Current Health Department Efforts in Health Literacy
Torrie T. Harris, Dr.P.H., M.P.H.
Louisiana Public Health Institute
The Louisiana Public Health Institute (LPHI) provides support to governmental public health through technical assistance and additional support with staff, sharing data, and stakeholder meetings, according to Torrie T. Harris. The LPHI was founded in 1997 as a 501(c)(3) nonprofit organization and is based in New Orleans. The LPHI’s mission is to promote and improve health and quality of life through diverse public–private partnerships with government, health care delivery systems, foundations, academia, community groups, the media, and private businesses at the community, parish, and state levels. Through these partnerships, LPHI fosters innovation and leverages resources to address current and emerging health issues by providing expertise in the following areas:
- Fiscal and administrative management
- Population-based health program delivery
- Community health
- Mental health
- School health and wellness
- Health policy development, implementation, and evaluation
- Training and technical assistance
- Research and evaluation
- Health information services
- Health communications and social marketing
One of the advantages of being in a small, nonprofit organization such as the LPHI, Harris said, is the lack of bureaucracy and the ability to save time when processing grants and contracts.
There are 37 public health institutes (PHIs) across the United States (25 operating PHIs, 6 provisional and developmental PHIs, and 6 affiliate members). These organizations make up the National Network of Public Health Institutes (NNPHI). NNPHI was established in 2001 with funding from the Centers for Disease Control and Prevention (CDC) and the Robert Wood Johnson Foundation. The NNPHI provides a forum for learning for PHIs across the country and fosters the development of emerging institutes nationwide.
The Louisiana PHI has two main divisions, health systems and community health. The health systems division, which is responsible for the primary care and behavioral health programs, has several ongoing areas of activity, Harris said. For example, a health information exchange was created in New Orleans using a grant from the Centers for Medicare & Medicaid Services (CMS). With support from Johnson & Johnson, a program was launched to integrate mental health services into primary care clinics across New Orleans. The Kellogg Foundation is supporting School Health Connections, a program that allows schools to hire a school health coordinator and maintain the staff person for 3 years. A school-based health coalition addresses health issues throughout the community. A “4 Real Health Teen Pregnancy Prevention Project” trains youth on sexual health topics. Harris said that although teaching reproductive or sexual health is not permitted in Louisiana schools, the program aimed at reproductive health training is allowed because it is offered in the summer as part of a summer enrichment program. She added that Louisiana has the second highest rate of HIV infection in the nation. Another PHI program is the Louisiana Positive Charge initiative, which links newly diagnosed individuals and persons living with HIV infection who are not in care to HIV primary care. Patient-centered approaches used within this program include assessing clients for basic health literacy and for their knowledge of HIV/AIDS, medication management, and other aspects of care.
One project in the community health division is Fit NOLA, an initiative to tackle obesity and the lack of physical activity in New Orleans. The city government is promoting this program as a way to improve Louisiana’s health ranking from 50th in the nation in 2013 to 18th, Harris said. The LPHI is working with government partners to try to meet this ambitious goal. The Fit NOLA project has a steering committee that is focused
on physical activity and obesity and the mayor and health commissioner engage nontraditional partners (e.g., the business community) as partners in this effort. Harris said New Orleans is well known for its food and celebratory atmosphere, aspects of the culture that have negative consequences in terms of obesity. Other barriers to healthy behaviors in New Orleans include natural disasters and a rainy hurricane season that discourages outdoor exercise. Blue Cross Blue Shield has provided a challenge grant to support communities across the state to enact similar projects focusing on physical activity and obesity.
Harris said another effort of Fit NOLA is the collaboration among a community health clinic, Tulane University, a farmers’ market, the police department, and a number of other organizations. This effort offers diabetic patients and their support groups doctor-prescribed prescriptions for fruits and vegetables. This approach gives patients a voucher that is redeemable at the local farmers’ market and is worth double its value.
Harris said the New Orleans Recreation and Development Commission is working, with community input, to enhance the infrastructure of parks in low-income neighborhoods. A technical assistance effort to increase the number of bike paths in cities and to improve pedestrian safety by enhancing infrastructure of streets and roads is run by the Center for Community Capacity.
Another project in the healthy communities portfolio is a mapping project, Harris said. A website, HealthyNOLA.org, provides information on health outcomes in the 72 neighborhoods in New Orleans. Neighborhood liaisons help people navigate the website to ensure that the information is correct. Harris said the website is intended as an empowerment tool to assist individuals in making a difference in their own neighborhoods.
