JHC Link Newsletter Summaries

Volume 12, Issue 7

Article Summaries:

The form and content of Direct to Consumer (DTC) pharmaceutical advertising is governed by the FDA, whose goal is to make certain that these ads provide "fair balance," that is, communicate balanced risk and benefit information. Nevertheless, it is clear that consumers have a better understanding of drug benefits versus drug risks after exposure to DTC advertising. This article examines one potential contributing factor to this situation - the effect of "qualifying language" on perceptions of drug appeal, anticipated pleasantness of drug use, and the expected occurrence of drug-related side effects. Three types of qualifying language were examined individually and in combination: language related to severity/duration of side effects ("side effects tend to be mild and often go away"), language that communicated conditional outcomes ("if side effects occur, they may include") and language related to drug discontinuation ("few people were bothered enough to stop taking"). Results indicate that drug appeal and the anticipated drug using experience were almost always more positive in the presence of qualifying language, especially when multiple forms were used in combination. Qualifying language appears to exert its influence by causing individuals to reduce their estimate of the likelihood of experiencing drug-related side effects. The findings highlight a significant gap in FDA DTC regulations which currently permit the use of qualifying language and have implications for the way in which fair balance is evaluated. Because qualifying language tends to reduce negative perceptions and increase positive perceptions, DTC ads which use qualifying language to communicate drug-related side effects may actually be contributing to the "benefit" versus "risk" side of the fair balance equation.
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The Relative Persuasiveness of Gain-Framed Loss-Framed Messages for Encouraging Disease Prevention Behaviors: A Meta-Analytic Review
-- Daniel J. O'Keefe; Jakob D. Jensen

The general research question motivating the present review was whether gain-framed and loss-framed appeals significantly differ in persuasiveness concerning disease prevention actions. O'Keefe and Jensen also examined whether the relative persuasiveness of gain- and loss-framed appeals varies depending on the particular prevention behavior being advocated. Such behavior-specific analyses have considerable practical importance, because the best evidence of whether gain-framed appeals are especially persuasive for encouraging (say) skin cancer prevention behaviors comes from studies specifically concerning those behaviors. A meta-analytic review of 93 studies (N = 21,656) finds that in disease prevention messages, gain-framed appeals, which emphasize the advantages of compliance with the communicator's recommendation, are statistically significantly more persuasive than loss-framed appeals, which emphasize the disadvantages of noncompliance. However, this difference is quite small (corresponding to r = .03) and appears attributable to a relatively large (and statistically significant) effect for messages advocating dental hygiene behaviors. Despite very good statistical power, the analysis finds no statistically significant differences in persuasiveness between gain- and loss-framed messages concerning other preventive actions such as safer-sex behaviors, skin cancer prevention behaviors, or diet and nutrition behaviors.
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Assessing Health Numeracy Among Community-Dwelling Older Adults
-- Lorie Donelle; Laurie Hoffman-Goetz; Jose F. Arocha

Adequate health numeracy skill is a fundamental requirement for individual decision making about health care and patients are required to make sense of increasingly complex health information. Current estimates of health context numeracy skills are drawn largely from U.S. samples. The article by Donelle, Hoffman-Goetz and Arocha provides a description of health based prose and numeracy skill among a group of independently functioning older Canadians. Interviews conducted with 140 older adults assessed how prose and numeracy skills, math anxiety, and level of education affect people's numeracy skill. Overall, most participants had good prose literacy skill and could understand basic numeric information. Fewer people understood complex numeric information. The observed gradient in participant numeracy skills was contingent on which of the three numeracy assessment instruments was used. In addition, math anxiety was associated with general context but not health context numeracy assessment instruments. Finally, given the link between prose health literacy and numeracy skill observed in this study, a measure of prose health literacy should be considered when assessing health numeracy.
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Perceptions of Traditional Information Sources and Use of the World Wide Web to Seek Health Information: Findings From the Health Information National Trends Survey
-- Stephen A. Rains

Health information is more widely available than ever before in history. One may acquire medical information from one's health care provider, friends, family, co-workers, television, radio, newspapers, magazines and countless other sources. Despite the variety of sources available, research has recently documented growing use of the Internet to seek health information. Rains explored the factors in one's information-media environment that are associated with use of the Internet for health information. Using data from the Health Information National Trends Survey (N = 3982), trust in traditional sources of health information, including one's health care provider, family and mass media, were examined as predictors of Internet usage and perceptions. Results showed that trust in information-oriented media, entertainment-oriented media and one's health care provider all predicted Web use behavior and/or perceptions. Distrust in these traditional sources of health information was associated with increased Web use. The findings from this study provide evidence that the information-media environment in which a potential information seeker is situated is associated with his or her use and perceptions of the Web as a source for medical information.
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Utilizing Computerized Entertainment Education in the Development of Decision Aids for Lower Literate and Naïve Computer Users
-- Maria L. Jibaja-Weiss; Robert J. Volk

