CONNECTING CONSUMERS TO eHEALTH
Theoretically Based Recommendations for a Consumer-Facing Communications Strategy on eHealth
Jenna Bramble
A Capstone Project
Presented to the Faculty of the School of Communication
In Partial Fulfillment of the Requirements
For the Degree of Master of Arts in Public Communication
Supervisor: Professor Kathryn Montgomery
May 3, 2011
ABSTRACT
The American healthcare system is in the midst of dramatic and rapid change. With the
passage of the American Recovery and Reinvestment Act (ARRA) of 2009, which put in place
incentive programs for adoption and implementation of electronic health record (EHR) systems,
the healthcare system is finally beginning to catch up with the rest of the connected world.
Health information technology (IT) has the potential to transform the way that physicians care
for patients and the way that patients care for themselves. In an effort to inform and empower
consumers to take advantage of such innovations in healthcare, this capstone explores theories of
communication and develops a set of recommendations to inform the creation of a consumer
outreach strategy on eHealth. The review of relevant literature on framing and theories of health
behavior change serves as the basis for a set of recommendations proposed to the Consumer
Consortium on eHealth, an organization dedicated to reaching a broad audience of consumers in
an effort to empower them to become equal partners in their care through the use of health IT (or
eHealth) tools. The proposed recommendations are meant to guide the development of the
Consumer Consortium’s overall communications strategy by providing theoretical frameworks
and tenets from which to build a comprehensive outreach campaign.
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TABLE OF CONTENTS
INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
ABOUT THE CONSUMER CONSORTIUM ON eHEALTH . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
EXPLANATION OF LITERATURE FOCUS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
REVIEW OF LITERATURE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10
Framing Theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
Health Behavior Change Theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
16
Health and eHealth Literacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
27
LIMITATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
SUGGESTIONS FOR FUTURE RESEARCH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
35
CONCLUSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
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INTRODUCTION
On March 25, 2011 the Office of the National Coordinator for Health Information
Technology (ONC) within the U.S. Department of Health and Human Services (HHS) released
the Federal Health Information Technology Strategic Plan. Among the five goals presented in the
Plan, ranging from achieving adoption and meaningful use of health information technology (IT)
tools to using health IT to improve population health, one goal was focused solely on
empowering individuals to improve their health by utilizing tools and resources available
through health IT (ONC, 2011).
The purpose of implementing interoperable EHR systems across the U.S. is to improve
care delivery and the overall patient experience and with the movement to encourage physicians
to convert to the use of electronic health record (EHR) systems in the U.S., patient engagement
in the adoption stage is critical to success.1 Electronic health records systems provide
opportunities for patients to have more open communication with their physicians and greater
access to their health information, therefore putting more power into the patients’ hands and
increasing potential for the patient to engage in preventive health behaviors.
Efforts are already underway within the ONC to launch a large-scale communications
campaign directed at consumers across the U.S. The goal of the campaign is to introduce
consumers to the tools and resources available to them through health IT and to empower them
to take advantage of those tools in meaningful ways to manage their own health and become
equal partners in their care. For many consumers, health IT will bring a welcome departure from
1
Due to the ongoing debate about the use of the term “consumer” versus “patient” within health communication,
this capstone uses the two terms interchangeably. The author does not favor one term over another and
concludes that when engaging in health communication, the appropriate term is dictated by the nature of the
population or communication campaign.
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the current health care environment that is reliant on paper records and limited communication
between physician and patient. According to a recent survey conducted by the Commonwealth
Fund (2011) more than seven out of ten adults believe that the U.S. healthcare system needs a
fundamental change, if not complete rebuilding. When asked about access to health information,
over 25 percent of those surveyed indicated that their physicians had failed to inform them of
medical test results or only did so after the patient called repeatedly (Commonwealth Fund,
2011). The same issues with access to health information also occurred at the level of care
coordination, which transpires when a patient seeks care from multiple physicians. Almost 25
percent of those surveyed experienced instances when a physician failed to provide medical
information or test results to another physician who needed to have it in order to care for the
patient (Commonwealth Fund, 2011).
Heeding the call to action, the public and private sectors across health IT have recently
deployed several consumer-facing communication efforts of varying sizes and scope. One
particular effort, the Consumer Consortium on eHealth, aims to convene the broadest possible
cross-section of stakeholder organizations across the health IT and healthcare landscapes in order
to develop a national grassroots effort to reach and engage consumers in managing their care
through health IT (Consortium Steering Committee, 2011). Through inclusion and collaboration,
the Consortium intends to gather and synthesize strategies and best practices from a wide-range
of organizations that have experience in consumer communications. Through reliance on prior
experience, focus groups, surveys and appropriate assumptions, the Consortium will develop a
framework for scalable, adaptable messaging and communication strategies surrounding health
IT that is intended to reach a diverse national audience (Consortium Steering Committee, 2011).
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In support of the Consortium effort, this capstone project will offer recommendations to
inform the overall strategic direction of consumer communication based on accepted theories of
message framing and health behavior change. Multiple studies across various fields have
demonstrated the value of theory when developing a comprehensive communications strategy.
Theoretical approaches “provide powerful tools for identifying specific beliefs that need to be
addressed if one wishes to change a given behavior” as well as better understanding of behaviors
and frameworks to guide strategic development and evaluation (Fishbein & Yzer, 2003).
Through a comprehensive review of relevant literature, recommendations are developed that
serve to provide foundational parameters to guide the Consortium in gathering and compiling
best practices, tools and resources that will build the overall communications strategy. By
offering a solid starting point grounded in research and theoretical models, this capstone project
will complement the Consortium efforts and help accelerate the strategic process.
ABOUT THE CONSUMER CONSORTIUM ON eHEALTH
The Consumer Consortium on eHealth will serve as a collaborative forum for sharing best
practices, initiatives, tools, resources, ideas and experience related to effective consumer
engagement on health IT. The scope of the project is to convene a broad, cross-section of
stakeholders to develop and coordinate a program to get individuals more engaged in their health
and healthcare through health IT. The Consortium will build on the collective wisdom, expertise
and credibility of the participants and aim to reach consensus on strategies, tactics, approaches
and an overall program for consumer engagement on eHealth. The participants in the Consortium
will have the opportunity to engage with their constituents within the context of a broader
coordinated program. Ultimately, the program is intended to lead to better communication
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between individuals and their providers to support further development and use of health IT to
improve health and healthcare. The Consortium, due to its open and collaborative nature, will
strive to complement and support rather than replicate other efforts. (Consortium Steering
Committee, 2011).
