Institute of Medicine discusses how to talk about medical evidence [see http://www.iom.edu/Global/Perspectives/2012/~/media/Files/Perspectives-Files/2012/Discussion-Papers/VSRT-Evidence.pdf].

One of the interesting issues considered addresses ways that language relates to patient confidence about evidence and health care. 1,068 US adults were surveyed to answer this question: 71% were White, 48% male, 46% 55 years of age and older, 55% rated themselves as in ‘very good’ or ‘excellent’ health, 62% were not living with any chronic condition, 88% had health insurance, and 36% usually or always bring a list of questions with them to ask their doctors.

The summary of findings is in Table 1. ‘What is proven to work best’ was found to be the phrase leading to the greatest level of confidence, 79%–in the evidence used for their health care.

I wonder, given that so many come prepared to ask questions, if the participants would ask any questions about the evidence. Things like ‘is the evidence based on someone my age, my biological sex, or my race/ethcnity?’

I wonder, too, about the levels of education for this group. IOM has convened panels to write reports about health illiteracy in this nation. What does ‘evidence’ mean to the large percentage of adults in the US who are health illiterate? What does ‘evidence’ mean to this group of mostly white, mostly insured, and very healthy personal advocates [they ask a lot of questions on their own behalf] participants?

Hopefully, the responses do not become scripts for medical interview education.

The paper also makes ‘evident’ that US health consumers want their personal goals to take a priority in conversations about their health with health professionals. So, we need to understand what goals the patient has about the ‘evidence’ being used to guide decisions. Is it their goal to understand more about what makes up medical evidence? If so, I am not ‘confident’ that this advances that aim.

When is reading a mammogram like looking for a polar bear in a snowstorm?

August 9, 2012

When you have dense breast tissue… at least, that is what some physicians say [go here, for more: http://www.womentowomen.com/breasthealth/densebreasttissue-mammograms.aspx ].

It has been 15 years since my annual mammogram led to a callback from the doctor for more x-rays and then a needle biopsy and finally ‘the all clear’ — no sign of cancer pronouncement. But it happened again last week. I got my annual mammogram on my way out of town to go to Atlanta for a visit with my daughter and granddaughter and son-in-law. And the day after I had the screening, I got a message on my home machine to call for a return visit…

Things have changed in the last 15 years, of course. Now, digital mammography makes some things more likely to be seen on the x-ray compared to film. Go here for a comparison: http://www.umm.edu/breastcenter/digital_mammography.htm?gclid=CNbCiKu_27ECFUlnOgodsH4A_A

At any rate, I returned to the imagery center for more x-rays. Here is how the communication went. First, it was nearly impossible to understand the message on my answering machine. My husband and I listened to it a half dozen times. We looked up the phone numbers of the imagery center, and none of them matched what we thought we were hearing. Nonetheless, I wrote what we thought they were saying and tried the number. It rang out to a message saying that it was long distance. Not likely then to be what I needed to call. Next, I tried calling the number using the first 3 numbers that all the numbers online for the imagery center used. And the last 4 numbers we thought the caller was saying that appeared nowhere in the online listing. Success. I got a nurse who checked and said, “When can you come in?” And I made an appointment for the day after I would return from my visit, which was a week after the first mammogram.

I went to the imagery center, this time with my husband coming in. The volunteer greeted me with, “Oh. I am so sorry.” Yikes. Not what you want to hear. She remembered me from the week before because we had a long chat about my height. At any rate, I would venture to say–“so sorry” is not quite the right expression in this situation. Perhaps “sorry you have to come in for more tests” if ‘sorry’ is to be used at all. The expression and her empathy were, however, unsettling.

Once I was in the room with the x-ray technician, I encountered the other end of the spectrum. The communication was reactive rather than proactive regarding what she wanted me to do. “Put your arm up and grab the handle? I did. “No. Turn this way. Face the machine.” Her tone was irritated. Wow. It is 9:30 in the morning. Why is she so grumpy? I am the one getting my boob smashed again.

She sighed. Letting out a clear expression of annoyance, she said. “Stick your bum out.” Who talks like that? “No. Look at me– Like this–” she said as though talking to someone she regarded to be extremely stupid. Finally, she was satisfied.

Time for another image. She turns me a bit and I try to enact what I have learned. I stick my bum out. “No.” she says harshly. “Stand up straight.” My arm began to quiver. Unavoidably uncertain about what I was doing wrong. Several more images and abrupt commands later, we were done.

“Will the radiologist come in here to discuss these with me?”

“No. Wait in the waiting room. I will get you when he is ready for you.”

I asked the volunteer if she would get my husband when I got called to the radiologist meeting. She told me to ask the technician to do it. So, when the technician came to get me, I asked her. And she did. No attitude. Wow!

And then there was the radiologist. I don’t think he could have been nicer or clearer. He put two pictures up on a screen and pointed to a small round dark spot about the size of a pellet for a BB gun. “This is what we’re looking at that’s different,” he said. “All this is your muscle and dense breast tissue.” It all looked like a lot of snow to me but I could see the BB…

“We’re going to do an ultrasound to see what we can learn about that spot.”

“What will the ultrasound tell you?”

He launched into a helpful answer that I will summarize as, ‘if the sound waves go through the mass, it’s a cyst. If they don’t it may be something we need to take a look at.’

The sound waves showed no mass. He spent plenty of time making sure that it did not appear in any direction. And then he announced, “I believe it’s a cyst. I will call this ‘normal’ and you won’t need to return for a year. Unless, of course, you see or notice changes that should be checked. Any questions.”

Hip Hip Hooray…. But I wish someone would give me a satisfaction survey to fill out about the volunteer and x-ray technician. I have a few thoughts about how their communication could be improved.

Are you fearful of being labeled ‘difficult’?

June 12, 2012

I am trying to imagine how my medical doctors perceive me. I tend to ask a lot of questions. I even bring — surprise surprise — information to an appointment and want to discuss it. I find that asking questions and sharing information leads my doctors to use vocabulary with me that I don’t understand and have to ask to have explained. And I am OK with that. But I cannot remember a time when I worried that my doctor, or my childrens’ doctors, or doctors treating my husband would label me ‘difficult’ because I asked lots of questions. But others do have these concerns.

A study published in Health Affairs conducted by Dominick Frosch and collaborators used focus group discussions to learn what barriers limited efforts to share decision-making with their doctors. They learned that participants wanted to be more involved in considering treatment and care options, but concerns that doctors would label them ‘difficult’ kept them from doing so. This suggests to me that doctors may need to make more explicit efforts to invite participation in shared decision-making, thus reducing the perception that participation will make an unfavorable impression.

Read more at: http://content.healthaffairs.org/content/31/5/1030