A scoping review of wildfire smoke risk communications: issues, gaps, and recommendations.

BACKGROUND: Wildfire smoke exposure has become a growing public health concern, as megafires and fires at the wildland urban interface increase in incidence and severity. Smoke contains many pollutants that negatively impact health and is linked to a number of health complications and chronic diseases. Communicating effectively with the public, especially at-risk populations, to reduce their exposure to this environmental pollutant has become a public health priority. Although wildfire smoke risk communication research has also increased in the past decade, best practice guidance is limited, and most health communications do not adhere to health literacy principles: readability, accessibility, and actionability. This scoping review identifies peer-reviewed studies about wildfire smoke risk communications to identify gaps in research and evaluation of communications and programs that seek to educate the public. METHODS: Four hundred fifty-one articles were identified from Web of Science and PubMed databases. After screening, 21 articles were included in the final sample for the abstraction process and qualitative thematic analysis. Ten articles were based in the US, with the other half in Australia, Canada, Italy, and other countries. Fifteen articles examined communication materials and messaging recommendations. Eight papers described communication delivery strategies. Eleven articles discussed behavior change. Six articles touched on risk communications for vulnerable populations; findings were limited and called for increasing awareness and prioritizing risk communications for at-risk populations. RESULTS: This scoping review found limited studies describing behavior change to reduce wildfire smoke exposure, characteristics of effective communication materials and messaging, and communication delivery strategies. Literature on risk communications, dissemination, and behavior change for vulnerable populations was even more limited. CONCLUSIONS: Recommendations include providing risk communications that are easy-to-understand and adapted to specific needs of at-risk groups. Communications should provide a limited number of messages that include specific actions for avoiding smoke exposure. Effective communications should use mixed media formats and a wide variety of dissemination strategies. There is a pressing need for more intervention research and effectiveness evaluation of risk communications about wildfire smoke exposure, and more development and dissemination of risk communications for both the general public and vulnerable populations.

Promoting Convergence Between Health Literacy and Health Communication.

Health communication and health literacy are complementary areas of study and application. However, the important connections between the work conducted in these two related areas of inquiry do not appear to have always been well understood, nor appreciated, leading to limited integration and coordination between health communication and health literacy inquiry. Part of the problem may be that these two related areas developed from different professional trajectories, with health communication developing primarily from a social science orientation, and health literacy emerging primarily from a health professional application perspective. While health literacy grew out of the professional disciplines of medicine and education, health communication was undergirded by communication and social science research. Due to these different initial starting points, a lack of understanding has grown between these two areas of inquiry, resulting in a lack of appreciation for how well these fields fit together and how they can be mutually supportive in both research and applications. While there are many scholars who study both health communication and health literacy, some researchers are not well-versed in both areas, and do not understand how they can contribute to one another. In this chapter, the authors examine the parallel development of these two interdependent areas of study, trace their inter-connections, and propose strategies to enhance collaboration and integration within health literacy as well as health communication research and applications.

Barriers and Facilitators to Promoting Oral Health Literacy and Patient Communication among Dental Providers in California.

Studies demonstrate that dental providers value effective provider-patient communication but use few recommended communication techniques. This study explored perspectives of California dental providers and oral health literacy experts in the United States on use of communication techniques. We conducted a qualitative key informant interview study with 50 participants between November 2019 and March 2020, including 44 dental providers (dentists, hygienists, and assistants) in public or private practice in California and 6 oral health literacy (OHL) experts. We undertook thematic analysis of interview transcripts and descriptive statistics about interviewees from pre-surveys. Dental providers reported frequently speaking slowly, and using simple language and models/radiographs to communicate with patients, while infrequently using interpretation/translation, illustrations, teach-back, or motivational interviewing. Providers reported using only 6 of the 18 American Medical Association's (AMA) recommended communication techniques and only 3 of the 7 AMA's basic communication techniques. A majority of providers indicated using one of five oral health assessment and educational strategies. Key barriers to effective communication included limited time, financial incentives promoting treatment over prevention, lack of OHL training, limited plain-language patient education materials, and patients with low OHL knowledge. Dental organizations should prioritize supporting dental providers in effective patient communication practices. Standardizing OHL continuing education, creating an evidence-based OHL toolkit for dental teams, ensuring accessible interpretation/translation services, and incentivizing dental providers to deliver education could improve oral health literacy and outcomes.

