If only I ate in moderation and exercised regularly—but I do not. While I have not recently experienced the judgmental comments or nonverbal communications of my doctors and nurses, I internalized the comments and reactions of my pediatrician. As an adult, I practiced the same unhealthy behavior of many overweight women who have ignored their health due to stigma and shame. For them, that point in a doctor visit—stepping on the scale—is associated with intense negative emotions that keep too many people who are overweight and obese from obtaining proper preventive healthcare.

Treatment includes treating all people with respect

Two points I find interesting on the topic of obesity are that weight counseling in the primary care setting has decreased ¹ and that there is a need to educate healthcare providers about treating obese people with respect and dignity.

At a recent conference on obesity, it was reported that physicians have not found weight counseling to be effective—one reason for the reduction in time spent on this intervention. This decrease in counseling time is occurring despite an increase in patient visits for diabetes, hypertension, and other obesity-related issues. A Healthy People 2020 goal has been set to increase the proportion of obese-adult office visits that include counseling and education on losing weight and living a healthy lifestyle. But are physicians and other healthcare providers equipped to counsel these patients? Do they have effective tools and the resources to guide their patients about weight loss?

At the obesity conference, Christopher N. Sciamanna, MD, from the Penn State University College of Medicine, said that physicians must have effective tools, including Web sites and programs, to guide the treatment of obese patients. He added that physicians need education on what to say and do to help obese patients.¹ Weight counseling is not adequately addressed with a few quick statements emphasizing that a patient’s diabetes, cardiovascular disease, or arthritis will be further compromised if he or she does not lose weight. In the absence of knowing what to say and in feeling defeated because of the ineffectiveness of what has been offered, has the course of action for physicians been to say and do less?

Caring for patients with obesity

I started writing this blog when I read a statistic about the high number of women who avoid well-care visits because of the embarrassment and shame they feel about their weight. The case study I read mentioned a healthcare provider rolling her eyes when recording the patient’s weight. The article described a patient’s humiliation when the scale stopped at 350 pounds and the dressing gown was too small. I went on to read more about the challenges of treating people with obesity and realized what a learning curve it is. However, a core tenet of caring for any patient is respect; and in the case of obesity, a few basic considerations have been described in an article from the National Institutes of Health and the Weight-control Information Network (WIN). Excerpts from the article are listed below. To read the full article, go to Medical Care for Patients with Obesity.²

· Have suitable equipment and supplies on hand to improve patient access to care.

· Create a positive, open, and comfortable office space.

o    Provide reading materials in the waiting room that focus on healthy habits‚ rather than physical looks or being “thin.”

· Use medical devices that can correctly assess patients with obesity.

o    Use large adult blood pressure cuffs or thigh cuffs on patients with an upper-arm circumference greater than 34 cm.

· Be respectful when talking about the patient’s weight.

o    Weigh patients in a private area and only when medically needed.

o    Record weight without comments.

· Offer well-care services.

o    Allow enough time during office visits to provide well-care services.

· Promote healthy behaviors.

o    Ask patients if they want to talk about weight loss. If they want to talk about losing weight‚ let them know that a weight loss of 5 to 7 percent of body weight may lower their chance of developing diabetes. Work with patients to establish realistic goals.

o    Start small. Encourage patients to start with simple goals such as walking for 10 minutes‚ three times a day. Once they achieve this goal‚ they can build on it.

o    Offer patients information and referrals to registered dietitians‚ other health providers‚ and support groups‚ as needed.

o    Promote self-acceptance and encourage patients to lead full and active lives.

 References: 1. Sciamanna C, et al. Decline in U.S. physician lifestyle counseling during the obesity epidemic. OBESITY 2011; ABSTRACT 28-OR. 2. Medical Care for Patients with Obesity. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health. NIH Publication No. 03–5335. February 2003. Updated July 2011. 

Ide Mills, LCSW
Senior Vice President, Health Education
HealthEd

One of the first things we as health educators learn about behavior change—a core focus of our profession—is that increasing knowledge is only the first step. On its own, knowledge is not enough to cause the behavior change “tipping point” that Malcolm Gladwell describes so well in his best-selling book.

An educational piece, program, or intervention must address the barriers, motivators, and other influences that are keeping the individual or community from moving toward the behavior we wish for them to adopt. This is where models and theories of behavior change come in.

Why use theories and models?

Theories and models are important because they are backed by research and evidence. They also help make our jobs easier and more effective by serving as a road map for the steps we need to take. And they help keep health educators accountable when we evaluate the outcomes of tactics or programs.

When developing educational materials, programs, or campaigns, it is critical that theories and models serve as a foundation and weave throughout all aspects of our work. Otherwise, we simply develop content based on intuition rather than evidence. Using intuition alone can result in a campaign that may waste resources because it will have little chance of creating real behavior change.