BACKGROUND
In a speech delivered on January 8, 2009, President Barack Obama promised that the
federal government would make “immediate investments necessary to ensure that, within five
years, all of America's medical records are computerized" (Favreau & Obama, 2009). Carrying
the torch from President George W. Bush’s 2004 Executive Order entitled the “President’s
Health Information Technology Plan,” President Obama and Congress have taken the necessary
steps to fund the creation of technology and standards to enable health records to be stored and
shared electronically. Stimulus funds from the American Recovery and Reinvestment Act
(ARRA) of 2009 have been dedicated to fund an incentive program established within the Health
Information Technology for Economic and Clinical Health (HITECH) Act. The incentives,
provided through the Medicare and Medicaid programs, are meant to reward healthcare
providers (i.e., physicians and hospitals) that adopt EHR systems and begin migrating health
records to digital formats. According to President Obama, electronic medical records will “save
billions of dollars and thousands of jobs and will save lives by reducing the deadly but
preventable medical errors that pervade our healthcare system” (Favreau & Obama, 2009).
Benefits of EHRs for healthcare providers are numerous and include cutting the cost of
maintaining and storing paper health records, reducing avoidable medical errors and providing
opportunities for doctors and researchers to access health data that could aid in improving public
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health services and provide more insight into disease management (GAO, 2010). EHRs also
provide immediate access to a patient’s health information and, in many cases, are able to be
securely exchanged between physicians for more efficient coordination of care efforts (IOM,
2003).
As EHR adoption moves forward, it is becoming clear how health IT has the potential to
transform the American healthcare environment. For the purpose of this capstone project, health
IT is defined as “the application of information processing involving both computer hardware
and software that deals with the storage, retrieval, sharing, and use of health care information,
data, and knowledge for communication and decision making” (Brailer & Thompson, 2004).
A 2011 study conducted through the University of Chicago found that 78 percent of
consumers believe that their doctors should be using electronic health records and another 72
percent believe that doctors should be sharing patient health information in order to improve
coordination of care (Gaylin, et. al., 2011). Such evidence is encouraging in the push for
adoption and implementation of EHRs and the number of healthcare providers adopting EHR
systems is growing slowly, but steadily across the U.S. Just over 30 percent of primary care
physicians and 20 percent of hospitals are currently employing some form of electronic health
record system (O’Doherty, 2011).
It is important to note that EHRs have just as many, if not more, benefits for patients as
they demonstrate for providers. In fact, ensuring patient access to their health information is a
requirement for providers seeking incentives through the HITECH program. As part of the
meaningful use requirements, which are benchmarks issued through the Centers for Medicare &
Medicaid Services (CMS), providers must be able to provide patients with various health
information in electronic form. For example, providers must produce electronic copies of a
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patient’s health information, including allergies and medication lists, upon request (42 C.F.R.
495.6 (d)(12), 2010). Providers are also responsible for giving patients electronic access to
clinical summaries for each office visit, as well as having the ability to electronically exchange
key clinical information with other authorized providers (42 C.F.R. 495.6 (d)(13,14), 2010).
However, in the results of a recent PricewaterhouseCoopers survey, it was reported that
86 percent of consumers cannot or do not access their health records electronically (PwC, 2011).
To clarify, there are many ways for patients to access their health information, including through
the use of EHRs and personal health records (PHRs). The difference between the two is that the
EHR is provider controlled, meaning the patient has mediated access to their health information,
whereas a PHR is entirely patient controlled is not connected to a provider or EHR (Gibbons,
2011). 2
There are a number of reasons why patients may not be using EHRs to manage their
health, including lack of access, lack of motivation and lack of information. Despite the two
years that have passed since ARRA was signed by President Obama, very little coverage of the
effort to achieve widespread adoption of EHRs has emerged outside the health IT and healthcare
trade publications. A search of the Factiva database for “electronic health records” or “EHR”
brought back only 28 articles in the past year across national publications, including The
Washington Post, The New York Times and The Wall Street Journal, as well as the wire services
Associated Press and Reuters. Of the 28 articles, 24 were focused on provider stories or business
and policy aspects of EHR adoption. These results illustrate an important point in the discussion
2
According to a recent survey conducted by IDC Health Insights (2011), only 7 percent of consumers have been
exposed to or used a PHR. For the purposes of this project, PHR use will not be studied or promoted due to the low
rate of consumer awareness and the overall national support and push for adoption and use of EHRs.
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of electronic health records: very little effort has been made within the health IT industry and
federal government to communicate with patients about EHRs and the potential of health IT
tools and resources to create a more patient-centered healthcare system.
Patient support and buy-in for EHR adoption is crucial for achieving success. Patients
create the demand for EHRs and increase system utility by providing their consent for their
health information to be exchanged among physicians. Despite the provisions of the Health
Insurance Portability and Accountability Act (HIPAA) Privacy Rule, which allows covered
entities (i.e. healthcare providers or health plans) to exchange protected health information (PHI)
with one another for “minimum necessary” purposes without patient consent, the patient retains
the right to restrict access to his or her data at any time (HIPAA Privacy Rule, 2003). It should
also be noted that even though the definition of “minimum necessary” requirements is left to the
discretion of the covered entities, often referring to billing, treatment or coordination of care, for
liability reasons many entities still require patient consent to exchange any information. Another
important consideration is that many benefits of PHI exchange come from sharing patient
information that goes beyond “minimum necessary” standards and would, therefore, require
consent (Seib, 2010).
As health IT begins to move slowly toward a tipping point, it is clear that patient support
of this movement is necessary to achieve a wholesale reform in the way the American healthcare
system operates. One of the main goals of EHRs through meaningful use is to provide health
information in digital form, in such a way that is accessible and useful to patients (Ricciardi,
2011). As a result, patients will have the ability to track their health and manage their
information to make appropriate decisions about their health, rather than relying on providers or
only visiting providers when there is a problem (Parker, 2006). Increased knowledge about the
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benefits of health IT is also thought to increase the likelihood that patients will consent to
allowing their health information to be exchanged among providers for purposes outside of
coordination of care – an assertion grounded in health behavior change literature – which will
help achieve other goals in the Federal Health IT Strategic Plan, including improving population
health and inspiring confidence and trust in health IT (Moorman & Matulich, 1993; ONC, 2011).
The introduction of EHRs into the American healthcare system has transformed the way
that many providers record and maintain patient information and it will soon transform the way
providers interact with and care for their patients. However, it will take both parties, the
providers and the patients, to actively utilize the information and capabilities available through
EHRs in order for that transformation to occur.
EXPLANATION OF LITERATURE FOCUS
In order to conduct a focused review of the literature, it was necessary to identify a clear
objective for the outcome of the Consumer Consortium on eHealth campaign. Based on the
nature of EHRs as being provider-controlled, it is important that a call to action be identified in
order to motivate patients to engage with EHRs through their physicians and seek to utilize other
EHR related tools, including secure electronic provider-patient communication, online patient
portals, and online appointment scheduling systems. As previously discussed, it is also essential
that patients are motivated to consent to the release of their electronic health information for the
purposes of clinical research and quality outcomes reporting. Therefore, for the purposes of this
capstone project, the following objectives provide the basis for the review of literature:
1. Communication efforts should promote consumer awareness of EHRs
2. Communication efforts should encourage consumer engagement with EHRs
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a. If EHRs are not currently available through a provider, communication efforts
should empower consumers to move to a provider with an EHR system or
encourage their current providers to adopt EHRs
3. Communication efforts should encourage consumers to consent to the release of their
electronic health information for exchange with other physicians to improve coordination
of care and consent to release of de-identified electronic health data for the purposes of
clinical research and quality outcomes reporting
Guided by the three identified objectives, the literature review first explores framing theory
as a means to set a baseline for communicating information about EHRs to consumers. Framing
will provide a guide for message development and ensure consistency across all forms of
communication within the strategy.
