Health Communication: Implications for Reform and Public Policy
Abstract and Keywords
This chapter reiterates that health communication is a powerful yet economical tool for improving health behavior change and treatment adherence. Individual chapters that elaborate major concepts are noted and major themes synthesized. Health communication is discussed in the context of how we might both select and train clinicians to improve methods of care delivery.
We began this volume with a statement from Dr. Jim Yong Kim: “The rocket science in health and health care is how we deliver it.” Before taking the post as president of the World Bank, Dr. Kim served as president of Dartmouth College, and as chair of the Department of Global Health and Social Medicine at Harvard Medical School. He co-founded the nonprofit health-care NGO, Partners in Health, which aims to provide high-quality primary and preventive care in underserved communities. One of the defining characteristics of Partners in Health is its emphasis on training and hiring members of the communities to be served. This approach is seen as a valuable way of fostering the long-term commitments and relationships that are so critical to meeting health-care needs in these communities, in part, because individuals resonate with and communicate most effectively with those who share their lives and understand their circumstances. Although this NGO provides a model framework for effective health-care delivery, its philosophy is not new. Sir William Osler is well known for teaching that, if physicians would only listen, their patients would tell them the diagnosis; it has been argued that communication may be the most important ingredient in the medical-care process (e.g., Roter & Hall, 2006).
The chapters in this book address the various elements of effective health communication—and there are many. Yet amidst the complexity and nuances of the authors’ treatment of communication, several powerful themes emerge: the vital importance of clear, comprehensible communication; the foundational nature of an open, trust-based relationship between patient and clinician; and the critical role that context writ large plays in individual health behavior. Literature on these topics abounds, as illustrated in the present compilation of chapters, yet implementation of these core themes in the realm of health and medical practice has been challenging. The reason may be that actual recommendations for improving communication and improving health outcomes are often simple at the broadest point but become quite idiosyncratic for any given case. For example, when motivating health-behavior change it is clear that individually tailored messages work best—this is a straightforward recommendation—but in practice, this means that the clinician will need to know the patient well enough to recognize what motivates him or her, and then frame the discussion in terms of those (p. 491) elements. For any given behavior—let us say, controlling blood glucose levels through diet—the best motivator may be a love for reading and consequent desire to maintain good eyesight for one individual, maintaining job productivity by not experiencing energy lows for a second, and continued mobility and good circulation in order to play outdoor games with children or grandchildren for a third. Although the target outcome and the behavior necessary to achieve it may be the same in each case, the medical communication will be unique and, thus, what is a simple recommendation in the abstract becomes idiosyncratic in practice.
In addition to this simple-in-principle but complex-in-practice reality, there is also a perceptual barrier in that many believe that such a basic tool as communication—something we all do every day—does not require much effort to implement or is not worth a programmatic investment of time and energy. This is changing, however, spurred on by the growing body of outcomes-based evidence that demonstrates the many ways in which health communication influences important endpoints.
As outcomes-based reimbursement systems replace volume-based approaches in programs such as Medicare and Medicaid, factors that improve health outcomes are being actively pursued regardless of whether they involve advanced technologies. Both the American College of Graduate Medical Education and the Association of American Medical Colleges now include interpersonal communication among the core medical practice skills. In the area of health communication, technology can indeed be helpful (e.g., more efficiently coordinated care using electronic health records; better adherence as a result of electronic monitoring or reminders; as discussed in Chapter 17). The low-tech, patient-centered and relationship-based aspects of health communication are also receiving the attention and emphasis that they deserve. The chapters of this volume summarize and critically evaluate the empirical evidence relevant to various aspects of health communication while pointing the way forward for ongoing research and practical application of findings.
The Information-Motivation-Strategy (IMS) model outlined in Chapter 2 provides the organizing framework for this book and represents the foundational elements of effective health communication (DiMatteo, Haskard-Zolnierek, & Martin, 2012); the model reflects back the major themes found in these chapters—information, collaborative partnerships, and context.