The Gulf Region Health Outreach Project, Primary Care Capacity Program is supported with funds from the Gulf Coast oil spill British Petroleum medical settlement. To enhance primary care capacity, Harris said that the LPHI is focusing on improving health information systems, hiring mental health specialists, and increasing the capacity of federally qualified health centers and similar clinics across the Gulf Coast to provide patient-centered medical homes for their patients. Health literacy and community asset mapping is included to help the health departments with their public health improvement plans, community health assessments, and obtaining accreditation from the Public Health Accreditation Board.
Another program is the Louisiana Campaign for Tobacco-Free Living, which is a statewide tobacco control program funded by the cigarette excise tax. This program implements and evaluates comprehensive initiatives that prevent and reduce tobacco use and exposure to secondhand smoke. Harris said that efforts are under way to reach several target audiences, including communities of color, colleges and universities, youth ages 11 to 17, musi-
cians, and service industry employees. In Louisiana the Smoke Free Air Act covers restaurants that only serve food. If there is a bar in the restaurant, smoking is allowed in outdoor areas. In bars that do not serve food, smoking is permitted. Harris said many restaurant workers and musicians are inhaling secondhand smoke. A component of the program’s multimedia campaign is a website that targets musicians and service industry employees (http://www.letsbetotallyclear.org). The Louisiana Cultural Economy Foundation, an organization that supports Louisiana cultural workers, is involved in this initiative. These are examples of how the PHI’s Media and Communication Division and the Research and Evaluation Division complement programmatic activities.
Harris concluded her presentations by saying that PHIs can complement and support the work of public health departments because they are able to advocate for health policies. PHIs are also able to meet with decision makers to educate and inform them on community health issues that may affect their constituents.
Susan Bockrath, M.P.H., CHES
Nebraska Association of Local Health Directors
Outreach Partnership to Improve Health Literacy
Bockrath said that Nebraska is large—about half the size of California with one-tenth of California’s population density; about 14 percent of the population is elderly (a somewhat higher percentage than the national average) and the state lacks ethnic and racial diversity relative to many other states (i.e., 90 percent of the population identified as white in the most recent Census). There is a growing Hispanic population and estimates predict that Hispanics will make up about a quarter of Nebraska’s population by 2050. There is also a sizable refugee community, with Omaha having the largest population of Sudanese individuals outside of Sudan. Omaha is home to a large African American community. There are also four native tribes in Nebraska.
Health Literacy Nebraska was founded in May 2011. A statewide summit was held in January 2012. Since then two working groups have been formed. The first has focused on training and developed the “Plain Language on the Plains” quarterly webinar. The second working group has identified health literacy questions to be incorporated into the CDC Behavioral Risk Factor Surveillance System (BRFSS) survey for Nebraska (see Box 3-1). The results of the survey will be used to create a map of
Behavioral Risk Factor Surveillance Survey Health Literacy Items
- 1. How confident are you filling out medical forms yourself? For example, insurance forms, questionnaires, and doctor’s office forms?
- Not at all
- A little bit
- Quite a bit
- 2. How often do you have problems learning about your health condition because of difficulty understanding written information?
- 3. How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?
a Following the workshop the questions were pilot tested. After consultation with content experts on the pilot test results, Health Literacy Nebraska revised the questions. The revised questions may be found in Appendix D.
SOURCES: Adapted from Chew et al., 2008, and Morris et al., 2006.
health literacy and to analyze the relationship between health literacy and negative health outcomes.
Bockrath said the overriding goal of Nebraska’s Outreach Partnership to Improve Health Literacy (funded through the Health Resources and Services Administration [HRSA] Office of Rural Health Policy) is to improve literacy at the local level in all of Nebraska’s 93 counties. These counties are served by 21 local health departments. Many of the local health departments are responsible for large geographic areas, some as large as the state of Maryland. Nebraska’s public health system is decentralized in the sense that all of them are stand-alone agencies. Sixteen rural health departments
are participating in the project and are responsible for 83 of the 89 designated rural or frontier counties in the state. Nebraska’s three urban districts are currently not able to receive direct services from the project because the funds are exclusively for rural jurisdictions.
Bockrath said the project began with a needs assessment conducted through a survey and site visits. Results of the assessment led to a focus on the following objectives for the 3-year project:
- All written communication and materials are health literate and at an appropriate reading level for the intended audience.