Second, the review summarizes health behavior change theory, with a focus on the Health
Belief Model and the importance of information and motivation in behavior change
communication. Using the discussion of framing as a guide, the behavior change discussion will
focus on changing consumer behavior from not accessing EHRs, to becoming active users of
EHRs and other health IT tools.
The final section will provide a brief discussion on the importance of considering health
literacy and eHealth literacy when developing a consumer-facing health communications
campaign. Health literacy offers a starting point for developing communications and, as other
theories in this review, emphasizes the need for awareness and education as part of the overall
communications strategy (Parker, 2006).
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REVIEW OF LITERTATURE
Overview
In developing a consumer-facing communication strategy, it is important to first set the
baseline for intended goals and objectives in order to identify a specific behavior to change or
reinforce. As suggested by the review of framing theory, EHR use should be framed as a
preventive health behavior given its potential for improving patient management of his own
health. By using positively framed messages through gain-framing, preventive health behaviors
can easily be communicated through a strategy that seeks to empower consumers rather than rely
on fear appeals or negative messaging (Rothman, et. al., 2006).
Once the EHR message is framed appropriately, investigation into health behavior
change models emphasize the need to perform thorough audience research in order to select
behaviors to target that fit within the given population (Rosenstock, 1974; Fishbein 2000).
Within both models, there is significant consideration on the underlying variables that ultimately
dictate whether a behavior will be adopted. It is critical to understand how different audiences
weight the variables in order to develop a campaign strategy that will effectively activate the
various components and provide the necessary resources to achieve behavior change among a
targeted group.
Education (also called health knowledge) is also a necessary element to any successful
behavior change strategy. As demonstrated throughout the literature review, education provides
audiences with the necessary schemas that make message delivery more effective and more
likely to encourage behavior change. Moorman and Matulich (1993) identified health knowledge
as a variable strong enough to facilitate the adoption of preventive health behaviors even in the
absence of strong motivating factors. Given the poor state of health literacy in the U.S.,
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awareness and education are keystones to any health behavior change campaign. In the case of
EHRs as a preventive health behavior, existing awareness or knowledge of eHealth is also a
critical factor in promoting its successful adoption and use.
A detailed review of relevant literature follows. Proposed Recommendations based on the
information gathered from the review begin on page 27.
Framing Theory
Framing as a communications practice has long been considered an abstract concept in
the space of message development (Entman, 1993). Although the idea of framing and its effects
is widely acknowledged across the social sciences, there have been few generally accepted
definitions for framing as a communications tool or for framing effects as a psychological
phenomenon. One of the few comprehensive definitions of framing comes from Entman (1993)
who described the practice of framing as involving selection and salience. To frame is “to select
some aspects of a perceived reality and make them more salient in a communicating text, in such
a way as to promote a particular problem definition, causal interpretation, moral evaluation,
and/or treatment recommendation” (Entman, 1993, p. 52). According to Chong and Druckman
(2007) two types of frames are most widely used: equivalency communication frames, as
proposed by Tversky and Kahneman (1987), which present different but logically equivalent
messages; and emphasis frames, which focus on “qualitatively different yet potentially relevant
considerations” (Chong & Druckman, 2007, p. 114). In the context of EHRs, there is little
available data concerning EHR adoption and exchange that would produce the quantitative data
often employed in equivalency frames.
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Achieving salience for selected pieces of an issue is the key to framing theory. Framing is
not effective unless the individual encountering the frame possesses a pre-existing knowledge
structure, or schema, about the issue being framed. The underlying premise of framing theory is
that issues can be presented or construed from varying perspectives and that even small
manipulations of a message can produce changes in opinion (Chong & Druckman, 2007). It
should be noted that framing is not the same as traditional persuasion or other models of belief
change as it does not seek to change an individual’s beliefs about an attitude object and framing
effects do not depend on the recipient’s acceptance of a message argument (Chong & Druckman,
2007; Nelson et al., 1997). Instead, framing is intended to change how an individual weights the
message in order to evaluate the attitude object (Nelson et al., 1997). This implies that framing
can actually be more effective at changing an individual’s cognitions about a behavior or object
because it provides a cognitive shortcut to reaching a conclusion, rather than forcing a message
recipient to process new message assertions and a suggested change in cognition or behavior
(Nelson et al., 1997). Framing provides the basis for individuals to change their opinions based
on their own evaluation criteria.
Framing should not be confused with issue priming. While issue priming also relies on an
individual’s existing schema and, in the case of intentional priming, reinforces existing beliefs
about an issue, it differs from framing in that it only serves to make certain aspects of an issue
more accessible to an individual (Price & Tewksbury, 1997). By increasing accessibility,
priming can also have the effect of changing an individual’s evaluation standards for an issue.
However, priming effects, as they are often related to agenda-setting in the media, are only
temporary due to the changing nature of the flow of news (Scheufele & Tewksbury, 2006). In
contrast, Price and Tewksbury (1997) describe framing in the context of applicability. Rather
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than determining what part of an issue is to be presented, framing influences how an issue is
presented in such a way that will activate accessible schema for a message recipient (Price &
Tewksbury, 1997).
According to Price and Tewksbury (1997) the applicability of framing is much less
sensitive to the passage of time, unlike the accessibility concept of priming. The assumption is
that although the accessibility of an issue may fade, an individual will retain the issue frame and
continue to apply it each time he or she is presented with the information about the issue, until he
or she is presented with and accepts countervailing information (Price & Tewksbury, 1997).
Essentially, as a message recipient continues to apply the same frames to certain issues, the
possibility for lasting opinion change is more plausible, which makes it more difficult for
conflicting frames to take hold.
Regardless of the differences between the two concepts, priming and framing work hand
in hand, as the effectiveness of frames is directly correlated with issue accessibility (Scheufele &
Tewksbury, 2006). The same is true with framing and issue involvement as described by Chong
and Druckman (2007) in their discussion of moderators to framing. Other moderators include
individual predispositions (e.g. values) and the perceived strength of a frame. Chong and
Druckman (2007, p. 116) posit that strong frames are often those that “connect a proposal to a
positive idea or value that is widely available in the population.” Obviously, their suggestion is
only based on observation and previous literature, as there is no widely accepted general formula
for creating a strong frame.
In the context of EHRs, issue involvement as a moderator to framing effects is an
especially relevant consideration. At this time, many patients are unaware of the federal
government’s effort to encourage the spread of EHR adoption and issue involvement is very
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fragmented among those who work in the health information technology arena, those who work
in healthcare or for related non-profit organizations, and those who do not fall in either category
and only have as much awareness as what is provided by the mainstream media.