Example

Social cognitive theory (SCT) is a popular theory often used in behavior change programs. Its main focus is on how people and their social and physical environments influence each other to affect behavior. Programs that use SCT:

• Inspire people to believe that they have the ability to change their behavior
• Help people understand why changing a certain behavior is in their own best interest
• Explain to people how their current behavior is affecting their health
• Provide people with relevant and accurate information about the behavior and its impact
• Explain to people how they have control over their behavior
• Help identify personal, social, and environmental barriers to behavior change
• Assist with developing a plan on how to overcome the barriers

Behavior-change programs that incorporate SCT also:

• Provide examples and success stories of those who have successfully changed their behavior
• Teach the skills necessary to achieve the desired behavior change
• Encourage people to reach out for support from family, friends, and others
• Focus on incremental changes
• Reward each milestone of change

Learn more

If you would like to learn more about theories and models and their application, a terrific, free downloadable book called Theories at a Glance is available from the National Cancer Institute.

Dominika Samojlik, MPH, CHES 
Community Manager, Health Education
HealthEd

Yes, there were a couple of representatives from manufacturers like Bristol-Myers Squibb. But they were vastly outnumbered by their healthcare peers:

• Managed care organizations
• Large healthcare providers
• Physicians and researchers

Mobile is potentially the greatest opportunity for pharma to break out of its innovation funk. And “The Healthcare City,” as New Brunswick bills itself, would have been a great place for pharma to stoke its creative fires—right in the industry’s backyard.

It’s not as if patients aren’t asking for mobile solutions …

“We have the opportunity to drive an ‘Arab Spring’ in healthcare,” said blogger Casey Quinlan, author of Cancer for Christmas and an outspoken patient advocate. Quinlan, diagnosed with breast cancer in 2007, said there were not enough tools available to help her manage her disease and treatment side effects.

“If there had been an app that would have helped me manage my neutropenia (low white blood cell count) and anemia (low red or total blood cell count),” Quinlan told the audience, “I would have easily paid a couple hundred dollars for it.”

Amy Gurowitz, who is launching a learning community for people with MS, said she surveyed her beta testers about their use of tracker apps. Only one person reported using one. “They didn’t even know that these tools are out there,” Gurowitz said, suggesting there is a market for such tools if they can be promoted effectively to patients.

It’s not as if pharma companies are ignoring mobile opportunities…

To be fair, pharma has produced a growing number of mobile apps and tools. (Quick plug: You can read about some mobile pharma case studies in an earlier blog post I co-wrote with digital buddy Megan Beardsley). Some have been built for patients, while most target healthcare providers. 

Still, I’m not convinced that pharma is fully prepared for the coming mobile onslaught. And I’m not the only one.

At a conference break, I caught the attention of Paulo Machado, a leading voice in pharma innovation and the former Innovation Director at AstraZeneca. During our conversation, Paulo really helped crystallize pharma’s conundrum.

In essence, he said, pharma companies are manufacturers. And it’s much harder for manufacturers to evolve away from a product-centric mindset than it is for service providers—your payers, hospitals, clinics, and most other health organizations.

Paulo said that healthcare reform is driving service companies away from the fee-for-service model. “They actually have to run profitable businesses now,” he observed.

Translation: Payers, not pharma, may end up leading the charge into mobile health.

Any tool that helps patients improve outcomes and lower costs will be mission-critical

Sure enough, later in the day Michael Monson, SVP Performance & Innovation at the Visiting Nurse Service of New York (VNSNY), encouraged mobile health entrepreneurs to bring him innovative ideas… like, now.

Headquartered in Manhattan, VNSNY is the country’s largest not-for-profit home healthcare service. It is both a provider and a payer. Monson explained that innovation is a large component of the company’s strategic approach. As healthcare evolves in the US, mobile seems to be a major way forward.

 “We really like using behavioral science,” Monson said, referencing partner Welldoc, which is running a mobile adherence pilot for VNSNY with diabetes patients. Welldoc was in the news recently when Ford announced a beta test in which diabetic drivers could “ask” their cars to check their blood glucose levels. The Ford beta is being powered by a Welldoc wireless health monitoring platform.

It’s innovations like these—“software devices that enhance consumers’ lives,” Monson said—that are going to power the future of mobile health.

Mobilization can work for pharma too

The economic rewards for innovation certainly favor companies like Monson’s. But I believe pharma also needs to stand up and put the industry’s significant weight behind mobile health initiatives. Apps would be the logical place to start—they are the most “product-like” side of mobile—and the FDA already issued guidance for health apps this summer.

For pharma innovators interested in going mobile, some next steps should include:

• Familiarizing yourself with the FDA mobile app guidelines
• Getting outside the pharma space
  • Download and use some of the mobile tools that other healthcare organizations have built
  • Look for parallels that could be applicable to branded/unbranded product marketing

Finally, challenge your agencies to think blue sky—have them bring their strongest ideas for mobile to the table, and explore opportunities to pilot in 2012.