Clear, understandable communication
As Chapter 3 cogently illustrates, the importance of an individual’s comprehension of medical information pertaining to his or her case cannot be overstated. We argue that such comprehension is not only desirable but is also the responsibility of health professionals. Clear communication allows patients to understand, and it requires the use of clear, plain language as well as careful checking to be sure the patient has absorbed the information. When such actions on the part of clinicians occur in caring for patients who are health literate, the aims of an effective medical encounter are most likely to be achieved. Best practices, as outlined in Chapter 3, include taking simplifying steps (e.g., using simple language), using communication aids (e.g., pictures, multimedia), and confirming understanding (e.g., with “teach-back” or “show-me” techniques) with all patients (using “universal precautions”), because it is often difficult to ascertain an individual’s level of sophistication in a particular area.
From a public-policy perspective, it is important to offer ongoing encouragement and incentives for health-care providers to implement clear and straightforward methods of communicating health information. Many tools exist to help clinicians and health-care organizations best frame their health-relevant messages—some good examples include the health literacy programs, kits, and developmental resources available through organizations such as the American Medical Association and academic programs such as the Harvard School of Public Health. Help is available, in forums such as these, for a variety of communication options including print, interaction, and assorted nonprint media. These resources, when properly utilized, can do a great deal to improve communications with and understanding on the part of patients.
The value of more formal communication training, particularly early in health professional education when clinical habits are being formed, should not be minimized, however. Chapter 7 details the skills needed by practicing health professionals and how to best teach these skills, advocating an approach that takes into account specific educational strategies as well as the location and timing of the training programs themselves. Medical schools, nursing schools, dental schools, and other institutions for training health professionals will likely see real improvements in the quality of their graduates when a greater proportion of the curriculum is devoted to improving these communication skills.
(p. 492) Not all the responsibility lies with clinicians, of course. We can do better, in the public education sector, to teach the reading, comprehension, integration, and critical evaluation skills that are so crucial to understanding (among other things) health information. Beginning in primary school, children should be encouraged not only to practice good health behaviors, but also to think about why those behaviors make sense. It is true that children, teenagers, and even young adults have difficulty caring much about very long-term outcomes (such as lifespan mortality risk or the likelihood of developing a chronic disease in later life), but they can nonetheless learn to understand and evaluate those risks. The motivational component can then be built on top of the foundational risk-related information.
Providing systems and infrastructure that facilitate access to clear, accurate health information is another important health-enhancing strategy. For example, the Internet allows access to health information by almost anyone at virtually any time of the day or night. The problem is that this information takes all forms; some of it is easy to understand, whereas some is highly technical and difficult to process. Some web-based information is both accurate and complete, whereas some is biased or slanted toward a particular intervention or product; and some information is simply incorrect. Electronic information-sharing databases do exist, but they are not uniform in their structure, accessibility, or reliability, and it is often difficult for individuals to know whether an information source is trustworthy or not. Creating databases of basic-language, empirically-based health information, perhaps affiliated with well-known and trusted institutions, could do a great deal to ensure that patients receive scientifically sound health information while making their searches for such information less time-intensive and daunting.
Limited health literacy is a problem for individuals and for the broader society. Although implementation of large-scale interventions to improve health literacy and increase the effectiveness of medical information sharing is not an inexpensive proposition, we argue that these costs should be balanced against the costs (both monetary and human costs) associated with the failure to implement them.
With regard to incentives, the current shift toward outcomes-based reimbursements seems to make good sense. Because different clinicians (and clinical facilities) serve populations with unique challenges, however, it is unfair to hold everyone to the same objective standard. Instead, a system in which demonstrated ongoing improvements are made would be more equitable. In this case, baseline measures would be made and targets based on those start-values would be set. Then, the clinicians, patients, and health-care systems that achieve better outcomes over time can be rewarded (e.g., with less expensive health insurance rates for patients or better compensations for care delivered by hospitals or outpatient facilities).