As discussed, message framing is often employed to reduce the complexity of an issue,
offering recipients a cognitive shortcut in processing the issue presented (Scheufele &
Tewksbury, 2006). Therefore, framing proves especially effective for recipients with low issue
involvement since they are most likely to refrain from processing a message in detail and base
their attitudes on simple inferences (Maheswaran & Meyers-Levy, 1990). However, according to
an experiment conducted by Nelson, Oxley and Clawson (1997), framing had strong effects on
those with high issue involvement as well. The authors explained that although framing is
effective for any audience with some issue involvement, since it relies on the activation of
existing schema, frames are often more effective for those with high issue involvement since the
schema are more accessible at any given time (Nelson, et al., 1997).
Framing effects are also dependent on the type of frame employed. When presenting a
message frame, an issue can be presented positively, negatively, or neutrally (Maheswaran &
Meyers-Levy, 1990; Angst & Agarwal, 2009). A positively framed message, also called a gain
frame, describes an issue in terms of benefits gained, while a negatively framed message, also
called a loss frame, describes an issue in terms of benefits lost (Maheswaran & Meyers-Levy,
1990). In contrast, neutrally framed messages contain weak arguments and do not address how
an issue could have positive or negative outcomes for the recipient (Angst & Agarwal, 2009).
The most heavily cited theory of gain versus loss framing, called prospect theory, comes
from the work of Tversky and Kahneman (1981). Prospect theory was based on the results of a
number of experiments in which the authors presented individuals with sets of two choices and
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asked them to choose one. One set contained the choice between a sure gain and the combination
of a possible gain with a possible loss. The other set contained the choice between a sure loss
and, again, the combination of a possible gain with a possible loss (Tversky & Kahneman, 1981).
Results demonstrated that a large majority of respondents made the risk averse choice for the
sure gain in the first problem, and in the second problem a large majority took the risky option
when faced with a sure loss (Tverksy & Kahneman, 1981). Therefore, prospect theory essentially
postulates that when presented with gain frames, individuals will be risk averse and when
presented with loss frames, individuals will be more likely to take risks (Tverksy & Kahneman,
1981).
Prospect theory has been explored through various applications, especially in the context
of health behaviors (Rothman, et al., 2006). The principles of gain and loss frames can be easily
applied to health communication in terms of the prevention and detection of possible health
problems. Prevention behaviors are essentially the steps that individuals take to maintain their
health and minimize the risk of illness, while detection behaviors are those for which individuals
take the necessary steps to detect a potential health problem (Rothman et al., 2006). For the
purposes of analysis, prevention is considered a sure gain, since engaging in preventive health
behavior ensures that an individual will remain healthy as opposed to the opposite, not engaging
in prevention, which could be a risky decision (Rothman & Salovey, 1997). Detection, however,
is often considered a risk since there is a chance that the results of detection could be
unfavorable. The alternative to detection, however, could be a sure loss (Rothman & Salovey,
1997). This consideration is made more salient by the fact that detection messages are often used
to target high risk behaviors.
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Clearly, considerations for prevention and detection as gains and losses directly
correspond with the postulate of prospect theory (Rothman & Salovey, 1997). As a result, a
framework for message framing has been developed and tested in multiple areas of health
communications. Principles of the framework suggest that gain/positive frames are most
effective for messages of prevention and loss/negative frames should be used when promoting
detection (Rothman, et al., 2006).
In keeping with the principles of positive and negative frames for health messages,
positive frames should be more effective for encouraging use of EHRs as a preventive health
behavior. According to the framework, evidence also demonstrates that positive frames are most
effective when individuals already have positive views (i.e. individual predispositions act as a
framing moderator) of the behavior (Rothman, et al., 2006). Therefore, an important
consideration to ensuring the effectiveness of positive frames in this context is the addition of
education, or providing background information to individuals prior to presenting the framed
messages, as a way to influence predispositions and increase the effectiveness of the frame.
Health Behavior Change Theory
The Health Belief Model
Once an issue is appropriately framed, a communication strategy should be developed
around a framework that informs targeting and changing certain behaviors. As mentioned
previously, the objectives for this particular communication effort are to promote awareness and
encourage comfort and engagement with health IT tools and resources, specifically EHRs. In
order to narrow the focus of initial communication efforts, we first turn to one of the oldest
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models for health behavior change, the Health Belief Model (HBM), to identify the most basic
variables that should be considered when designing a health behavior change campaign.
The HBM was originally developed by a group of investigators at the United States
Public Health Service (now the Public Health Service Commissioned Corps within the Office of
the Assistant Secretary for Health) during the 1950s and 60s (Rosenstock, 1974). At that time,
the Public Health Service was primarily oriented toward prevention, including offering screening
tests for early detection of tuberculosis, and later diseases like polio and influenza (Rosenstock,
1974). The model emerged as a practical solution from sets of research problems meant to
explain why individuals were not taking advantage of free screenings and other preventive health
behaviors. Based in psychology, the HBM seeks to explain individuals’ health behaviors when
considering their attitudes and beliefs (Janz & Becker, 1984). Admittedly, the model is limiting
as it only focuses on individual level variables, but it still continues to be a major organizing
framework for explaining preventive health behaviors and crafting basic health behavior change
communications.
The HBM is derived from a value-expectancy framework, which assumes that individuals
will take specific action if they believe their actions will produce benefits (Oliver & Berger,
1979). The HBM operates on the basis of five main dimensions: perceived susceptibility,
perceived seriousness or severity, perceived benefits of taking action, perceived barriers and a
cue to action (Rosenstock, 1974). Essentially, the framework identifies four attitudinal variables
that will enable an individual to take preventive health action or prevent her from doing so. A
fifth variable, cue to action, adds a motivational dimension to the model as a way to encourage
adoption of the intended behavior change when combined with the other four elements
(Rosenstock, 1974).
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In order for the framework to be effective, a very specific behavior must be identified and
defined in order to align all the dimensions and achieve the desired intensity of each one. Early
applications of the HBM sought to understand vaccination behavior and encourage individuals to
be inoculated against influenza (Janz & Becker, 1984). In order for a healthy individual to feel
the need to be vaccinated, he would first have to perceive that he was susceptible to the flu and,
as an added element, perceive a high level of disease severity. Raising adequate awareness of the
threat is the cornerstone of the first two elements and should not be underestimated as part of a
communications strategy. Once the first two dimensions were satisfied, the individual would
have to be presented with ample information regarding the benefits of the vaccination.
Communication would also have to address any perceived barriers to undergoing the
vaccination, such as discomfort, in order to eliminate possible prohibitions and produce a
positive benefits-over-barriers analysis (Rosenstock, 1974
In later formulations of the HBM, an additional construct, self-efficacy, was included to
strengthen the motivational aspect of the model. Self-efficacy is defined as “the conviction that
one can successfully execute the behavior required to produce the outcomes” (Bandura, 1977, p.