Jeff Greene
Director, Digital Strategy
HealthEd

So will being “empowered,” “active,” and “informed” lead to better outcomes for me as I fight my illness? As a health educator, I should know how to be an “active patient,” right? I am certainly doing my best to actively participate in my health care, but it is challenging at times. I have new empathy for those who are frightened by their illness and have limited understanding and support. 

After my diagnosis, one of the first steps I took to actively participate in my medical care was to understand my illness and my treatment. This was more complicated than I thought. For instance, it took me 4 attempts to wrap my head around using a nebulizer and the medications. In the hospital I had three different respiratory therapists (RTs) who set up my inhalant medications each day. I had another RT once I got home. 

I had to ask each of them how the medications worked, the differences in the medications, and what I could expect from them. It would have been best if I told them I did not understand what they were saying. I should have asked them to use plain language. But I also realized that some clinicians are not skilled at this. Unfortunately, it wasn’t until I was at home that I received a clear explanation that helped me understand the hows and the whats of treatment. The visiting RT used an analogy and a visual image of what was happening in my lungs and how the medicine would help.

Learning more about my illness, I realized there were numerous resources to turn to—the Web, my family, and different members of my healthcare team. I just had to ask. However that is not a simple statement. What did I really want to know, and how would these answers make me more empowered? I searched the Web for clinical trial results related to my illness and wrote down questions about the treatment I may be eligible to receive. I had prepared a litany of questions citing the studies, the articles, and centers from where the information was gleaned. This made me feel more credible and prepared in case I was shot down for asking too many questions.

Imagine me worrying about not being taken seriously, being dismissed for asking questions! I am the person who helped her patients write the lists, showed them how to research their illnesses, and instilled them with a sense of confidence to talk with their healthcare providers (HCPs). Yes, I too was reticent. My little blue book of notes and questions bolstered my confidence and demonstrated to my nurse and doctor I was a partner in my care.

Thankfully, I do have the resources to help me take an active role in my healthcare. I am fortunate, but what about those that don’t have the internal or external resources… where do they turn? I hope they have the support of their doctors, nurses, social workers or other HCPs to figure out what to research, questions to ask, and the confidence in themselves to participate in their healthcare. The HCPs can be a strong ally when lost in a sea of foreign words and phrases that frighten any of us. I hope all HCPs incorporate analogies, visuals, and write out information as needed.

Other ways to learn is by teaching back what you were taught to demonstrate what you heard. While it is often used when a nurse teaches a skill or health related behavior—self injections, catheter care, or medication regimens—it can be useful in describing complicated medical information. The use of illustrations to describe body anatomy and mapping out a diagnostic workup and treatment plan is a fundamental step. This can be highly effective if medical information is new and learning is compromised due to heightened anxiety and stress.

My advice to other patients is to write down your questions and your thoughts about treatment relative to you. This reframes the issue from the abstract to you personally. Share what is important in your life with your healthcare team. It gives them a richer perspective on what is important to you and factors that you will consider in making your treatment decisions. Make note of your reactions to treatment—it improves your accuracy as a historian.

Being an informed patient and an active participant in my healthcare, I hope this plays a role in my treatment outcomes. However what is critically important is that I realize I have developed a deep trust in my doctors and my healthcare team. We have respect for each other and have built a partnership that I believe will contribute to a positive outcome.

Ide Mills 
Senior Vice President, Health Education
HealthEd

Those are just a few comments men are hearing from their families, friends, and colleagues during November. And that’s the point—to get people talking about why men are growing mustaches this month.

Turning November into Movember

Movember is a global initiative to heighten awareness of men’s health issues. It began in Australia in 2003. In 2010 in the United States, 64,500 men and women joined Movember, and they raised $7.5 million. More and more people are talking about how important it is for men to pay closer attention to their health.  

Globally, Movember focuses on men’s health in general, which makes sense when you think of the number of men who are diagnosed with cancer, heart disease, diabetes, and mental illness. In addition to those men living with chronic or life-threatening illnesses, it critically important to heighten awareness of preventive health measures men can take. Movember’s primary focus, however, is raising awareness about and raising money for prostate cancer. 

Raising awareness for men’s health

According to a Movember study, the US campaign has successfully raised awareness of men’s health issues.  It has also convinced men to take a more proactive approach to their health. When Movember participants were surveyed:

• 96 of 100 spent time thinking about improving their general health
• 87 of 100 understood that their health depends on how well they take care of themselves
• 86 of 100 had a general checkup
• 77 of 100 discussed men’s health with their family, friends, or colleagues during Movember
• 64 of 100 worried about their general health
• 59 of 100 carried out personal research on men’s health issues during Movember

Despite this progress, the research shows that 1 of 2 men would rather ignore a health-related issue than go to a doctor.

Supporting Movember at HealthEd

riThis is HealthEd’s first year supporting the Movember movement. Several Mo Bros (as they are called) are growing mustaches, and their Mo Sistas are supporting their Mo Bros' trials and tribulations.

You know the initiative is taking hold when the women (and men) in the office have brought home the information to their spouses, partners, brothers, fathers, and sons. Some of these men have joined Movember and are growing mustaches too.