Comparison of Brief Summary Formats Through a Health Literacy Lens.

BACKGROUND: Print pharmaceutical advertisements in the United States require inclusion of a brief summary of side effects, warnings, precautions, and contraindications from the labeling. The full package insert, which sponsors have traditionally used to fulfill the brief summary requirement, does not adhere to health literacy best practices, limiting its value to consumers. This study compared the understandability and usability of brief summaries in 3 formats designed to be more consumer friendly. METHODS: Three brief summary formats were tested: (1) 2-column "Question and Answer"; (2) "Prescription Drug Facts Box," similar to current US over-the-counter drug facts labeling; and (3) "Health Literacy," based on clear communication principles. Researchers evaluated the formats using the Suitability Assessment of Materials (SAM) tool and conducted structured, scripted, one-on-one interviews (usability tests) with participants with estimated low to average education levels. This research was replicated across 2 therapeutic areas (type 2 diabetes and plaque psoriasis). RESULTS: SAM scores showed that the Health Literacy format outperformed the Question and Answer format and the Prescription Drug Facts Box format in both therapeutic areas, with both Health Literacy brief summaries rated on the SAM as "superior." Qualitative usability tests supported the SAM findings, with the Health Literacy format preferred consistently over the Question and Answer format, and more often than not over the Prescription Drug Facts Box format. CONCLUSIONS: Sponsors can employ a user-tested Health Literacy format to improve the understandability and usability of brief summaries with patients.

Integrating Participatory Design and Health Literacy to Improve Research and Interventions.

Health communication is an essential health promotion strategy to convert scientific findings into actionable, empowering information for the public. Health communication interventions have shown positive outcomes, but many efforts have been disappointing. A key weakness is that expert-designed health communication is often overly generic and not adequately aligned with the abilities, preferences and life situations of specific audiences. The emergence of the field of health literacy is providing powerful theoretical guidance and practice strategies. Health literacy, in concert with other determinants of health, has greatly advanced understanding of factors that facilitate or hinder health promotion at individual, organizational and community settings. However, health literacy models are incomplete and interventions have shown only modest success to date. A challenge is to move beyond the current focus on individual comprehension and address deeper factors of motivation, self-efficacy and empowerment, as well as socio-environmental influences, and their impact to improve health outcomes and reduce health disparities. Integrating participatory design theory and methods drawn from social sciences and design sciences can significantly improve health literacy models and interventions. Likewise, researchers and practitioners using participatory design can greatly benefit from incorporating health literacy principles into their efforts. Such interventions at multiple levels are showing positive health outcomes and reduction of health disparities, but this approach is complex and not yet widespread. This chapter focuses on research findings about health literacy and participatory design to improve health promotion, and practical guidance and case examples for researchers, practitioners and policymakers.

Risk perception and perceived self-efficacy of deaf and hard-of-hearing seniors and young adults in emergencies.

OBJECTIVES: The authors explored the factors influencing risk perception and perceived self-efficacy before and during an emergency for deaf and hard-of-hearing (Deaf/HH) seniors and young adults. METHODS: The authors collected demographic survey data and conducted four focus groups with 38 Deaf/HH residents of the San Francisco Bay Area; two groups were with young adults (ages 18-35), including one group of college students and one group of young professionals, and two were with older adults (ages 50-90). RESULTS: Significant differences were found between Deaf/HH young adults and seniors in both the sources of self-efficacy and risk perception and their attitudes toward preparedness. All groups demonstrated high resilience. Deaf/HH young professionals expressed more concern about their risk in an emergency than Deaf/HH college students. Alternately, the risk perception of Deaf/HH older adults was often rooted in their past experiences (survival of past emergencies, inaccessibility of communications during drills). CONCLUSIONS: Policy implications include the need to dedicate more resources to increasing accessibility and relevance of emergency communications technology for Deaf/HH populations. This could help increase adaptability before, during, and after emergencies among all groups of Deaf/HH people, particularly among young Deaf/HH professionals.

Risk perception and perceived self-efficacy of deaf and hard-of-hearing seniors and young adults in emergencies.

