Policy making in the health and health care areas straddle both of these perspectives. On one hand there are calls by passionate stakeholders for health equity, full healthcare access and coverage for all, community-based health strategies and struggles with how to reduce inequalities in health status and health care access and affordability. On the other hand are proposals for a logical set of controls and processes for allocating scarce resources to people in the community (as well as debates as who is ‘in the community’ and who is not, for example, undocumented immigrants), the use of economic analysis to set priorities as to where returns on public investments are most likely to occur, and the struggle to incorporate evidence-based decision-making into health policy debates and health care practice.
These and many other issues have been the back story for the health care (or health care payment, depending on your POV) policy debate. But I want to switch gears to the development of disease prevention and health promotion policy, or Healthy People 2020 (a process I have been following for a few years now here). Policy preferences are inherent in Healthy People – the national disease prevention and health promotion objectives established each decade. For example, the overarching goals of Healthy People 2010 were to (1) increase the quality and years of healthy life and (2) eliminate health disparities. Inherent in these goals are the need to discuss and arrive at a social consensus about what we mean by such terms as “quality,” ‘healthy,” and” disparities.” The importance of these debates cannot be underestimated when we consider that they drive resource allocations and collective actions (at least by Federal and state governments and many of the 350 Healthy People Consortium partners) to improve the population’s health. The magnitude and complexity of such an undertaking as Healthy People is also reflected in its expansion from an initial 226 objectives in 15 priority areas in the 1990 version to 467 objectives across 28 focus areas in 2010.
Whether a topic is included as an objective, or set of objectives, in Healthy People reflects a communal assessment, or policy making process, about its perceived value for signaling progress in improving our Nation’s health. While health outcomes, risk factors, preventive services and data and surveillance systems have been part of the structure of national health objectives from the beginning, there have been few objectives related to how to impact health objectives. An early exception was for community, workplace and school-based health promotion programs that were seen as cross-cutting issues that could be adapted and used to address other risk behaviors and/or public health practice (e.g., Increase the proportion of middle, junior high, and senior high schools that provide school health education to prevent health problems in the following areas: unintentional injury; violence; suicide; tobacco use and addiction; alcohol and other drug use; unintended pregnancy, HIV/AIDS, and STD infection; unhealthy dietary patterns; inadequate physical activity; and environmental health. Increase the proportion of worksites with formal smoking policies that prohibit smoking or limit it to separately ventilated areas. Increase the number of culturally appropriate and linguistically competent programs, in health departments).
A number of HHS agencies have extensive experience, going back decades, with addressing a wide variety of public health topics with health communication and social marketing strategies, for example the National High Blood Pressure and Cholesterol Education Programs of the National Heart, Lung and Blood Institute (Bellicha & McGrath, 1990); the National Cancer Institute’s 5 A Day for Better Health program (Lefebvre, Doner, Johnston, Loughrey, Balch & Sutton, 1995); and the integration of health communication into many of the prevention programs at the Centers for Disease Control and Prevention (CDC; Roper, 1993). Yet, it was only in Healthy People 2010 that a cross-cutting area of Health Communication appeared. The creation of this Focus Area confirmed the importance of communication as an intellectual framework, a scientific endeavor, and a set of processes and interventions for health improvement in public health policy making. In addition, its six objectives were deliberately broad to convey how health communication can contribute to all aspects of disease prevention and control, health promotion, and medical and dental care including how people are exposed to, search for, and use health information; individuals' ability to reduce or eliminate unhealthy behaviors and adopt healthy behaviors; their ability to gain access to the public health and health care systems and understand clinical recommendations and expected outcomes; how to disseminate information about individual and population health risks and craft public health messages and campaigns; and the development of e-health applications, including online personal health records, health Web sites, interactive personal health tools, and telemedicine systems.
Since the launch of Healthy People 2010, there have been mid-course reviews of each focus area. At the latest progress review meeting for the health communication focus area (pdf), it was reported that:
• Access to the internet at home among the total US population aged 18 years and older had increased.
