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G Public Communications and Its Role in Reducing and Eliminating Health Disparities Kasisomayajula Viswanath, Ph.D. Harvard University An amazing feature of the waning years of the 20th century and the begin- ning of the 21st century is the stunning transformation in both the generation and delivery of information of all kinds--a development that few of us have yet come to grips with. Combined with revolutionary developments in the biomedical sci- ences and telecommunications, plenty of health information and delivery chan- nels now exist. The number of health-related news stories on television and in both the mainstream and ethnic printed news media has been steadily increasing over the last 25 years (Figures G-1 to G-3).1 The increase is evident in major disease areas such as cardiovascular disease, tobacco/smoking, HIV/AIDS, and Background paper prepared for the Institute of Medicine's Committee on the Review and Assess- ment of the National Institute of Health's (NIH) Strategic Research Plan to Reduce and Ultimately Eliminate Health Disparities. 1Media attention to leading health issues from 1980 to 2004 was assessed as the number of stories published/broadcast that mentioned four major health topics: cardiovascular disease, tobacco-related cancer, obesity, and HIV/AIDS. The print, television, and online media environment was assessed using LexisNexis, Vanderbilt University's TV News Archive, Ethnic NewsWatch, and Google. The following search terms were entered into each of these databases/archives: cardiovascular disease or heart disease, tobacco or smoking and cancer, obesity, and HIV or human immunodeficiency virus or acquired immune deficiency syndrome. Using LexisNexis, almost 300 publications under the U.S. News category were searched. Vanderbilt University's TV News Archive was used to search news coverage of the health issues on the four major U.S. national broadcast networks (ABC, CBS, NBC, and CNN). Ethnic NewsWatch provided information on coverage of health issues in almost 300 English- and Spanish-language ethnic newspapers, magazines, and journals. The search terms were also entered into Google to assess the number of Internet web pages that mention the four major health issues. 215

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216 EXAMINING THE HEALTH DISPARITIES RESEARCH PLAN OF THE NIH 160 140 120 100 80 Stories of # 60 40 20 0 1980-4 1985-9 1990-4 1995-9 2000-4 Years Heart Disease Tobacco/Smoking Obesity HIV/AIDS FIGURE G-1 National TV news coverage of leading health issues. SOURCE: See Foot- note 1. 7 6 5 thousands) 4 (in 3 Stories 2 of # 1 0 1980-4 1985-9 1990-4 1995-9 2000-4 Years Heart Disease Tobacco/Smoking Obesity HIV/AIDS FIGURE G-2 Ethnic print media coverage of leading health issues. SOURCE: See Foot- note 1.

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APPENDIX G 217 80 70 60 thousands)50 (in 40 Stories 30 of # 20 10 0 1980-4 1985-9 1990-4 1995-9 2000-4 Years Heart Disease Tobacco/Smoking Obesity HIV/AIDS FIGURE G-3 Print news coverage of leading health issues. SOURCE: See Footnote 1. obesity.2 In addition, the number of Internet sites offering health information of varying quality is increasing rapidly. This strong secular trend in the information explosion in health is matched only by the public's increasing hunger for such information. For example, the proportion of Internet users looking for health information has risen from 55 percent in 2000 to almost 79 percent in 2005 (Pew Internet & American Life Project, 2000, 2005). This explosion in health information poses two fundamental challenges. One is a need to translate scientific information in a usable format and language that can be understood and used by different audiences through appropriate channels. Such a translation would require attention to the dissemination of evidence-based and timely information to different publics--a role that the National Institutes of Health (NIH) is uniquely qualified for. This challenge is compounded by the large number of channels and actors, which make it difficult to control the inter- pretation of biomedical information as it cascades through different segments of society. A second and equally, if not more, important challenge is that we need to ensure that the information is available to all of those who need it, regardless of 2In the absence of a denominator, it is difficult to argue that media attention to health news is increasing in relation to other topics. It is equally conceivable that the increase may also be related to more channels of information. What the numbers do suggest is a change in the information environ- ment where more information on health is available on organized communication channels such as the news media.