- Regularly use a functional, user-friendly system of sharing and collaboration related to all focus areas, across all rural local health departments and tribal health departments.
- Address language access for all audiences using health-literate strategies.
- Health-literate practice is implemented throughout the public health system.
Bockrath said that site visits and technical assistance have been offered to 19 sites. One hundred forty-four local health department staff and directors participated in onsite training and qualitative data gathering. One of the project’s most successful activities, Bockrath said, has been the conduct of five health-literate writers’ workshops. A total of 77 local health department staff participated in these all-day events held in various locations across the state. During the workshops, staff work on their own health information materials. The workshops include a didactic session, where an overview of health literacy is provided, but the emphasis is on the local level and review of local materials. Bockrath said these workshops have been well received.
The project also sent eight people to the Institute for Healthcare Advancement’s Health Literacy Conference in May 2013. In addition, software licenses for Health Literacy AdvisorTM and hard copy “Starter Kits” have been distributed to all of the local health departments.
To improve communication and collaboration, Bockrath said the project’s infrastructure has been strengthened in several ways. Improvements have been made to the Nebraska Association of Local Health Departments website and an internal listserv was created to facilitate direct communication with staff, directors, and partners. The project also purchased GoToWebinarTM software that is being used to enable web-based collaborative document review. According to feedback obtained from the writers’ workshops, staff want to be able to continue to work across the state with their partners and with counterparts in other health departments. In
response, Bockrath said regular collaboration opportunities will be set up using this software.
Bockrath said the project is also applying health literacy to the task of addressing language access. The project will cosponsor a conference highlighting health literacy and cultural competency during the summer of 2014. In other areas, training is planned to better prepare the local health department staff to spread the word about health literacy. The goal is to have local health department personnel talking to their partners about health literacy as it pertains to their local clinics, hospitals, and other service sites. During the third year of the project, all of the project health departments will be developing their own pilot projects.
Bockrath discussed the applicability of the attributes of health-literate health care organizations1 to her work with local public health organizations. The first three attributes, that among other things address leadership, planning, and workforce development, are directly applicable to Nebraska’s public health departments, she said, especially as these issues are at the heart of their grant project. Leadership within Nebraska’s local health departments has embraced health literacy because it is viewed as providing great returns on investment for clients, Bockrath said. Efforts continue at the local level to connect health literacy to ongoing work in the area of quality improvement and to create policies on health literacy.
Some of the attributes are not being met, Bockrath said. For example, the attribute related to the inclusion of “populations served in the design, implementation, and evaluation of information and services” is not being addressed systematically by Nebraska’s local health departments. Results from the survey conducted before the initiation of the grant-funded interventions found that less than one third of staff had been testing or developing materials with target populations. At the time of the survey, respondents tended to rate their health department’s health literacy capabilities fairly high. When asked whether they were meeting the needs of populations of various literacy skills, 43 percent reported that they were. Bockrath hypothesized that if the survey were conducted again, the health departments would likely rate themselves less favorably because they have since learned, through workshops and training, some of the better approaches used to achieve improved outcomes.
Nebraska’s local health departments have not always included the populations served when designing and implementing programs, Bockrath said. This deficit is, in her view, explained by a lack of resources and the fact that involving target audiences in this work is time consuming and resource intensive. The need to travel vast distances to reach target populations in
1 The 10 attributes can be found in the discussion paper Attributes of Health Literate Health Care Organizations at http://www.iom.edu/health-lit-attributes (accessed July 25, 2014).
many parts of the state is also a barrier. Sometimes, a coalition partner who represents a group of interest serves as a proxy for the intended audience. This individual is asked if a particular communication is effective. Bockrath suggested that these coalition partners need to be asked to take the next step and involve the members of their community.
Through the survey and site visits conducted early in the grant cycle, Bockrath found inconsistent use of health literacy techniques such as the “Teach-Back” method. She said that “usability testing” could be a proxy for teach-back at the population level. She added that the survey found deficits in terms of having written materials available to meet the needs of individuals with limited English proficiency.
Many of Nebraska’s local health departments do not provide direct clinical services. The organizational attributes that have been developed that emphasize clinical services are less applicable to those public health departments.
Bockrath concluded her presentation by saying that many aspects of the attributes of health-literate health care organizations are relevant to public health departments. In her view, language access issues need to be further highlighted. It is a topic that is central to both health literacy and cultural competency. She added that it would be helpful to integrate initiatives aimed at furthering health literacy and cultural competency and to identify language access as a good place for public health departments to start.
