The impact of health communication on health‐related decision making: A review of evidence

Clearing the air: evaluating institutions' social media health messaging on wildfire and smoke risks in the US Pacific Northwest

BACKGROUND

Wildfire smoke contributes substantially to the global disease burden and is a major cause of air pollution in the US states of Oregon and Washington. Climate change is expected to bring more wildfires to this region. Social media is a popular platform for health promotion and a need exists for effective communication about smoke risks and mitigation measures to educate citizens and safeguard public health.

METHODS

Using a sample of 1,287 Tweets from 2022, we aimed to analyze temporal Tweeting patterns in relation to potential smoke exposure and evaluate and compare institutions' use of social media communication best practices which include (i) encouraging adoption of smoke-protective actions; (ii) leveraging numeric, verbal, and Air Quality Index risk information; and (iii) promoting community-building. Tweets were characterized using keyword searches and the Linguistic Inquiry and Word Count (LIWC) software. Descriptive and inferential statistics were carried out.

RESULTS

44% of Tweets in our sample were authored between January-August 2022, prior to peak wildfire smoke levels, whereas 54% of Tweets were authored during the two-month peak in smoke (September-October). Institutional accounts used Twitter (or X) to encourage the adoption of smoke-related protective actions (82% of Tweets), more than they used it to disseminate wildfire smoke risk information (25%) or promote community-building (47%). Only 10% of Tweets discussed populations vulnerable to wildfire smoke health effects, and 14% mentioned smoke mitigation measures. Tweets from Washington-based accounts used significantly more verbal and numeric risk information to discuss wildfire smoke than Oregon-based accounts (p = 0.042 and p = 0.003, respectively); however, Tweets from Oregon-based accounts on average contained a higher percentage of words associated with community-building language (p < 0.001).

CONCLUSIONS

This research provides practical recommendations for public health practitioners and researchers communicating wildfire smoke risks on social media. As exposures to wildfire smoke rise due to climate change, reducing the environmental disease burden requires health officials to leverage popular communication platforms, distribute necessary health-related messaging rapidly, and get the message right. Timely, evidence-based, and theory-driven messaging is critical for educating and empowering individuals to make informed decisions about protecting themselves from harmful exposures. Thus, proactive and sustained communications about wildfire smoke should be prioritized even during wildfire "off-seasons."

Unpacking the influencing factors of telehealth usage among older consumers

This research unpacks the challenges and motivations of telehealth usage among older consumers-an understudied population in the extant telehealth literature. Through surveying a sample of older consumers who regularly migrate to winter in the southern areas of the United States, our qualitative analysis uncovers motivations (i.e., convenience, ease of use, efficiency, and a forced option) and challenges (i.e., telehealth limitations, privacy concerns, and lack of trust, access, and skills) of older consumers' telehealth usage. Furthermore, logistic regression identifies attitude toward telehealth, gender, and health status as significant predictors of telehealth usage behavior. Contributions to theory and practice are also discussed.

Analysis of government agencies and stakeholders’ twitter communications during the first surge of COVID-19 in Brazil

BACKGROUND: Official authorities are in charge of communicating with the public in a consistent and coherent manner. The impact of social media on managing the coronavirus 2019 (COVID-19) pandemic potentially influenced social behavior in Brazil. OBJECTIVE: Using Twitter, this study analyzes communications about the COVID-19 pandemic from official agencies of the Brazilian government and key public sector decision-makers. METHOD: We captured public Twitter messages about COVID-19 exchanged between authorities at the federal, state, and municipal levels of government. These messages were further classified into guidance and information messages or disinformation messages. Finally, through analysis of tweets and their frequency, we evidenced the level of information generated by the three levels of government. RESULTS: Our analyses show an underestimation of the magnitude of the pandemic by Brazilian government authorities. None of the spheres of government anticipated the imminent health crisis, did not issue good recommendations and guidelines, and did not take preventive actions. CONCLUSION: The lack of governmental actions and adequate guidance in Brazil has led to an explosive increase in infected people and deaths. Surprisingly, this was not due to technical or structural reasons. It resulted from conflicting communication strategies implemented by the federal, state, and municipal governments in attempts to minimize the effects of COVID-19 on their local health structures.

