Kent Nakamoto

Health literacy and patient empowerment in health communication: The importance of separating conjoined twins

OBJECTIVE Patient empowerment and health literacy have both been studied empirically, but they have hardly ever been explicitly linked. METHODS Pertinent literature from the development of both concepts was studied, drawing not only on health care literature, but also on management research. RESULTS This article argues that it is important to recognize that the concepts are distinct, both conceptually and empirically. At the same time, the impacts of health literacy and patient empowerment are deeply intertwined. High literacy does not necessarily entail empowerment and vice versa, and mismatches of the two can have deleterious consequences. High levels of health literacy without a corresponding high degree of patient empowerment creates an unnecessary dependence of patients on health professionals, while a high degree of empowerment without a corresponding degree of health literacy poses the risk of dangerous health choices. CONCLUSION We discuss the importance of carefully conceptualizing both approaches, the implications for their measurement and the design of health interventions. PRACTICE IMPLICATIONS Communication programs must include the empowerment that motivates consumers to engage and the literacy that enables them to make informed and reasoned choices.

Opioid Deaths in Rural Virginia: A Description of the High Prevalence of Accidental Fatalities Involving Prescribed Medications

In rural Virginia, drug overdose deaths increased 300% from 1997 to 2003. Polydrug deaths predominate (57.9%) in this review of 893 medical examiner cases. Prescription opioids (74.0%), antidepressants (49.0%), and benzodiazepines (39.3%) were more prevalent than illicit drugs. Two-thirds of decedents were 35-54 years old; 37% were female. When compared to western Virginia metropolitan cases, polydrug abuse was more common, specific medication combinations were found, the death rate per population was higher, and fewer illicit drugs were detected. These rural prescription overdose deaths differ from urban illicit drug deaths, suggesting the need for different strategies in prevention, treatment, and intervention by clinicians and policymakers.

The shielding effects of brand image against lower quality countries-of-origin in global manufacturing

Abstract Two studies are conducted, based on the framework of accessibility–diagnosticity and information integration. The goals of these studies are to examine the protective effects of brand image against lower quality countries-of-origin in global manufacturing. Study 1 shows that brands with high familiarity and high quality reputations (called strong brands hereafter) have much smaller perceived-quality discounting for lower quality countries-of-origin than brands with mediocre familiarity and mediocre quality reputations ( weak brands hereafter). Study 2, conducted with a different set of brands and consumers from a different country, shows similar shielding effects of brand image as found in Study 1. The findings of judgment-weight allocation of Study 2 strongly support the hypotheses of accessibility–diagnosticity and information integration, explaining why the shielding effects of brand image occur. The authors discuss implications of the findings, especially with regard to the global manufacturing/country-of-origin management, and the brand management for strong and weak brands.

Web site success metrics: addressing the duality of goals

T he Internet’s ascension from an obscure U.S. Department of Defense experiment to a cultural icon has been remarkable. In less than a decade, it has extended into nearly every facet of society, from commerce to education to gaming. As of August 2006, there were approximately 92 million Web sites [3]. With the sheer quantity of sites, evaluating their success has added importance, but determining appropriate metrics to measure success isn’t a trivial task. Previous research on Web site success has often taken the perspective of the user, more specifically looking at consumer adoption of e-commerce Web sites. However, Web sites will have various goals, and success is clearly linked to achieving these goals. In addition, users and Web site owners may have different goals as well, and unless there is convergence of these goals, success will be evaluated differently by the two parties. Since users view the organization through its Web site and the organization represents itself through its Web site, we argue that successful Web sites should be designed to address the multiple goals of the owner while taking into account the multiple audiences of the site. The better a site can help the convergence of the goals of the users and the owners, the more successful the site will be. These perspectives are captured in the following Web site success considerations:

The Effect of Social Support Features and Gamification on a Web-Based Intervention for Rheumatoid Arthritis Patients: Randomized Controlled Trial