Jennifer Dillaha, M.D.
Arkansas Department of Health
Dillaha described the Arkansas Department of Health as a unified health department, with its main office in Little Rock overseeing 94 local health units in Arkansas’ 75 counties. All staff in local health departments are employees of the state of Arkansas Department of Health. The department is divided into centers. The Center for Health Advancement is responsible for most of the state’s health promotion programs. The Center for Local Public Health operates all the local health units in the state’s five regions.
Arkansas has a population of nearly 3 million and a relatively high poverty rate (fifth in the nation), but about the highest in terms of child poverty. The state is also characterized by a high rate of disability; poor health status; low levels of educational attainment; and low rates of Internet usage. Dillaha said that it is estimated (using the RAND predictive model)
that 37 percent of adults in Arkansas have low health literacy (defined as basic and below basic health literacy).2
Dillaha reviewed the origins of the health literacy movement in Arkansas. In 2007, Dillaha, as director of the Center for Health Advancement, became aware that people could not access, understand, and use available health information. After reading the Institute of Medicine report Health Literacy: A Prescription to End Confusion (IOM, 2004), she partnered with a local pediatrician, Chad Rodgers, who had received health literacy training through the American Medical Association, to disseminate information on health literacy. They gave a presentation at a 2007 public health grand rounds on health literacy, which ignited interest and caused a ripple effect. Over the next year and a half, Dillaha identified people and organizations interested in health literacy.
In 2008 health literacy was integrated into the strategic plan for the Arkansas Department of Health, Dillaha said. The current version of this plan, shown in Figure 3-1, has health literacy identified as a crosscutting strategy.
Dillaha highlighted two important events that occurred in 2009. First, the Partnership for Health Literacy in Arkansas (PHLA) was formed at a meeting sponsored by the Arkansas Department of Health, Arkansas Literacy Councils, University of Arkansas Division of Agriculture Cooperative Extension Service, and Arkansas Children’s Hospital. Second, the Partnership became the official Health Literacy Section of the Arkansas Public Health Association. This organization provides interested partners with a fiduciary umbrella and access to other important resources. Since 2009, Dillaha has given a number of talks to interested parties, including the Governor’s Roundtable on Healthcare, health care providers through the HRSA-funded Arkansas Geriatric Education Center, staff of the University of Arkansas for Medical Sciences Area Health Education Centers, Federally Qualified Community Health Centers, geriatric clinics that are part of the Arkansas Aging Initiative, and additional talks at public health grand rounds.
Dillaha said PHLA has implemented health literacy interventions aimed at improving health outcomes in three domains: culture and society; the health system; and the education system. In 2013 the Partnership sponsored an all-day conference on adult education that benefitted from the participation of Winston Lawrence from the Literacy Assistance Center in New York and Greg Smith from the Florida Literacy Coalition. In 2014 the conference will focus on health literacy for older adults with the assistance of Michael Villaire from the Institute for Healthcare Advancement.
2 See presentation by Chloe Bird on page 10 for a description of RAND’s predictive model for health literacy and its mapping project.
FIGURE 3-1 Arkansas Department of Health strategic map.
SOURCE: Arkansas Department of Health, 2013.
Various programs within the Arkansas Department of Health have integrated health literacy into their planning and programs, Dillaha said. For example, the Chronic Disease Branch has used CDC funds to expand the ability of the Arkansas Literacy Councils to empower patients, especially in the area of health promotion and prevention with the use of the Staying Healthy Curriculum from Florida, which teaches health vocabulary and concepts to new readers and to English language learners.
The Family Health Branch of the health department has implemented home visiting as a strategy that supports health literacy, Dillaha said. With funding available through the Patient Protection and Affordable Care Act, a Nurse-Family Partnership program was initiated following the David Olds model,3 which Dillaha described as being primarily a health literacy intervention. Arkansas Children’s Hospital, in partnership with the Department of Health Family Health Branch, also received funding to establish the Arkansas Home Visiting Network, which includes a focus on health literacy. Also, the Arkansas Women’s Health Program worked with Health and Human Services Region VI on the Health Equity Partnership, which integrated health literacy into family planning materials.