Last week a staff member brought her 12-year-old son to the office. He proudly shared that he knew all about Movember because his teacher was growing a mustache for the cause. It is important for all men, young and old, to talk about and take action when it comes to their health.

Learning is step 1

The first step is to learn about diseases that have a big impact on men, and how those conditions can affect men’s physical and emotional well-being. Men, and those who care about them, need to:

• Recognize the signs and symptoms of the disorders
• Learn about screening tests for early detection
• Make lifestyle changes to prevent or manage illnesses

Helping men take action is step 2

To move someone to action means changing his or her attitudes and beliefs. With its resources, open discussions, and support, the Movember movement can help men change their behaviors and improve their health by motivating them to:

• Go to regular well-care visits
• Perform appropriate self-exams
• Discuss health risk factors with their healthcare provider
• Eat a balanced diet
• Exercise regularly
• Stop smoking
• Limit their use of alcohol

At HealthEd, we apply the Health Belief model in educating our staff about men’s health issues. In the process of developing newsletters to share with staff, family, and friends, we consider the basic constructs of the model:

• Perceived susceptibility
• Perceived severity
• Perceived benefits
• Perceived barriers
• Cues to action
• Self-efficacy

Some people think that because we are a healthcare marketing agency, the staff is more aware than others of men’s health and health concerns in general. And that the men of HealthEd are being proactive in their care. While our men may have a heightened awareness of the issues, Movember can reinforce what our staff already knows and inspire them to take action for better health. 

Ide Mills 
Senior Vice President, Health Education
HealthEd

Nurses are the largest group of healthcare professionals and the largest group of health educators. Because of their prominent role, they’re often needed to interpret and share their vast knowledge, yet they fall behind other professions in terms of adopting new communication technology. Having worked in an academic cancer center for several years, I observed many nurses doing innovative work without ever sharing their knowledge and expertise outside the walls of the center.

Since 80% of patients use the Internet for health information, patients clearly are expressing a need to enhance the education provided by their care team with medical information and advice from the Internet. What better way for patients to learn more about their health condition than to read a blog post or a tweet from their own nurse?

Although 87% of nurses reported using the Internet for professional use, only 11% were on Twitter. How can we encourage more nurses to move beyond being online information consumers to being the online information leaders and creators that they are in the clinical setting? Nurses have the opportunity to assume a leadership role by sharing timely and accurate health information with patients through social media rather than just responding to content that patients bring to them. 

Who has the time to blog and tweet?

We all know how hard nurses work, and the last thing we want to do is add one more task to their already demanding job description. Social media needs to be viewed as an important patient teaching tool, not as one more thing to do. Phil Bauman, an early adopter of social media in healthcare, compiled a list of 140 healthcare uses for Twitter, many of which actually save nurses’ time. Saving time is especially important in the midst of healthcare reform and a nursing shortage, given that the role of nurses is being expanded to include more patient education, with a larger emphasis on prevention. Because of the immediacy of information, the wide reach, and the ease of use, social media is a necessary tool for nurses to foster a more prevention-focused health dialogue and promote a positive disease-management experience. 

A forum for sharing best practices

Aside from patient education, social media offers new and interesting ways for nurses to interact, to share experiences, and to compare and contrast lessons from their work experiences. Social media applications allow nurses to reach a wide range of colleagues from different disciplines and more quickly than previously possible. Nurses who use social media can attest to the benefits. Some have talked about having previously felt isolated within small clinics before they joined Twitter or found nursing blogs. The resulting interaction helped them to feel more connected to the greater nursing community. Being part of that community involves sharing knowledge. If more nurses took this approach, the online nurse community would be a truly great forum for learning and supporting one another.

I think the best way to sum up social media resistance is with a quote from nursing informatics educator Terri Schmidt: “Social media is like White Castle. You either love it or you hate it, but in the end, you’ll develop an appreciation for it.” I would hope that the long-term health benefits of social media are greater than those of White Castle, but after your first taste of either one, it’s very easy to get hooked.

Tara Rice
Manager, Health Education
HealthEd

As the US population continues to become more culturally diverse, health literacy is becoming more important. Studies have found that only 12 percent of adults have proficient health literacy. (Kutner, Greenberg, Jin & Paulsen, 2006). In other words, most adults lack the skills they need to effectively manage their health. 

A timely new study, Health Literacy Knowledge Among Direct-to-Consumer (DTC) Pharmaceutical Advertising Professionals (Mackert, 2011) addresses the issue of health literacy in pharmaceutical ads. It reports findings from interviews with advertising professionals. And it offers great insight on how pharmaceutical advertising professionals view health literacy and its role in DTC ads. Based on these findings, we interviewed our own Clear By Design™ health literacy team of experts—Bradley Aufderheide, Lisa Hunt, Julia Olff, Kevin Purcell, Ken Thorlton, and Luanne Koper—who address this topic from a variety of perspectives.