Overconfidence in Managing Health Concerns: The Dunning-Kruger Effect and Health Literacy

Health literacy is often low within the general population. The Dunning–Kruger effect (DKE) suggests that individuals may experience a cognitive bias in which they overestimate their own knowledge base. This study examines the DKE regarding health literacy and health behaviors. A community sample (n = 504) completed questionnaires measuring objective health literacy, confidence in health knowledge, and health behaviors and medical conditions. Results support the presence of a DKE for health literacy; individuals with low health literacy reported equal or greater confidence in health knowledge than individuals with higher health literacy. Individuals with lower health literacy reported more problematic engagement in health behaviors. Low health literacy can impact engagement in health behavior and effect health outcomes, but individuals may not realize this deficit. Implications for clinical intervention include the need to address cognitive bias and enhance motivation to participate in health literacy interventions.

Has public health messaging during the COVID-19 pandemic reflected local risks to health?: A content analysis of tweeting practices across Canadian geographies

During the COVID-19 pandemic, public health agencies and decision-makers have used social media to disseminate information, encourage changes to behaviour and promote community supports and resources. Their communications have served to educate the public on risks and initiate the widespread adoption of public health measures to 'flatten the curve'. We conducted a content analysis of COVID-19 Tweets by Canadian public health accounts during the first 6 months of the pandemic to explore differences in Tweeting practices by geography and identify opportunities to improve risk communication. We found that Canadian public health accounts in particular geographic settings did not always apply best practices for health communication. Tweeting practices differed considerably between jurisdictions with varying burdens of COVID-19. Going forward, Tweets authored by public health accounts that promote behaviour change and community-building ought to be utilized whenever risks to health are high to reflect an increase in disease transmission requiring intervention. Our study highlights the need for public health communicators to deliver messaging that is relevant for the levels of risk that their audiences are encountering in a given geographic context.

DECIDE: A Decision-Making Model for More Effective Decision Making by Health Care Managers

The purpose of this article is to describe a step-by-step process for decision making, and a model is developed to aid health care managers in making more quality decisions, which ultimately determines the success of organizations. The DECIDE model is the acronym of 6 particular activities needed in the decision-making process: (1) D = define the problem, (2) E = establish the criteria, (3) C = consider all the alternatives, (4) I = identify the best alternative, (5) D = develop and implement a plan of action, and (6) E = evaluate and monitor the solution and feedback when necessary. The DECIDE model is intended as a resource for health care managers when applying the crucial components of decision making, and it enables managers to improve their decision-making skills, which leads to more effective decisions.

Patients' Experiences of Cardiovascular Health Education and Risk Communication: A Qualitative Synthesis

Coronary heart disease (CHD) has no cure, and patients with myocardial infarction are at high risk for further cardiac events. Health education is a key driver for patients' understanding and motivation for lifestyle change, but little is known about patients' experience of such education. In this review, we aimed to explore how patients with CHD experience health education and in particular risk communication. A total of 2,221 articles were identified through a systematic search in five databases. 40 articles were included and synthesized using thematic analysis. Findings show that both "what" was communicated, and "the way" it was communicated, had the potential to influence patients' engagement with lifestyle changes. Communication about the potential of lifestyle change to reduce future risk was largely missing causing uncertainty, anxiety, and, for some, disengagement with lifestyle change. Recommendations for ways to improve health education and risk communication are discussed to inform international practice.

Parental Reports of Lunch-Packing Behaviours Lack Accuracy: Reported Barriers and Facilitators to Packing School Lunches

PURPOSE

Parents influence the foods their children consume and often provide proxy reports of this intake. One way parents exert this influence is by providing home-packed lunches. This study compared parental reports of foods packed in children's lunches with what was actually packed and identified parental barriers and facilitators to packing lunches.

METHODS

Grade 3 and 4 student-parent dyads (n = 321) in 19 elementary schools in Ontario participated. Parental reports and actual packed lunch contents were collected via self-administered surveys and direct observation, respectively. Parental barriers and facilitators were obtained through open and closed survey questions.