Patients are playing an increasingly active role in decision making about their health care. In response, numerous patient decision aids have been developed to assist clinicians in educating their patients and in helping patients acquire the knowledge and skills needed to make informed health-care decisions. Despite its importance, little attention has been given to health literacy in the development and evaluation of patient decision aids beyond reporting reading level. Jibaja-Weiss and Volk present an approach for low-literate, underserved populations by making design considerations for poor readers and naïve computer users and by using concepts from entertainment education to engage the user and to contextualize the content for the user. The Edutainment Decision Aid Model (EDAM) provides a framework for decision aid developers to link learning theory and entertainment education to decision-aid design for lower literate and naïve computer users. The EDAM uses two integrated components to promote user engagement: (1) soap opera scenes, and (2) interactive learning modules. These integrated elements engage the user in an interesting story while providing essential information about the choices and tools for clarifying values in making a decision. The system design goals are to make the program both didactic and entertaining and the navigation and graphical user interface as simple as possible. An initial evaluation of a low-literacy breast cancer treatment decision aid demonstrated increased knowledge among users, favorable ratings of the user interface, fewer worries about treatment, and greater clarity about treatment preferences. Designing patient decision aids that are educational, entertaining and targeted toward poor readers and those with limited computer skills is a promising strategy for aiding this population.
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Volume 12, Issue 8

Article Summaries:

"I Have Never Heard That One": Young Girls' Knowledge and Perception of Cervical Cancer
-- Maghboeba Mosavel; Nadia El-Shaarawi

Mosavel and El-Shaarawi studied the existing state of cancer and cervical cancer knowledge of low-income African-American and Hispanic adolescent girls. The results of the study demonstrate that study participants lacked any substantive information about cervical cancer and that cancer knowledge seemed to be derived from a highly personal and emotional context. Cancer knowledge was predicated by fear, uncertainty, anxiety and death. Our findings suggest that considerable contextual health promotion efforts are needed to improve knowledge about cancer in general. Furthermore, specific cervical cancer knowledge and education that is contextualized and community-driven must be geared towards adolescent girls. The need for these cervical cancer education efforts is now even more critical given the availability of the HPV vaccine and the need for families to make an informed decision.
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Patients' Shame and Attitudes Toward Discussing the Results of Literacy Screening
-- Michael S. Wolf; Mark V. Williams; Ruth M. Parker; Nina S. Parikh; Adam W. Nowlan; David W. Baker

We investigated patients' willingness to have their reading ability documented in their medical records and the degree of shame and embarrassment associated with such disclosure. Structured interviews were conducted among a consecutive sample of 283 primary care patients at an urban public hospital. Patients' literacy was measured using the Rapid Estimate of Adult Literacy in Medicine (REALM). Self report of degree of shame and embarrassment related to literacy skills was measured using an orally-administered questionnaire. Fifty-one percent of patients had low literacy skills (? 6th grade) and 27.9 percent were assessed as having marginal literacy (7th-8th grade). Half (47.6%) of patients reading at or below the 3rd grade level admitted feeling ashamed or embarrassed about their difficulties reading, compared to 19.2% of those reading at the 4th to 6th grade level and 6.5 percent of those reading at the 7th to 8th grade level (p<0.001). More than 90 percent of patients with low or marginal literacy reported it would be helpful for the doctor or nurse to know they did not understand some medical words. Patients with limited literacy were more likely to report feelings of shame as a result of disclosure (p<0.05). Healthcare providers must recognize the potential shame patients might experience as a result of literacy screening.
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Understanding Optimal Nutrition Among Women of Childbearing Age in the United States and Puerto Rico: Employing Formative Research to Lay the Foundation for National Birth Defects Prevention Campaigns
-- Lisa L. Massi Lindsey; Heather C. Hamner; Christine E. Prue; Alina L. Flores; Diana Valencia; Elia Correa-Sierra; Jenifer E. Kopfman