• In 2003, a baseline national survey found that only 12 percent of the total population aged 16 years and older were at a proficient level of health literacy.
• In a baseline survey of a sample of HHS-sponsored health communication campaigns in 2005, 95% of them were found to have included research conducted during program development and 59% provided for measurement of campaign impact.
• Less than 10% of a sample of health-related websites disclosed the identity of the persons/organizations responsible for the site.
• By 2006, there were a total of eight Centers of Excellence for Health Communication Research, all funded by the Federal government.
• 59% of patients reported that doctors or other health care providers always explained things so they could understand them.
What we have been hoping to achieve with the development of Healthy People 2020 is an even richer understanding of how health communication and social marketing can improve the Nation's health. More notable among these activities has been the attempt to integrate the explosion in the health information technology space and meld technology with steps to healthier action by millions of people. What this exercise has demonstrated to me is that there is a fundamental need to shift health communication research to become more policy focused, and to generate data that is useful in the policy-making context.
Implications for health communication policy research
Rich (2007) has noted that policy making is, in part, a learning process of information gathering and analysis to reduce uncertainty and maximize the effectiveness of the process. From this POV, health communication research has a number of challenges to create a research and empirical base to both illuminate and guide policy making for disease prevention and health promotion. Among the key ones is establishing on-going mechanisms to collect and report information about a core set of health communication and marketing variables, over time (decades), from representative samples of the US population that can be used to establish national benchmarks and monitor progress towards their attainment.
Indeed, one of the constraints for creating national policy in health communication (and to a lesser extent, health information technology) is the lack of national data systems that monitor and track relevant variables across population groups - two notable examples where this has been occurring are the Pew Internet and American Life surveys and the Health Information National Trends Survey (HINTS). When we consider how health information and communication technologies (ICT) are becoming an increasing part of people's everyday lives, these surveys are only scratching the surface of what we need to know. Of course, central to any movement in this arena is community consensus about what are the relevant questions to be posing to people (for the more public health inclined, we need an epidemiological dataset of health ICT use, frequency and impact as it relates to health behaviors and health status). Such questions could form the basis for developing a national health ICT survey or become integrated with on-going national surveys such as the National Health Interview Survey, the Behavioral Risk Factor Surveillance System or the HINTS; get incorporated into expanded data collection efforts such as the Healthcare Cost and Utilization Project or the Healthcare Effectiveness Data and Information Set; or become standalone activities such as a National Health Literacy Survey.
Yet, even if sufficient information about all kinds of health communication issues were available, there are a number of other factors that will influence whether such information is used by policy makers. Among some of those factors Rich (2007) identifies are format and style of presentation; timeliness of the information, potential users’ needs, values and interests; who provides the information to the policy maker; and whether the information comes from internal (e.g., government) or external (e.g., academia, nonprofit or private sector) sources. Indeed, one area of health communication research might revolve around issues of communicating disease prevention and health promotion information to and among policy makers.
Several areas were health communication research can complement and extend current national disease prevention and health promotion activities were identified in the midcourse review. Among them were:
• Develop instruments to assess levels of health literacy that are more sensitive to individual differences based on language, culture, and experience.
• Build a business case for improving health literacy based on cost savings to be realized from enhanced patient safety and increased compliance with instructions.
• Identify and disseminate health literacy best practices, including guidelines, standards, outcome measures, and innovative approaches directed toward improvement.
• Develop and scale public education and action models to increase user monitoring and validation of health information from various digital sources, including social network sites.
• Test various marketing strategies to increase and maintain health provider engagement and/or involvement with professional development in patient communication skills and cultural and linguistic competencies.
• Explore opportunities and approaches for engaging different segments of the public in the development and review of health content.