OBJECTIVES: The authors explored the factors influencing risk perception and perceived self-efficacy before and during an emergency for deaf and hard-of-hearing (Deaf/HH) seniors and young adults. METHODS: The authors collected demographic survey data and conducted four focus groups with 38 Deaf/HH residents of the San Francisco Bay Area; two groups were with young adults (ages 18-35), including one group of college students and one group of young professionals, and two were with older adults (ages 50-90). RESULTS: Significant differences were found between Deaf/HH young adults and seniors in both the sources of self-efficacy and risk perception and their attitudes toward preparedness. All groups demonstrated high resilience. Deaf/HH young professionals expressed more concern about their risk in an emergency than Deaf/HH college students. Alternately, the risk perception of Deaf/HH older adults was often rooted in their past experiences (survival of past emergencies, inaccessibility of communications during drills). CONCLUSIONS: Policy implications include the need to dedicate more resources to increasing accessibility and relevance of emergency communications technology for Deaf/HH populations. This could help increase adaptability before, during, and after emergencies among all groups of Deaf/HH people, particularly among young Deaf/HH professionals.

Development and First Phase Evaluation of a Maternity Leave Educational Tool for Pregnant, Working Women in California.

BACKGROUND: Despite the provision of maternity leave offered to mothers, many American women fail to take leave. METHODS: We developed an evidence-based maternity leave educational tool for working women in California using participatory design. We tested its short-term efficacy with a randomized controlled trial of pregnant English-speakers (n=155). RESULTS: Among intervention participants exposed to the tool, 65% reported that they learned something new; 38% were motivated to seek more information; and 49% said it helped them plan their maternity leave. Among participants who delivered at ≥ 37 weeks gestation and said the tool helped them plan their leave, 89% took more than one week of prenatal leave, a significantly higher proportion than among controls who did not receive the tool (64%, p=0.049). Other findings favored trial participants, but were not statistically significant in this small sample. More intervention participants took some prenatal leave (80%) vs. controls (74%, p=0.44). Among participants who had returned to work when surveyed (n=50), mean postnatal leave uptake was on average 1 week longer for intervention participants vs. controls (13.3 vs. 12.2 weeks, p=0.54). CONCLUSIONS: The first-phase evaluation of this tool shows that it successfully informed women about maternity leave options, clarified complex regulations, encouraged women to seek further information and helped plan maternity leave. Compared to controls, trial participants who used the tool to plan their leave were far more likely to take prenatal leave close to term. Future evaluation of the tool when mediated by a health provider or employer is warranted.

An Early Assessment of Accountable Care Organizations' Efforts to Engage Patients and Their Families.

Accountable care organizations (ACOs) have incentives to meet quality and cost targets to share in any resulting savings. Achieving these goals will require ACOs to engage more actively with patients and their families. The extent to which ACOs do so is currently unknown. Using mixed methods, including a national survey, phone interviews, and site-visits, we examine the extent to which ACOs actively engage patients and their families, explore challenges involved, and consider approaches for dealing with those challenges. Results indicate that greater ACO use of patient activation and engagement (PAE) activities at the point-of-care may be related to positive perceptions among ACO leaders of the impact of PAE investments on ACO costs, quality, and outcomes of care. We identify a number of important practices associated with greater PAE, including high-level leadership commitment, goal-setting supported by adequate resources, extensive provider training, use of interdisciplinary care teams, and frequent monitoring and reporting on progress.

Focus on Health Literacy: Recommendations to Improve European Union Risk Management Plan Public Summaries.

BACKGROUND: The complexity of drug risk information often exceeds patients' abilities to understand and effectively act on it. METHODS: The authors evaluated a layperson-focused European Union Risk Management Plan Public Summary and revised it to improve its understandability and usability by applying health literacy principles. The Suitability Assessment of Materials was used to test the appropriateness of the document for readers with low-to-average literacy levels. Two rounds of usability tests were conducted with American adults who had low to average education levels to identify areas of confusion. Revisions were made within perceived regulatory constraints. RESULTS: A number of health literacy principles can be applied to improve the understandability and usability of the document; however, the document contains many inherently complex concepts. CONCLUSIONS: The authors recommend that stakeholders reassess the intended use of the document by members of the public and rethink its scope and structure, with close involvement of patients and caregivers.

Integrating design science theory and methods to improve the development and evaluation of health communication programs.