Katie:

You’ve all read Dr. Mackert’s study and how those interviewed look at the use of health literacy principles in a DTC ad. What does your experience tell you are the key challenges to incorporating health literacy into a DTC ad? And how do you handle those challenges?

Lisa:

From an account management perspective, the most important challenge is ensuring that clients understand exactly what the principles of health literacy are and how, when applied appropriately, those principles can have a powerful and positive impact on educating and informing consumers.

Typically, our health literacy training seminars, such as those for Clear By Design™, are given to both core and extended brand teams. We help them understand and embrace health literacy by showing them why it’s in the brand’s best interest, how it can help with initiating patients on treatment, and, more importantly, how health literacy helps improve adherence to treatment, brand success, and patient outcomes.

Brad:

The limited format of a print ad can be difficult to effectively educate patients and address all barriers. The best ads drive the patients to a Web site or an 800 number to learn more. For an ad to be effective, it needs to quickly tell a story visually and through minimal copy. Applying health literacy principles to an ad helps patients gain awareness, internalize, learn, and act on the information they've gleaned about a brand. In ads that try to explain a disease state, the challenge is to create messages that meet the needs of their intended audience. Often, a client’s med-legal team may require language that is pulled directly from the PI, which is not written in a patient-friendly manner. Unless an ad is designed with health literacy in mind, the audience may not understand medical terminology used in the ad.

Julia:

With DTC ads, we always strive to develop materials that balance health literacy with presenting safety information in a way that meets regulatory requirements. The challenge here is that safety information is often written at a high reading level, using complex medical terminology. And it is frequently not written to support or drive action. It can also have the effect of raising concern instead of informing. As part of health literacy, we encourage pharmaceutical clients to revise their safety language using patient-friendly words, and to reduce the amount of data presented whenever possible. We also try to use graphics and illustrations to reduce the numeracy burden for patients and make it easier for them to understand and apply survival or risk data to their situation.

Katie:

Ken and Kevin, you you are responsible for the design and copywriting of DTC ads despite all these constraints. How do you approach these challenges?

Ken

From a design perspective, it’s all about adequate white space. So finding the right balance between exciting visual concepts and clinical content provides a unique challenge—not to mention the FDA’s requirement to make the size and placement of safety and risk information more prominent. The goal is to ensure that readers don’t get overwhelmed and move on to another page before they have a full understanding of the intended message. One way to solve this problem is to create a double-page spread ad. But if scope and budget do not allow this, be sure to work with your creative copywriters from the very beginning to ensure messages are succinct and don’t take up too much space.

Kevin

From the content perspective, our key challenges include the space limitations Ken mentioned balanced by health literacy principles, which often lead to increased content length because you have to define terms and provide context for new information. I believe health literacy and creativity can absolutely coexist; however, we must work that much harder to ensure that they do. Fortunately, some clients work with us to develop their fair balance so that it meets health literacy standards.

In my experience, more and more med-reg departments are inclined to consider (and even request) that fair balance language and disclaimers be created to meet the needs of their intended audience by adhering to health literacy principles. After all, if consumers can understand it, then the pharma company has done a better job of meeting the latest FDA requirements.

Katie

One of the key findings of this study is that because of business concerns, educational messages need to be tied directly to an advertised medicine and its benefits. How can we do this to still produce materials that follow health literacy guidelines?

Julia:

At HealthEd, we don’t necessarily see these needs as being in conflict. Patients benefit from well-designed materials that provide balanced information about the medicines that are available to them. The application of health literacy guidelines is one of the ways we can foster quality education within marketing.

Brad:

As the FDA and pharmaceutical companies’ interpretation of guidelines evolve, our clients are becoming more aware of and interested in educating the patient audience as opposed to only driving brand awareness. We have seen many clients investing in longer-form content channels such as digital, direct mail, and telephonic support to address these needs. In those venues, health literate communications are crucial to achieving measurable behavior change.

Lisa:

Here, the challenge we face is ensuring that any communication has an appropriate balance of risk and benefit. The goal of any communication should be to present the benefit and risk information in a balanced way. To me, consumers must be able to understand the information. And the information must include both the benefit and risk about the treatment. When health literacy principles are followed, consumers and potential patients will be able to make truly informed decisions about their health.

Katie:

Finally, how do we help the pharma and healthcare industries understand how important health literacy will be moving forward--especially now that the FDA is setting new standards that demand it?

Luanne:

Last year, in the notice of violation letters that the FDA sent to pharma, the FDA increasingly cited that the presentation of safety and risk information was not as simply and clearly stated as the benefit information in patient pieces. For the FDA, this violates the idea of fairly balancing claims. By letting our pharma clients know how often this violation gets cited, we may increase their interest in the importance of using health literacy principles to craft language that is readily understood by people with low literacy.

Also, DDMAC, the Division of Drug Marketing, Advertising and Communication, has been elevated from a government division to a government office called the Office of Prescription Drug Promotion, or OPDP. Within OPDP, they have made 2 divisions: one for professional promotion oversight and one for DTC promotion. I believe having an office that specializes in DTC will mean more resources will be devoted to reviewing materials. This will lead to more notices of violation to pharma companies. And that will get their attention.

