Rob Logan - Part II: 21th-century career developments and influences 

By Robert A. Logan Ph.D., School of Journalism and Mass Communication, University of Iowa, 1977

Introduction to Part II

Part II focuses on the author’s career developments in the 21st century, with occasional flashbacks. It explores the U.S. National Library of Medicine and Don Lindberg, the potential of health literacy, and closing thoughts. References are provided at the end. 

The U.S. National Library of Medicine (NLM) and Don Lindberg

Will Stephenson and Joye Patterson introduced me to the National Library of Medicine and Donald A.B. Lindberg, M.D., in 1972 and 1977, respectively. From 1977 to 2002, during my career in journalism/mass communication higher education, NLM and Lindberg provided the institutional and individual leadership models that I most admired. In 2003, I took early retirement from the faculty of the University of Missouri School of Journalism to join NLM and work with Dr. Lindberg. I was a member of NLM’s senior staff from 2005 until my retirement in 2019.

For five decades, the two NLM leadership contributions I most admired were the library’s adoption of mass media technology for medical professionals, bioscientists, and the public and its assertion of educational values during the conversion from analog to digital inter-professional and mass communication.             

My high regard for NLM began when Joye Patterson first suggested I use Index Medicus to generate news stories. Index Medicus (a periodical formerly published by NLM) organized the biomedical literature by indexing the research of leading refereed biomedical journals into disciplines and biomedical specialties (https://en.wikipedia.org/wiki/Index_Medicus, n.d.). In the late 20th century, it was replaced by MEDLINE and PubMed – NLM’s online, free, Internet-accessible gateway to biomedical literature (https://pubmed.ncbi.nlm.nih.gov/, n.d.). MEDLINE and Pub Med removed much of the lag time from original publication to user availability (and eventually provided access to published articles and so much more). 

While PubMed is one of many examples of NLM’s leadership in extending digital technology to medical professionals and the public, the tradition established by Index Medicus paved its legacy.             

Earlier, Index Medicus accelerated the professional and public diffusion of medical knowledge (what physicians call bench-to-bedside). Prior to the digital age, it used mass media (a printed periodical) to inform medical professionals and the public about basic and applied research in biosciences, biomedical research, and most areas of public health and medicine. 

MEDLINE and Pub Med (which embraced digital technology) enabled free public access to evidence-based medical knowledge for anyone with a computer (and later a smartphone or tablet) and the Internet. Smith (2021) describes MEDLINE and Pub Med’s evolution as examples of innovative medical informatics, focused organizational administration, and the value of professional and U.S. Congressional leadership. Smith (2021) explains that NLM avoided the temptation to monetize the public and professional diffusion of medical information and pursued MEDLINE and PubMed’s development based on educational values.

During our initial conversations in 1977, Don Lindberg noted NLM was the ideal place to develop digitally based services for medical professionals, which, if successfully implemented, could be expanded and made available to patients. Lindberg’s 1977 vision preceded the introduction of the PC and Mosaic, the first accessible free Internet gateway, by several years. At the time, Lindberg was an NLM grantee, a pathologist, a faculty member at the University of Missouri School of Medicine, and a recognized pioneer in the then-new fields of medical informatics and AI. I was one of his post-doctoral students. 

Imagine my excitement in the spring of 1984 when Lindberg told me he would become the director of NLM. I knew what was coming (Logan, 2021). 

From 1984 until his retirement in 2015, Lindberg and his biomedical informatics peers, and NLM’s staff with external assistance, adopted some of the Internet-based vision and digital tools used by innovative physicists, astronomers, and molecular biologists to bridge the communication gaps among biomedical scientists and researchers, clinical and public health practitioners, and the public. For the next 31 years, NLM accomplished every aspect of Lindberg's plan and much more (Humphreys, et.al., 2021). In a combination of vision, pragmatism, multidisciplinary thinking, and leadership, the pioneering innovations developed during Lindberg’s NLM tenure included MEDLINE, Pub Med, PubMed Central, Clinicaltrials.gov, MedlinePlus.gov, UMLS, PubChem, Entrez, GenBank, NCBI Blast, Hazardous Substances Data Bank, Toxicology Data Network, genetic surveillance platforms, support for electronic health records, expert systems, machine learning, medical libraries, High-Performance Computing and Communications, the Visible Human, and Turning the Pages (Humphreys, et al., 2021).