193). The concept of self-efficacy was used to more effectively address potential barriers to the
intended health behavior. By providing the targeted individual with the necessary self-efficacy,
whether through specific instructions or available resources, the individual would gain perceived
control over the behavior and feel competent to overcome barriers (Champion & Skinner, 2008).
Indirect moderators to the model exist in the form of age, gender, ethnicity,
socioeconomics, personality and knowledge of the health behavior, which can alter its
effectiveness in influencing and predicting preventive health behaviors (Rosenstock, 1974).
However, results from a number of empirical studies have supported the predictive value of the
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model. According to Janz and Becker (1984), a summary of 29 empirical studies across 10 years
demonstrated that perceived barriers were the strongest predictor of all types of health behaviors
observed (i.e., sick role and preventive). This evidence continues to demonstrate support for the
addition of the self-efficacy component within the model. Among preventive health behavior
studies, perceived susceptibility was the most powerful predictor of change in behavior (Janz &
Becker, 1984). Perceived benefits were an important consideration also, while perceived severity
of the health threat was the least important predictor of behavior. Therefore, it can be assumed
that an individual with high perceived susceptibility and a high level of perceived benefits,
coupled with high self-efficacy, will be more likely to engage in preventive health behavior than
an individual with low perceived susceptibility and high perceived barriers, regardless of the
perceived severity of the health threat.3
Again, due to the focus on very specific variables, it is important that the behavior to be
addressed remains consistent across all forms of communication that seek to address the
dimensions of the HBM. Because this is an individual-level model, audience research and
targeting are also necessary in order to design effective communication strategies. For example,
barriers to visiting a physician for regular check-ups will be much different for individuals living
in a rural area compared to those living within a large city. Tailored communications that follow
the HBM constructs have been shown to be most useful for community-based interventions, as
well as heavily targeted interventions with print based media and minimal contact (Champion &
Skinner, 2008).
3
Because of the low impact that perceived severity has on health behavior outcomes, this review will not explore
the salience of fear appeals or other emotional appeals in this context. In keeping with the goals of the ONC in its
aim to empower consumers to engage in health IT, the chosen literature will continue to emphasize motivation
and self-efficacy, rather than applications focused on negative frames or appeals.
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It should be noted that measurement of the overall effectiveness of the HBM has proven
extremely difficult due to the variable nature of each construct and the external factors that can
influence individual level behaviors (Champion & Skinner, 2008). However, many researchers
have gone on to expand the scope and build on the basic structure of the HBM in order to
produce a more comprehensive framework that accounts for more external variables and
individual level influencers. A brief review of other integrated and expanded conceptualizations
will serve to identify additional variables to consider when developing targeted health
communications as well as help narrow the overall focus on the strongest variables related to
predicting health behavior change.
The Integrative Model
Given the many theories of behavioral prediction that exist to guide communication
strategy for health behavior change, it is interesting to note that there are still only a handful of
variables that need to be considered when predicting or understanding behavioral determinants.
In an effort to create a framework that takes all variables into consideration in order to produce a
strong predictive model, Fishbein (2000) introduced an integrative model to marry a number of
theoretical perspectives. Essentially, the model posited that “any given behavior is most likely to
occur if one has a strong intention to perform the behavior, has the necessary skills and abilities
required to perform the behavior, and there are no other environmental or other constraints
preventing behavioral performance” (Fishbein & Cappella, 2006, p.S2). In parallel to the HBM,
the environmental constraints act as potential barriers and the construct of ability can include
self-efficacy as a moderator. However, in contrast, the integrative model introduces the construct
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of intention as well as a dimension of environmental factors and background influence that was
not included in any iterations of the HBM.
Drawing on behavioral models like that Theory of Planned Behavior and the Theory of
Reasoned Action, Fishbein (2000) placed the main emphasis on an individual’s intention to
perform a given behavior. Intention is a construct that is determined by attitude toward
performing the behavior, perceived norms concerning performance of the behavior, and selfefficacy (Fishbein, 2000). In comparison to the HBM, which only considers individual attitudes
and perceptions, intention is a dimension that combines both internal and external factors to
create behavior change. In fact, a study completed by Oliver and Berger in 1979, which added
intention as a measurement of the HBM as a predictive model for swine flu vaccination,
demonstrated that intention was the strongest predictor of behavior, outweighing other
behavioral variables of the HBM.
Clearly, when targeting audiences for health communication environmental factors
cannot be ignored. In his integrative model, Fishbein (2000) goes so far as to add media exposure
and past behavior as influencers that have an effect on intention and, therefore, behavior. He also
suggests that not all behaviors will be informed by the same underlying determinants of
intention, which underscores the importance of conducting necessary audience research to
attempt to understand the degree to which certain health behaviors are under attitudinal,
normative or self-efficacy control (Fishbein & Cappella, 2006). For example, for many young
adults, the intention to exercise may be under normative control due to outside influences of
media and social pressure to stay in shape and maintain a certain image. Older adults, in contrast,
may choose to exercise due to attitudes or self-efficacy for the purpose of staying active for
better health or to prevent possible issues that may arise from being sedentary.
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As with the HBM, the integrative model requires the identification of a single, specific
behavior to change or reinforce. According to Fishbein and Cappella (2006) it is also critical to
recognize that the definition of a behavior involves several elements, including the action, the
target and the context. In order for communication to be effective, the elements of the behavior
must remain focused and consistent.
Another construct to consider in the behavioral elements is time. Clearly, different
audiences will perceive certain behaviors with more urgency than others, so it is important to
identify a practical time period when defining the behavior to change (Fishbein & Cappella,
2006). Returning to the EHR adoption behavior, if an individual’s physician has not yet deployed
an EHR system, it would be foolish to direct the individual to adopt the EHR within a number of
months. In that case, the overall behavior would need to change from adoption to demand.
However, for an individual seeing a provider with and EHR system (who is also meeting
meaningful use requirements) it is appropriate to set a given time period in which the individual
should begin accessing and utilizing the EHR as mediated by the physician.
Obviously, the underlying theme of Fishbein’s integrative model, as with the HBM, is
that audience research and targeting is necessary in order for any predictive behavioral model to
be effective. Consistency is a key to achieving any desired behavior change outcome and also
provides a more controlled process for evaluating each variable and understanding the behavior
change trends in a given population. The process can help determine identify why behavior
change is or is not occurring, whether for reasons of intention or other external barriers that can
possibly be removed (Fishbein & Cappella, 2006).
In order to apply the integrative model to a communications strategy, one must consider
all the individual decision points that arise throughout the behavior change process in concert
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with the population evaluation. If the individual has the intention to perform the behavior, but
does not go through with the change, it will be the task of the communications strategist to
determine how to reduce environmental barriers or help the individual gain the ability to do so.