Ken:

As advertising has evolved and federal regulations have become stricter, it has presented an opportunity for the patient to be more involved in every aspect of their treatment. Fair balance in television commercials today seems laughable, but the fact that the consumer is now aware of all the side effects as well as the benefits is information that was not always easy to discern in the past. Moving forward, patients will be even more involved in their treatment and the tools that help them to do so will become more personalized and mobile. Pharmaceutical companies that understand this will have a much better chance at raising their messages to the “top of the heap.”

Julia:

Between the FDA’s new risks and benefits standards for communicating, and the HHS’s National Action Plan to Improve Health Literacy, we have a strong case for universal health-literate communications. As a health educator, I help determine and recommend health literacy requirements for specific patient audience. When making educational recommendations to clients, we highlight how government health literacy initiatives can be applied to improve patient and consumer communications that meet regulatory requirements. One of the most effective ways of demonstrating the value of health literacy principles is to measure the impact of the educational interventions on patient satisfaction and behavior. To this end, we have developed Return on Education™—an analytical framework to measure the effectiveness of patient education and marketing efforts to enhance patient outcomes.

Kevin:

It’s important to point out that there is a difference in quality between health literacy that is designed to meet FDA regulations and health literacy that is designed to truly help patients and caregivers. That’s where being able to show a financial Return On Education™ comes into play. The better we help clients use and implement health literacy principles, the greater the potential for a measurable financial return—and the greater the likelihood that the pharma industry will embrace the kind of work we do here at HealthEd.

Katie:

I want to thank our expert panel for weighing in on this issue today. I think one of the key themes to emerge is that true health literacy is more than just literacy. It must be considered by everyone who has a stake in creating patient-facing content. Defining and understanding health literacy is key. And we need to understand that health literacy is not a hindrance. It actually can help brands achieve their objectives.

Katie Margolis
Manager, Health Education
HealthEd

Bradley Aufderheide
SVP, Strategic Services
HealthEd

Lisa Hunt
SVP, Group Account Director
HealthEd

Luanne Koper
Vice President, Editorial Services
HealthEd

Julia Olff
Vice President, Health Education
HealthEd

Kevin Purcell
Copy Director
HealthEd

Ken Thorlton
SVP, Creative Director
HealthEd

References

Kutner, M., Greenberg, E., Jin,Y., and Paulsen, C. (2006). The Health Literacy of America’s Adults: Results From the 2003 National Assessment of Adult Literacy (NCES 2006–483).U.S.Department of Education.Washington, DC: National Center for Education Statistics. Retrieved from: http://nces.ed.gov/pubsearch/pubsinfo.asp?pubid=2006483

Mackert, M. (2011). Health literacy knowledge among direct-to-consumer pharmaceutical advertising professionals. Health Communication, 26, 525-533. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/21469006

U.S. Department of Health and Human Services. 2000. Healthy People 2010. Washington, DC: U.S. Government Printing Office. Retrieved from: http://www.healthypeople.gov/2010/

• In the Wild West that is the current health app marketplace, it's likely one of two things will happen. One, Nalty said, managed care will begin to incent physicians to "gently nudge" patients to use apps, with the goal of improving adherence and self-care. If health apps are potentially as powerful as their creators believe (and as patients are finding), then healthcare providers (HCPs) are going to need to get familiar with the best ones. Insurers will gladly reimburse physicians for the consulting time, if it leads to better healthcare outcomes and fewer hospital admissions
• On the other hand, Nalty predicted that within the next couple of years, consolidation will leave us with only a half dozen app "brands" to choose from. In the same way that consumers visit WebMD, the Mayo Clinic, and About.com for the majority of their online health content, a few leading brands will likely emerge in app stores. This scenario is already playing out for physicians, for whom the ePocrates app has captured the vast majority of market share. Healthcare marketers may spend less time building their own apps and more time developing content for the leading ones
• As this blogger has reported on multiple occasions, QR (quick response) codes should still be considered "sizzle" in the United States—no steak yet. An audience member from Augme Mobile, a technology vendor, reported that most QR programs his company launches also include a texting component. Because relatively few US consumers scan the quizzical QR graphics, having a texting option makes it easier for the majority of people to participate
• Given this uncertainty, maybe apps and QR codes aren't the way to go after all. Nalty shared a study that found that most people use their mobile devices for e-mail and search. (He was going fast, and I missed the source. But oft-quoted data from the Pew Research Center largely corroborates his statement.) Life science marketers, then—particularly those with consumer audiences in mind—must extend their online analytics and search programs to mobile devices and tailor their programs based on learned insights. Do consumers search differently on their PCs versus their phones? When they search on their phones, do consumers find your content? Does that content display correctly? In a nutshell, if you're marketing on the Web, you're marketing on mobile devices
• Finally, now that I've all but proclaimed "Apps are dead," if HCPs are your intended audience, then "Long live apps!" Another quick-moving slide from Nalty presented a sobering picture for the pharma sales rep: In rough numbers, physicians engage with their mobile phones about 11 times as often as they do with reps. It's reasonable to say, then, that partnerships with mobile vendors like ePocrates and the creation of HCP-targeted apps will emerge as key line items on pharma marketing budgets in the coming years