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218 EXAMINING THE HEALTH DISPARITIES RESEARCH PLAN OF THE NIH their social class, cultural, geographic, and individual backgrounds. This latter need is a particular challenge, given the profound information inequalities that characterize our society. While the number of channels through which informa- tion, particularly through subscription telecommunication services, increases, it also comes at a price that requires recurring expenditures and investment to obtain those services. Such challenges are compounded by the reality of profound disparities in disease burden among different social classes, possibly partly attributed to lack of information. For example, even as the overall burden of cancer is steadily falling, the decline varies for groups of different racial/ethnic and socioeconomic back- grounds (Kawachi and Kroenke, in press; Krieger, 2001; Lynch and Kaplan, 2000). African American males are much more likely to develop any type of cancer than white males. The incidence rate among African American males for developing any type of cancer is 689.2 per 100,000 compared with 556.5 among white males (Ries et al., 2004). A similar trend has been noted among American Indians and Alaskan Natives in which the incidences of leukemia and colorectal, stomach, and pancreatic cancers continue to increase (Paltoo and Chu, 2004). In addition to higher cancer incidences, minorities and lower socioeconomic groups also tend to have high rates of death due to cancer. Incidence rates of developing breast cancer are higher among white women than African American women (141.7 compared with 119.9); however, African Americans are more likely to die from breast cancer (mortality rate of 35.4 compared with 26.4) (Ries et al., 2004). Similarly, African Americans are 2.0 times more likely, Hispanics/Latinos are 1.9 times more likely, and American Indians and Alaska natives are 2.6 times more likely to have type 2 diabetes than whites of similar age (CDC and NCCDPHP, 2000). African American childhood and adolescent obesity rates are more than 2 times higher than all other American racial and ethnic groups com- bined (Story et al., 1999). Minority and low-income populations have higher rates of death and disability from cardiovascular disease. The rate of death due to cardiovascular disease among African Americans was 321.3 per 100,000, com- pared with 245.6 among whites (CDC, 2004). Another consideration is the evidence that a majority of health problems are attributable to lifestyles and behaviors that are modifiable given the right opportunity structure, access to health care, and, above all, information (Emmons, 2000). Most major chronic illnesses are preventable through appro- priate health strategies such as avoiding or quitting tobacco use, pursuing an active lifestyle, proper diet and nutrition, and timely health screening (IOM, 2002). Communication plays a central role in promoting preventive behaviors and influencing patient-provider interactions (Hornik, 2002; IOM, 2002; Smedley et al., 2003). What are some of the major challenges to disseminating evidence-based health information to different stakeholders, particularly in bridging health dis-

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APPENDIX G 219 parities? How is the dissemination constrained by the differential capacity of the community and the American publics to access, interpret, and use the information in their day-to-day health? The focus of this essay is to address these twin chal- lenges of the dissemination of health information and communication inequality through a delineation, clarification, and amplification of their dimensions insofar as they are relevant to reducing and eliminating health disparities. This assess- ment will be followed by a discussion of how the objectives of NIH's National Center on Minority Health and Health Disparities (NCMHD) could be achieved by a delineation of components of public communication. THE NCMHD STRATEGIC PLAN: PUBLIC INFORMATION AND OUTREACH OBJECTIVES NCMHD's Strategic Plan (2002-2006) outlined the following public infor- mation and outreach objectives: 1. Provide the latest research-based information to health care providers to enhance the care provided to individuals within populations experiencing health disparities. 2. Facilitate the incorporation of science-based information into the cur- ricula of medical and allied health professions schools and into continuing educa- tion activities of health professionals. 3. Maintain ongoing communication linkages and dialogues with minority, ethnic, and other special populations, including the underserved, who experience health disparities. 4. Develop computer databases and Internet resources to disseminate cur- rent information about scientific research and discoveries and other activities regarding health disparities. 5. Develop targeted public health education programs focused on particu- lar disease areas in order to reach those individuals within minority, ethnic, and other special populations who experience health disparities within these disease areas. NCMHD's objectives focus on two broad strategies and groups of audiences to reduce and eliminate health disparities. One strategy is to disseminate informa- tion on health to different individuals or groups that face a disproportionate burden of disease with regard to health. Such diffusion of information involves a primarily nonprofessional audience with limited resources, skills, and training. A second broad strategy is to disseminate research-based information to trained professionals in medicine and public health or to organizations and groups that deal primarily with the medically underserved. We will briefly discuss the dis- tinction between the two in the next section, which will then be followed by a more careful delineation.