In particular, I see the opportunity of integrating health information technology and health communication into a more systemic approach to research (Health ICT). Some interlocking issues that are important policy concerns include the need to link adoption of HIT to goals of improved health and health care and not to ones of technical interoperability, privacy and security (Clancy, Anderson & White, 2009). We might presume that some of these links are mediated by the structure and processes of the formal and informal communication systems HIT are embedded into, but the research is in its earliest stages of development.
Some of the other areas where we might explore the hoped for synergies in communication, social marketing and technologies include:
Delineate how HIT solutions are developed, implemented and expressed in a patient outcomes context, not just in the form of more efficient payment systems, comparative effectiveness studies, and monitoring adverse effects or public health emergencies (Clancy, Anderson & White, 2009).
How to design clinical decision support and patient engagement processes around adoption and use of electronic health records (EHRs) to drive targeted improvements in health care quality and efficiency. (c.f., Des Roches et al, 2010)?
What are the organizational and workforce cultural, behavioral and communication challenges that must be addressed by strategies for implementing EHRs in hospital and small practice settings (c.f., DeVore and Figlioli, 2010)?
How can we design the format, style and use of EHRs so that they engage patients and their families to improve health and care in a timely manner; insures patient needs are met; leads to satisfying communication with their health care providers; minimizes burdensome data collection requirements; and does not disrupt the patient-provider relationship (by, for example, lowering trust; c.f. Ralston et al, 2010)?
What factors influence patient decision-making about how much of their health information they share, with whom, how, and under what circumstances? How do these findings inform issues around consent, especially as it relates to health literacy and marketing practices? How do we move from permission-based to demand-driven marketing of participation in health information exchanges? (c.f., Tripathi et al, 2009).
If we shift some of our research priorities from clinical (or individual) contexts to a broader policy one, we can help policy-makers recognize the value of integrating communication, marketing and HIT as core strategic levers for public policy making to promote health and prevent disease. It will also build the case that these options deserve the sustained investment of resources in the years ahead.
Bellicha, T. and McGrath, J. Mass media approaches to reducing cardiovascular disease risk. Public Health Reports,1990;105:245-252.Clancy, C.M., Anderson, K.M. and White, P.J. Investing in health information infrastructure: can it help achieve health reform? Health Affairs, 2009;28:478-482.
DesRoches, C.M., Campbell, E.G., Vogeli, C., Zheng, J., Rao, S.R., Shields, A.E., Donelan, K., Rosenbaum, S., Bristol, S.J. and Jha, A.K. Electronic health records’ limited successes suggest more targeted uses. Health Affairs, 2010;29:639-646.
DeVore, S.D. and Figlioli. K. Lessons premier hospitals learned about implementing electronic health records. Health Affairs, 2010;29: 664-667.
Lefebvre R.C., Doner, L., Johnston, C., Loughrey, K., Balch, G. and Sutton, S.M. Use of database marketing and consumer-based health communication in message design: an example from the Office of Cancer Communications’ “5 a Day for Better Health” program. In: Maibach E, Parrott R, eds. Designing health messages: approaches from communication theory and public health practice. Newburg Park, California: Sage Publications, 1995:217–46.
Ralston,J.D., Coleman, K., Reid, R.J., Handley, M.R. and Larson, E.B. Patient experience should be part of meaningful-use criteria. Health Affairs, 2010;29: 607-613.
Rich, R.F. A knowledge utilization framework for making behavioral science useful to policy makers. In M.K Welch-Ross and L.G. Fasig (Eds.), Handbook on Communicating and Disseminating Behavioral Science. Thousand Oaks, CA: Sage Publications, 2007 (pp.233-249).
Roper, W.L. Health communication takes on new dimensions at CDC. Public Health Reports, 1993;108:179–183.
Stone, D. Policy Paradox: The Art of Political Decision Making. New York: W.W. Norton & Company, 1997.
Tripathi, M., Delano, D., Lund, B. and Rudolph, L. Engaging patients for health information exchange. Health Affairs, 2009;28; 435-443.