Mo and Denny (2021) describe NLM’s aggregate accomplishments, including how its services undergirded the global collaborative biomedical research that accelerated and enabled the development of a COVID-19 vaccine between 2020 and 2022. 

To offset the digital divide, NLM also created initiatives designed to improve medical communication with and the health of medically underserved audiences (Siegel, 2021). 

A book I recently co-edited details NLM’s and Lindberg’s leadership (Humphreys et al., 2021; Logan, 2021). I was proud to work at an institution that pioneered the use of digital technologies for educational purposes and asserted that its initiatives should empower healthcare professionals and advance the greater public interest. NLM’s diverse and multidimensional projects consistently reflected a larger educational, public, and professional service vision. 

I should add that there were leaders in journalism and mass communication higher education who realized that digital technology represented a new mass medium and the dawn of a cultural era. Some mass communication peers were commendably mindful of Innis, McLuhan, Carey, and Stephenson’s ideas that the evolution of mass media medium resulted in transformative cultural, economic, social, and professional changes (Innis, 1964, 1972; McLuhan, 1962, 1964; Carey, 1967, 1989; Stephenson, 1967). However, during the last half of my career, I suggest NLM best evinced the idea that the ultimate value of a new mass medium is to bridge the gaps (and contribute to) the professional, student, and public understanding of health and boost individual empowerment. 

Health Literacy’s Potential 

After arriving at NLM in 2003, I switched my research emphases from science and health communication to health literacy (HL). Health literacy represented a career extension and an evolution. This section identifies a few of HL’s similarities and differences with science, health communication, and related research areas and discusses the potential for future collaboration and constructive insights.

First, health literacy is operationally defined as: “…allows the public and personnel working in all health-related contexts to find, understand, evaluate, communicate, and use information. Health literacy is the use of a wide range of skills that improve the ability of people to act on information to live healthier lives. These skills include reading, writing, listening, speaking, numeracy, and critical analysis, as well as communication and interaction skills” (Centreforliteracy, n.d.). HL is divided into four areas of research and professional practice: personal, organizational, digital, and numeracy (healthypeople, n.d.). While HL is a branch of general literacy, its narrower focus facilitates research specificity and precision (Sorensen et al., 2012). 

Health literacy is like but also reflects a different direction than health, environment, and science communication and related fields, such as strategic communication, health promotion, and health education (Kreps et al., 2020). Science communication includes strategic communication. Health promotion and health education are separate but similar fields. 

To back up, I admire the collective work of science/environment and health communication research colleagues who advance specific constructs, such as self-efficacy, uncertainty, news gatekeeping, news framing, and news agenda setting (Bucci & Trench, 2014; Harrington & Record, 2023). I suggest the research evidence about these and other constructs has improved the professional communication between scientists and journalists and provided fresh insights regarding the audience for health and science news (Bucci & Trench, 2014; Logan, 2008, 2014; Harrington & Record, 2023). Among its contributions, the latter research suggests how the selection and framing/contextualization of science/health news by reporters, editors, and producers are associated with audience perceptions of the importance and policy urgency of diverse scientific and medical topics (Logan, 2001, 2008, 2014). This has important implications for science policy and the broader public appreciation of integrating scientific processes in making public policy decisions. While Joye Patterson and Will Stephenson abstained from promoting the idea that news coverage was linked to elevating popular support for science, they understood that science and health news could help the public better understand evidence-based thinking and the knowledge it generates, which they believed was socially constructive. 