Jeff Greene
Director, Digital Strategy
HealthEd

And yes, the pharmaceutical landscape has similar tensions. Between now and 2015, there will be an onslaught of generics from patent expiry of many blockbuster agents, which will further shift consumer preference to cheaper generics. At the same time, we will see a proliferation of more innovative, expensive, specialized therapies. The market potential for these therapies will be smaller than that of the big, rock-star primary-care brands seen in the past. The value and differentiation of the new medications will have to be made apparent to healthcare consumers, who are increasingly being incentivized to cash in on $4 generics at the local Target.

Engaged healthcare consumer (EHCs) have the right behaviors and attitudes to be go-getters—navigating healthcare systems, researching treatment options, advocating for more attention from their healthcare providers (HCPs), and asking for specific brands.

Take my dad. He is the poster child for good healthcare behaviors. He reads about diabetes and hypertension, makes a mental list of questions to raise with his doctors, researches medications, takes his pills every day (seriously). He is very motivated—in fact, it's sometimes a bit too much for me to handle (he talks a lot about the nuances of type 2 diabetes management and likes to measure my sugar, even though I am fine).

But low engaged healthcare consumers (LEHCs), like my mom, may feel uninvolved for many reasons. Maybe they are unmotivated, lack knowledge, or can't effectively dialogue with their HCPs. Or maybe, like my mom, they just don’t have the time or interest to “fuss over themselves because they are too busy taking care of other people and doing things they love.” Or perhaps they aren’t curious, or they don’t have access to the Internet (always possible). But the consequence may be that they get too little time with their HCP. They also may miss out on a more efficacious and/or tolerable branded agent, one that may also offer a relationship marketing program that supports them through the treatment experience. In the looming era of innovative, specialized therapies that have a smaller market potential, perhaps the LEHC, like my mom, not usually a target customer, can help maximize revenue. Additionally, it will be even more important that pharma focus on retaining EHCs, people like my dad.

So what can pharma do? First, drug companies must help activate LEHCs with communications that move them along a behavioral continuum and are clear, personally relevant, and employ health literacy principles. To accomplish this, deep insight into the LEHCs is key. Pharma companies must know where and how to reach LEHCs through appropriate channels. Could the right behavioral approach, along with communications that engage, shift the mind-set of LEHCs and claim them as attractive and lucrative customers?

For the EHC, it’s critical that pharma brands demonstrate rich value beyond the pill—an ongoing personally relevant brand experience to retain them and potentially activate them as power ambassadors for positive health behaviors and treatment successes. This can be accomplished through relationship marketing efforts, community building, and storytelling.

Although I still categorize my mom as an LEHC (the purist in me!), her adherence is improving, and she is being more proactive about talking with her HCP about symptoms and treatments. This is probably because of her having watched my dad, my brother, and me all these years. I think she and many like her may be more influenced by what people think of them than previously thought, or so posit the behavioral economists. Eventually, you don't want to miss out on something good if you see others getting results or if you don't want to feel socially rejected.

Perhaps for the LEHCs, marketing efforts can leverage and model their EHC compatriots' health behaviors through storytelling. And there may be no one more motivated than an EHC to do that happily, like my dad. The more that pharma brands can showcase patients' experiences and stories, in a meaningful and insightful way, the better. People seem to ultimately want better for themselves—and hearing about others’ success and how they achieved it is a powerful change agent. 

The pharma landscape is changing. The era of big-market, primary-care brands is ending, while smaller-market specialized therapies continue to proliferate. However, with the right behavioral models infused into strategy and tactical implementation, perhaps brands’ customer bases can be broadened and fully leveraged to maximize revenue. Let’s all imagine a world where everyone wants good health for themselves. It’s a win-win for healthcare consumers and pharma.  

Priya Karnik, MBA
Director of Strategic Services
HealthEd



To help meet these challenges, the White House Business Council and Business Forward, a nonprofit group of industry leaders focused on innovation, invited Mike Brzozowski of HealthEd and Susan Collins of SurroundHealth to participate in America’s Health & Wellness: a Roundtable Discussion. I sat down with Mike and Susan to find out more about what went on.

Jeff: First of all, tell us a little about the panel. Who was there? And what were they trying to accomplish?

Mike: The panel was hosted by the White House Business Council and Weight Watchers and produced by Business Forward. They brought together a broad cross section of people from corporations and nonprofit organizations for a roundtable discussion with Sam Kass, the White House Senior Policy Adviser for Healthy Food Initiatives.

