Scott C. Ratzan

Addressing the vaccine confidence gap.

Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK (H J Larson PhD); Department of Paediatrics, College of Physicians and Surgeons, Columbia University, New York, NY, USA (Prof L Z Cooper MD); National Institute for Health and Welfare (THL), Helsinki, Finland (J Eskola MD); Department of Paediatrics, Duke University, Durham, NC, USA (Prof S L Katz MD); Government Aff airs and Policy, Johnson & Johnson, New Brunswick, NJ, USA; (S Ratzan MD); and Journal New Decade of Vaccines 5Vaccines--often lauded as one of the greatest public health interventions--are losing public confidence. Some vaccine experts have referred to this decline in confidence as a crisis. We discuss some of the characteristics of the changing global environment that are contributing to increased public questioning of vaccines, and outline some of the specific determinants of public trust. Public decision making related to vaccine acceptance is neither driven by scientific nor economic evidence alone, but is also driven by a mix of psychological, sociocultural, and political factors, all of which need to be understood and taken into account by policy and other decision makers. Public trust in vaccines is highly variable and building trust depends on understanding perceptions of vaccines and vaccine risks, historical experiences, religious or political affiliations, and socioeconomic status. Although provision of accurate, scientifically based evidence on the risk-benefit ratios of vaccines is crucial, it is not enough to redress the gap between current levels of public confidence in vaccines and levels of trust needed to ensure adequate and sustained vaccine coverage. We call for more research not just on individual determinants of public trust, but on what mix of factors are most likely to sustain public trust. The vaccine community demands rigorous evidence on vaccine efficacy and safety and technical and operational feasibility when introducing a new vaccine, but has been negligent in demanding equally rigorous research to understand the psychological, social, and political factors that affect public trust in vaccines.

Health Literacy: A Second Decade of Distinction for Americans

Efforts to describe health literacy in the last decade have helped us define the issue and recognize that our publics skills and abilities are not adequate for successfully navigating the growing demands and complexity of healthcare. There have been significant developments in health literacy over the last decade, with milestones of progress. Much of the work done in the 1990s focused on defining health literacy, initially measuring its prevalence and subsequently looking at its associations. Since then, health literacy has grown from an issue of an under-recognized “silent epidemic” to an issue of health policy and reform. Ideas and objectives proposed have actually been adopted in recent years, with significant policy developments. This article recognizes many achievements and milestones while developing recommendations for implementation in the decade ahead.

Text4baby: Development and Implementation of a National Text Messaging Health Information Service

Text4baby is the first free national health text messaging service in the United States that aims to provide timely information to pregnant women and new mothers to help them improve their health and the health of their babies. Here we describe the development of the text messages and the large public-private partnership that led to the national launch of the service in 2010. Promotion at the local, state, and national levels produced rapid uptake across the United States. More than 320,000 people enrolled with text4baby between February 2010 and March 2012. Further evaluations of the effectiveness of the service are ongoing; however, important lessons can be learned from its development and uptake.

Health Literacy—Identification and Response

The term ‘‘health literacy’’ has now permeated the public health lexicon. The 2006 U.S. National Assessment of Adult Literacy (NAAL) is the first national survey to employ assessment tasks conducted specifically to measure the health literacy of adults living in the United States. These landmark data provide results on the scope of overall literacy and health literacy in America with a survey of over 19,000 U.S. adults. The health literacy scale and health literacy tasks were guided by the definition of health literacy accepted by the U.S. Institute of Medicine and Healthy People 2010 that states that health literacy is: ‘‘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; Ratzan & Parker, 2000; Institute of Medicine, 2004). Similarly, across the Atlantic, the UK government also embraced the U.S. definition. The UK Committee on Safety of Medicines highlighted this concept is a useful tool in identifying problems in communicating health information and enabling people to use that information to make health decisions. They further emphasized a component they called medication literacy, referring to the range of skills needed to access, understand and act on medicines information (Medicines and Healthcare Products Regulatory Agency, 2005). The most recent U.S. study employed a scale of 0 to 500 for overall literacy and for health literacy, and categorized skills in four performance levels: Below Basic, Basic, Intermediate, and Proficient. Official reports of the health literacy survey emphasized that the majority of adults (53%) had Intermediate health literacy. About 22% had Basic and 14% had Below Basic health literacy. The complete report is available at http:==nces.ed.gov=pubs2006=2006483.pdf. Additionally, adults in the oldest age group—65 and older—had lower average health literacy than adults in younger age groups. Adults ages 25 to 39 had higher average health literacy than adults in other age groups.

Misled and confused? Telling the public about MMR vaccine safety

The extraordinary events surrounding the measles, mumps, and rubella (MMR) vaccine in the United Kingdom have not only placed in jeopardy the use of this triple vaccine but have also spread concern to other parts of the world. Examination of the public’s worry about MMR vaccine reveals they have been exposed to a range of conflicting views resulting in the feeling of having been misled about the safety of the vaccine. There are various groups and individuals who have legitimate roles in informing the public about such subjects. But is each one behaving in an ethically responsible way? And if confidence falters, vaccine coverage dips, and an outbreak of measles, mumps, or rubella ensues, who, if anyone, will stand and say “I misled them, I confused them, this is my responsibility”? We examine the ethical issues of each group with a voice in the debate about vaccine safety.

Public-private partnerships for health.