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220 EXAMINING THE HEALTH DISPARITIES RESEARCH PLAN OF THE NIH KNOWLEDGE TRANSFER: RESEARCH DISSEMINATION, DIFFUSION, AND PUBLIC INFORMATION3 The nation's massive investment in the biomedical enterprise over the past few decades has resulted not only in advances in basic sciences, technology, and drug development but also in a fundamental understanding of how lifestyle changes can prevent some diseases and how evidence-based treatment can be effective (Hiatt and Rimer, 1999; IOM, 2002). Yet despite these advances, there are significant gaps in translation of this knowledge from the lab or research setting to clinical and community settings, thus limiting the advantages that might accrue from our investments. What is needed is a deeper understanding of: (a) how communication can accelerate the process of knowledge transfer from re- search settings to the community--from "bench to the bedside and bench to trench"--a process that demands a careful delineation in audience; (b) the publics involved; (c) communication processes; and (d) channels. Equally critical is a feedback loop between the audience, the consumers of research-based knowl- edge, and those who produce that knowledge. Two related communication strategies are worth considering in accelerating knowledge transfer: public health communication and research dissemination. Public health communication may be defined as the strategic communica- tion of evidence-based health information on primary and secondary preven- tion, detection, diagnosis, and treatment to lay or nonprofessional audiences. The public here may include citizen individuals or groups such as community activists, workers unions, and civil and social service organizations. Some have characterized this phenomenon as research diffusion, a passive movement of health information through a social system. We will use the term public health communication, implying that it includes both purposeful (campaigns) and secu- lar communications. Research dissemination is an effort to close the gap between discovery and program delivery through the promotion of adoption, reach, and impact of evidence-based interventions across primary prevention to end-of-life care (NIH and NCI, 2005). Dissemination is particularly targeted to health care settings, practitioners, policy makers, and community groups. Although reporters are seldom mentioned, it is also critical to add news media as a group that could serve as a significant mediator in translating evidence-based information to the public. 3I want to thank Dr. Jon Kerner, Deputy Director of Research Dissemination and Diffusion at the National Cancer Institute, for clarification of the terms diffusion and dissemination. The conceptual distinction between them has been muddy, and these terms have often been used interchangeably. Dr. Kerner and colleagues in his office have been engaged in the conceptual explication of diffusion and dissemination as well in promoting the science of dissemination in cancer control.

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APPENDIX G 221 Research dissemination stands in sharp contrast to research diffusion, which is a passive process that leaves the translation of scientific information to differ- ent publics to chance. In this process, scientific information is likely to spread only if the social actors, such as providers or the public health community, happen to come across the research results in a scientific publication or some other forum or if the news media picks up the article from a press release. According to some scholars, successful dissemination involves a push-pull process, thus explicitly suggesting the feedback loop mentioned earlier (Kerner et al., 2005). That is, those pushing the dissemination should help the audience adopt and use the scientific information, but those pushing the information should also be sensitive to the needs and wants of the ultimate end-users of that knowledge. We will briefly discuss the opportunities and challenges in public health com- munications and research dissemination and their relevance to health disparities. PUBLIC COMMUNICATION, OUTREACH, AND COMMUNICATION INEQUALITIES Functions of Health Communication Communication in health may serve several functions: informational, instru- mental, social control, and communal. The informational function is what we commonly describe as learning from media and other channels by acquiring knowledge on issues along a disease continuum, including prevention, detection, diagnoses, treatment, and end-of-life issues. Medical advice may also fall under this function. Several studies have noted the importance of communication in learning about health from either public health campaigns or incidental learning, and the threat of differential learning across social classes has also been noted (Hornik, 2002; IOM, 2002; Viswanath and Finnegan, 2002). The instrumental function is the provision of information that is useful, enabling practical action. It may include calling for a refill of prescriptions, verification of drug regimens on the Internet, clarification of questions with providers, learning of a time and place for preventive screening or vaccination, and skills in following certain health behaviors, among others. Communication performs the vital social control func- tion in defining social norms, reinforcing or inducing beliefs, and defining the limits of what is acceptable and unacceptable in health (Tichenor et al., 1980; Viswanath and Demers, 1999). Campaigns to change social norms around binge drinking (Wechsler et al., 2003) or tobacco use (Gilpin et al., 2003) are, in essence, serving the social control function. The communal function may include building a sense of community, social connectedness, norms of reciprocity, and access to social capital (Berkman, 1986; Demers, 1996; Friedland and McLeod, 1999; Kawachi, 1999; Kawachi and Berkman, 2000; Kawachi et al., 1999; Putnam, 2000; Stamm, 1985; Viswanath et al., in press). Social and emotional

