Emory Report

September 7 , 1999

 Volume 52, No. 3

Study shows simple messages improve health behavior

Pneumonia vaccination rates increased fivefold among older, low-literacy adults when patients where given one-page handouts asking them to speak with their physician about the vaccine, Emory researchers reported recently in the Journal of the American Medical Association.

"Ramifications of this study go far beyond the improved pneumococcal vaccination rates we observed," said first author Terry Jacobson, associate professor of medicine. "We have demonstrated that glitzy, high-tech bells and whistles and complex behavior-change theory are not always necessary to inspire healthy behaviors. Reviving the communication basics of simplicity and clarity can produce dramatic results--and it can do so cost--effectively."

Jacobson emphasized that for simple messages to work, they must be aimed at simple behavior changes; in this study, patients were asked to show their doctor the one-page handout or to ask their doctor about the pneumonia vaccine. A one-page sheet would not be appropriate for encouraging more complicated or difficult behaviors, like quitting smoking or changing one's diet, Jacobson said.

"People in health education are often afraid to target messages to lower literacy levels," he said. "But even literate patients want health messages to be clear to let them know precisely what to do. People prefer simpler health messages; they're more satisfied with them, and they actually do work."

Another problem confounding attempts to simplify health messages is the misconception that literate older adults are health literate. Jacobson said a much greater percentage of the elderly are low-literate or have lower reading skills than is often believed, and even many literate, educated older Americans do not clearly understand health information.

Jacobson's team hopes to modify this health education tool both to other conditions, such as improving flu vaccine rates, and to other populations, such as patients in managed care systems.

The current study was conducted under the auspices of the Pneumococcal Vaccine Intervention Project at Grady Health Systems. Mean age of the 318 study participants was 63 years, the majority (64.7 percent) had less than a high school education, 93 percent were African-American, nearly 70 percent were women, and one quarter were uninsured. All were patients visiting Grady Health System for primary care. Those at risk for pneumonia--those who were at least 65 or had a chronic disease such as heart or lung disease or diabetes--were approached by investigators.

About half the group (the intervention group) received a one-page handout written at a fifth-grade reading level, encouraging subjects to "ask your doctor about the pneumonia shot." The other half (control group) received a simply written one-page handout about nutrition. Patients who received the vaccine prompt were more than five times as likely to be vaccinated than the control subjects, and subjects in the intervention group discussed the shot with their physicians nearly four times as often as control subjects.

"Given the relatively low prevalence of pneumococcal vaccination rates, we advocate a collaborative or team approach to improve them," the authors reported. "Through chart review, nurses or allied health care personnel can communicate the need for vaccinations with physicians or patients. However, the message also should be reinforced through dialogue between the physician and an empowered patient who might be interested in other preventive services as well."

Jacobson emphasized that this type of tool "activates" elderly patients, who are traditionally passive in the health care setting, to get more involved with their care.

A message that encourages patients to talk to their doctors about the vaccine opens the door to other conversations. "If we just showed the study subjects a video or other sophisticated educational modalities about the importance of the vaccine, few if any of them would have approached their physicians about it," he said. "Although it is commonly thought that video is more effective or preferred by patients, older patients do report preference for simple printed materials."

According to the authors, about 40,000 Americans die each year from Streptococcus pneumoniae infection. Of recent concern to public health providers is the rise in pneumococcal strains resistant to the penicillin. Sixty percent of pneumococcal patients are older; only about half receive vaccinations, and vaccination rates are equally low among younger persons who are immuno-compromised or who have other chronic diseases.

Jacobson's co-authors included Donna Thomas and Assisstant Professor Susan Rey of the School of Medicine, Felicia James Morton of the Office of Health Promotion and Disease Prevention for Grady Health System, and Gardiner Offult and Jennifer Shevlin of the VA Hospital. The research was funded in part by a grant from the National Vaccine Program, Centers for Disease Control and Prevention.

--Lorri Preston

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