RESULTS

Median portions packed were significantly higher for sugar-sweetened beverages and snacks and significantly lower for fruits, fruit juice, vegetables, milk/alternatives, and meat/alternatives than parents reported. Packing a healthy lunch was "important/very important/of the utmost importance" for 95.9% of respondents, and 97.5% perceived their nutrition knowledge as "adequate/good/very good". Barriers to packing a lunch included: child's food preferences, time, finances, allergy policies, and food safety. Nutrition resources, observing other children's lunches, child's input, and planning ahead were identified as facilitators.

CONCLUSIONS

Strategies to improve packed lunches should move beyond parental nutrition knowledge and importance of lunch packing to address parental barriers and facilitators.

A qualitative study exploring the difficulties influencing decision making at the end of life for people with dementia

Background

Dementia is a progressive neurodegenerative condition characterized by declining functional and cognitive abilities. The quality of end of life care for people with dementia in the UK can be poor. Several difficult decisions may arise at the end of life, relating to the care of the person with dementia, for example management of comorbidities.

Objective

To explore difficulties in decision making for practitioners and family carers at the end of life for people with dementia.

Design

Qualitative methodology using focus groups and semi‐structured interviews and thematic analysis methods.

Settings and participants

Former (n=4) and current (n=6) family carers of people with experience of end of life care for a person with dementia were recruited from an English dementia voluntary group in 2015. A further 24 health and care professionals were purposively sampled to include a broad range of expertise and experience in dementia end of life care.

Results

Four key themes were identified as follows: challenges of delivering coherent care in dynamic systems; uncertainty amongst decision makers; internal and external conflict amongst decision makers; and a lack of preparedness for the end of life. Overarching difficulties such as poor communication, uncertainty and conflict about the needs of the person with dementia as well as the decision maker's own role can characterize decision making at the end of life.

Conclusions

This study suggests that decision making at the end of life for people with dementia has the potential to be improved. More planning earlier in the course of dementia with an on‐going approach to conversation may increase preparedness and family carers’ expectations of end of life.

Explaining the causal links between illness management and symptom reduction: Development of an evidence-based patient education strategy

OBJECTIVE

To determine whether explaining the causal links between illness management and symptom reduction would help younger and older adults learn and apply health information.

METHOD

Ninety younger and 51 older adults read about a fictitious disease with or without explanations about the cause-and-effects (causal information) of illness management. A knowledge test (applied vs. factual items) was administered immediately and 1-week following the presentation of health booklets. Reading comprehension, working memory and health literacy were assessed as covariate variables.

RESULTS

Younger adults outperformed older individuals on the applied and factual items at both time points. After controlling for covariates, causal information facilitated the comprehension and application of health information for younger but not older adults. Reading comprehension was the best predictor of test performance in the older sample.

CONCLUSIONS

Providing an explanation of why illness management is effective for reducing symptomatology can help improve knowledge and application of health information for younger individuals. For older adults, lowering the verbal demands of patient education materials may be a better way to help them learn new health information.

PRACTICE IMPLICATIONS

Use of causal information as a teaching strategy in patient education may enhance individuals' ability to learn about and implement self-care strategies.

Providing feedback to service customers

Purpose

In services, customers’ successful performance of expected roles is critical to ensuring successful service outcomes. To help customers perform their roles better, service providers offer them feedback on their performance. To improve the design of customer feedback that contains both positive and negative messages, the purpose of this paper is to examine the order and the repetition effect of feedback message types on customer feedback satisfaction, motivation, and compliance intention, focusing on the moderating effect of customer involvement level. This paper also examines whether feedback satisfaction and motivation mediate the moderation effect of the order or repetition of feedback message type and customer involvement level on compliance intention.

Design/methodology/approach

This study employs two between-subject quasi-experimental designs: 2 (feedback message order: positive message first vs negative message first) × 2 (involvement level: high vs low) and a 2 (repeated feedback type: positive vs negative) × 2 (involvement level: high vs low). Data collection occurred through an online survey using eight health checkup scenarios. Hypotheses were tested by using MANOVA and PROCESS.