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222 EXAMINING THE HEALTH DISPARITIES RESEARCH PLAN OF THE NIH support during treatment is another example of the communal function of health communication. Communication, therefore, is central to learning about health, defining the norms of acceptable health behavior, and providing information to make appropriate decisions regarding treatment. Communication Inequality Two more principles of communication are worth noting. First, communica- tion is always controlled as it spreads through the system. Second, more germane to the discussion here, communication or, more precisely, information is always unequally distributed. Inequalities in communication offer one potent explana- tion for inequalities in health. Communication inequality is defined as the differ- ences among social groups in their ability to generate, disseminate, and use information at the macro level and to access, process, and act on information at the individual level. Although much of the discussion on communication inequal- ity is focused at the individual level, the macro level of inequality will be briefly addressed in the next section on dissemination, as there has been limited research in that area. In general, three common indicators of socioeconomic status (SES) often used in the literature are education, income, and, less often, occupation and employment (for a thoughtful discussion on SES and its association with cancer as an example, see Kawachi and Kroenke, in press). More recently, a number of scholars have argued for more refined measures of social class at multiple levels including individual, household, neighborhood, regional, and even national lev- els in addition to commonly used measures of education, income, and occupa- tion. These include indicators such as poverty, material and social deprivation, wealth, and macro determinants of health including poverty and the distribution of income and wealth among others (Krieger et al., 1997; Subramanian et al., 2002). Often, race and ethnicity are used synonymously with lower SES--a highly questionable premise given the large variation among different ethnic and racial groups as well as within the ethnic groups. The differences are manifest both within and across groups on such dimensions as income, education, occupation, and language. Any temptation to use race and ethnicity as synonymous with SES must therefore be resisted in the interest of more nuanced sensitivity to the differences within and across groups as will be evident from examples discussed in this chapter. Lastly, the interactive and multiplicative effects of different indicators of SES and the complex pathways through which they are related to health outcomes is yet another subject that is beginning to attract attention (Lahelma et al., 2004). There are several dimensions to communication inequality: (a) access to and use of information channels and services, (b) attention to and processing of health information, and (c) capacity and ability to act on information provided.

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APPENDIX G 223 SES, Race, and Ethnicity and Their Relation to Inequalities in Access to and Use of Information Education is the most common indicator often used as a proxy for social class. Education enables one to cultivate certain tastes and interests for different media content, provides skills in processing information, and offers the ability to apply information for day-to-day use. For example, education may provide the necessary confidence, sense of efficacy, and knowledge in enabling someone to navigate complex health systems. Income provides the tangible resources to ac- cess and subscribe to media services. Discretionary income may allow one to invest in recurring expenditures such as cable TV, the Internet, newspapers, and magazines. One may hypothesize that the greater the discretionary income, the greater the opportunity to obtain a variety of information services to improve one's well-being and derive intellectual nourishment and entertainment. Less investigated is the role of occupation and employment, though it is reasonable to speculate on occupation's influence on communication choices. Apart from wages, occupation provides opportunities for social networks, particularly in providing exposure to heterogeneous networks that are helpful in spreading new information. Employment and occupation are likely to be related to the use of, and exposure to, local community media and information channels (Viswanath et al., 1990), which, in turn, are related to knowledge and social capital, the roles of which in health and politics are acknowledged to be critical (Berkman, 1986; Kawachi and Berkman, 2000; Viswanath et al., 2000; Viswanath et al., in press). One may speculate that the effects of income, education, and occupation are not necessarily exclusive but potentially complementary and interactive. Differences in access to communication services may include such dimen- sions as the ease of availability of information, the use of different media chan- nels, and the affordability in subscription to communications services among different SES groups. The data from National Cancer Institute's (NCI's) Health Information National Trends Survey (HINTS) tellingly demonstrate differential access and exposure to information services among different social groups.4 In- come, education, and employment are positively associated with subscription to cable or satellite TV and the Internet--services that allow for access to diverse information sources (Table G-1). Similarly, income and education are associated with daily readership of newspapers (Figures G-4 and G-5). Television is one medium where the association with income and education is negative or non- existent (data not shown). Although different patterns of media use among different racial/ethnic groups do not necessarily indicate inequality, they deserve consideration. For example, African Americans spend more time with television but less with newspapers 4HINTS is a national survey of cancer communication behaviors of American adults conducted by the National Cancer Institute. The first survey was fielded in 2002/2003 through a random-digit- dialing sample of almost 6,400 adults with oversampling of African Americans and Hispanics.