As the constructs represent potentially shared areas among science mass communication and health communication with health literacy research, other commonalities include numeracy (or the public’s understanding of scientific information, biostatistics, and scientific processes) and the impact of health misinformation and disinformation in the news and social media on popular misunderstandings about science and medicine. Certainly, some negative public attitudes about vaccinations during the COVID-19 pandemic (in several nations) illustrate the need for more research (and professional and policy concern) about consumer numeracy and public exposure to misinformation and disinformation in the news, mass, and social media (McCaffery, et.al., 2020, 2023; Pickles, et.al., 2022; Wolf, et.al, 2020; Logan, 2023). 

The attention to ‘plain language’ within HL also helps media practitioners refine their use of health terms and concepts for the public (Parker & Ratzen, 2020; Oransky, 2020). Additional areas in HL practice encourage better access to medical information for journalists and the public (which attracted NLM’s attention during HL’s nascent stage) (Oransky, 2020). 

Conversely, there are important differences among HL, science communication, and health communication researchers, which partially stem from their professional locus and focus (Kreps et al., 2020). For instance, health literacy practitioners (and most health education and health promotion specialists) tend to work in medical education, schools of education, schools of public health, or health-related fields rather than higher education schools of mass communication and communication. Health communication faculty frequently work in higher education schools of communication or schools of journalism/mass communication, as do many science communication researchers. HL research tends to focus less on assessing news and social media content and, instead, frequently evaluates how health literacy levels (or prior knowledge) impact clinical and public health outcomes. So, HL research tends to concentrate on the issues that challenge clinical and public health practitioners instead of evaluating and potentially enhancing the impact of news, mass and social media, or health educational efforts in primary and secondary schools.   

Perhaps the differences in disciplinary locus and focus are best illustrated by HL’s primary research findings, which suggest:  

• Low health literacy levels are normative in many countries (Pelikin, Strabmayr, & Ganahl, 2020)
• Health literacy levels are statistically associated with survival and recovery rates (and patient preventive behaviors) for cancer, stroke, heart disease, and a variety of chronic illnesses and overall life expectancy (Baker, 2006; Flaherty, 2008; Parker & Ratzen, 2012; Rudd, 2017; O’Conor et al., 2020)

HL associations extend to other health concerns, such as oral health, depression, medication knowledge, accident/injury prevention, health screening, and immunizations (O’Conor et al., 2020; Guo et al., 2023)

HL is also associated with how patients and caregivers optimally use the healthcare delivery system (it impacts outcomes, such as whether a person has a physician or provider, sees a provider/MD annually, receives recommended vaccinations, gets screenings, unnecessarily uses emergency clinical services, follows health provider instructions, is re-hospitalized after surgery or a medical procedure) (Parker & Ratzen, 2012; Rudd, 2017; O’Conor et al., 2020; McCaffery et al., 2023)

Improving HL represents a constructive approach to addressing many aspects of the ‘Quadruple Aim’ (enhance quality of care, advance community health, reduce medical costs, and improve the care and experience of patients, caregivers, and providers within the healthcare delivery system) (Andresen, Rosof, & Arteagan, 2020; Rickard & Hudson, 2020; Berwick, Nolan, & Wittington, 2008; Bodenheimer & Sinsky, 2014).

Compared to science and health communication, HL provides a different path by focusing on individual, public health, and health care delivery system outcomes instead of validating evidence-based constructs.

However, HL findings also suggest that it is one of the social determinants of health. In turn, assessing HL’s role as a social determinant furnishes stimulating opportunities for collaboration among social determinants, health literacy, science’s mass communication, health communication, and researchers in related fields (Schillinger, 2020). While the evidence is preliminary, some practitioners also suggest that HL may be the most modifiable social determinant of health (Nutbeam & Lloyd, 2011; Schillinger, 2020; McCaffery et al., 2023).