Another health literacy effort is the Coordinated School Health initiative, which Dillaha described as a partnership that includes the Arkansas Department of Health, the Department of Education, and many other organizations focused on education. This initiative aims to bring school-based health promotion efforts under one coordinating umbrella. Through this initiative, Arkansas Children’s Hospital is making HealthTeacher available to all of the public health schools in the state by the end of 2014. HealthTeacher is a K through 12 health education curriculum specifically designed to advance health literacy. The HealthTeacher curriculum is already available to all of the state’s Catholic schools through Arkansas Children’s Hospital’s partnership with Mercy Health.
As part of CDC’s National Public Health Improvement Initiative, Dillaha said that three initiatives are under way in Arkansas: a Plain Language Quality Improvement Project; a Health Literacy Research Conference; and an effort to work on the state’s public health accreditation. The Plain Language Learning Community, a group of Health Department staff facilitated by the Health Department’s Office of Health Communications and Marketing, advocates for improving communication through the use of plain language. Their recommendations are being implemented across the department, Dillaha said. Health literacy research conferences were held in 2011 and 2012
3 “The Nurse-Family Partnership (NFP) is a program of prenatal and infancy home visiting by nurses for low-income first-time mothers.” http://www.brookings.edu/~/media/research/files/reports/2010/10/13%20investing%20in%20young%20children%20haskins/1013_investing_in_young_children_haskins_ch6.pdf (accessed February 20, 2012).
and featured Andrew Pleasant and R. V. Rikard as speakers. The CDC grant also provided funds to obtain estimates of health literacy levels using the RAND methodology so that county level and Census-tract level data would be available to researchers. The research conference has been transferred to the University of Arkansas for Medical Sciences Translational Research Institute. This institute now holds quarterly health literacy research grand rounds that have featured presentations from health literacy experts such as Terry Davis and Michael Wolf.
Dillaha said the health literacy community is working to provide training for health care providers to implement the Agency for Healthcare Research and Quality (AHRQ) Health Literacy Universal Precautions Toolkit throughout Arkansas. Providers trained in implementing the toolkit include the University of Arkansas for Medical Sciences Regional Centers (Area Health Education Centers); clinics participating in the Arkansas Chronic Illness Collaborative; 69 primary care clinics participating in CMS’ Comprehensive Primary Care Initiative; and some clinics and staff at the University of Arkansas for Medical Sciences. Plans call for training to be made available to the Arkansas Department of Health’s local health units, as well as to the state’s Federally Qualified Community Health Centers.
Dillaha said the State Health Assessment and State Health Improvement Plan, a document that was completed as part of the public health accreditation process, focuses on three areas: life expectancy, infant mortality, and health literacy. This document is available at the health department’s website (http://www.healthy.arkansas.gov).
Creation of the Arkansas Action Plan to Improve Health Literacy is a dynamic process, Dillaha said. The goals of the National Action Plan to Improve Health Literacy (http://www.health.gov/communication/hlactionplan/pdf/Health_Literacy_Action_Plan.pdf) were adapted to meet the unique needs of Arkansas. The partners throughout the state are setting their own objectives, which will be tracked. This work in progress can be found at the Partnership for Health Literacy in Arkansas’ website (PHLA. net). The Action Plan’s seven goals are as follows:
- Make health and safety information easy to understand so that people who need it can get it and use it to take action.
- Make changes that improve the health literacy of the health care system.
- Include health literacy in the lesson plans for all children in Arkansas, from infants through college students.
- Work with the adult education system and other organizations in Arkansas to improve the health literacy of the people in the communities they serve.
- Build a network of health literacy partners committed to making
changes at their organizations that will improve health literacy in Arkansas.
- Do research to better understand and measure what works to improve health literacy of the public and the health care system.
- Share and promote the use of health literacy practices that are based on the best science available.
Dillaha shared some of the lessons learned from her experiences in Arkansas. She emphasized the importance of establishing an understanding of health literacy that is widely accepted. The Arkansas partnership has not developed a single definition, but rather describes what health literacy is. In her experience, many individuals have a health literacy story to share. In an era of constrained resources, efforts to improve health literacy need to be implemented using resources currently available, which may mean using current resources differently and following health literacy principles. The experience in Arkansas has also reinforced the importance of supporting health literacy partners and helping them reach their goals, Dillaha said.
Merely increasing awareness of the problem of low health literacy is insufficient to improve it, Dillaha said. She pointed out that greater capacity is needed within health departments to address health literacy. An important strategy for improvement, she said, is the identification and support of change agents. These are people who can operate in their own spheres of influence and are key to developing partnerships, promoting systems change, and stimulating new thinking.