Neural tube defects (NTDs) are serious birth defects of the brain and spine that that can be prevented by consuming the B vitamin folic acid. Previous efforts to reduce NTD rates have focused on increasing the number of childbearing-aged women who take a vitamin containing folic acid every day. As the first stage of formative research in campaign planning, the XXXX article in this issue presents two exploratory, qualitative studies that were conducted in order to (a) understand the complexity of vitamin use among women in the U.S. and Puerto Rico and (b) serve as a foundation on which to develop national communication and education interventions. Results indicated that campaign messages designed to increase folic acid use through multivitamin supplementation in the U.S. must address women's barriers to vitamin use, increase women's perceived need for multivitamins, and address the relationship between daily food choices and the need for supplementation. Future campaign messages in Puerto Rico must focus on many of these same issues, in addition to increasing women's knowledge about when folic acid should be taken in relation to pregnancy and address women's incorrect perceptions that vitamins cause weight gain. In addition to laying the foundation for creative new approaches to increase multivitamin consumption, the results of both studies shed some light on theoretical constructs that might, and might not, explain this behavior among women of childbearing age.
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Immunization in the Print Media - Perspectives Presented by the Press
- Felicity Goodyear-Smith; Helen Petousis-Harris; Colleen Vanlaar; Nikki Turner; Stephen Ram

Successful vaccination programmes result in reduction in vaccine preventable diseases. This means that there is diminishing public awareness of the potential devastating consequences of these diseases in a community (such as the effect of a poliomyelitis epidemic) and a corresponding increase in concern regarding the safety of vaccines. Media activities can both positively and negatively directly affect immunization uptake. Whether the reduction in anti-immunization messages is sustainable in an environment where little disease is present, or relies on reminders of disease remains to be seen. If there are few cases, the general fear of alleged vaccine-events becomes more prominent. An analysis of print media clippings from 400 national publications in 2001 and 2003 for references to immunization and vaccine-preventable diseases, coded as supportive, neutral or opposing immunization, indicated a significant reduction in articles and perspectives media opposed to immunization in 2003 than in 2001. This may be at least partly attributed to a comprehensive campaign by immunization promoters, including the Ministry of Health, of a systematic media strategy. This strategy involved the provision of key accessible, trained personnel to talk to the media on a wide range of immunization issues, available for rapid follow-up when alarmist stories broke, and who ensured that when vaccine-preventable diseases did occur, they got media attention. It was noted that many of the negative stories about vaccination surfaced in letters to the editor or opinion pieces, and such releases were regularly responded to by letters to the editor supportive of immunization.
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Messages From Moms: Barriers to and Facilitators of Behavior Change in a Lead Poisoning Preventive Education Project
-- Catherine M. Jordan; Patricia A. Lee; Ruth Olkon; Phyllis L. Pirie

Qualitative focus group data from participants of an intensive, culture-specific, lead poisoning preventive education research project were analyzed to assess success of communication strategies, and specifically, to identify barriers to and facilitators of adopting behavior changes encouraged in the project. Effectiveness of education in preventing lead poisoning is addressed elsewhere. Education focused on housecleaning, hygiene, water, and nutrition. Ninety-five participants of six ethnicities agreed to participate in focus groups. Seventy-eight actually attended. Barriers to behavior change included the effort required or unpleasantness of a prevention strategy, presentation of familiar information, denial of the problem, busyness, perceived lack of control, lack of social support, cultural traditions, and misunderstandings. Requiring one-time behavior changes, teaching simple, easy strategies, making less appealing tasks fun, demonstrating concepts, and presenting novel material that piques interest were features of the education that facilitated behavior change. Factors internal to the participant, such as love of the child or cultural practices, also served to motivate the participant to change behavior or to facilitate adoption of a prevention strategy. We offer recommendations to assist others in designing effective health education and risk communication prevention or intervention programs.
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Women Seeking Health Information: Distinguishing the Web User
-- Dorothy Warner; J. Drew Procaccino
Given the advantages of using the Web for health information-seeking and a survey result that women are more likely to use the Web as a channel to locate health information, the authors explored the health information-seeking process and behavior of women who use the Web to seek such information. Although based on previously collected data, this paper represents an extension of the earlier analysis with its focus on women who, at least to some extent, seek healthcare information via The Web (herein, Web user), a topic not thoroughly addressed in the earlier study. A comparison of female Web users and non-Web users who seek health information revealed that Web users sought health information at a higher rate than non Web users. Web users were more likely to communicate with medical professionals about the health information found and claimed that their decisions about health treatments were influenced by the health information. In most cases, Web users expressed a higher awareness of resources, regardless of format. However, Web users did not report that finding health information, from any channel, was noticeably easier.
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