The social determinants of health (identified by scholars in yet another discipline) assess how public health, clinical health, illness, recovery, and empowerment are impacted by an array of socially derived intermediate variables that include and eclipse conventional demographics (Nutbeam & Lloyd, 2011; Smith & Carbone, 2023). While HL is one of several demographic influences (such as education and income), non-demographic social determinants include conditions such as employment, access to green space, access to health care, food security, and neighborhood cohesion (Schillinger, 2020). 

Consequently, assessing HL within a social determinant framework raises two foundational research questions: Is health literacy empirically more (or less) robust than other social determinants of health? To what comparative degree is HL a modifiable social determinant of health? 

Since evidence-based answers are QED (yet to be determined), the resulting knowledge gap creates significant opportunities for collaborations among HL, science communication, and health communication researchers (and related fields) to assess and conceptually frame the comparative role and importance of HL, the news media, social media, and educational and community interventions as intermediate variables that impact diverse health outcomes. 

Certainly, an interdisciplinary approach to addressing these research questions would generate a new era of collaboration that could lift all boats. In suggesting this, I return to NLM’s legacy that the ultimate contributions of a new mass medium and evidence-based community interventions are to bridge the gaps in public, student, and professional understanding of health and science (and other issues) and boost empowerment.

Otherwise, the public benefits of assessing whether health literacy is the most modifiable social determinant of health, coupled with the simultaneous evaluation of the comparative impact of journalism and mass media content and the potential for multidisciplinary interaction, generated my interest in HL research and practice. Like Lindberg’s and Stephenson’s influence and my first encounter at Brent Books, I was overwhelmed by my first exposure to HL findings and its conceptual horizons. I was also intrigued by the sheer diversity of stakeholders who were engaged in HL research and practice which included physicians, other clinicians, public health professionals, researchers from several disciplines, caregivers, hospitals, insurers, schools, government regulatory and research branches, medical societies, Pharma, patient and community organizations (to name a few). I also began to understand the importance of assessing similar research questions about health’s social determinants in diverse healthcare delivery payer settings (for-profit, publicly funded, and mixed). 

Unsurprisingly, I dove into NLM’s HL activities, co-edited two books and a journal issue on HL research and practice, and participated in the Roundtable on Health Literacy, National Academies of Sciences, Engineering, and Medicine (Logan & Siegel, 2017, 2020; Logan, 2015, 2023; Kurtz-Rossi & Logan, 2015; Auld et al., 2020; Hernandez & Parker, 2020).   

The multidimensional elements of the HL field and its synergy with related disciplines provided a capstone to my career's diverse elements.

Closing thoughts  

I gratefully thanked Stuart Brent (1912-2010) about 15 years after first visiting his store, which closed in 1994 (about-stuart-and-the-brent-family, n.d.). Whenever I produce a book in recent years, I imagine finding it on a shelf in Brent Books.

Besides key experiences, mentors, and ideas, I appreciated the assistance of my former students and colleagues at the University of Missouri-Columbia School of Journalism and the School of Medicine, the University of Iowa, the University of South Florida, California Polytechnic State University-San Luis Obispo, and in a few newsrooms. My friends and family also had an implicit influence. My grandmother Ollie (who was English) befriended psychiatrists and psychologists and admired Scottish philosophers (such as David Hume and Adam Smith). Her enthusiasm created a groundwork for me to work with William Stephenson in the 1970s. Her influence may be why I had solo time to explore downtown Chicago in 1964. 

Finally, I am surprised that my career has been semi-linear and spanned six decades. While my initial exposure to reducing gaps in understanding and creating knowledge was accidental, it suggests the value of self-determination and finding a sense of purpose after being overwhelmed and a bit humiliated. I hope my experience suggests that producing original research, helping people understand knowledge, and removing barriers between public knowledge and professional proficiency is a virtue.   

My deep appreciation to those who create knowledge, mass communicate knowledge, provide evidence-based solutions to improve the public’s understanding of health and science, expand multidisciplinary-conceptual research foundations, and persevere.   

References

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