Comprehensive Notes on Health Communication, Health Literacy, and Printed Materials
Shannon-Weaver Model
The Shannon-Weaver model is a communication model that includes the following components:
- Sender: Encodes a message (encoding means packing the message in text or symbols).
- Channel/Medium: Sender transmits the message through a channel or medium (e.g., phone, email, speech).
- Noise: During transmission, the message may encounter noise (interference).
- Receiver: Message goes to a receiver who interprets (decodes) the information.
- Feedback: Receiver may transmit feedback (a reaction) to the sender.
Limitations of the Shannon-Weaver Model
The model does not account for:
- Context (formal/informal).
- Relationship between sender and receiver (e.g., authority differences).
- Meaning attached to a channel (e.g., phone vs. text).
- Process of encoding/decoding where we make meaning.
Communication Channel
A communication channel is a medium that can impact an agenda and set a stage for action.
Critiques of Communication Efforts
It is sometimes complicated and difficult to assess the impact of a communications effort, especially with technology involved.
Health Communication Definition
According to the CDC and NCI, health communication is "The study and use of communication strategies to inform and influence individual decisions that enhance health."
Field of Health Communication (Harvard T.H. Chan School of Public Health)
Health communication is the study of how health information is generated and disseminated and how that information affects individuals, community groups, institutions, and public policy. It includes the study of secular communication, as well as the strategic communication of evidence-based health information to professional and non-professional audiences.
The Harvard T.H. Chan School of Public Health has established the Health Communication Concentration (HCC) to provide formal and systematized training in health communication for public health leaders, practitioners, and researchers.
Printed Materials in Healthcare
Healthcare and public health systems rely heavily on printed materials, including:
- Medical history forms
- Insurance forms
- Informed consent forms
- Patients’ rights and responsibilities
- Test results
- Directions to the lab or pharmacy
- Hospital discharge and home care instructions
- Clinical research protocols and announcements
- Vaccine Information Statements (VIS)
Health Literacy
Healthy People 2020 & 2030: Health Communication Objectives
- HC/HIT-1: Improve the health literacy of the population.
- HC/HIT-1.1: Increase the proportion of persons who report their health care provider always gave them easy-to-understand instructions about what to do to take care of their illness or health condition.
- HC/HIT-1.2: Increase the proportion of persons who report their health care provider always asked them to describe how they will follow the instructions.
- HC/HIT-1.3: Increase the proportion of persons who report that their health care providers' office always offered help in filling out a form.
- HC/HIT-2: Increase the proportion of persons who report that their health care providers have satisfactory communication skills.
- HC/HIT-2.1: Increase the proportion of persons who report that their health care providers always listened carefully to them.
Healthy People 2030 Objectives Progress (2023)
- HC/HIT-03: Increase the proportion of adults whose health care providers involved them in decisions as much as they wanted - Improving.
- HC/HIT-01: Increase the proportion of adults whose health care provider checked their understanding - Little or no detectable change.
- HC/HIT-02: Decrease the proportion of adults who report poor communication with their health care provider - Little or no detectable change.
- HC/HIT-D11: Increase the proportion of adults with limited English proficiency who say their providers explain things clearly - Developmental.
Milken Institute: Healthy People 2030 Objectives in Health Literacy
| Objectives | Baseline (% of Adults) | Target |
|---|---|---|
| Increase the proportion of adults whose health care provider checked their understanding | 26.6% (2017) | 32.2% |
| Decrease the proportion of adults who report poor communication with their health care provider | 8.9% (2017) | 8.0% |
| Increase the proportion of adults whose health care providers involved them in decisions as much as they wanted | 52.8% (2017) | 62.7% |
Health Literacy Definition (August 2020)
- Personal health literacy: The degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.
- Organizational health literacy: The degree to which organizations equitably enable individuals to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.
HLS-EU Health Literacy Matrix
| Access/obtain | Understand | Process/appraise | Apply/use | |
|---|---|---|---|---|
| Health care | Ability to access information on medical and clinical issues | Ability to understand medical information and derive meaning | Ability to interpret and evaluate medical information | Ability to make informed decisions on medical issues |
| Disease prevention | Ability to access information on risk factors for health | Ability to understand information on risk factors and derive meaning | Ability to interpret and evaluate information on risk factors for health | Ability to make informed decisions on risk factors for health |
| Health promotion | Ability to update oneself on determinants of health in the social and physical environment | Ability to understand information on determinants of health in the social and physical environment and derive meaning | Ability to interpret and evaluate information on health determinants in the social and physical context | Ability to make informed decisions on health determinants in the social and physical environment |
Numeracy Skills in Health Literacy
Health literacy includes numeracy skills such as:
- Calculating cholesterol
- Measuring medications
- Understanding nutrition labels
Health Literacy: At-Risk Populations
Populations most likely to experience low health literacy:
- Older adults
- Racial and ethnic minorities
- People with less than a high school degree or GED certificate
- People with low-income levels
- Non-native speakers of English
- People with compromised health status
Factors affecting a person’s health literacy skills: education, language, culture, access to resources, and age.
Health Literacy Levels
- Only 12% of adults have Proficient health literacy (National Assessment of Adult Literacy).
- 14% of adults (30 million people) have Below Basic health literacy.