Background Rheumatoid arthritis (RA) is chronic systematic disease that affects people during the most productive period of their lives. Web-based health interventions have been effective in many studies; however, there is little evidence and few studies showing the effectiveness of online social support and especially gamification on patients’ behavioral and health outcomes. Objective The aim of this study was to look into the effects of a Web-based intervention that included online social support features and gamification on physical activity, health care utilization, medication overuse, empowerment, and RA knowledge of RA patients. The effect of gamification on website use was also investigated. Methods We conducted a 5-arm parallel randomized controlled trial for RA patients in Ticino (Italian-speaking part of Switzerland). A total of 157 patients were recruited through brochures left with physicians and were randomly allocated to 1 of 4 experimental conditions with different types of access to online social support and gamification features and a control group that had no access to the website. Data were collected at 3 time points through questionnaires at baseline, posttest 2 months later, and at follow-up after another 2 months. Primary outcomes were physical activity, health care utilization, and medication overuse; secondary outcomes included empowerment and RA knowledge. All outcomes were self-reported. Intention-to-treat analysis was followed and multilevel linear mixed models were used to study the change of outcomes over time. Results The best-fit multilevel models (growth curve models) that described the change in the primary outcomes over the course of the intervention included time and empowerment as time-variant predictors. The growth curve analyses of experimental conditions were compared to the control group. Physical activity increased over time for patients having access to social support sections plus gaming (unstandardized beta coefficient [B]=3.39, P=.02). Health care utilization showed a significant decrease for patients accessing social support features (B=–0.41, P=.01) and patients accessing both social support features and gaming (B=–0.33, P=.03). Patients who had access to either social support sections or the gaming experience of the website gained more empowerment (B=2.59, P=.03; B=2.29, P=.05; respectively). Patients who were offered a gamified experience used the website more often than the ones without gaming (t 91=–2.41, P=.02; U=812, P=.02). Conclusions The Web-based intervention had a positive impact (more desirable outcomes) on intervention groups compared to the control group. Social support sections on the website decreased health care utilization and medication overuse and increased empowerment. Gamification alone or with social support increased physical activity and empowerment and decreased health care utilization. This study provides evidence demonstrating the potential positive effect of gamification and online social support on health and behavioral outcomes. Trial Registration International Standard Randomized Controlled Trial Number (ISRCTN): 57366516; http://www.controlled-trials. com/ISRCTN57366516 (Archived by webcite at http://www.webcitation.org/6PBvvAvvV).

Health literacy beyond knowledge and behaviour: letting the patient be a patient.

Health literacy is widely regarded as critical for managing personal health (Nutbeam and Kickbusch 2000; Schloman 2004; Andrus and Roth 2002) and is an important sociopolitical issue in that limited health literacy can result in enormous burdens to healthcare systems (Dubow 2004; DeBuono 2004). Lack of specific skills and knowledge associated with health literacy has been shown to negatively affect people’s understanding and use of information provided by health professionals. Much descriptive research has sought to elucidate the concept of health literacy, its measurement, and the problem of low health literacy. The term ‘‘health literacy’’ was first used by Simonds in the context of school health education. Simonds argued for the importance of students becoming as ‘‘literate’’ in health as they were in other disciplines (Ratzan 2001). This view crystallized an understanding of health literacy as ‘‘functional literacy’’, as exemplified by the American Medical Association report where health literacy is conceived as ‘‘the ability to read and comprehend prescription bottles, appointment slips, and the other essential health-related materials’’ (Ad hoc committee on health literacy for the counsel of scientific affairs. American Medical Association 1999). This functional approach to health literacy assumes epistemic objectivity; that is, reading skill and comprehension are objectively measurable. Certainly, deficiencies in reading and numeracy skills represent a major barrier to health education and management (Brown et al. 2003; Schloman 2004; Williams et al. 1995; Parker et al. 2003), and this has given rise to a large body of research on proposing tests for assessing literacy levels and strategies for improving the accessibility of materials such as patient education leaflets and informed-consent documents (Maag 2005). In recent years, however, an expanded view of health literacy has been motivated by evidence of an at best weak link between the ability to read and understand health communication and patients’ actual performance. This gap between functional skills and patient practice created the need to extend the definition of health literacy to include factors that can influence health decisions (Ratzan 2001; Kickbusch and Ratzan 2001; Cutilli 2005; Parker 2000; Nutbeam 2000; McCray 2005) as reflected in the WHO definition of health literacy as ‘‘the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health’’ (World Health Organization 1998). Some recent definitions of health literacy have expanded the concept to the point where literacy becomes the ability to make sound decisions in all domains; from home and the workplace to the political arena (Kickbusch et al. 2005). However, with these skill-based enrichments of the concept (especially in health promotion-oriented visions), health literacy has grown broader in extension but impoverished in its intension. Factors that extend the limited definition of functional literacy have been incorporated but, at the same time, have lost focus on the central link between the person’s goals and actions, reducing health literacy to a set of skills and taking for granted motivation and the meaning of ‘‘good health’’. S. Rubinelli (&) P. J. Schulz Institute of Communication and Health, University of Lugano, Via Buffi 13, 6904 Lugano (CH), Switzerland e-mail: sara.rubinelli@lu.unisi.ch

The Effects of Price Discount and Product Complementarity on Consumer Evaluations of Bundle Components

Existing research in bundling has primarily focused on consumer evaluations of a bundle as a whole. Drawing upon reference price theory and mental accounting theory, this paper investigates the effects of price discounts on consumer evaluations of the discounted product in a bundle. It examines how these effects interplay with complementarity of bundle components. The results of three experimental studies indicate that bundle price discounts hurt consumer evaluations of the discounted bundle component, and complementarity of bundle components attenuates these negative effects by altering a consumers selection of mental accounts in the evaluation process.