Collaborative, trust-based relationships
The value of the therapeutic relationship itself would be difficult to overstate. Not only is the clinician-patient relationship the context through which information flows, but it also serves as a primary venue in which the motivations toward adherence and behavior change are identified and cultivated. Without a trusting bond, patients are less likely to be open to suggestions made by the clinician and are less likely to share difficulties, concerns, and questions. Yet these issues are exactly the ones that a clinician needs to know in order to help the patient think through options, devise solutions to problems, and plan for the days ahead in which the patient alone will determine adherence or appropriate health-related actions.
Developing a healthy, trust-based partnership takes time, and for this reason it is often seen as something that is difficult to do. It involves a number of different elements including sensitivity to nonverbal communication (the focus of Chapter 4), actively engaging patients in the decision-making process (see especially Chapter 6), and elements of give and take that are often understood as an “art” rather than a precise, technical skill (see Chapter 5). What actually happens in encounters when a partnership is being constructed includes such things as allowing time for the patient to fully answer open-ended questions (e.g., not interrupting and not immediately jumping in with a response as soon as the patient pauses). It includes getting to know the patient as an individual with a psychosocial context, not just as the carrier of a particular diagnosis or health aim. Is it really possible to develop such relationships amid the bustle and time pressures of a contemporary medical environment?
Clinicians often fear that partnership building will take too much time; for instance, if one allows patients to ramble on in response to open-ended questions they may never stop! Research demonstrates, however, that allowing a patient to complete his or her response without redirection usually (p. 493) adds only a little time to the encounter—about six seconds on average (Marvel, Epstein, Flowers, & Beckman, 1999), an amount that can easily be earned back over the course of the relationship if not that same encounter. Another study (conducted in a tertiary treatment center where patients tended to have complex, difficult presentations) found that when patients were allowed to talk without interruption, the average talk time was just over a minute and a half, with almost 80% of patients finishing their opening statements in two minutes or less (Langewitz, Denz, Keller, Kiss, Ruttiman, & Wossmer, 2002). Further, data indicate that when experienced physicians use a patient-centered approach it does not require a greater time investment (Roter, Hall, Kern, Barker, Cloe, & Roca, 1995). Patients are also less likely, in the context of a strong provider-patient partnership, to introduce new content near the end of the encounter (Marvel et al., 1999)—something that is not only frustrating for clinicians but often takes more time because the interaction then has to be re-opened and sometimes the new information requires an adjustment to recommendations that were made earlier.
Just as it makes sense to select, for clinical training, individuals who have some propensity for clear communication (and then to hone those abilities), we believe that it is reasonable to include, as part of the process for selecting future clinicians, assessments of empathic and relational ability. This is not to say that someone who does not come by these qualities naturally has no future as a clinician. It is to say, however, that the possession of these skills should be recognized and rewarded, and that it is worth the investment in time and training to enhance these skills for those who struggle. Some individuals seem to connect with others almost automatically—it appears to come naturally. For others it takes work, and this work is important work. Chapters 5, 6, and 7 all discuss ways in which these qualities can be enhanced, and we believe that medical training institutions (medical schools, nursing schools, and so on) would do well to incorporate such principles and techniques systematically in their programs.
Individuals in context
When collaborative, trust-based relationships exist, it is virtually impossible to decontextualize the patient. As the partnership develops, the clinician gains intimate knowledge about the patient’s fears, hopes, desires, motivations, and barriers to carrying out the health behaviors to which she or he aspires. Elements of the patient’s environment can be harnessed to help the patient accomplish aims, and elements that prevent attainment of goals and others can be tackled when they are getting in the way of those goals.
One situation that is frequently encountered by clinicians is a triadic interaction—that is, the patient comes to the visit with someone else (e.g., an elderly parent comes with a child or a youngster is accompanied by a parent). Sometimes even more than three people may be involved, such as when a newly diagnosed child comes to the visit with both parents, or in the context of a support group. Cases such as these are detailed in Chapter 8, and they pose unique challenges as well as opportunities. Family and friends are able to serve as potent motivators and effective systems for reminding and reinforcing behavior; but these individuals can also sabotage the health goals (purposely or inadvertently) if they have not understood and are not committed, along with the patient, to the medical recommendations. In some ways, then, the dyad may be even more difficult because patients will surely interact with these individuals; if they are not present in the medical interaction, there is no opportunity to actively engage their support. Indeed, patients’ social networks are crucial to both the initiation and maintenance of good health behaviors, as Chapter 16 discusses.
