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Reflections on the Presentations and Discussions
Isham invited members of the roundtable to reflect on the day’s proceedings. Rudd was impressed with the insightful presentations and said the case studies presented deserve careful examination. She suggested deconstructing these case studies by asking questions such as “Why did you do X first and not Y? How did you do A, B, and C?” In her view, such an analysis will begin to uncover optimal strategies and guide further action.
Alvarado-Little reflected on her experience as a spoken language interpreter and the need to focus on next steps so that there is a plan in place to address the needs of those with low health literacy. She described going into a room with a doctor, providing interpretation services for a patient and family member, and at the conclusion of the visit, having the doctor turn to her and ask, “Do you think they understood everything?” Her response was, “Well, if you’re asking me, we should go back in.” Alvarado-Little said that from her perspective, there is much work to be done.
McGarry said that during the planning phase of the workshop, he was concerned that health literacy would not be demonstrated adequately in the public health sector. However, he has learned through Pleasant’s work and the workshop presentations that health literacy in the context of public health addresses a different set of issues from health literacy in a clinical context. He noted that there are some commonalities. In his view, health literacy needs to be prioritized by public health departments, perhaps within their communication divisions. McGarry added that the project on integrating primary care in public health mounted by the Association of State and Territorial Health Officers offers a great opportunity for the medical and public health communities to work together to achieve common health
literacy goals. Because many health departments provide clinical preventive services and well-child visits, McGarry said the successful Reach Out and Read Program could be expanded substantially in these environments.
Parnell concluded from the presentations that a focus on working in partnerships and through collaboration is needed to find common ground. She added that innovation will help move the health literacy agenda forward, as will adoption of evidence-based best practices. Parnell agreed with Alvarado-Little’s comments and said that cultural humility and access to language services are an essential part of health literacy.
Fowler observed that there are many opportunities to promote health literacy within public health departments. She was impressed with the programs that have been put in place in Arkansas, a state with few resources and with communities with unique health literacy challenges, for example, Appalachia. In her view, the health literacy messages conveyed by the poets featured in the workshop were an excellent example of using innovative communication approaches. Based on the day’s proceedings, Fowler concluded that the definition of health literacy needs to be updated. She said any updating process would have to consider the many possible ways to communicate with different populations. Fowler reiterated some of the opportunities presented by the Patient Protection and Affordable Care Act (ACA), for example, through accountable care organizations and patient-centered medical homes. She added that there is also value-based purchasing for hospitals under the ACA and, according to this new financing mechanism, 30 percent of the bonus payments to hospitals will be based on patient satisfaction. She said there will be new penalties for hospitals that have higher rates of readmissions. Readmissions are sometimes the result of patients not following directions and not taking their medication because of poor health literacy. Finally, Fowler mentioned that the ACA includes a requirement for health plans to use plain language when describing health benefits and options. For example, the plans will have to provide information on typical out-of-pocket costs related to three common conditions so that individuals considering their insurance options will better understand their coverage.
Robinson said she appreciated learning about oral health literacy issues from Horowitz. She has found many similarities between the issues raised within the health and public health communities and oral health. She pointed out that dental disease is essentially a chronic disease that can be managed in ways that are similar to those used for other chronic diseases. She added that there are many opportunities to work with colleagues and other disciplines to further the health literacy agenda within dentistry. Robinson observed a crosscutting issue across all the workshop panels—champions are needed who can shepherd the cause and provide leadership in their particular sphere of influence on both a community and a systems
level. She described a presentation given by a social scientist at Stanford University, Hayagreeva Rao, at a prevention summit she recently attended that was hosted by the American Dental Association. In his remarks, Rao stated that to have a successful social campaign, an “air war” and a “ground war” are needed. The air war prepares the way for the success of the ground war. Robinson likened the concept of the air war to policies and systems that are in alignment to promote best practices and health literacy. She said examples of the ground war would include community activities such as the poets’ workshops in the Bay Area and the activities described as part of the case studies in Arkansas, Louisiana, and Nebraska. The presentations by the young poets represent a powerful experience that uses emotional content to pull the audience in and prepare them to hear the message. In effect, such approaches make the message very “sticky.” Robinson said she agreed with Rudd that we cannot wait for the educational sector to inform the public. People are dying. This is a call to action. Public health departments play a major role in this process, but they require resources to become fully equipped to assume these responsibilities, Robinson said.
Hall observed that there was a recurring theme throughout the day, “What gets measured gets managed.” In the context of informed consent, she noted that such consent was obtained to protect providers and organizations from lawsuits. She asked, “What if the consent process was designed and measured in a way that protected the patient and served to truly educate the patient?” She suggested that the development of metrics and the act of measuring could be an effective driver of change. In her experience, change does not happen until there is a metric assigned to the behavior or activity. Once the metric is in place, people start to buy in because they understand the importance and value of the behavior being measured. In this world of competing priorities and information overload, introducing health literacy to an organization is all too often perceived as yet another work stream. Adoption of health literacy would be more likely, she said, if it is introduced and integrated with other programs and services for which there are metrics.
Logan found Rudd’s focus on the importance of community and civic engagement to be critical to the success of health literacy efforts. He said that Neuhauser nicely operationalized the process of engagement in the seven steps that she described as essential to the success of a health communication intervention.
Parson summarized in three words the main points she took away from the workshop: communication, partnership, and innovation. She reiterated a point made by Rudd that any communication strategy has to focus on “who it should be by” and “who it should be for.” She said communications must be designed so that they effectively reach diverse populations. Parson also found illuminating the presentations on new technology and social
media that encourage participation of young people and novel approaches to communication. She added that communication and education need to begin in preschool and continue throughout the educational trajectory.