Findings

The customer involvement level moderated the effect of the presentation order of feedback message type on customer responses. With highly involved customers, offering positive feedback initially produced responses that were more favorable. With customers with low involvement, the order did not matter. The effects of feedback satisfaction and motivation as mediators in the effect of order on compliance intention were significant only with highly involved customers. The mediation effect of motivation was much stronger than that of feedback satisfaction. The repetition of a particular feedback type took effect only with customers with low-involvement level. Compared to the no-repetition condition (positive-negative), when positive feedback was repeated (positive-negative-positive), motivation increased. Compared to the no-repetition condition (negative-positive), when negative feedback was repeated (negative-positive-negative), feedback satisfaction and compliance intention decreased. In terms of mediating effect, only feedback satisfaction was a meaningful mediator and only when negative feedback was repeated to low-involvement customers.

Originality/value

This study contributes to research by extending feedback studies in services to include a consideration of the order and repetition of feedback message types as design variables; it contributes practically by suggesting how to design feedback for better customer responses such as feedback satisfaction, motivation, and compliance intention.

Muslim immigrant women's views on cervical cancer screening and HPV self-sampling in Ontario, Canada

Background

Canada has observed significant decreases in incidence and mortality of cervical cancer in recent decades, and this has been attributed to appropriate screening (i.e., the Pap test). However, certain subgroups including Muslim immigrants show higher rates of cervical cancer mortality despite their lower incidence. Low levels of screening have been attributed to such barriers as lack of a family physician, inconvenient clinic hours, having a male physician, and cultural barriers (e.g., modesty, language). HPV self –sampling helps to alleviate many of these barriers. However, little is known about the acceptability of this evidence-based strategy among Muslim women. This study explored Muslim immigrant women’s views on cervical cancer screening and the acceptability of HPV self-sampling.

Methods

An exploratory community-based mixed methods design was used. A convenience sample of 30 women was recruited over a 3-month period (June–August 2015) in the Greater Toronto Area. All were between 21 and 69 years old, foreign-born, self-identified as Muslim, and had good knowledge of English. Data were collected through focus groups.

Results

This study provides critical insights about the importance of religious and cultural beliefs in shaping the daily and health care experiences of Muslim women and their cancer screening decisions. Our study showed the deterring impact of beliefs and health practices in home countries on Muslim immigrant women’s utilization of screening services. Limited knowledge about cervical cancer and screening guidelines and need for provision of culturally appropriate sexual health information were emphasized. The results revealed that HPV self-sampling provides a favorable alternative model of care to the traditional provider-administered Pap testing for this population.

Conclusion

To enhance Muslim immigrant women screening uptake, efforts should made to increase 1) their knowledge of the Canadian health care system and preventive services at the time of entry to Canada, and 2) access to culturally sensitive education programs, female health professionals, and alternative modes of screening like HPV self-sampling. Health professionals need to take an active role in offering screening during health encounters, be educated about sexual health communication with minority women, and be aware of the detrimental impact of preconceived assumptions about sexual activity of Muslim women.

Applying health communications to mental illness stigma change

Purpose

– Advocates and researchers have made mental illness stigma elimination a public health priority. Research on stigma change strategies has highlighted programmatic delivery strengths; however, an area in need of further development is in messaging capable of attaining specific behavior change. The paper aims to discuss these issues.

Design/methodology/approach

– Change goals were incorporated into an existing model of stigma change to propose the TLC4 model (Targeted, Local, Credible, Continuous, Contact, Change Goals). This paper reviews health communications literature regarding tailored messaging, applying these principles to stigma change programs to enhance behavioral impact.

Findings

– Tailored messages comprises four elements: capturing and maintaining attention, actively thinking about information, having emotional appeal, and making material relevant to each person. Incorporation of these elements enhances the likelihood of an individual making a behavior change.

Originality/value

– This review can guide facilitators of stigma change programs to craft presentations with tailored messages in directive call-to-actions. Future directions for evaluation of message and behavioral change impact are discussed.