However, if the individual does not intend to change her behavior, a strategy must be developed
to identify the underlying beliefs that influence the intention and target them in way that will
help instill the intention (Fishbein & Cappella, 2006). As with the HBM, a critical part of a
health behavior change strategy is offering a cue to action and the necessary resources to
increase self-efficacy. In terms of the integrative model, the strategy must also take into account
influencing the necessary attitudes and social norms that could also influence an individual’s
likelihood to engage in behavior change.
Health Motivation
Whether speaking in terms of self-efficacy of the HBM or intention in the integrative
model, in order for an individual to engage in a specific health behavior, proper motivation is the
underlying component in each theory that must be considered when developing a communication
strategy. In the context of health behavior change, motivation is considered “health motivation,”
which is defined by Moorman and Matulich (1993) as “consumers’ goal-directed arousal to
engage in preventive health behaviors” (p. 210). A moderator to health motivation, which can
increase or decrease the likelihood that an individual will perform a given behavior, is “health
ability” defined as “consumers’ resources, skills, or proficiencies for performing preventive
health behaviors” (Moorman & Matulich, 1993, p. 210). Similar to self-efficacy, health ability
provides consumers with the necessary internal and external factors to perform a given health
behavior.
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Consistent with prior research, Moorman and Matulich (1993) theorize that an individual
with high motivation and high ability will be the most likely to perform a given preventive health
behavior, while someone with low motivation and moderate to high ability will be the least
likely. It has often been demonstrated that even individuals with low ability are more likely to
perform a preventive health behavior when possessing high motivation (Celsi & Olson, 1988).
Again, as with framing and the health behavior change models, awareness and knowledge are
key factors in the process of influencing and promoting preventive health behaviors.
In terms of health status, however, Moorman and Matulich (1993) came to an unexpected
conclusion in consideration of previous research. Results of the testing revealed that individuals
with high motivation and high ability in terms of health status (i.e., good health and physical
attributes necessary to easily perform the identified preventive behavior) were less likely to
perform preventive health behaviors than those with high motivation and poor health status
(Moorman & Matulich, 1993). The authors concluded that those in poor health used their health
status as a motivator to overcome their moderate to low health ability in order to perform the
preventive behavior, while healthy individuals, despite being motivated, were unable to justify
performing preventive health behaviors (Moorman & Matulich, 1993). The results of this study
emphasize the importance of appropriate messaging to targeted audiences as described in the
review of the HBM and integrative model as a way to ensure that motivation and ability work in
concert to achieve the desired outcome.
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Health and eHealth Literacy
The obvious common thread throughout the reviewed literature is the need for individual
awareness or the existence of cognitive structures related to preventive health behaviors in order
for health behavior change communications to be effective. In order to underscore the
importance of education in a health behavior change campaign and set a baseline for beginning
to devise an education strategy within the overall communication effort, it is necessary to discuss
the current state of health literacy, and more recently eHealth literacy, in the U.S.
Health literacy is defined as the degree to which individuals have the capacity to obtain,
process, and understand basic health information and services needed to make appropriate health
decisions (HHS, 2000). An expanded definition from Zarcadoolas, Pleasant and Greer in 2005
also includes “the wide range of skills and competencies that people develop to seek out,
comprehend, evaluate and use health information and concepts to make informed choices, reduce
health risks and increase quality of life” (p. 197).
According to the most recent research presented by the Institute of Medicine and the U.S.
Department of Health and Human Services, over 90 million people in the U.S. have limited
health literacy (IOM, 2004). While most constructs of health literacy stem from overall literacy,
health literacy is also based on the interaction of an individual with the healthcare system and
skills in other health contexts, including submitting and retrieving prescriptions and seeking
appropriate treatment for illnesses (i.e., self-medicating or seeking a physician’s diagnosis)
(Parker, 2006). Studies have demonstrated that low health literacy is linked to poor individuallevel health management, lower rates of medication compliance, higher rates of hospitalizations,
and worse overall health outcomes (Parker, 2006; AHRQ, 2011). Clearly, preventive health
behavior is rare among populations with low health literacy.
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In conjunction with the push for improved health literacy, many scholars are now
reporting on the need for improved eHealth literacy to accommodate the rapid technological
changes that are occurring within the healthcare system. Aside from the traditional definitions of
health literacy, eHealth literacy also includes the additional components of technology/computer
literacy and awareness surrounding the growing options for managing health data and seeking
health information on the Internet (Marsh-Jordan, 2011). A formal definition provided by
Norman and Skinner (2006) presents eHealth literacy as “the ability to seek, find, understand and
appraise health information from electronic sources and apply the knowledge gained to
addressing or solving a health problem” (p.e9). Currently, the definition should also be adapted
to include the ability to access and engage in mediated forms of electronic health information,
such as EHRs.
It is clear that the increasingly digital nature of healthcare requires that education aiming
to improve individuals’ health literacy also includes components that seek to instruct and
empower them to become more comfortable with technology. Despite the fact that 80 percent of
Internet-connected individuals use the Internet to seek health information, most providers do not
engage them as partners in care (Marsh-Jordan, 2011). There is a clear disconnect in the way that
providers engage individuals and the way the individuals engage in their own health data and
information; but it is a disconnect that can be closed through education on eHealth and through
communications to empower individuals to become more health literate and more comfortable
engaging with their providers.
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RECOMMENDATIONS
The following are theoretically based recommendations that will serve to inform the
development of a nationally focused, adaptable communications strategy intended to promote
consumer awareness of and engagement with eHealth. These recommendations will be presented
to the Steering Committee of the Consumer Consortium on eHealth, and its related work groups,
in order to guide future discussions on strategy development. These recommendations, in concert
with the Review of Literature, will provide a foundational knowledge of widely accepted and
tested health communication theories, from which the Committee can build out a comprehensive
consumer-facing communications strategy.
Frame EHR Use as a Preventive Health Behavior
In order to begin communicating with patients about the benefits of EHRs, it is important
to first set a baseline for how the information will perceived. Framing is often considered a
method to reduce the complexity of an issue as well as making certain aspects of an issue more
salient than others (Entman, 1993). Framing EHR adoption and use as a preventive health
behavior will provide a strong baseline for presenting information and building a health
communications campaign that will fit within the accepted models for health behavior
communication theory, which are explored in further recommendations.
For patients, EHRs are the closest Americans have come to achieving a true longitudinal
health record, or a record that aggregates health events in a patient’s life from birth to death. That
type of record could provide a number of preventive health benefits, including allowing the easy
transport of patient data from provider to provider, giving doctors the full picture of a patient’s
health history and giving patients more information about their health and care. Patients with
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fragmented records are at higher risk for dangerous drug interactions or overdoses or to be
subject to medical mistakes (IOM, 2003). Not only do EHRs help doctors make more complete
clinical decisions for their patients, they also allow for patients to view their own health
information to make proactive decisions about how to keep themselves healthy.
