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«HEALTH PSYCHOLOGY Series Editors: Sheila Payne and Sandra Horn Di an ne Be rr y ion at ce nic cti mu Pra om and h C ory alt The He Health ...»

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In order to assess the extent to which leaflets were being used by consumers following implementation of the Directive, Raynor and Knapp (2000) carried out a study in community pharmacies in Leeds (UK). Patients were recruited as they collected their prescriptions and were telephoned seven days later for a structured interview. The interviews showed that leaflets were not provided with one-third of the prescriptions that were collected. Of those that were provided, 17 per cent of the sample reported that they had taken no notice of the leaflet, and 26 per cent said that they had not kept it. Only 40 per cent of the sample said that they had read some of the leaflet, and only 20 per cent said that they had read all of it. Finally, only 7 patients out of the sample of 215 reported taking an action as a direct result of reading the leaflet (e.g. returning to the pharmacy or GP). More recently, Hughes et al. (2002) found that, although the majority of participants in their study had received a medicine information leaflet when purchasing an over-the-counter medicine, only a small number had actually read it. The most common reason given for not reading it was that it was not the first time that they had purchased the medicine. People were more likely to have read the leaflet if the medicine was new to them, or if they had experienced a particular adverse effect.

In 1998, the European Commission published a further Guideline (European Commission, 1998) to standardize the way in which information about the frequency of occurrence of medication side effects is described in PILs. The Guideline recommended that the frequency of side effects could be banded into five groupings, based on five verbal descriptors, ranging from ‘very rare’ to ‘very common’, with each term being associated with a Health promotion and the wider public 101 specified range of frequencies of occurrence, as shown in Figure 7.1. Thus, according to the Guideline, a side effect should be described as being ‘common’, for example, if it occurs in between 1 and 10 per cent of people who take the medicine.

Unfortunately, the EC’s recommendations were not based on sound empirical evidence, nor were they evaluated prior to implementation. As mentioned in the previous chapter, a series of studies by my research group showed that members of the general public, patients and doctors consistently overestimated the likelihood of side effects occurring when the probabilities were described using the EC recommended descriptors. For example, although the EC recommended that a side effect should be considered to be ‘common’ if it occurred in ‘between 1 and 10 per cent of people who take the medicine’, our studies showed that people estimate the level of risk of ‘common’ side effects to be around 50 per cent (e.g. Berry et al., 2002, 2003, 2004; Knapp et al., 2004).

More recently, the EC has updated its regulations (European Commission,

2005) in relation to the preparation of PILs. The modifications are relatively minor, mostly focusing on changes to the order of information in the PIL, and the additional need for systematic user testing before leaflets are published and distributed.

As noted earlier, it is important not to give patients either too little or too much information on PILs. Clearly, what would be considered to be the ‘right’ amount of information will depend on a number of factors, including the educational level of the recipients and the health behaviour in question.

Figure 7.1 EU-recommended verbal descriptors together with assigned probability ranges 102 Health communication As far as medicines are concerned, the International Medicine Benefit/Risk Foundation (IMBRF, 1993) recommended that the minimum information patients should be given should cover the medicine’s name and dose, its purpose and benefit, how it should be taken, and special precautions and adverse effects.

Similarly, Mottram and Reed (1997) pointed out that patients need to know certain points of information in order to avoid harm and to derive full benefit from their prescriptions. This information includes how to take the drug, how to store it, how it is expected to help, how to recognize problems, such as adverse effects, and what to do about them if they occur.

In addition to disseminating health information via PILs, important information also needs to be conveyed on product labels. This not only applies to medicines but also to the foods that we eat. Research is increasingly showing clear links between inadequacies in diet and health problems.

Nutritional labelling and health claims on food products

Many food products now feature labels that convey important nutritional and health-related information. In recent years there has been an increased emphasis on the use and regulation of such product labelling. The UK government’s recent White Paper on public health, for example, expressed a commitment to working with the food industry to develop better information on nutritional content on packaged food. This included the intention to introduce a clear coding system that would be in common use by 2006, and that busy people could understand at a glance (Department of Health, 2004). Improvements have also been brought about through increased controls on communication, such as restrictions on product advertising. Again the UK White Paper has committed to restricted advertising and promotion to children of food and drinks that are high in fat, salt and sugar, as well as further restrictions on advertising of tobacco, including banning advertising on the Internet, and reducing the size of tobacco advertisements that are allowed in shops.

Nutritional and health claims on foods clearly have the potential to contribute to the achievement of public health objectives. Basically, a nutritional claim means ‘any representation that states, suggests, or implies that a food has particular nutritional properties including, but not limited to, the energy value and content of the protein, fat and carbohydrates, as well as the content of vitamins and minerals’ (Richardson et al., 2003, p. 100). In contrast, a health claim means ‘any representation that states, suggests, or implies that a relationship exists between a food, or constituent of that food, and health’ (p. 100). Richardson (2005) proposes that nutrition and health claims can exert an effect on consumer behaviour to an extent that


♦ are aware of the claim ♦ understand the claim Health promotion and the wider public 103 ♦ make appropriate health inferences from the claim ♦ consider the claim credible ♦ attach attitudinal relevance to the claim, that is, the claims are appealing and motivating ♦ translate the claim into action, for example purchase intent.