The patient’s personal social systems are not the only ones that are important to his or her health outcomes. The medical-care system itself must be negotiated, and the individuals within it must communicate effectively with one another. In the absence of either of these conditions, substantial detriments to appropriate health behaviors on the part of the patient are likely. Chapters 9 and 19 address these issues in detail.
Social networks are sometimes difficult to differentiate from the larger cultural context—another important predictor of health-related behaviors. Chapter 14 deals specifically with cultural issues, and Chapter 18 discusses additional social and economic factors that influence patient experience and behavior, but these begin to blend with the patient him- or herself. People have cultural ties and affiliations, they are of a particular age and sex, they can be classified according to a socioeconomic system, but they also have their own personal experiences, beliefs, and expectations, some of which are consistent with cultural or other social norms and values and others that are not. Part Three of this volume deals with some of these, including health beliefs (p. 494) (Chapter 10), risk perceptions (Chapter 11), readiness for change (Chapter 12), and both persuasion and commitment (Chapters 13 and 15, respectively).
Because individuals change as they develop and because experiences accumulate and influence some of the factors listed earlier, a particular diagnosis or health challenge at one point in life may be quite different from that same challenge at another life stage. Part Five focuses in on some of these unique qualities including issues related to pediatric adherence (Chapter 21) in which external influences on adherence (e.g., family) may be even greater than for adults; health behaviors and adherence in adolescence (Chapter 22) because identity formation is ongoing and peer relationships are especially salient; and particular challenges to adherence and health behaviors encountered in later life (Chapter 23) where co-morbidities are more common and risk factors that are less prevalent in younger people exist.
Although everyone, regardless of age, surely experiences challenges and stumbling blocks when attempting to live a healthy lifestyle, some situations embody greater-than-average difficulties. Two of these are tackled in Chapters 24 and 25 of this book. Chapter 24 addresses the ways in which depression and other mental health issues influence adherence and health behavior change, and Chapter 25 deals with managing multiple conditions and multifaceted regimens with pediatric diabetes used as an illustrative model. In both of these cases the task of the clinician is especially complex requiring a deep understanding of the unique psychological challenges (e.g., of depression, of development) as well as awareness of influential cognitive, emotional, social, and environmental constraints that are most relevant to health in pediatric populations and in those with mental health comorbidities.
When thinking about the patient in context—whether that involves readiness to change, cultural embededness, degree of social isolation/connectedness, financial security, or something else, it must be remembered that these factors meaningfully influence the patient’s willingness and ability to carry out effective health behaviors. What does this mean for how we deliver health care? How does this influence our approach to public policy?
It means that a one-size-fits-all approach, despite the appeal of its simplicity, will not work. Mechanized, mass-produced health messages or interventions will be effective for those few who happen to match that approach but for the masses of others this sort of intervention will fall short. Continuing to make wholesale adjustments to these large-scale “solutions” will likely do no more than shift the problem (and the effectiveness) to a different subset of the population without improving overall goal achievement. It means that we must instead shift our general approach to one of patient centeredness and individualization. In the short term this may, indeed, take a bit more time—but as discussed earlier, it will not likely be much more time. In the long term this is the only sensible course of action. Health plays out over time, changes are often made slowly, and diseases frequently result from an accumulation of behaviors and risk factors often over years. We believe that it is only by embarking on this long-term journey with patients that we will be able to meaningfully influence their health beyond what our current systems have achieved. Thus, we offer that perhaps rocket science is really social science and that, as such, all members of the health-care team are engineers of sorts, working together to achieve the delicate balance required for optimal health.
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