Traditional communication theory and research methods provide valuable guidance about designing and evaluating health communication programs. However, efforts to use health communication programs to educate, motivate, and support people to adopt healthy behaviors often fail to meet the desired goals. One reason for this failure is that health promotion issues are complex, changeable, and highly related to the specific needs and contexts of the intended audiences. It is a daunting challenge to effectively influence health behaviors, particularly culturally learned and reinforced behaviors concerning lifestyle factors related to diet, exercise, and substance (such as alcohol and tobacco) use. Too often, program development and evaluation are not adequately linked to provide rapid feedback to health communication program developers so that important revisions can be made to design the most relevant and personally motivating health communication programs for specific audiences. Design science theory and methods commonly used in engineering, computer science, and other fields can address such program and evaluation weaknesses. Design science researchers study human-created programs using tightly connected build-and-evaluate loops in which they use intensive participatory methods to understand problems and develop solutions concurrently and throughout the duration of the program. Such thinking and strategies are especially relevant to address complex health communication issues. In this article, the authors explore the history, scientific foundation, methods, and applications of design science and its potential to enhance health communication programs and their evaluation.

Assessment of state- and territorial-level preparedness capacity for serving deaf and hard-of-hearing populations in disasters.

OBJECTIVES: Substantial evidence exists that emergency preparedness and response efforts are not effectively reaching populations with functional and access needs, especially barriers related to literacy, language, culture, or disabilities. More than 36 million Americans are Deaf or hard of hearing (Deaf/HH). These groups experienced higher risks of injury, death, and property loss in recent disasters than the general public. We conducted a participatory research study to examine national recommendations on preparedness communication for the Deaf/HH. METHODS: We assessed whether previous recommendations regarding the Deaf/HH have been incorporated into state- and territorial-level emergency operations plans (EOPs), interviewed state- and territorial-level preparedness directors about capacity to serve the Deaf/HH, and proposed strategies to benefit Deaf/HH populations during emergencies. We analyzed 55 EOPs and 50 key informant (KI) interviews with state directors. RESULTS: Fifty-five percent of EOPs mentioned vulnerable populations; however, only 31% specifically mentioned Deaf/HH populations in their plan. Study findings indicated significant relationships among the following factors: a state-level KI's familiarity with communication issues for the Deaf/HH, making relay calls (i.e., calls to services to relay communication between Deaf and hearing people), and whether the KI's department provides trainings about serving Deaf/HH populations in emergencies. We found significant associations between a state's percentage of Deaf/HH individuals and a KI's familiarity with Deaf/HH communication issues and provision by government of any disability services to Deaf/HH populations in emergencies. Further, we found significant relationships between KIs attending training on serving the Deaf/HH and familiarity with Deaf/HH communication issues, including how to make relay calls. CONCLUSION: This study provides new knowledge that can help emergency agencies improve their preparedness training, planning, and capacity to serve Deaf/HH populations in emergencies.

Using design science and artificial intelligence to improve health communication: ChronologyMD case example.

OBJECTIVE: This paper describes how design science theory and methods and use of artificial intelligence (AI) components can improve the effectiveness of health communication. METHODS: We identified key weaknesses of traditional health communication and features of more successful eHealth/AI communication. We examined characteristics of the design science paradigm and the value of its user-centered methods to develop eHealth/AI communication. We analyzed a case example of the participatory design of AI components in the ChronologyMD project intended to improve management of Crohn's disease. RESULTS: eHealth/AI communication created with user-centered design shows improved relevance to users' needs for personalized, timely and interactive communication and is associated with better health outcomes than traditional approaches. Participatory design was essential to develop ChronologyMD system architecture and software applications that benefitted patients. CONCLUSION: AI components can greatly improve eHealth/AI communication, if designed with the intended audiences. Design science theory and its iterative, participatory methods linked with traditional health communication theory and methods can create effective AI health communication. PRACTICE IMPLICATIONS: eHealth/AI communication researchers, developers and practitioners can benefit from a holistic approach that draws from theory and methods in both design sciences and also human and social sciences to create successful AI health communication.

Artificial intelligence and immediacy: designing health communication to personally engage consumers and providers.