There was a broad range of attendees, including human resources professionals at large financial services companies responsible for health and wellness initiatives, food service professionals, people from City Harvest, hospital groups, PR firms, a representative from the Beverage Council, Weight Watchers CEO David Kirchhoff, and of course Susan and me.

Jeff: What was one of the more interesting things you heard during the discussion?

Mike: One of the more startling things I heard Sam say was that the Pentagon views obesity as a national security issue. The armed forces can’t get enough qualified recruits because they are too overweight. What an unexpected and interesting impact of the obesity epidemic.

Susan: Dr. Olajide Williams of Columbia University also talked about the impact of obesity on children’s self-esteem. While we often hear about the toll on health, I think we sometimes overlook the tremendous toll on children’s emotional health and well-being—which affects them for a lifetime.

Jeff: What are some of the reasons given for the obesity epidemic?

Susan: The issue is not just about education. There’s a lot of information out there. But it’s about changing some of the fundamental structural problems that affect large parts of America, such as “food deserts.” For example, many inner-city neighborhoods don’t even have one grocery store. That’s why residents of these neighborhoods live in a food desert. They have to buy their food at the corner convenience store, fast-food places, and gas stations.

The White House is trying to get supermarkets to open more locations in these areas to give residents better food choices. Really, the issue requires us to address obesity on multiple levels—education, skill building, and access to safe and healthy foods, which is also known as food security.

Mike: Jilly Stephens of City Harvest highlighted this through the work of City Harvest’s mobile fruit and vegetable stands. She noted that when some young children first see packaged baby carrots, some of them think they are orange puffed cheese snacks. City Harvest has shown that education—such as chefs showing how to prepare vegetables, children taste testing, and parents getting very simple recipes and tips—has led to an increase in the consumption of fruits and vegetables among children in poor neighborhoods. Neither access alone nor education alone is likely to be effective. But combining them can make a powerful difference.

Jeff: Were there any initiatives that you felt made a difference?

Susan: Columbia’s Dr. Williams is leading an amazing initiative called Hip Hop Public Health, through which he’s teaching inner-city youth how to make healthy choices and influence their parents. He has assembled a cadre of hip-hop artists to support the initiative and to help get kids engaged. Then he leverages kids' indirect purchasing power to influence the types of foods their parents buy and eat. City Harvest is doing amazing work in trying to get fruit and vegetables into fresh markets in underserved communities.

Mike: Also the Children’s Museum in New York City is working with Head Start to teach kids good eating habits while ensuring that school cafeterias carry fresh food.

Jeff: It’s such a complicated issue. What can be done to address it?

Mike: Well, first of all, I’m thrilled that Michelle Obama is taking on this issue. Obesity's impact on our economy, through rising healthcare costs, is staggering. I think the White House can amplify the message through forums like the one Susan and I attended.

But really, this can’t be solved by government policy or public service announcements. An integrated effort with all factions of the private sector tackling this problem is crucial to its success. There needs to be a focus on coalition building between food growers and beverage manufacturers, food and pharmacy retailers, food service organization, hospitals, doctors, pharmaceutical companies, and others. They—we—all need to embrace this.

It’s the small changes everyone makes that will turn this tide. Having a national champion like Michelle Obama helps, but we need more celebrity focus here. It’s a national crisis and needs to be addressed as one.

The roundtable talked about the “sparks” of innovation that are occurring around the table and around the nation. The goal is to have all those sparks fuse together. And to use the stories of success and successful outcomes to create more sparks and more movement.

Susan: Too often, efforts occur in isolation. Only by gathering together all of these sparks of inspiration can we create a movement that all of us—businesses, parents, teachers, healthcare providers, children, chefs, and public health professionals—can push forward.

Jeff: How is HealthEd doing its part to solve this problem? 

Mike: As a patient education and health and wellness company, we know how critical it is to provide patients, caregivers, and consumers with easy, practical, and motivational ways to modify behavior, in addition to providing disease state and medication management.

We continually recommend lifestyle modification programs to all our clients as a highly valued way to support their brand goals. It’s the right thing to do. We also develop comprehensive initiatives that focus on obesity. For example, we’re working on a family-oriented game that educates consumers about making healthy choices to combat obesity. We’ve already developed a game for a diabetes manufacturer that helps patients identify differences in carbs, protein, and caloric intake when they’re using a certain medicine.

The common theme here is engagement. We must go beyond just educating with information. It’s not enough. People need to be involved and engaged to tackle this problem. It has to be an everyday behavior modification regimen—a true lifestyle change.

Susan: With SurroundHealth, we’ve created a healthcare social network that pulls together health professionals from within healthcare and public health to share best practices, wisdom, and resources related to issues such as childhood obesity. Our goal is to harness the sparks for improving the health of children and communities—not just in America but around the world.

Jeff Greene
Director, Digital Strategy
HealthEd

Mike Brzozowski
Chief Strategy Officer
HealthEd

Susan Collins, MS, CHES, RD
Senior Vice President,
Health Education Research and Development
HealthEd

Community Leader
SurroundHealth