The twenty-first century heralds most health and social services predominately provided and financed directly by government. In recent years given the fact that health commands an ever-growing proportion of the GDP, however, governments and other stakeholders have looked to share the administrative, financial, and implementation burden. Moreover, the challenges to deliver health services at a high level of efficiency and quality place the current systems at risk. Globally, as well as in many countries, governments are turning to the private sector to ‘‘partner’’ in the development of innovative solutions for the advancement of health. This idea of a public–private partnership (PPP or P3) is an approach in which the resources of interested stakeholders from the public and private sector (e.g., governmental authorities, nongovernmental organizations, and private entities) are combined to advance research, develop products, or provide services to attain a mutually agreed-upon goal. In November 2002 the World Health Oganization further weighed in, suggesting the way to improve health in developing countries could be with such ‘‘partnerships among communities, civil societies, the private sector and government.’’ While this idea is not new, it nonetheless has grown in application in recent years. The Initiative on Public–Private Partnerships for Health has identified 90 PPPs in health from 1974 to 2003. Yet, before 1990, the term ‘‘public–private partnership’’ rarely appeared in articles abstracted by PubMed; the number currently is projected to be more than 30 per year. Many of the most visible PPPs are globally designed, with different partners to address public health challenges. Some have developed into the largest organizations on their own such as The Global Fund to Fight AIDS, Tuberculosis & Malaria, a Geneva-based UN-connected organization, established in 2002 to dramatically upscale global financing of interventions against the three pandemics. The Global Alliance for Vaccines and Immunization (GAVI) is three-quarters financed by the Bill and Melinda Gates Foundation. The Drugs for Neglected Disease Initiative was founded in 2003 by Médecins Sans Frontières and five public-sector research organizations—Kenya Medical Research Institute, Indian Council of Medical Research, Malaysian Ministry of Health, Oswaldo Cruz Foundation in Brazil, and France’s Institut Pasteur. Other development agencies have catalyzed the formation of PPPs. For example, USAID supported PPPs that promote handwashing with soap and implement largescale handwashing interventions and use lessons to promote the approach at a global

Measurement and Evaluation Outcomes for mHealth Communication: Don't We Have an App for That?

mHealth investors implementers and evaluators share a common challenge to articulate a strategy that will maintain enthusiasm in the field while right-sizing expectations and re-envisioning success. A successful strategy will need to envision the development of thousands of locally relevant interventions of modest impact rather than simply rely on the eventual emergence of a limited number of high-impact global interventions capable of carrying the field. The unanswered question remains not if but rather how fast and how efficiently mHealth will realize its transformative potential. Innovation and evaluation in synergy can help to drive that transformation -- safeguarding evidence-based interventions from being upended by the unsubstantiated anecdote while enabling the innovation process to change the status quo. (Excerpt)

The status and scope of health communication.

We examine the field of health communication with a multimethodological analysis, presenting a brief historical synopsis of the academic literature as well as the results of a survey administered to academicians who identified communication and health to be major fields of interest. After this descriptive backdrop of health communication, we offer a prescription for an ideal health communicator--that is, one with an interdisciplinary background--to use ethical, persuasive means to craft, deliver, and evaluate campaigns that promote good health and disease prevention; to plan, influence, and implement health policy; and to employ ethical decision making that will enhance the quality of life for individuals and communities throughout the globe.

Our New “Social” Communication Age in Health

In 1962, the noted Communications scholar Marshall McLuhan proclaimed: ‘‘We are today as far into the electric age as the Elizabethans had advanced into the typographical and mechanical age. And we are experiencing the same confusions and indecisions which they had felt when living simultaneously in two contrasted forms of society and experience’’ (quoted in Gleick, 2011). Were he still alive, Marshall McLuhan would have turned 100 earlier this year. It would have been interesting to hear how he viewed the past decade with the explosion of the Internet and the use of telephones. This past decade was witness to unparalleled change as less than half of the people in the world had ever made a phone call at the turn of the century; today over half have access to a mobile phone device. New communication forms have emerged. Broadband with camera phones, new terms, and multibillion dollar industries in what is referred to as the social media space—blogs, Facebook, Twitter, YouTube, LinkedIn, to name a few. These all have different reach and connectivity, adding diversity, opinions, partisanship, opinions, ‘‘facts,’’ and transitions to our modern day media. Furthermore, search engines on the Internet have developed since the formation of Google in 1998. Google applied some of their acumen to health communication a decade later as they created an early warning system for flu that apparently discovered an outbreak a week before the Centers for Disease Control and Prevention identified it through traditional epidemiological and reporting networks. Bing, a rival search engine supported by Microsoft, also is looking for applications in health to apply specialized technology of consumers looking for information on chronic disease such as diabetes linking articles, Twitter feeds, and expert advice into a single search response. There is a great opportunity to leverage these new communication technologies and tools in this era of convergence with social media. Interactive voice and video, linkage of Twitter with voice (speak to tweet), texting with SMS (short message service), linking location-based service applications (e.g., Loopt and Foursquare), and developing smartphone applications for linking health with mobile communication in disease prevention, wellness, and alerts all enhance our abilities for effective health communication.

Health Literacy: Making a Difference in the USA

While there has been much talk by the new administration about education and health there has been little discussion of how to strategically approach such challenges across departments. We would like to propose health literacy as a unique opportunit y for the Department of Health and Human Services and the Department of Education to join with the private and the voluntary sector to cooperate for maximal impact. Two of the most important issues for Americans are better education and better health care. If one links bothÐquality health services and educational imperativesÐthere will be a great return on investment. There is still little awareness of the impact that low levels of literacy have on the health of America: the economic cost to the nation’s health bill has been estimated to be over