The Impact of Search Engine Selection and Sorting Criteria on Vaccination Beliefs and Attitudes: Two Experiments Manipulating Google Output

Background During the past 2 decades, the Internet has evolved to become a necessity in our daily lives. The selection and sorting algorithms of search engines exert tremendous influence over the global spread of information and other communication processes. Objective This study is concerned with demonstrating the influence of selection and sorting/ranking criteria operating in search engines on users’ knowledge, beliefs, and attitudes of websites about vaccination. In particular, it is to compare the effects of search engines that deliver websites emphasizing on the pro side of vaccination with those focusing on the con side and with normal Google as a control group. Method We conducted 2 online experiments using manipulated search engines. A pilot study was to verify the existence of dangerous health literacy in connection with searching and using health information on the Internet by exploring the effect of 2 manipulated search engines that yielded either pro or con vaccination sites only, with a group receiving normal Google as control. A pre-post test design was used; participants were American marketing students enrolled in a study-abroad program in Lugano, Switzerland. The second experiment manipulated the search engine by applying different ratios of con versus pro vaccination webpages displayed in the search results. Participants were recruited from Amazon’s Mechanical Turk platform where it was published as a human intelligence task (HIT). Results Both experiments showed knowledge highest in the group offered only pro vaccination sites (Z=–2.088, P=.03; Kruskal-Wallis H test [H5]=11.30, P=.04). They acknowledged the importance/benefits (Z=–2.326, P=.02; H5=11.34, P=.04) and effectiveness (Z=–2.230, P=.03) of vaccination more, whereas groups offered antivaccination sites only showed increased concern about effects (Z=–2.582, P=.01; H5=16.88, P=.005) and harmful health outcomes (Z=–2.200, P=.02) of vaccination. Normal Google users perceived information quality to be positive despite a small effect on knowledge and a negative effect on their beliefs and attitudes toward vaccination and willingness to recommend the information (χ2 5=14.1, P=.01). More exposure to antivaccination websites lowered participants’ knowledge (J=4783.5, z=−2.142, P=.03) increased their fear of side effects (J=6496, z=2.724, P=.006), and lowered their acknowledgment of benefits (J=4805, z=–2.067, P=.03). Conclusion The selection and sorting/ranking criteria of search engines play a vital role in online health information seeking. Search engines delivering websites containing credible and evidence-based medical information impact positively Internet users seeking health information. Whereas sites retrieved by biased search engines create some opinion change in users. These effects are apparently independent of users’ site credibility and evaluation judgments. Users are affected beneficially or detrimentally but are unaware, suggesting they are not consciously perceptive of indicators that steer them toward the credible sources or away from the dangerous ones. In this sense, the online health information seeker is flying blind.

Prescription Drug Abuse Among Prisoners in Rural Southwestern Virginia

Abstract Non-medical use of prescription medications is on the rise across the U.S., particularly in rural areas. In this study of 233 prisoners and probationers in southwestern Virginia, we add to an emerging profile of individuals abusing prescription medications. In this retrospective review of 2000-2004 augmented Addiction Severity Index data, those abusing prescription medications reported increased illicit drug and alcohol abuse, poly-drug abuse, psychiatric problems, and arrests for property crimes. Forty percent reported abuse of OxyContin®, a drug implicated in a number of deaths in this region. Compared to non-users, OxyContin® users were younger, more likely to be female, and more likely to abuse benzodiazepines, methadone, cocaine, and heroin. Longevity of abuse of these other drugs belies suggestions that OxyContin® was acting as a “gateway” drug leading naïve users into addiction and risk of death.

Alternatives to information processing in consumer research New perspectives on old controversies

Abstract The proposition advanced by Zajonc (1980) that affect is somehow separate from cognition has sparked heated debate over the place of these factors in consumer judgment. It seems, however, that the controversy is symptomatic of broader concerns surrounding the origins of consumer preference. Motivating many of these concerns are the limitations of the traditional information processing approach in explaining the control of judgment processes. It is noted that this issue is a venerable one, and that current thinking on the issue reflects views espoused a century ago. However, recent research on cognitive schemas, attention and automaticity, as well as studies of affective constructs can contribute to a richer understanding of the organization and expression of consumer preferences.