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224 EXAMINING THE HEALTH DISPARITIES RESEARCH PLAN OF THE NIH (Figure G-6). They also have lower access to the Internet and cable and satellite TV (Table G-1). In addition, almost 18 percent of the U.S. population that is 5 years or older speaks a language other than English at home. The proportion of non-English speakers varies from state to state, from roughly 3 percent in West Virginia to TABLE G-1 Access to Information Services Among Different Socioeconomic Status and Racial/Ethnic Groups Percent Reporting Access to: Cable/Satellite TV % Internet % Education (n = 6,149) High school or less 77.17 38.17 Some college plus 83.25 80.64 Income (n = 6,149) < $24,999 70.91 35.52 $25,000$49,999 79.20 62.69 $50,000+ 89.53 87.64 Employment status (n = 6,131) Employed 82.03 73.52 Not employed 78.70 47.36 Race (n = 5,372) White 82.56 66.02 African American 77.30 55.81 Ethnicity (n = 5,666) Non-Hispanic 81.72 66.42 Hispanic 77.08 44.94 NOTE: For all ethnicity assessments, multiracial persons were excluded from the analysis. 4+ 1-3 Days Never 0 10 20 30 40 50 60 Percent (%) HS or Less Some College Plus NOTE: HS, high school. FIGURE G-4 Days read newspaper in last week, by education. SOURCE: See Footnote 4.

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APPENDIX G 225 4+ 1-3 Days Never 0 10 20 30 40 50 60 Percent (%) <$24,999 $25,000 - $49,999 $50,000+ FIGURE G-5 Days read newspaper in last week, by income. SOURCE: See Footnote 4. 4+ Days 1-3 Never 0 10 20 30 40 50 60 Percent (%) White African-American FIGURE G-6 Days read newspaper in last week, by race. SOURCE: See Footnote 4. almost 40 percent in California. In fact, roughly 2033 percent of the population 5 years or older in California, Florida, Arizona, Hawaii, Nevada, New Jersey, New York, and Texas speak a language other than English. Their exposure, use, and access to English-language mass media are likely limited and perhaps non- existent. Media access, in the case of non-English-speaking minority groups, must take into account ethnic media that are widely prevalent both in print and online versions (Viswanath and Lee, in press). Despite such long-standing evidence in inequalities in access at the indi- vidual level, some have suggested that these differences will disappear, due to

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APPENDIX G 243 complement and supplement each other is usually more effective (Hornik, 2002; IOM, 2002). For example, the National Youth Anti-Drug Media Campaign is an integrated social marketing effort that uses advertising, mass media, and the Internet with outreach efforts to different partners, including Hollywood and racial ethnic organizations. The decision to select one or more channels depends on factors such as reach, control over the message, intensity, and costs. Mass media can provide a wide reach with a lower cost per person, but it is also difficult to exert control over how the message is disseminated and to collect immediate feedback from the audience. On the other hand, one might be able to exert greater control over the message and obtain immediate feedback when using interpersonal or organi- zational channels, but these offer limited reach and may be more expensive. Given the complexity and intractability of the problem of health disparities, it is desirable to use both mass media as well as interpersonal and organizational channels. Channel selection is based on the principle that the information provided through those channels draws distinct groups of people who are interested in that information and who share some common characteristics. Often, the audience characteristics that are considered in channel selection include: Demographics such as age, gender, income, and residence. For example, local newspapers are optimal for reaching a variety of people and are usually consumed by adults who are enjoy strong social ties to the local media (Viswanath et al., 1990). Magazines and radio provide ideal vehicles for careful segmentation given the specialized content they offer. There are varieties of magazines that cater to different age and gender groups. Race or ethnicity, while often included in demographics, are unique factors given the nature of the media that reaches different racial and ethnic groups and the heterogeneity among different racial and ethnic groups. Ameri- can society is becoming increasingly diverse with more than 32.5 million Americans identifying themselves as foreign-born. Hispanics constitute about 13 percent of the population and African Americans another 13 percent. Asian Americans account for about 4 percent of the U.S. population. The U.S. Census Bureau projects that between 2000 and 2050, the U.S. population will likely increase from the current 282 million to roughly 419 million when almost 1 out of 2 Americans is likely to be non-White. That is, factors that usually drive the establishment and maintenance of ethnic media, such as audience size, general consumption expenditures, and SES, are already in place. In fact, there is al- ready a tremendous diversity in American mass media catering to different ethnic and racial groups: African and African American, Arab, Chinese, Fili- pino, Hispanic, Asian Indian, Japanese, Korean, and Vietnamese, among many others. These media play a variety of roles such as community boosters, trans- mitting culture, assimilation into the mainstream of American culture, and