A focus group study on breast cancer risk presentation: one format does not fit all

Identifying a strategy that would optimize both the communication and understanding of the individual breast cancer risk remains a considerable challenge. This study explored the preferences of women with a family history of breast cancer about six presentation formats of individual breast cancer risk, as calculated from a risk prediction model. Thirty-four unaffected women attending genetic counseling because of a family history of breast cancer participated in six focus groups conducted in Québec City (2), Montréal (2) and Toronto (2), Canada. Six risk formats were presented for a fictitious case involving a 35-year-old woman (1-numerical: cumulative risk probabilities by age until 80 years; 2-risk curves: probabilities expressed in a risk curve that also provided a risk curve for a woman with no family history in first-degree relatives; 3-relative risk of breast cancer by age 80 years; 4 and 5-absolute risk of breast cancer and absolute chance of not developing breast cancer in the next 20 years; 6-qualitative: color-coded figure). Participants were asked to indicate their appreciation of each format. A group discussion followed during which participants commented on each format. The most and least appreciated formats were risk curves and relative risk, respectively. Overall, participants advocated the use of formats that combine quantitative, qualitative and visual features. Using a combination of approaches to communicate individual breast cancer risks could be associated with higher satisfaction of counselees. Given the increasing use of risk prediction models, it may be relevant to consider the preferences of both the counselee and the professional.

What e-patients want from the doctor-patient relationship: content analysis of posts on discussion boards

BACKGROUND

People with long-term conditions are encouraged to take control and ownership of managing their condition. Interactions between health care staff and patients become partnerships with sharing of expertise. This has changed the doctor-patient relationship and the division of roles and responsibilities that traditionally existed, but what each party expects from the other may not always be clear. Information that people with long-term conditions share on Internet discussion boards can provide useful insights into their expectations of health care staff. This paper reports on a small study about the expectations that people with a long-term condition (diabetes) have of their doctors using information gleaned from Internet discussion boards.

OBJECTIVE

The aim of this study was to ascertain what people with diabetes who use Internet discussion forums want from their doctors. The study objectives were to identify what people with diabetes (1) consider their role in condition management, (2) consider their doctor's role in managing their condition, (3) see as positive elements of their interactions with medical staff, and (4) find problematic in their interactions with medical staff.

METHODS

The study used qualitative methodology to explore the experiences, views, and perceptions of individuals participating on 4 Internet message boards. Posts made on the discussion boards were analyzed using the principles of qualitative content analysis. The meanings of sections of data were noted using codes that were developed inductively; those with similar codes were merged into subcategories and related subcategories were combined to form categories.

RESULTS

The key themes identified in the study were ownership of condition management, power issues between people with long-term conditions and doctors, and ways in which people seek to manage their doctors.

CONCLUSIONS

People with diabetes valued doctors who showed respect for them and their knowledge, and were willing to listen and openly discuss their options. Patients felt that they could and should take responsibility for and control of their day-to-day disease management. They saw doctors as having a role in this process, but when this was lacking, many people felt able to use alternative means to achieve their goal, although the doctor's function in terms of gatekeeping resources could create difficulties for them in this respect.

The health literacy skills framework

Although there are a variety of models and frameworks that describe factors that are associated with health literacy skills, few illustrate the full pathway from development and moderators of health literacy skills, their application, and the outcomes that result all in one framework or model. This article introduces the Health Literacy Skills conceptual framework that does encompass this full continuum. To develop the framework, the authors reviewed and built upon existing health literacy frameworks. The Health Literacy Skills framework hypothesizes the relations between health literacy and health-related outcomes and depicts how health literacy functions at the level of the individual. The framework also reflects how factors external to the individual (e.g., family, setting, community, culture, and media) influence the constructs and relations represented in the framework. The framework is organized into 4 primary components: (a) factors that influence the development and use of health literacy skills; (b) health-related stimuli; (c) health literacy skills needed to comprehend the stimulus and perform the task; and (d) mediators between health literacy and health outcomes. Previous theoretical frameworks lend support to the proposed causal pathways it illustrates. The authors hope this conceptual framework can serve as a springboard for further discussion and advancement in operationalizing this complex construct. The Health Literacy Skills framework could also be used to guide the development of interventions to improve health literacy. Future research should be conducted to fully test the relations in the framework.

