Years of working to improve global health as a public health physician and Editor of the Journal of Health Communication has reminded me that research, development of medicines, and providing people with access to care are only parts of improving health. In this complicated health environment, people make choices for “health” that are often ill-informed, with outcomes deleterious to their own, communities’ and societies’ well being.
Nothing would be clearer in this regard than the current situation with immunizations. While vaccines (first discovered in 1792) now enter their fourth century of proven success in eradicating scourges of the past—notably smallpox and nearly polio—immunizations are challenged and refused in many parts of the world.
There is complexity on why there is lack of uptake of vaccinations. In many cases, it is a question of resources as in the 72 poorest countries that require an additional US $1 billion per year to implement the Global Immunization Vision and Strategy. Nonetheless, there are people who refuse a proven intervention that has enhanced health globally. The scientific, medical, and public health establishment continues to provide evidence of the value of immunization. New vaccines have been developed to protect not only against the next flu epidemic, but also against cancer and other diseases once thought impossible to prevent. Routine immunization also has helped minimize childhood deaths from measles, mumps, rubella, pertussis, chicken pox, rotavirus, and other diseases. In 2008, global immunization rates were at their highest level ever (82% in 2008 with a record 106 million children). This is still short of the Global Immunization Vision and Strategy established by the WHO and Unicef that aimed by 2010 for countries to reach at least 90% national vaccination coverage.
This means that nearly 23.5 million children are still not fully immunized annually. Furthermore, nearly 9 million children under the age of 5 die each year from causes that can be prevented (by immunization, for example) or treated. In our effort to reach Millennium Development Goal 4 to Reduce Child Mortality, which includes vaccinations as a core component, we should work to advance an idea of creating “vaccine literacy.”
“Vaccine literacy” advocacy could be built on the idea of “health literacy,” defined as the degree to which people have the capacity to obtain, process, and understand basic health information and services to make appropriate health decisions. In a 2009 Ministerial declaration, the United Nations proclaimed health literacy is an important factor in ensuring significant health outcomes calling for the development of appropriate action plans to promote health literacy. Chinese Health Minister Chen Zhu launched health literacy as a goal in China and stated “Promoting health literacy is a fundamental cost effective strategy.”
Two decades of research has shown that limited health literacy affects people of all ages, races, incomes, and education levels globally. Limited health literacy is also linked to worse health outcomes and higher costs, with staggering economic consequences from this silent epidemic. The cost of low health literacy in the U.S. is estimated to be between $106 billion to $236 billion a year. As we face the challenges of simultaneously containing health care costs, improving quality, and expanding access, it is vital that we advocate for a systematic approach to creating effective, innovative health communications as a key to improving health literacy.
In the U.S., the Institute of Medicine Roundtable on Health Literacy has helped elevate health literacy dialogue. United States Health and Human Services Secretary Sebelius also indicated, “Health literacy is needed to make health reform a success,” as she launched the US Department of Health and Human Services National Action Plan to Improve Health Literacy. The plan entails providing everyone with access to accurate and actionable health information, and supporting lifelong learning of skills that promote good health. This comes at an important time, particularly since the recently passed Patient Protection and Affordable Care Act includes provisions to address health literacy.
The recently introduced 2011 Healthy Lifestyles and Prevention (HeLP) America Act (introduced in Senate S 174) suggests the need to address health literacy. It strengthens federal initiatives to improve the health literacy of consumers by making health information more understandable and health care systems easier to navigate through continued research and dissemination of effective interventions. With a focus on vulnerable populations, one may endeavor that those without protection of vaccines are indeed “vulnerable.” The Act suggests that interventions and tools designed to strengthen health literacy will advance: (1) the provision of simplified, patient-centered written materials; (2) technology-based communication techniques; (3) consumer navigation services; and (4) the training of health professional providers.