In the exploration of framing, theories related to positive and negative frames have most
often been associated with health behaviors. In keeping with the principles of positive and
negative frames for health messages, positive frames should be more effective for encouraging
use of EHRs as a preventive health behavior. A preventive health behavior is defined by Kasl
and Cobb as “any activity undertaken by a person who believes himself to be healthy for the
purpose of preventing disease or detecting disease in an asymptomatic stage” (1966, p. 246).
According to the health communications framework developed by Rothman and his colleagues
(2006), evidence demonstrates that positive frames are most effective when individuals already
have positive views (i.e. individual predispositions act as a framing moderator) of the behavior
(Rothman, et al., 2006). Therefore, an important consideration to ensuring the effectiveness of
positive frames in this context is the addition of education, or providing background information
to individuals prior to presenting the framed messages, as a way to influence predispositions and
increase the effectiveness of the frame.
Framing engagement with EHRs as a preventive health behavior not only lends itself to
positive messaging, but also works in conjunction with educational components of the campaign.
Based on theory explored in the Review of Literature, frames are more effective when audiences
have some level of issue involvement. Frames are also effective when they are consistent and
audiences are able to easily recall selected aspects of an issue when a frame has been employed
to reduce complexity.
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It is recommended that the Consortium strategy employ overall preventive health frames
to promote positive messaging and help reduce the complexity of the health IT issue. Focusing
on preventive health frames also draws the health IT conversation away from policy and privacy
issues, which can be sources of concern for consumers unfamiliar with the benefits of health IT,
and encourages audiences to focus on making decisions about engaging with health IT based on
the primary concern for their health. Framing can guide the conversation about health IT away
from potential problem areas (i.e., cost, possibilities of data breaches) often highlighted by the
media and health IT naysayers, and make it a personal discussion and decision between a
consumer and his or her provider. The preventive frame can also be easily adapted based on
audience makeup. For example, when communicating to an audience of senior citizens, EHRs
can be touted for their usefulness in managing medications and other components of a senior’s
care. For a younger audience, EHRs can provide consumers with access to their health history
and help them make more conscious decisions about eating better, exercising, and maintaining
overall health.
In concert with a targeted education component that deepens awareness and encourages
issue involvement, the frame will become more effective in influencing behavior change in the
form of EHR acceptance and engagement.
Aim to Increase Health and eHealth Literacy as Part of the Overall Strategy
When studying health motivation and ability, Moorman and Matulich (1993) included the
elements of health knowledge and health status as moderators to both concepts. Similar to issue
involvement within framing theory, health knowledge is the extent to which consumers have
existing schema related to health behaviors, therefore, making them more likely to process and
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accept cues to action for performing health maintenance behaviors (Moorman & Matulich,
1993). Consumers with high levels of health knowledge possess high health ability. When
presented with the appropriate motivation, which can be determined by employing the HBM or
Integrative Model, knowledgeable consumers will be most likely to perform preventive health
behaviors (Moorman & Matulich, 1993). In fact, following their general theory-testing approach,
the authors found that health knowledge alone was enough to facilitate preventive health
behaviors in the absence of sufficient motivating communications. These findings were also
consistent across a number of other theories are considered accepted within most health behavior
change models and framing theory.
Behavior change is not the only reason for the Consumer Consortium strategy to focus on
increasing health literacy. It has been reported on numerous occasions that health literate
individuals (and now eHealth literate individuals) create a more health conscious population. A
health literate public is made up of individuals who seek care earlier because they are able to
recognize warning signs, they comprehend and comply with provider instructions, they actively
seek health information on the Internet (and through EHRs can also manage their own health
information on the Internet), and are not afraid to ask questions (Parker, 2006). The new hightech healthcare environment has the potential to foster a culture of total health rather than one
that relies on health services for treatment. However, this all begins with appropriate education
and empowerment to inspire the intended transformation.
It is recommended that the Consortium include efforts to increase education and
awareness as keystones to the overarching communications strategy. All communication
materials should provide background information about the tools and resources available through
health IT. Increasing consumer awareness and education is central to the success of any
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widespread communication effort, especially when communicating a complex issue like health
IT.
Build the Strategy and Adaptable Messages Around Specific, Targeted Behaviors
Health communications, like any field of communication, requires specific research and
targeting prior to message development and delivery. In each health behavior change theory
explored in the Review, identification of a single, specific behavior to change or reinforce is
critical across all models. According to Fishbein and Cappella (2006) it is also critical to
recognize that the definition of a behavior involves several elements, including the action, the
target and the context. In order for communication to be effective, the elements of the behavior
must remain specific and consistent.
For instance, if the identified behavior is “consumer adoption of an EHR from a primary
health care provider,” the action is “adoption”, the target is “EHR” and the context is “from a
primary care provider.” With all research and subsequent communication, the developed strategy
must construct the elements to fit the targeted audience and ensure consistency in the
components across all communications. An underserved population, for example, may not have
access to a consistent primary care provider and, therefore, the identified context would not be
appropriate or effective in promoting behavior change. However, a mother of two children in a
suburban area most likely sees a primary care provider regularly and the context would be
appropriate in behavior change messages directed toward her.
It is recommended that the Consortium strategy identify specific behaviors and targets
around which to construct overarching messages. Messages should then be adapted by
Consortium members to suit the appropriate context for targeted audiences. Again, message
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sources should be instructed to maintain consistency in action, target, and context across all
communications within the campaign.
Present a Clear Cue to Action
As demonstrated through the exploration of the Health Belief Model, health
communications must target specific behaviors to change (i.e., encourage preventive health
behaviors) by focusing on specific individual-level psychological constructs, including perceived
susceptibility, perceived benefits and perceived barriers to completing the behavior change
(Rosenstock, 1974). However, it is important to note that even after necessary psychological
constructs have been satisfied, it is necessary for an audience to receive a cue to action to serve
as a motivator for behavior change. For example, if a communications effort seeks to encourage
vaccination for swine flu, the messages cannot focus solely on the threat of swine flu and the
benefits of the vaccine. The communications campaign must include the explicit statement of
what the audience should do, in other words go get vaccinated (Janz & Becker, 1984).
It is recommended that the Consortium include clear cues to action across all levels of the
communication strategy in terms of how the audience is being encouraged to engage with health
IT. For example, an overarching cue to action must call consumers to talk to their providers
about health IT or call consumers to learn more about health IT tools. While this may be a
common sense recommendation, it is often overlooked in large-scale communication campaigns,
which tend to rely on education and use of emotional appeals to communicate ideas or opinions,
yet lack a clear and obvious cue to action.
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Provide Instructions/Additional Information to Encourage Audiences to Act on the Cue
to Action
Based on the constructs of the Health Belief Model and other health behavior change
theories, it is imperative to account for barriers that could potentially prevent a targeted audience
from completing a desired health behavior. As a result, health behavior change messages must
include supplementary information along with the cue to action that will eliminate potential
barriers and give the targeted audience the self-efficacy needed to follow through on the cue to
action (Bandura, 1977). Self-efficacy is defined as “the conviction that one can successfully
execute the behavior required to produce the outcomes” (Bandura, 1977, p. 193).