Breast cancer and screening information needs and preferred communication medium among Iranian immigrant women in Toronto

Few studies have investigated what information women from minority immigrant groups need about breast cancer and screening. Nor has much research been conducted about how such women would prefer to receive this information. Mere translation of breast cancer and screening information from generic materials, without considering and respecting women's unique historical, political, and cultural experiences, is insufficient. This study explored breast cancer and screening information needs and preferred methods of communication among Iranian immigrant women. A convenience sample of 50 women was recruited and interviewed over a 4-month period (June-September 2008); all resided in Toronto Canada, and had no history of breast cancer. Tape-recorded interviews were transcribed and analysed using a thematic analysis technique. While generic breast health communication focusing on physiological risk information meets some of the needs of Iranian immigrant women, results showed that the needs of this group go beyond this basic information. This group is influenced by historical, sociopolitical, and cultural experiences pre- and post-immigration. Their experiences with chemical war, unsafe physical environment (air and water pollution), and their sociopolitical situation appear to have limited their access to accurate and reliable breast cancer and screening information in their homeland. Moreover, the behavioural and psychosocial changes they face after immigration appear to have a strong influence on their breast cancer and screening information needs. Considering their limited time due to their multiple demands post-migration, multi-media methods were highly preferred as a communication means by this group. The results of this study can be used to guide the design and implementation of culturally sensitive breast health information. For instance, video presentations conducted by a trusted Iranian healthcare professional focusing on socioculturally relevant breast cancer risk factors, symptoms, and screening methods, as well as a list of available breast health resources, could improve Iranian women's knowledge and uptake of breast health practices.

Healthcare quality and moderators of patient satisfaction: testing for causality

PURPOSE

The purpose of this article is to present a comprehensive structural equation based service quality and patient satisfaction model taking into account the patient's condition before and after discharge. The authors aim to test for causality in a sample of patients from United Arab Emirates public hospitals.

DESIGN/METHODOLOGY/APPROACH

Data were collected using questionnaires completed by adults discharged (n = 244) from UAE public hospitals. The proposed model consists of five main constructs. Three represent service quality: quality of care (four variables); process and administration (four variables) and information (four variables). There is also one construct that represents patient's status (two variables--health status before admission and after discharge). Finally, there is one construct that represents patient's satisfaction with care (two variables--general and relative satisfaction). Structural equation modeling and LISREL using maximum likelihood estimation was used to test hypothesized model(s)/parameters(s) derived deductively from the literature.

FINDINGS

The structural equation modeling representation provides a comprehensive picture that allows healthcare constructs and patient satisfaction causality to be tested. The goodness-of-fit statistics supported the healthcare quality-patient status-satisfaction model.

ORIGINALITY/VALUE

The model has been found to capture attributes that characterize healthcare quality in a developing country and could represent other modern healthcare systems. Also, it can be used to evaluate other healthcare practices from patients' viewpoints. The study highlights the importance of healthcare quality as patient satisfaction predictors by capturing other effects such as patient status.

Perceptions about collaborative decisions: perceived provider effectiveness among 2003 and 2007 Health Information National Trends Survey (HINTS) respondents

Patient-provider communication is an important element in cancer treatment and prevention. We examined the degree of concordance perceived to exist between the patient's preferences for inclusion in decision-making processes and their actual experiences among two population-based cohorts of U.S. adults with and without cancer histories who were surveyed in 2003 and 2007. Associations were examined between selected sociodemographic characteristics of respondents and the extent to which respondents perceived their health providers "always" involved them in decisions about their health to the extent desired. Data came from the Health Information National Trends Survey (HINTS), and SPSS and SAS-Callable SUDAAN statistical packages were used to analyze the data. Results showed a decrement in the proportion of favorable responses between 2003 and 2007. While there was no gender effect on the reported perceptions in either year, there was a significant effect of ethnicity (p = .001) in both years. Age, income, and employment were also independently associated (p = .001) in 2007. In contrast to 2003, higher education was significantly associated with communication satisfaction, as was having a cancer diagnosis, in 2007. There was a significant relationship between several sociodemographic variables and respondent perceptions about the consistency with which providers included patients as desired in decision-making. We conclude that communication between patient and provider remains suboptimal in cancer prevention and treatment.