OBJECTIVE: We describe how ehealth communication programs can be improved by using artificial intelligence (AI) to increase immediacy. METHODS: We analyzed major deficiencies in ehealth communication programs, illustrating how programs often fail to fully engage audiences and can even have negative consequences by undermining the effective delivery of information intended to guide health decision-making and influence adoption of health-promoting behaviors. We examined the use of AI in ehealth practices to promote immediacy and provided examples from the ChronologyMD project. RESULTS: Strategic use of AI is shown to help enhance immediacy in ehealth programs by making health communication more engaging, relevant, exciting, and actionable. CONCLUSION: AI can enhance the "immediacy" of ehealth by humanizing health promotion efforts, promoting physical and emotional closeness, increasing authenticity and enthusiasm in health promotion efforts, supporting personal involvement in communication interactions, increasing exposure to relevant messages, reducing demands on healthcare staff, improving program efficiency, and minimizing costs. PRACTICE IMPLICATIONS: User-centered AI approaches, such as the use of personally involving verbal and nonverbal cues, natural language translation, virtual coaches, and comfortable human-computer interfaces can promote active information processing and adoption of new ideas. Immediacy can improve information access, trust, sharing, motivation, and behavior changes.

Responding to the deaf in disasters: establishing the need for systematic training for state-level emergency management agencies and community organizations.

BACKGROUND: Deaf and hard-of-hearing (Deaf/HH) individuals have been underserved before and during emergencies. This paper will assess Deaf/HH related emergency preparedness training needs for state emergency management agencies and deaf-serving community-based organizations (CBOs). METHODS: Four approaches were used: 1) a literature review; 2) results from 50 key informant (KI) interviews from state and territorial-level emergency management and public health agencies; 3) results from 14 KI interviews with deaf-serving CBOs in the San Francisco Bay Area; and 4) a pilot program evaluation of an emergency responder training serving the Deaf/HH in one urban community. RESULTS: Results from literature review and state and territorial level KIs indicate that there is a substantive gap in emergency preparedness training on serving Deaf/HH provided by state agencies. In addition, local KI interviews with 14 deaf-serving CBOs found gaps in training within deaf-serving CBOs. These gaps have implications for preparing for and responding to all-hazards emergencies including weather-related or earthquake-related natural disasters, terrorist attacks, and nuclear-chemical disasters. CONCLUSION: Emergency preparedness trainings specific to responding to or promoting preparedness of the Deaf/HH is rare, even for state agency personnel, and frequently lack standardization, evaluation, or institutionalization in emergency management infrastructure. This has significant policy and research implications. Similarly, CBOs are not adequately trained to serve the needs of their constituents.

Availability and readability of emergency preparedness materials for deaf and hard-of-hearing and older adult populations: issues and assessments.

A major public health challenge is to communicate effectively with vulnerable populations about preparing for disasters and other health emergencies. People who are Deaf or Hard of Hearing (Deaf/HH) and older adults are particularly vulnerable during health emergencies and require communications that are accessible and understandable. Although health literacy studies indicate that the readability of health communication materials often exceeds people's literacy levels, we could find no research about the readability of emergency preparedness materials (EPM) intended for Deaf/HH and older adult populations. The objective of this study was to explore issues related to EPM for Deaf/HH and older adult populations, to assess the availability and readability of materials for these populations, and to recommend improvements. In two California counties, we interviewed staff at 14 community-based organizations (CBOs) serving Deaf/HH clients and 20 CBOs serving older adults selected from a stratified, random sample of 227 CBOs. We collected 40 EPM from 10 CBOs and 2 public health departments and 40 EPM from 14 local and national websites with EPM for the public. We used computerized assessments to test the U.S. grade reading levels of the 16 eligible CBO and health department EPM, and the 18 eligible website materials. Results showed that less than half of CBOs had EPM for their clients. All EPM intended for clients of Deaf/HH-serving CBOs tested above the recommended 4(th) grade reading level, and 91% of the materials intended for clients of older adult-serving CBOs scored above the recommended 6(th) grade level. EPM for these populations should be widely available through CBOs and public health departments, adhere to health literacy principles, and be accessible in alternative formats including American Sign Language. Developers should engage the intended users of EPM as co-designers and testers. This study adds to the limited literature about EPM for these populations.

Fee-for-service and managed care for seniors and people with disabilities on Medicaid: implications for the managed care mandate in California.