Many countries in the western world now regulate the information that appears on nutritional labels and in health claims. Generally, there is more consensus over the former, whereas health claims are far more controversial.

Within the European Union, the use of health claims on products is only allowed if there has been a thorough scientific evaluation of the evidence for the claim.

Clearly, food labels of either sort will only be beneficial if they are presented in a format that consumers can readily understand. In line with this, Richardson et al. (2003) suggested that health claims must not only be truthful, but that they should be unambiguous and understandable for the intended consumer. In addition, they must make clear that the claim applies only to food consumed in the context of a total dietary pattern and should not encourage over-consumption of a given food. Probably not surprisingly, empirical evidence suggests that consumers often have difficulty understanding many food labels. An additional problem for public health is that they are predominantly read and ‘used’ by a relatively limited sector of the population, such as younger adults, women, more highly educated people and those with a particular interest in health and nutrition. At present, therefore, the effectiveness of nutritional labelling tends to rely largely on a motivated and educated public to make healthy choices. Clearly, if nutritional labels are to be a more widespread public health tool, more needs to be done to ensure their applicability to a larger proportion of the population.

Disseminating health information via the media

The mass media play an important role in disseminating health information to the general public in much of the western world. Nowadays, the media enable information on a whole range of health topics to be conveyed straight into the homes of a large proportion of the population. This may be done via news reports in the written press and on radio and television (such as when a new health scare breaks out), feature articles in magazines and newspapers, radio and television documentaries, and the increasing number of television soap operas and ‘docu-soaps’. The latter often take the form of the televization of a typical day, or week, in an accident and emergency department, for example, or on a hospital’s children’s ward.

Two distinct models of health education via the mass media were identied by Redman et al. (1990). These are the ‘direct effect’ model and the 104 Health communication ‘agenda setting’ model. In the case of the former, the objective is to change or prevent harmful behaviour and promote positive health behaviours, using similar types of direct method as might be used by an individual health professional. In contrast, in the ‘agenda setting’ model, the media are used to raise awareness of a health problem or to gain support for a particular healthrelated public policy. Some health campaigns, such as drink drive campaigns, often use a mixture of both methods.

Clearly, the growing influence of the media can be considered to be positive or negative, depending on the particular circumstances (and irrespective of whichever of the above two models is used). On the positive side, the media can be very good at raising awareness of particular health issues, and for reducing the amount of stigma associated with some illnesses.

Richard Nixon, former US President, once remarked that ‘American people don’t believe anything until they see it on TV’ (Chrystal, 2005, p. 155), and there may be some truth in this (and not just in the USA).

Many fictional television programmes that feature a particular health issue (such as cancer, therapeutic abortion and AIDs/HIV) often include an information or help-line number at the end of the programme. A number of studies have shown that the organizations concerned often report a record number of calls immediately after such shows have been broadcast. Marcus (2000), for example, reported that after an episode of the US television programme, General Hospital, the National Cancer Institute confirmed that 207 callers responded to the public service announcement that followed the programme.

Unfortunately, the media can have less positive influences. Many popular characters in fictional programmes, such as television soap operas, often portray negative role models as far as health behaviours are concerned.

Signorelli (1993), for instance, noted that characters on popular television shows consistently role model unhealthy behaviours, such as overeating high-calorie, high-sodium and high-fat foods, snacking and eating on the move. Similarly, analysis showed that characters drank alcohol more than twice as often as tea or coffee and 15 times more often than water.

As far as news items are concerned, the media still often disseminate incomplete, biased or inaccurate information. Although we can all have some sympathy with Dame Rose Macaulay’s suggestion that ‘you should always believe all you read in newspapers as this makes them more interesting’ (Chrystal, 2005, p. 137), one does need to be cautious. Moynihan et al.

(2000), for example, analysed 207 US news media stories (relating to three different drugs) that appeared between 1994 and 1998, and found that the majority included inadequate or incomplete information about the risks, benefits and costs of the medicines. Similarly, Carlson et al. (1997) found that more than two-thirds of reports of the study of breast cancer and mammography contained factual inaccuracies.

One point noted by Moynihan et al. (2000) was that over 80 per cent of the articles only reported information about risks and benefits of the Health promotion and the wider public 105 medicines in ‘relative’ terms. However, referring to the ‘doubled risk of cancer’, for example, without indicating what the actual size of the risk is, can be very misleading. Indeed, as we saw in the previous chapter, the 1995 ‘pill scare’ in the UK was greatly exacerbated by the media, who emphasized the doubled risk of thrombosis that was associated with taking the thirdgeneration oral contraceptive, without mentioning that the absolute level of risk was still extremely low. Such biased reporting was also apparent in reports of the more recent hormone replacement therapy scare (Paling, 2004).

In defence of the media, Bennett (1998) pointed out that the media do not usually create public interest. Rather, they simply amplify (albeit sometimes to a considerable degree) existing public interest in particular ‘forms of mishap’. Thus, the public and the media reinforce each other in a negative way. Bennett (1998) identified a number of ‘media triggers’ that he suggested determine the extent of coverage that is given to a particular issue. These include questions of blame, alleged secrets or cover-ups, human interest, links with high-profile issues or personalities and the existence of conflict. In addition, media interest is greater when a large number of people are, or could be, affected by the health risk in question.

Communication via computers and the Internet

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