Writing about health disparities
Medical communicators can address health disparities through the subjects they cover, the context they give and the messages they help clinicians convey. Framing, images and assumptions about patients shape how readers understand both a problem and the possibilities for changing it.
Assignments affected
US-focused writing advice from 2018 identifies assignments where health disparities and social determinants of health are relevant:
- Educational materials for physicians and allied professionals, including community health workers, lay health advisers and patient navigators.
- Hospital publications for providers, patients, families and neighbourhood residents.
- Websites of hospitals, government health agencies, and pharmaceutical and device companies.
- Research publications, including how disadvantaged subgroups are discussed.
- Review articles, including whether the literature addresses disparities or has ignored crucial populations.
- Public-health publications.
- Journalism for magazines, books and websites.
- Training materials for pharmaceutical representatives.
- Websites for a range of audiences.
- Consumer publications of professional organisations and foundations, such as the American Heart Association, American Nurses Association and Kaiser Family Foundation.
- Newspapers and news sites for general or focused audiences.
Writers can inform professionals and the public about existing efforts by government agencies, professional societies, foundations, pharmaceutical companies and the media to address disparities. Writers and editors cannot ignore policy and funding decisions at any level of government. They can also explain how closer integration of medicine and population health affects their audiences.
Framing and stereotypes
Frames shape the context of a health issue through the facts selected and the way they are juxtaposed; those facts may evoke emotions as well as convey information. Writers can avoid damaging and frequently inaccurate stereotypes when presenting disparities and their social determinants.
A public-health dean argues that words define a problem and create a context for solving it: describing gun violence as an epidemic was, in his view, progress in changing how people discussed it. Terms may be especially important to populations whose members feel vulnerable as well as being described that way by academics. The same dean argues that describing a cause of death as heart disease, excess weight or lack of education affects whether society sees it as unacceptable and worth changing. Assuming that poor people will not live long may weaken the perceived need to apply research to their health or fund it; presenting a condition previously treated as inevitable as intolerable can help create momentum for change.
Images also convey messages: a waiting-room mammography poster showing a healthy white woman beside a sexually transmitted disease prevention poster showing a healthy Black woman raises a question about what the juxtaposition communicates to minority patients. The 2018 writing advice recommends sensitising clinicians to disproportionately poor literacy and numeracy among Black and Latino patients only where this can be explained without encouraging stereotypes.
Writers should preserve the distinction between health disparities and health inequities. They can explain where research shows that circumstances can improve, remain alert to the influence of perceptions, and incorporate prevention and determinants outside healthcare where appropriate.
Materials for clinicians and patients
Patient–clinician communication includes verbal, nonverbal and written exchanges. Writers preparing patient-directed material for clinicians to provide can take account of factors associated with poor communication. A 2018 review identified minority-group membership, limited English proficiency, and low health and digital literacy among patient factors, and limited cultural competence, weak shared-decision-making skills and unconscious bias among clinician factors. It recommended:
- Interventions aimed at patients, clinicians or both to guard against unconscious bias and improve communication.
- Screening for health literacy and English proficiency.
- Integrating patient–clinician communication into performance processes.
- Using health information technology to address unconscious bias.
Writers can encourage genuine listening among hospital staff, including recognition that illness and family stressors may affect how patients and relatives behave. A physician-writer found that listening can build relationships, solve problems, ensure understanding, resolve conflict and improve accuracy. A patient's nodding does not necessarily establish that communication has been effective.
Writers can provide patient-directed materials that help physicians support people overwhelmed by reliable and unreliable health information, as well as communications and strategies that help physicians manage their own information overload. They can encourage referral to social workers or community organisations only where structures ensure that patients will not be left without effective support. They may also help develop screening tools for social needs.
Communications can remind clinicians how social circumstances change the problems patients face: poor wiring and unreliable electricity may prevent insulin refrigeration, while lack of transport may make nutritious food inaccessible. Writers can help providers understand structural racism and discrimination and their effects on communication, and identify power differences that may limit joint decision-making.
In 2018, CDC and NIH guidance for providers working with patients with low health literacy was available free and could also serve writers and editors. The National Academy of Medicine’s Vital Directions material on chronic-disease prevention was recommended for writers working on continuing education, websites and newsletters, with information on nutrition, physical activity, obesity, tobacco and coordination with the Department of Agriculture and other agencies.
Communities and professional audiences
A community may be defined by shared conditions, caring responsibilities, activities or institutions rather than geography alone. Examples include people with diabetes, carers of relatives with disabilities, farmers’-market shoppers, followers of a government or religious leader, people attending a senior centre, playground or nursery school, and readers of a local bulletin board. One topic may need five or six distinct versions of an article for different groups. The CDC’s Gateway to Health Communication and Social Marketing Practice was suggested as preparation in 2018.
Writers can report community initiatives to providers, policymakers and the public, and help different categories of provider understand one another. They can encourage nurses’ role in bridging communication between providers and the public. Collaboration on social determinants may extend from continuing medical education to recruiting students and residents into primary care and family medicine.
Reporting subjects
Stories about clinicians advocating for communities, including service on local school boards, can be subjects for newspapers and medical journals. Other proposed subjects include community-based residency training, community health workers, graduate medical education and diversity in the pipeline to health professions. Writers can explain community-based health centres and their role in access to care, hospital–community partnerships, efforts to reduce readmissions through social support, learning from care processes and real-world evidence, and the benefits and problems of electronic health records. The American Academy of Family Physicians’ EveryONE Project, addressing diversity and social determinants affecting individuals, families and communities, was another recommended subject in 2018.
The 2018 US-focused catalogue proposes these subjects for professionals, the public or both:
- Health outcomes and the contribution of healthcare services.
- Behaviour patterns and the external conditions shaping them.
- Social epigenomics.
- Environmental influences on health inequalities.
- Chronic stress, poverty and racism.
- The limits of focusing on individual illness rather than population health.
- System-wide health strategies.
- Structural conditions affecting underserved populations’ options.
- Partnerships across professions, policymakers and communities.
- Partnerships with local public schools.
- Community activation and shifts in power.
- The risk of eroding community trust.
- How institutions build trust.
- The community as an equal partner.
- Neighbourhood factors contributing to poor health.
- Local government policies affecting health.
- Disaster planning.
- Violence as a health issue.
- Misconceptions about childhood in the United States.
- Adolescent health.
- Tobacco companies’ targeting of vulnerable populations.
- Isolation among older people.
- The health benefits of work for older people.
- Transport and housing policies for older people.
- Intergenerational programmes.
- Social engagement.
- Older people with disabilities, particularly outside institutional care.
- Regional differences in health outcomes.
- Poor sleep and health among underserved populations.
- University–community partnerships in primary and secondary education.
The authors’ ethical argument is that medical communicators should help remedy disparities, adapt as the health system changes and inform patients, families, communities, researchers, providers and industry about that change.