Pleasant began the discussion of the panel’s presentations by thanking the representatives from Arkansas, Louisiana, and Nebraska for sharing their experiences and serving as case studies for the commissioned paper (at the end of this report). In his view, the work within these three states represents stellar examples of how health literacy can be integrated into public health departments across the country.
Roundtable member Patrick McGarry asked Bockrath about the state-specific health literacy questions that will be added to the BRFSS. How were the questions formulated and how will they be used? Bockrath replied that the questions were adapted from those developed through the research of Chu and Wallace. She pointed out that Health Literacy Nebraska, and not the State Health Department, is paying for the addition of the three questions. These same three questions were included in Kansas’ BRFSS survey in 2012. This will allow some cross-border, Nebraska-to-Kansas comparisons. Bockrath stated that the usefulness of the information will be assessed and, if deemed of value, the hope is that the state will want to pay for the inclu-
sion of these survey items on a regular basis. In her view, the BRFSS data will be useful in raising awareness of the problem of low health literacy. She still finds areas where decision makers are in denial in terms of the existence of the problem. Second, she stated that the data will be useful in demonstrating the value of low health literacy in predicting negative health outcomes. Bockrath said the BRFSS survey could also provide important information on whether public health communications are improving.
Rudd observed that the term “case study” gives the false impression that a unique experience is being described. In fact, the three cases offer a lesson in how to integrate health literacy throughout a state. She asked the panel whether there was a way to identify the steps along this pathway to integration that other states could take. She specifically asked the panel to respond to two potential actions that could theoretically be taken. First, could a requirement be put in place for all employees of public health departments, whether state or local, to take a short online course in health literacy, such as the one developed by CDC? Such a course could be required of all existing staff and part of the orientation for all incoming staff. Second, would it be possible to have a regulation that all contractors with departments of public health who are responsible for the design of websites and health education materials show evidence of meeting certain criteria, for example, that they pilot test materials with the intended audience?
Harris shared her experiences as the director for Health Equity in Kentucky. While there, she worked with the commissioner and the Workforce Development Division on staff training. A webinar about cultural and linguistic competency as related to health equity was designed, called Train. Staff were required to take the webinar and brown bag lunches were offered to complement the webinar. Most public health departments have access to this webinar. Harris added that to implement such a policy, it is important to encourage decision makers and work with human resources entities. She added that the implementation of such policies takes time.
In terms of contractors, Harris stated that it would be necessary to work with staff who develop health system contracts. When Harris was involved in the state’s Tobacco-Free Living Program, she created a standard that required the input from the diverse populations targeted by the messages on panels set up to develop plans and messaging. There was a history of issuing messages that did not reflect the needs of high-risk populations. The new policy helps to ensure that vendors and contractors have a diversity perspective.
Dillaha questioned whether a mandate such as those proposed by Rudd would be workable. She has found that it is most helpful to make training accessible and then to encourage participation. Arkansas is a relatively poor state with serious information technology infrastructure issues. For
example, she said the state purchased 10 licenses for the Health Literacy AdvisorTM software and made sure that at least one person in each region had access to the program. However, the software could not be used because of computer systems incompatibility.
Dillaha said a state agency outside of the health department is responsible for the development of websites. Given the volume of their work, it is difficult for them to adequately address the needs of the health department. As a result, a staff member at the Office of Health Communications and Marketing taught herself HTML so that the website-based needs of the department could be met. Dillaha added that this individual is part of the plain-language learning community and receives requests to perform readability analyses for online content. Dillaha concluded that some health departments would not be able to implement a mandated training requirement, given their lack of staff and expertise. In her view, developing the infrastructure and growing the expertise are priorities. Bockrath added that having such infrastructure and expertise could be adopted by health departments as a best practice goal.
Dogan Eroglu from the CDC’s Office of the Associate Director for Communication commented that after hearing Pleasant’s summary of the health department survey he was worried and asked himself, “Is it that bad?” When he learned through the discussion that health literacy activities were ongoing, but hidden, he was relieved. When Eroglu heard from the representatives from Arkansas, Louisiana, and Nebraska, he stated that he was encouraged. In his view, there appear to be great practices and tools available that need to be taken to scale.