Using the Colored Eco-Genetic Relationship Map with children

BACKGROUND

The Colored Eco-Genetic Relationship Map (CEGRM) is a hybridized assessment tool that combines the ecomap, the family genogram, and the genetic pedigree to produce a unique, participant-generated picture of an individual's social networks, information exchange patterns, and sources of support. To date, the CEGRM has been used successfully with adults, providing insights into their social networks and the communication patterns they use in the update and exchange of health-related information.

OBJECTIVE

To explore the feasibility and the utility of adapting elements of the CEGRM for use with children.

METHODS

Twenty children, 7 to 10 years of age, distributed by gender, socioeconomic status, and geographic heritage, participated in one-on-one sessions in which they created modified CEGRMs using adapted art directives. A qualitative descriptive design and approach to analysis were used.

RESULTS

Children were able to create a modified CEGRM, and resultant discussions provided considerable insights. A focused analysis revealed a kaleidoscope of social networks being accessed by today's children as well as surprising information exchange sources and patterns. Although all the children included one parent, family composition varied. Extended family, other adults, peers, and media sources were not only prevalent but also often preferred over the nuclear family as sources of health information. Of particular interest, mothers were rarely identified as children's primary source of health-related information.

DISCUSSION

Elements of the CEGRM are adapted easily for use with children using children's drawings and may prove to be an effective, adjunctive assessment and interventional tool for parents, researchers, educators, and providers working with young children.

Ethics and Patient Education: Health Literacy and Cultural Dilemmas

This article discusses health literacy and cultural factors that have implications for the ethical practice of health education. It specifically focuses on recent data that speaks to the challenges in carrying out patient education from the perspective of comprehension and equitable distribution of health-related information across diverse cultures and communities. It discusses strategies for reducing the negative impact of low health literacy among diverse groups and the importance of acknowledging this pervasive problem in the context of ensuring equity in the optimal delivery of health promotion messages.

Depression literacy among Chinese stroke survivors

OBJECTIVES

Mental health literacy is fundamental to the pursuit of health. Little is known about patients' literacy levels regarding depression even though it is common among elderly stroke survivors. This paper will report the level of mental health literacy and thematic constructs of depression interpreted by a group of stroke survivors.

METHOD

Qualitative data on patients' understanding of 'depression' in Chinese were translated and analyzed by an academic and a researcher separately to identify emerging constructs using a thematic approach. Out of 214 ischemic stroke older adults, aged 50+, 85 were able to explain the term in their own words after their first stroke attack.

RESULTS

The majority of stroke patients (60%, 129 out of 214) had never heard of depression and only four referred to it as a medical disease. Only a third would like to learn more about depression. Older Chinese adults depicted depression mainly by using words in the cognitive and affective domains, but the descriptors used were mostly non-specific and might not match the diagnostic criteria for depression or the commonly used screening tools.

CONCLUSION

Low mental health literacy among older patients indicated that much more work needs to be done in health promotion and education on depression literacy.

The ethics of information: absolute risk reduction and patient understanding of screening

Some experts have argued that patients should routinely be told the specific magnitude and absolute probability of potential risks and benefits of screening tests. This position is motivated by the idea that framing risk information in ways that are less precise violates the ethical principle of respect for autonomy and its application in informed consent or shared decision-making. In this Perspective, we consider a number of problems with this view that have not been adequately addressed. The most important challenges stem from the danger that patients will misunderstand the information or have irrational responses to it. Any initiative in this area should take such factors into account and should consider carefully how to apply the ethical principles of respect for autonomy and beneficence.

Ethics and Patient—Provider Communication

Effective health educator—client communication processes are a prerequisite to the acquisition and appropriate application of new knowledge, to discussions that focus on treatment risks and options, and to the mediation of (a) optimal self-management practices, (b) adherence to health recommendations, (c) client satisfaction, (d) autonomous, responsible decision making, and (e) provision of supportive and helpful advice. But is there room for improvement? To provide more uniform high-quality communications to all citizens and to support the practice principles embedded in the Health Education Code of Ethics, this article outlines results of the related literature, the authors' research, and a specific post hoc analysis of a national sample that strongly suggests that much more needs to be done to ensure health providers effectively communicate health promotion messages without bias in at least five related communication domains.