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244 EXAMINING THE HEALTH DISPARITIES RESEARCH PLAN OF THE NIH watching out for the community (Viswanath and Lee, in press). The ethnic media offers an ideal and optimal set of vehicles in addition to the mainstream channels in providing health information to audiences of diverse racial and ethnic backgrounds. Yet, we know little about how widely these vehicles are being used to provide health information and how successful those efforts have been--both areas worthy of future investigation. Lifestyle and orientation refer to factors that go beyond demographics to interests and orientations. These may include media catering to audiences with subject interests including travel, news, recreation, sports, sexuality, health, mov- ies, and shopping, among many others. In contrast to reaching general audiences, research dissemination to pro- vider organizations may be done through professional and civic organizations such as medical societies, nursing organizations, and national civic organiza- tions. These organizations are optimal vehicles for the release of state-of-the- art information on prevention, screening, diagnoses, and treatment through their professional meetings, newsletters, and workshops. Some professional organizations are fruitful avenues for national research dissemination, includ- ing the Association of American Indian Physicians, the National Medical Asso- ciation (African Americans), the National Hispanic Medical Association, the Association of Black Cardiologists, the Association of Physicians of Indian Origin, the National Association of Hispanic Nurses, the National Black Nurses Association, and the National Council of La Raza Institute for Hispanic Health, among many others. A significant challenge is reaching nonprofessional audiences and commu- nity groups; this warrants creativity in the form of using existing structures or in funding the creation of new ones. For example, cancer education, training, and research could be conducted through NCI's Community Networks to Reduce Cancer Health Disparities through Education, Research and Training Program. EXCEED (Excellence Centers to Eliminate Ethnic/Racial Disparities), funded by AHRQ, has centers that focus on health communication in medical settings. NIH's Hispanic Communications Initiative includes an aim to address communi- cation strategies with Hispanic/Latino community-based organizations. National nongovernmental organizations and their local chapters, including the ACS, the American Lung Association, the AHA, the National Association for the Ad- vancement of Colored People, and the National Council of La Raza, are some potential avenues in reaching hardly reached groups. Despite the opportunities and the availability of organizations, researchers lack a systematic body of evidence on the appropriate dissemination vehicles for groups suffering from a disproportionate burden of disease and ill health. We have little idea of the effectiveness, receptivity, resources, barriers, and capacity of these community groups to carry out dissemination and the conditions under