Overview of Literacy Levels
| Level | Score Ranges | Key Abilities |
|---|---|---|
| Below Basic | Prose: 0-209 Document: 0-204 Quantitative: 0-234 | Adults at the Below Basic level range from being nonliterate in English to having the abilities to locate easily identifiable information in short, commonplace prose texts; locate easily identifiable information and following written instructions in simple documents; locate numbers and using them to perform simple quantitative operations (primarily addition) when the mathematical information is very concrete and familiar. |
| Basic | Prose: 210-264 Document: 205-249 Quantitative: 235-289 | Reading and understanding information in short, commonplace prose texts; reading and understanding information in simple documents; locating easily identifiable quantitative information and using it to solve simple, one-step problems when the arithmetic operation is specified or easily inferred. |
| Intermediate | Prose: 265-339 Document: 250-334 Quantitative: 290-349 | Reading and understanding moderately dense, less commonplace prose texts as well as summarizing, making simple inferences, determining cause and effect, and recognizing the author's purpose; locating information in dense, complex documents and making simple inferences about the information; locating less familiar quantitative information and using it to solve problems when the arithmetic operation is not specified or easily inferred. |
| Proficient | Prose: 340-500 Document: 335-500 Quantitative: 350-500 | Reading lengthy, complex, abstract prose texts as well as synthesizing information and making complex inferences; integrating, synthesizing, and analyzing multiple pieces of information located in complex documents; locating more abstract quantitative information and using it to solve multi-step problems when the arithmetic operations are not easily inferred and the problems are more complex. |
PIAAC Literacy, Numeracy, and Adaptive Problem Solving
- Average scores on literacy, numeracy, and adaptive problem solving vary by self-reported health status.
- Comparisons of 2023 results with 2012/14 and 2017 PIAAC assessments need to be made with caution due to differences in the assessments and scoring methodology. For example, 2023 PIAAC was administered completely on a tablet (digitally), whereas in previous PIAAC assessments, respondents were offered an option of paper-and-pencil format instead of taking it on a computer.
Consequences of Low Health Literacy
Low health literacy is associated with:
- More hospitalizations
- Greater use of emergency care
- Lower receipt of mammography screening and influenza vaccine
- Poorer ability to demonstrate taking medications appropriately
- Poorer ability to interpret labels and health messages
- Among elderly persons, poorer overall health status and higher mortality rates
Increased Costs
Limited health literacy, through all its impacts - medical errors, miscommunication, increased illness and disability, loss of wages, and compromised public health - is estimated to cost the U.S. economy up to 349 billion every year.
CDC Clear Communication Index
The CDC Clear Communication Index (Index) is a research-based tool to help develop and assess public communication materials.
- The Index has 4 introductory questions and 20 scored items drawn from scientific literature in communication and related disciplines.
- The items represent the most important characteristics that enhance and aid people's understanding of information.
Strategies for Clear Communication
- Make Your Message Clear
- Text Appearance Matters
- Visuals Help Tell Your Story
- Layout and Design
- Consider Culture
- Translations Take Your Message Further
Checklist for Easy-to-Understand Print Materials
Message Content
- Limit messages to three to four per document/section.
- Remove unnecessary information.
- Place important information at the beginning and repeat at the end.
- Identify action steps or desired behaviors.
- Post-test materials.
Text Appearance
- Use white space.
- Margins at least 1/2 inch.
- Print large enough (at least 12 points).
- Use bold, italics, and text boxes to highlight information.
- Avoid all capital letters.
- Left-justify text.
- Use columns with a line length of 40-50 characters.
- Post-test materials.
Visuals
- Attractive cover with main message and target audience.
- Simple and instructive visuals.
- Visuals explain the messages found in the text.
- Place visuals near related text with captions.
- Captions should convey the main points.
- Post-test materials.
Layout and Design
- Logical information order for the audience.
- Chunk information using headings and subheadings; use bullets for lists.
- Eliminate jargon and technical language; explain unavoidable technical terms.
- Use concrete nouns, active voice, short words/sentences, and a conversational style.
- Post-test materials.
Translation
- Culturally appropriate language and content/visuals.
- Back translate pieces.
- Translator fluent in intended audience’s linguistic variation.
- Post-test materials.
Understandability
- Test the complexity of the language for comprehension.
- Pre-test and post-test materials with the intended audience.
Instruments to Assess Print Materials
- Flesch-Kincaid Grade Level and Flesch Reading Ease Score
- FOG (Frequency of Gobbledygook)
- Fry Readability Formula
- SMOG (Simple Measure of Gobbledygook)
- SAM (Suitability Assessment of Materials)
- PMOSE/IKIRSCH Document Readability Formula
PEMAT (Patient Education Materials Assessment Tool)
An Instrument To Assess the Understandability and Actionability of Print and Audiovisual Patient Education Materials.
SAM (Suitability Assessment of Materials)
Originally designed for printed materials, expanded to video; includes literacy and provides a numeric score (Superior, Adequate, Not Suitable).
Readability
- 6th-grade reading level – 75% comprehension
- 3rd-grade reading level – 90% comprehension
- Adults at all reading skill levels prefer and learn better with easy-to-read instructions.
Estimating Reading Level (SMOG Formula)
- Count the number of words with three or more syllables in three chains of 10 sentences in different parts of your draft.
- Look up the approximate grade level in the chart.
Using Fry Formula
- Randomly choose three samples from your document with 100 words each.
- Count the number of sentences in the hundred words, estimating the length of the fraction of the last sentence to the nearest 1/10th.
- Count the total number of syllables in the 100-word passage. Do not count numbers. Do count proper nouns. If you don't have a hand counter available, an easy way is to simply put a mark above every syllable after the first syllable in each word. Then, when you get to the end of the passage, count the number of marks and add 100 to include the first syllable in each word that you did not mark.
- Find the average number of sentences and the average number of syllables for the three samples by dividing the total of all three samples by three.
- Use the graph to plot the average sentence length and number of syllables. The two lines will intersect at the approximate grade level. If a great deal of variability is found, try putting more sample counts into the average.
SAM Scoring
Scoring uses the following point system:
- 2 points for a superior rating
- 1 point for an adequate rating
- 0 points for a not suitable rating
- N/A if the factor does not apply to this material