OBJECTIVE: To assess differences in perceived quality of care between fee-for-service (FFS) and managed care Medicaid (MMC) by seniors and persons with disabilities (SPD) and to generate hypotheses for future evaluations of the new managed care mandate for SPD in California. METHODS: A cross-sectional telephone survey of 403 SPD Medicaid beneficiaries comparing perceived access to, satisfaction with, and quality of care between beneficiaries who had voluntarily enrolled in MMC with those who had remained in FFS. RESULTS: Beneficiaries in MMC were more likely to be "very satisfied" with their benefits than those in FFS. There was no significant difference on any measure of access to care. Most beneficiaries in MMC reported their access to and quality of health care was either the same or better than it had been in FFS. CONCLUSION: On most measures, MMC was rated either the same or better than FFS by SPD beneficiaries who voluntarily enrolled in MMC.

New directions in eHealth communication: opportunities and challenges.

OBJECTIVE: This article reviews key communication issues involved in the design of effective and humane eHealth applications to help guide strategic development and implementation of health information technologies. BACKGROUND: There is a communication revolution brewing in the delivery of health care and the promotion of health fueled by the growth of powerful new health information technologies. CONCLUSION: The development, adoption, and implementation of a broad range of new eHealth applications (such as online health information websites, interactive electronic health records, health decision support programs, tailored health education programs, health care system portals, mobile health communication programs, and advanced telehealth applications) holds tremendous promise to increase consumer and provider access to relevant health information, enhance the quality of care, reduce health care errors, increase collaboration, and encourage the adoption of healthy behaviors. PRACTICE IMPLICATIONS: With the growth of new and exciting health information technology opportunities, however, comes the daunting responsibility to design interoperable, easy to use, engaging, and accessible eHealth applications that communicate the right information needed to guide health care and health promotion for diverse audiences.

A multilingual mass communication intervention for seniors and people with disabilities on Medicaid: a randomized controlled trial.

OBJECTIVES: To evaluate the following: (1) baseline knowledge, attitudes, and behavioral intentions about Medicaid managed care (MMC) among seniors and people with disabilities (SPD) receiving Medicaid benefits; (2) SPD Medicaid beneficiaries' use of and satisfaction with a user-designed MMC guidebook; and (3) guidebook effects on changes in MMC knowledge, attitudes, and intended behaviors of SPD beneficiaries. DATA SOURCES/STUDY SETTING: Survey data collected between February and May 2008 from a random sample of SPD receiving Medicaid benefits in three California counties. STUDY DESIGN: This randomized controlled trial of 319 intervention and 373 control SPD Medicaid beneficiaries used pre- and postintervention telephone surveys to compare changes in MMC knowledge, attitudes, and intended behaviors. DATA COLLECTION METHODS: Baseline and follow-up telephone interviews were conducted in English, Spanish, Cantonese, and Mandarin. PRINCIPAL FINDINGS: Seventy-seven percent of intervention participants reported using the guidebook. Nearly all (97.9 percent) found it somewhat or very useful. Intervention participants showed gains in knowledge, positive attitudes, and intentions to enroll in MMC that are statistically significant compared with control participants. However, knowledge levels remained low even among intervention participants. CONCLUSIONS: Findings suggest that the guidebook is an effective way to improve recipients' MMC knowledge, confidence, and behavioral intentions.

Participatory design of mass health communication in three languages for seniors and people with disabilities on Medicaid.

OBJECTIVES: We used participatory design methods to develop and test guidebooks about health care choices intended for 600 000 English-, Spanish-, and Chinese-speaking seniors and people with disabilities receiving Medicaid in California. METHODS: Design and testing processes were conducted with consumers and professionals; they included 24 advisory group interviews, 36 usability tests, 18 focus groups (105 participants), 51 key informant interviews, guidebook readability and suitability testing, linguistic adaptation, and iterative revisions of 4 prototypes. RESULTS: Participatory design processes identified preferences of intended audiences for guidebook content, linguistic adaptation, and format; guidebook readability was scored at the sixth- to eighth-grade level and suitability at 95%. These findings informed the design of a separate efficacy study that showed high guidebook usage and satisfaction, and better gains in knowledge, confidence, and intended behaviors among intervention participants than among control participants. CONCLUSIONS: Participatory design can be used effectively in mass communication to inform vulnerable audiences of health care choices. The techniques described can be adapted for a broad range of health communication interventions.