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APPENDIX G 245 which they could be effective. NCMHD may do well to promote research in this important area. IMPACT SOUGHT AND TIMETABLE This element is included to compel clarity in specifying communication goals. NCMHD's broad objectives are fine, such as incorporation of science- based information into the curricula of medical and other professions schools or maintenance of communication and dialogue with minority, ethnic, and other special populations. The development of programs and measurement of their success in achieving those objectives, however, requires greater specificity and operationalization. For example, one specific goal under the objective of incorporation of science-based information into the medical curriculum could be the treatment guidelines for diabetes among African Americans. Yet another example is incor- porating cultural competence into medical school curricula. The objective of maintaining a dialogue with ethnic groups also requires greater specificity to assess the impact. One possible goal could be a periodic survey of specific groups to do needs assessment surveys to understand the barriers in obtaining access to, and the use of, health information. Such specificity will help to clarify exactly what objectives are being pur- sued and will aid in developing appropriate products, target audiences, and mes- sage strategies. It will also help to identify the necessary incentives that will facilitate the adoption of the innovation. Specification of a timeline will provide an idea of requirements in staffing, resources, and budget. A timeline will minimize the danger of setting unrealistic goals, a common feature of public health education. Moreover, specifying the timeline for translation could narrow the long period between research discovery and delivery. TRACKING AND EVALUATION It is essential that there be mechanisms in place to track the success of the outreach programs and products. Tracking and evaluation offers several advantages: Mid-course correction of current outreach efforts, Lessons learned for future outreach efforts, and The refinement and redefinition of current outreach objectives and the development of new goals. It is important that the evaluation distinguish between hard and soft out- comes. Soft measures include, for example, how many brochures have been

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246 EXAMINING THE HEALTH DISPARITIES RESEARCH PLAN OF THE NIH distributed to provider groups on treatment. Another soft measure is how many linkages have been created with community organizations. The soft outcomes are intermediate process measures, outcomes of process evaluation that could be helpful in serving as markers of outreach efforts. Yet more important is the development of hard measures that actually assess change in the provider practice or health behaviors as a result of the outreach efforts. This will also provide the necessary feedback loop discussed earlier so that NIH can ascertain and incorpo- rate the needs of different publics into programming. SOME RECOMMENDATIONS TO HELP NCMHD ACHIEVE ITS OUTREACH OBJECTIVES The current NCMHD objectives for public information and outreach appro- priately identify challenges in identifying target audiences that may help in bridg- ing the deep chasm between research discovery and delivery, when it comes to health disparities. As NCMHD refines its strategic plan in subsequent years, some additional considerations will be necessary for success. Surveillance System for Public Communications There is currently no comprehensive system in place for communication and outreach surveillance that will help NCMHD systematically assess the needs of academic, professional, and community groups working with the underserved groups and use that information in program planning. Similarly, we know little about the information needs, media use, and information-seeking patterns of citizens suffering from disproportionate disease burdens. It is unclear what sys- tems are in place to do such surveillance and how they are being fed back in program planning. There is a need for more information that addresses the following questions: What is the priority assigned in studying health disparities in the medical and allied health school curricula? What barriers exist to integrating health disparities issues within the health professions schools? Some questions pertaining to providers working with underserved groups include: What are the sources of information on health disparities among providers? Where do they go to seek information on health disparities in general? What can be done to increase awareness among providers that disparities exist? For example, a recent article in the journal Circulation showed that only 34 percent of the cardiolo-

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APPENDIX G 247 gists surveyed agreed that there are disparities in health care in the U.S. system, and 5 percent felt that these might exist in their practices (Lurie et al., 2005). To what extent do the NIH ICs serve as guidance for providing the latest scientific information related to health disparities? What are the barriers faced by the providers working with underserved groups in adopting the latest evidence-based information in their day-to-day prac- tice? What incentive structures will encourage them to incorporate innovations in their practice? What are the organizational factors--structures, culture, and hierarchies-- that deter providers from using the most up-to-date information to treat patients? On community groups and citizens, some questions that a surveillance pro- gram may address include the following: The Internet has the potential to provide detailed medical information tailored to the specific needs of different groups in formats that they can use. Yet, how helpful are the NIH IC websites in communicating with groups that are suffering from disparities in health information, access to health care, and use? To what extent does the digital divide between social classes discussed earlier deter the use of the Internet-based health information? Is it only likely to exacer- bate the disparities? How can NCMHD assist target audience groups with the incorporation of the latest evidence-based information into their practice and day-to-day health behaviors? How can investment in Internet-based resources be designed to yield a maximum dividend in reducing and eliminating disparities given the challenges of digital divide or communication inequality discussed earlier? These are only some examples of questions that are worth exploring in future research on dissemination, and they have strong implications for practice. It is strongly recommended that NCMHD develop a surveillance system that will track the health information needs, sources, and information-seeking patterns of different audience subgroups, as well address the needs of providers and institu- tions working with medically underserved groups. The NCI's HINTS study could serve as one model in developing a surveillance system on information needs of health disparities groups. Developing the Science of Communication and Dissemination Currently, a number of NIH ICs are supporting research on public health communication and provider-patient communication and developing an infra- structure to promote dissemination. It is unclear what proportion of the ICs'