Wayte said he benefitted from Horowitz’s description of ways to encourage mothers to adopt good oral health habits for their infants. He said that in the area of heart disease and stroke, there are also teachable moments that can motivate individuals to create new habits. The work of the poets as part of The Bigger Picture project is inspiring, he said. His organization is also relying on social media campaigns, health technology, and art to communicate public health messages, especially in the area of women’s health.
Rush observed that health insurance companies and others have many messages they want to communicate. He learned from the presentations that success hinges on how messages are delivered and how consumers are involved in understanding and crafting the messages. He noted that it is not what individuals read, but what they remember that is important. Rush found that the workshop has provided a great impetus for collaborations among health literacy, public health, and the health system to further improve communication through simple, accessible, understandable, and actionable ways. He added that there are also opportunities for collaboration on research to determine the impact of health literacy interventions and public health messages.
Parker reiterated the need for public health literacy measures and the sentiment that “what gets measured gets done.” She noted that a publication she coauthored in 2005 with Julie Gazmararian, Jim Curran, and Barbara DeBuono discussed the need for such measures. Parker said there is an opportunity to develop such measures with the implementation of the ACA.
Brach said that health literacy in the context of public health or health care have much in common. For example, she said, they both need to address workforce training issues; involve the communities they serve and the target audiences of their messages; use models and tools to make their work easier; and address the challenges of adoption and dissemination. She found it heartening to see how the attributes of a health-literate organization, which was developed with health care delivery organizations in mind, appeared to have relevance and be helpful to those leading the way in public health.
Pleasant raised the issue of the medical and social needs of the more than 10 million individuals who are incarcerated, many of whom are of low health literacy. He said there is a potentially great opportunity to address health literacy in a public health context with this population. He reported that individuals in jails and prisons account for 19 percent of all HIV cases, 30 percent of all hepatitis C cases, and 15 percent of all hepatitis B cases.
He added that more than 30 percent of this population suffers from a mental health condition, and more than half have some form of addiction. In his opinion, attention to this population provides an incredible opportunity to advance not only public health, but to prove the validity and usefulness of health literacy. He indicated that this topic would be timely for graduate students to consider.
Pleasant said the intention of the commissioned paper was to perform a critical analysis to illustrate the opportunity that health literacy presents to improve public health at a lower cost. He added that there was no intention to criticize public health. He said the authors of the commissioned paper decided to characterize the extent to which public health departments had decided that health literacy was important enough to highlight so that when the investigators called or e-mailed, their front office person would be able to identify someone connected to health literacy within the organization. He pointed out that if the health department did not answer the survey, or could not identify such a person, it did not necessarily mean that the health department was not involved in health literacy activities.
In Pleasant’s opinion, health literacy should be highlighted as an important and critical part of the mission of public health. On the topic of health literacy training, Pleasant noted that the Ohio State University College of Nursing will soon have an undergraduate degree in health and wellness innovation and health literacy. There is also a university-wide health wellness initiative called Buckeye Wellness.
In response to Isham’s invitation to audience members to pose questions, Marie Fongwa, a member of the audience, discussed the importance of integrating the topics of health literacy, cultural competence, and health disparities into program planning. She cautioned that health literacy is not just a concern of ethnic or racial minority groups, however. Many individuals, even those who are highly literate, cannot interpret the health care jargon. She noted that health literacy is part of being culturally competent. Audience member Shanpin Fangchiang agreed and said everyone can be considered a learner. She added that health literacy could be incorporated into several areas within a school’s curriculum.
Carter-Pokras said that public health and health literacy will be major themes at education sessions at the 2014 American Public Health Association meeting in New Orleans.
Bishop discussed the role of communications offices within health departments. Many of these offices have a public relations function and so do not have a health literacy focus. He said that ideally, communication offices would be involved in health literacy and would have staff that could offer expertise and assistance to other offices within health departments. He said such in-house expertise could help with politically charged issues such as gun control and water fluoridation. His state is addressing proposed
changes to the level of fluoride in drinking water and the public is seeing competing messages from the government and advocacy groups about the benefits and risks of fluoride. Educating the public on these complex issues is challenging and in need of communication and health literacy expertise.
Dillaha said cultural competency and health literacy encompass the notion of equal opportunity for health and respect for all persons.
Isham observed that in its early days, health literacy addressed issues related to the communication between individual patients and providers within the health care system. Health literacy in the context of public health is different insofar as it addresses the health of populations in diverse geographic settings. He found this concept well illustrated in Bird’s presentation when she said that an individual living in an area with relatively high health literacy benefits from the knowledge and ability of friends and neighbors. In contrast, those living in areas of low health literacy may not benefit from such interactions and, in fact, such interactions may be counterproductive. Isham added that what happens in populations actually matters to individuals in those populations. In addition, it is not just interventions that affect the ability of individuals to act on their own behalf, but also interventions that change the environment in which individuals live. This is an area that needs more attention, said Isham.
Isham said that Pleasant’s background paper provided important information on the crisis facing contemporary public health departments in terms of both resources and skills. The attributes of a health-literate health care organization need to be adapted and expanded to be relevant to public health organizations, Isham said. These attributes may vary for federal, state, or local organizations. He said he was at times optimistic when hearing about the present state of health literacy training, but was left concerned at the conclusion of the workshop about opportunities for preparing the future public health workforce. Lastly, there is wide variation in definitions of public health literacy that are used across the country, and reaching a consistent view of the concept is one of the many challenges ahead, Isham said.
