Sarah Goodwin

Kathi Ovnic
Holly Korschun
September 1, 1999

EMBARGOED FOR RELEASE until 4 p.m. E.S.T., Tuesday, Aug. 17, 1999


KEEP IT SIMPLE: Simple Health Messages Can Significantly Improve Health Behavior, including Doc/Patient Relationship, per JAMA Paper


Pneumonia vaccination rates increased five-fold among older, low-literacy adults when patients where given one-page handouts asking them to speak with their physician about the vaccine, report researchers from Emory University in this week's Journal of the American Medical Association.

"Ramifications of this study go far beyond the improved pneumococcal vaccination rates we observed," says first author Terry A. Jacobson, M.D., assistant professor of medicine at the Emory University School of Medicine. "We have demonstrated that glitzy, high-tech, bells and whistles and complex behavior change theory are not always necessary to inspire healthy behaviors. Reviving the communication basics of simplicity and clarity can produce dramatic results ­ and it can do so cost-effectively."

Dr. Jacobson emphasizes that for simple messages to work, they must be aimed at simple behavior changes; in this study, patients were asked to show their doctor the one-page handout or to ask their doctor about the pneumonia vaccine. A one-page sheet would not be appropriate, he says, for encouraging more complicated or difficult behaviors like quitting smoking or changing one's diet.

"People in health education are often afraid to target messages to lower literacy levels," he says. "But even literate patients want health messages to be clear to let them know what to do. People actually prefer simpler health messages, they're satisfied with them ­ and they work."

Another problem confounding attempts to simplify health messages is the misconception that even literate older adults are health literate. Dr. Jacobson says a much greater percentage of the elderly are low-literate or have lower reading skills than is often believed ­ and even among literate, educated older Americans, many do not clearly understand health information. The Atlanta team hopes to modify this health education tool to other health conditions, such as improving flu vaccine rates, and to other populations such as patients in managed care systems.

The current study was conducted under the auspices of the Pneumococcal Vaccine Intervention Project at Grady Health Systems. Mean age of the 318 study participants was 63 years, the majority (64.7 percent) had less than a high school education, 93 percent were African-American, nearly 70 percent were women and one quarter were uninsured. Participants all were patients visiting Grady Health System primary care clinics for primary care and were approached there by investigators if they had risk factors putting them at risk for pneumonia, such as being at least age 65 or having a chronic disease such as heart or lung disease, or diabetes.

About half the group (the intervention group) received a one-page handout written at a fifth-grade reading level, encouraging subjects to "ask your doctor about the pneumonia shot." The other half (control group) received a simply written one-page handout about nutrition. Patients who received the vaccine prompt were more than five times more likely to be vaccinated than the control subjects, and the odds subjects in the intervention group discussed the shot with their physicians were nearly four times that of control subjects.

"Given the relatively low prevalence of pneumococcal vaccination rates compared with that specified in Healthy People 2000, we advocate a collaborative or team approach to improve vaccination rates," the authors report. "Through chart review, nurses or allied health care personnel can communicate the need for vaccinations with physicians or patients. However, the message also should be reinforced through dialogue between the physician and an empowered patient who might be interested in other preventive services as well." Dr. Jacobson emphasizes that this type of tool "activates" elderly patients, who are traditionally passive in the health care setting, to get more involved with their care.

A message that encourages patients to talk to their doctors about the vaccine opens the door to other conversations. "And if we just showed the study subjects a video or other sophisticated educational modalities about the importance of the vaccine, few if any of them would have approached their physicians about it," he says. "Although it is commonly thought that video is more effective or preferred by patients, older patients do report preference for printed materials."

According to the authors, about 40,000 Americans die each year from infection by Streptococcus pneumoniae infection. Of recent concern to public health providers is the rise in pneumococcal strains resistant to the antibiotic penicillin. Only about half of the 60 percent of older patients are currently receiving the vaccine and vaccination rates are equally low among younger persons who are immune-compromised or who have other chronic diseases.

Dr. Jacobson's co-authors include Donna M. Thomas, M.P.H., and Susan Ray, M.D., assistant professor of medicine (infectious diseases) at the Emory University School of Medicine; Felicia James Morton, M.S.P.H., health educator at the Office of Health Promotion and Disease Prevention (directed by Dr. Jacobson) for Grady Health System; and Gardiner Offult, R.N., M.P.H., and Jennifer Shevlin, M.S.P.H., Atlanta Veterans Affairs Medical Center. In addition, Ms. Thomas, Ms. Offult and Dr. Ray are supported by the Georgia Emerging Infections Program.

The research was funded in part by a grant from the National Vaccine Program, Centers for Disease Control and Prevention.