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248 EXAMINING THE HEALTH DISPARITIES RESEARCH PLAN OF THE NIH budget is set aside for doing research on studying public communication. There is a significant gap in our understanding of public information when it comes to minority and low-SES audiences, as well as the appropriate models of dissemina- tion to transfer the latest medical knowledge to academia and providers dealing with health disparities groups. In short, there is a need to develop and accelerate work on the science of health communication and research dissemination, with a particular focus on minorities and low-SES groups. A strong program of research on communication and dissemination could address the following issues: How does inequality in communication contribute to and exacerbate ex- isting health disparities? How do daily hassles of racism, discrimination, and poverty affect infor- mation seeking and processing? What are the intervention and policy options that could bridge informa- tion inequities to reduce and eliminate health disparities? What is the capacity of community groups in accessing and using evidence-based information to communicate with their membership? What are the barriers faced by health care providers in obtaining and using the latest scientific information on health disparities? How can medical establishments be prepared for translating knowledge and accelerating information dissemination to groups and providers working on health disparities? What are the training needs of providers to improve communication with patients facing a disproportionate disease burden? How can NCMHD develop the training of future scientists who can con- tribute to the study of public communication to bridge health disparities? These questions are only suggestive and are not meant to be exhaustive. They do give an idea of the need for a more evidence-based and scientific ap- proach to public information outreach on health disparities. SOME CONCLUDING REMARKS With the development of a strategic plan, NCMHD made a sound start by clearly identifying the objectives for research, research infrastructure, and public information and community outreach. The objectives for public information and community outreach suggest two broad strategies to reduce health disparities: (a) ensuring the dissemination of health information to individuals and community groups that are suffering from health disparities and (b) disseminating research- based information to trained medical and public health professionals working with groups that are traditionally underserved to ensure access as well as quality health care.

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APPENDIX G 249 This essay provided some broad outlines that can enable NCMHD to achieve its objectives by taking the following steps: Continue to refine and operationalize the objectives by the greater speci- fication of intended outcomes and the development of specific measures. Be aware of, and sensitive to, the issue of communication inequities in developing any programs of public information and outreach. Develop strategic research dissemination plans that address professional groups that work with groups suffering from an unfair disease burden. Systematize outreach efforts by clearly identifying sponsors, audiences, messages, partners, channels, and tracking systems. Such systematic efforts can draw from communication science using the suggested planning matrix. Work deliberately and proactively in developing programs and initiatives that contribute to the development of science of communication and research dissemination with a particular focus on health disparities. Develop a surveillance system for public health communication with a focus on groups that suffer from health disparities. Currently, little information is available on the information needs of the underserved, and what is available is in disparate locations in the federal government or in the private sector. A well- developed system can track health information needs, media use, seeking behav- iors, and knowledge of low-SES and minority groups and can contribute to both the science of surveillance as well as program planning. To be successful, NCMHD should set aside a budget for both doing and studying public information efforts. NCMHD can play a lead role in coordinating the disparate communica- tion and outreach efforts by various NIH ICs in their attempts to reduce and eliminate health disparities. Relevant expertise and resources often reside within the ICs, but NCMHD's coordination may bring synergy to individual IC efforts. Equally desirable is a partnership with other federal agencies, such as CDC, CMS, the Health Resources Services Administration, and AHRQ, among others, and nonfederal and private-sector partners. The unprecedented advances in engineering and biomedical sciences offer a tremendous opportunity to prevent and treat diseases that have long plagued hu- mans. These advances, coupled with the communications revolution in telecommu- nications and informatics, offer the potential to intervene along the different stages of the disease control continuum--from prevention to survivorship and end of life--thereby reducing mortality and morbidity due to disease. Yet the persistent inequities in health and the corresponding inequality in communications among different social groups could disrupt the revolution, resulting in the rich getting richer and the poor poorer, in terms of health and information. A national action plan involving careful, systematic, scientific, strategic, and deliberate efforts to address the twin disparities in communication and health could potentially help to fulfill the promise of the revolution to all instead of a few.

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