While policy interventions are important steps forward, on their own these are not enough. What is needed is sophisticated vaccine advocacy in the United States and globally. (There are parts of Washington State with similar paltry vaccination coverage to northern Nigeria.) The challenge is to develop a new approach to counter the current anti-vaccine sentiment. The anti-vaccine activists are organized well, promulgating skepticism with inconsistencies, fallacies, and misconceptions aimed at the public and decision makers. The recent exposure by the BMJ of the fraud in the Wakefield 1998 Lancet article that purportedly linked autism with vaccines, as well as the preponderance of evidence that has countered the Thimerosol and other “harms” arguments, should provide an exigence for the health polity to unite and advance interest in vaccination coverage.
Unlike specific disease categories such as HIV, TB, and malaria, as well as certain cancers and diabetes, vaccination as an approach doesn't have a well-organized grass roots or grass tops advocacy constituency. First of all, there is no “victim,” as vaccines are largely a victim of their own success. There are no visible signs of polio, measles, mumps, rubella, and pertussis; this means that the current generations of moms in developed countries do not remember being fearful of contracting these diseases and are less compelled to adhere to vaccine guidelines.
Additionally, vaccine advocacy is difficult, as there is not a larger advocacy constituency, there is no victim, and even the health professional community's fears of potential adverse events and liability opposes their desire to advocate for vaccination. And, of course, there is misunderstanding about public health, such as understanding of the importance of herd immunity.
The fundamental tenet of where education—and knowledge about immunizations—can make an impact should be clear. Vaccine literacy is not simply knowledge about vaccines, but also developing a system with decreased complexity to communicate and offer vaccines as sine qua non of a functioning health system. The goal is a change in social norm of advancing vaccine uptake, providing herd immunity with a foundation of vaccine/health literacy at a level commensurate with age, mental capacity, gender, and environment.
For example, children and young people can learn about how vaccines work, the diseases they prevent, and the value for society. Concomitantly, they can garner competencies for health and hygiene, nutrition, and physical activity while learning about sexual and reproductive health behavior. Learning opportunities also exist during non-immunization experiences, to reinforce in families and recipients the disease preventative and public health benefit of immunization. Adolescents might have more of a focus on reproductive health practice (e.g., use of condoms) along with vaccination to prevent cancer (from human papilloma virus) and detection (periodic pap smears)—breast self examinations, testicular examinations, annual pap smears, etc. As one ages, imbued vaccine literacy among overall health can continue to enhance knowledge and practice.
The way people interact with the health system has great impact on whether they can improve their health. And improving people's understanding of health information is an important first step in advancing vaccination coverage.
Finally, as the world has moved from wired to wireless, over 5 billion people can be reached with communication opportunities that help individuals to be more involved in their health decisions, and treatment can add connectivity and connectedness to help develop a health literate public, and if necessary, remind people of the need to take proactive health protective behaviors and to take part in national vaccination campaigns and/or respond to challenges with the next potential flu (e.g., H5N1) epidemic. Such communication for health literacy can advance public understanding of the health risks and associations of both individual and community behaviors, allow the attainment of knowledge and ability to access the health care sector for more information, and finally, develop the ability of individuals to make decisions based on a “true” health knowledge base.
I am hopeful that public and private organizations, governments, and multilateral and nongovernmental institutions will work to advance health literacy and also develop a vaccine literacy with the level of attention it deserves. As plans with the United Nations, key countries, and the United States move forward, we all have the opportunity to use our resources and expertise to assist in the advancement of global health and to improve the overall health of the nation, communities, and families.
Acknowledgments
An abridged version of this editorial was published on the Harvard Business Review blog as “a take” on Healthcare and Innovation as part of the Harvard Advanced Leadership Initiative Healthcare Reform Think Tank, March, 2011.
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Scott C. Ratzan
Scott C. Ratzan, MD, is Editor-in-Chief, Journal of Health Communication: International Perspectives and Vice President, Global Health, Johnson & Johnson. He is a participant and presenter at the Harvard Advanced Leadership Initiative Healthcare Reform Think Tank.Related Research Data