This means that any cue to action must be accompanied by necessary instructions that can
assist a person with overcoming any barriers to successfully engaging in the desired preventive
health behavior. For example, if the desired behavior is for a consumer to utilize a mobile app to
remind them to take medication or visit their doctor, the messaging should also include
information about where to find and acquire the app as well as how to use it or information about
frequently asked questions. The idea of including supplementary information to increase selfefficacy ties in very closely with the behavioral element of context as described by Fishbein and
Cappella (2006).
Not all populations will require the same level of additional information with the cue to
action, depending on the perceived barriers that may exist. It is important that the instructions or
additional information align with the context and are appropriate for the targeted audience in
order for them to be effective.
It is recommended that the Consortium strategy outline the necessary components of an
effective cue to action, including additional information and instructions as required for different
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audiences. Again, it must be stressed that the overarching Consortium messages be adaptable for
various message disseminators in order for audiences to be targeted effectively.
Account for Third-Party Messengers
The Integrative Model as explored in the Review of Literature takes into account a
number of moderating factors that can influence audience members’ decisions in adoption of
certain health behaviors (Fishbein & Cappella, 2006). Unlike the Health Belief Model, which
only focuses on individual-level decision making, the Integrative Model considers environmental
factors, such as media exposure and social interactions as having the potential to encourage or
discourage the desired health behavior change. As a result, it is imperative that any health
communication effort account for additional messengers outside of those developing the
campaign. The communication strategy must include efforts designed to educate and train
members of the media and other third-party messengers to ensure that the overall message is
relayed clearly, consistently and in a manner that supports the intended efforts.
It is recommended that the Consortium incorporate a media and third-party training
program within the overall strategy that serves to provide necessary background information on
health IT and the efforts of the Consumer Consortium on eHealth to those who seek to report and
disseminate information independent of the Consortium. Such a program will ensure that all
information produced and provided outside the Consortium is relayed effectively and in
alignment with strategic messaging.
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LIMITATIONS
The Consumer Consortium on eHealth is intended to be a national grassroots effort to
empower and engage consumers in eHealth tools and resources. To that end, the work of the
Steering Committee is limited to creating a broad set of messages and strategic recommendations
that can be adapted among the various member organizations within the Consortium. Due to the
broad range of audiences that this initiative is seeking to reach, it is impossible for the Steering
Committee, for which the recommendations within this capstone are intended to serve, to create
individual-level strategies and delivery methods. Therefore, this capstone is limited to informing
a broad level communication strategy development effort rather than inform message delivery.
The recommendations in this capstone are also not intended to inform research and
audience targeting strategies. Again, due to the broad scope of the overall Consortium effort, it is
outside the capacity of the Steering Committee to perform the appropriate audience research in
order to propose community or organization-level tactics for the deployment of the overall
communication strategy. Therefore, this capstone remains limited to recommendations that are
intended to support the development of a high-level, theoretically grounded framework for
communications strategy.
SUGGESTIONS FOR FUTURE RESEARCH
In consideration of the limitations of this capstone, valuable information could be
attained through additional research on audience targeting and delivery methods, which could
serve to advise organization-level strategy deployment upon the adoption of the overarching
Consortium strategy. Such granular research should include work related to trusted messengers
for message delivery, including a review of literature based on opinion leaders and communityPage | 35
based communications campaigns. Information related to avenues for message delivery should
be sought, including the advantages and disadvantages between mediated versus interpersonal
communication tactics.
Research surrounding message adaptation will also be valuable for member organizations
once they begin adapting the proposed broad-level Consortium messages for their own
audiences. Again, audience research and targeting is a key to developing effective messages, but
it would be beneficial for organizations to determine how best to craft each message in order to
maintain the underlying theme or overarching message strategy agreed upon by the full
Consortium.
CONCLUSION
The first meeting of the Consumer Consortium on eHealth convened on April 26, 2011.
Over 80 representatives from across the health IT, healthcare, and consumer advocacy
communities were present and each echoed the importance of consumer engagement with health
IT as we reach this critical stage in the transformation of the U.S. healthcare system. Presenters
at the meeting stressed the timeliness and urgency of the Consortium effort and discussed how
collaboration and cooperation were the only ways for the proposed consumer outreach campaign
to be a success.
However, one of the most interesting outcomes of the meeting was hearing about
different communication strategies currently used by some of the organizations in attendance,
and realizing that most strategies were underpinned with theory, whether intentional or not. For
example, Ms. Ruth Perot from the National Health IT Collaborative for the Underserved
discussed the importance of seeking trusted messengers and tailoring messages for different
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underserved populations. She explained, for instance, that many older black men still have a high
level of trepidation when visiting their physicians due to the legacy left by the Tuskeegee
syphilis experiment conducted between 1932 and 1972. Therefore, it is critical that all
communication directed at that population be done so through avenues of trusted messengers
(i.e., community leaders, family members, influential colleagues) and with messaging tailored to
meet the needs and satisfy the concerns of that particular audience (Perot, 2011).
Education and health literacy were also recurring themes throughout the meeting with
most participants emphasizing the importance of educating consumers about the health IT tools
and resources available to them. Without education, it is difficult to connect with an audience
and move on to engaging them or calling them to some kind of action. Based on the past
experiences of most meeting participants, it was determined that providing information before
engaging in aggressive messaging campaigns made a larger impact on consumers than launching
a campaign without a focus on education and information. Again, whether intentional or not, it is
clear that communication theory had some influence on the development of previous consumer
outreach campaigns.
The meeting of the Consumer Consortium demonstrates the need for looking back at best
practices and accepted methods of communication in order to improve future efforts to have a
larger impact. Recognizing the importance of communication theory and understanding the
reasoning behind using education, targeting and tailored messages will also contribute to that
improvement and increased impact. Clearly, most theory is based in common sense and can help
guide communication strategy development down a path that is grounded in tested and
acceptable truths.
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This capstone project has sought to marry theory and practice in pursuit of the
development of a strong consumer-facing communications strategy in order to promote the use
of health IT for improved health and healthcare. By providing a comprehensive review of some
of the leading health behavior change theories, it is the hope of the author that this information
will serve to guide future discussions among the Consumer Consortium on eHealth and
encourage participants to understand why common sense practices, like segmenting audiences
and adapting messages, are used. By having a basic knowledge of the tested theories behind most
health communication campaigns, Consortium participants can build on those frameworks with
additional experiences in order to develop an overall strategy that is foundationally sound and
guided by accepted methods that have been tested and proven over many years.
Health IT has the power to transform the way Americans engage in and manage their
health. Similarly, health communication theory, when put into practice, has the power to
transform the way groups like the Consumer Consortium on eHealth think about and develop
communications strategies. By taking advantage of the breadth of knowledge and experience
provided by the theories explored in this capstone to support the Consortium strategy for
promoting consumer engagement in eHealth, the reach and impact of the effort is sure to meet
and surpass the levels of success expected.
Page | 38
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