Deb Scholten, health director at the Northeast Nebraska Public Health Department, is a colleague of Bockrath and involved in both the Nebraska Association of Local Health Directors and Health Literacy Nebraska. Scholten observed that although the Nebraska health department started its health literacy project in 2008, the case study illustrates how Nebraska remains in an early stage of public health development in terms of its local health departments. She noted that only 22 of the state’s 96 counties had health departments prior to 2001. Scholten said that in the four counties where she works, there is a notion that public health is something new that the government thought up. Many of the health directors had never heard of public health. This lack of a basic understanding of public health is itself a barrier that needs to be overcome. She added that new employees are required to take online courses on three topics: public health 101; health literacy; and public health emergency response preparedness.
Roundtable member Cindy Brach from AHRQ asked Bockrath whether having templates would help her organization implement the attributes of a health-literate health care organization. Bockrath replied that templates are needed for health literacy policies for local health departments in general,
and not specific to the attributes. She added that many templates are available for states to use, but she was not aware of one that characterizes health literacy policy requirements of local health departments. Bockrath stated that such a template would be useful because although health department directors are committed to integrating health literacy into training opportunities and programs, they do not have time to develop policies from scratch.
Harris said such a template would not necessarily be helpful. Instead, she thinks agencies need to have clear objectives that address cultural and linguistic competency and to have processes in place to ensure that the target audience is included as part of the planning process. In the end, the health department should be able to answer these questions in the affirmative: “Did we include the intended audience at the outset of planning?” “Did we market this intervention to the appropriate population?” and “Did the intervention work?”
Dillaha said that model policies could be helpful and be considered a template. She added that states with limited resources can gain from the experiences of others. A template could facilitate sharing of successful policies and processes. Models can stimulate thinking and discussion. Bockrath agreed and said the term “model” seemed more appropriate in this context than “template.”
Brach asked Dillaha why the Arkansas Department of Health decided to prioritize training in universal precautions. Dillaha replied that the focus on universal precautions came about because the department needed to overcome the perspective held by many public health professionals and health care providers that health literacy is a deficit of the person rather than the system in which they operate. The toolkit allows providers, whether they are in a primary care clinic or a local health unit, to assess their practices and then look for evidence of ways to improve them. She noted that a particularly useful section of the toolkit teaches the “plan, do, study” cycle, a much-needed concept to incorporate into both the public health and health care systems. Dillaha added that the toolkit provides simple exercises that clinic staff can do on their own and it allows them to, in effect, “own the process.” Dillaha observed that many providers are frustrated with the current system and acknowledged that there is room for improvement. Some improvements, especially in the area of communications, are not costly and not difficult to implement. She added that the use of the toolkit is a relatively easy way to engage individuals new to the area and to address the so-called low-hanging fruit.
Rudd said the planning committee for the workshop articulated a strategic long-term plan of building relationships with people in public health and then examining the 10 attributes of a health-literate health care organization and their applicability to public health. She added that the
presentations and discussion have greatly added to an understanding of what a health-literate public health organization would look like. Isham invited the panel to make additional comments on the 10 attributes and how they might be adapted to public health organizations. Bockrath reiterated her concern that the attributes that are related to communications with health plans and health insurance coverage issues are often not directly relevant to public health departments. In Nebraska, for example, she noted that there is no reimbursement for public health services. She added that attribute 7, which addresses navigational issues, is more relevant to clinical services within the health care system than to public health. Bockrath said these attributes do not need to be eliminated. Instead, the attributes can be written so that public health interests are reflected. It is important that health department personnel understand that the attributes apply to them as well as to others.
Bockrath stated that issues related to language access could be further accentuated in the attributes because it is something essential to public health, especially for those serving rural areas. Bockrath said that having CLAS (Culturally and Linguistically Appropriate Services) standards as part of the attributes would be useful because health departments are key access points for community interaction. This level of engagement would be enhanced by the practices that are called for in the CLAS standards.
Dillaha added that some of the attributes may relate more closely to clinical areas, while others could apply more directly to public health. For example, issues related to septic systems are under the purview of public health, and attributes related to these functions would likely not be applicable to clinical settings. In short, Dillaha suggested that some of the attributes could be generally applicable while others could target either health care or public health entities.
Harris concluded the discussion by noting that health literacy is about understanding our own biases, being aware of other people’s cultural experiences, looking at the environment in which they live, and understanding some of their challenges. She added that it is important to meet individuals where they are, form trusting relationships, and find ways to sustain programs and efforts that will really help their communities.
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