Implications of Health Literacy for Public Health Workshop Summary (2014) / Chapter Skim
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Appendix C: A Prescription Is Not Enough: Improving Public Health with Health Literacy
Appendix C: A Prescription Is Not Enough: Improving Public Health with Health Literacy
Pages 109-158
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Appendix C A Prescription Is Not Enough: Improving Public Health with Health Literacy1 Andrew Pleasant, Ph.D.,a Jennifer Cabe, M.A.,a Laurie Martin, Sc.D., M.P.H.,b and R
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, 133 Findings from a Brief Inquiry of Public Health Professionals at State, Local, Tribal, and Territorial Public Health Departments, 136 The Potential Utility of Health Literacy to Public Health, 145 Conclusions and Recommendations, 152 References, 156 BOX 1 Public Health Opportunity: Advancing Health Literacy in Jails and A Prisons, 148 FIGURES 1 Public health departments in Nebraska, 126 2 Percentage of Arkansas population with low health literacy, 131 3 Health literacy within state departments of public health, 133 4 "THIS IS PUBLIC HEALTH" campaign sticker, 150 TABLES 1 Perceived Relevance of the 10 Attributes of a Health-Literate Organization, 138 2 Health Literacy Activities Within Public Health Departments, 139
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V.) Rikard would like to thank the IOM Roundtable on Health Literacy staff and members for their courage and compassion in addressing the health inequities of low health literacy and poor health.
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In particular, this article focuses on efforts within state, local, tribal, and territorial public health organizations. Overall, while a growing body of evidence strongly suggests that health literacy can be effective in public health when explicitly addressed, the concept and associated best practices of health literacy do not seem to be consistently or universally used within public health organizations.
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focusing on the attributes of a health-literate organization will have a positive effect on this situation. However, as this article will illustrate, public health departments currently seem not to be universally or explicitly addressing health literacy.
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Although more research is certainly needed, we now have 8 more years of research since the Surgeon General's Workshop on Improving Health Literacy. That research indicates more explicitly and robustly that public health efforts need to engage with the field of health literacy in order to effectively and efficiently reach the mutual goal of a healthy public.
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This is true from the very beginning of the volume as the title explicitly states that a prescription is needed versus -- in the common parlance of public health -- a program. One small effort that has moved toward a more explicit inclusion of public health within a definition of health literacy is the Calgary Charter on Health Literacy.
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Behavior change is a highly targeted and valued outcome in public health efforts as well. Research by many scholars makes it precisely clear that health literacy interventions must include a keen awareness of fundamental literacy, scientific literacy, cultural literacy, and civic literacy.
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. It seems that an early pioneer in defining public health depicted a stronger role for health literacy than current public health organizations do today.
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That means health professionals will engage with the whole person, versus just diagnosing and treating a disease. Involving people early and often also inevitably shifts the focus to prevention rather than treatment of an illness after it manifests.
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public health system and the state of public health in the country are not healthy. For example, the authors of this report (NRC and IOM, 2013)
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. Advancing health literacy to prevent disease and promote wellness is a proposition that is directly in line with the mission of public health organizations and has the added promise of not only improving health and well-being, but doing so at a lower overall cost over time.
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The following set of case studies illustrates how health literacy can be effectively put in place across that spectrum. While the potential usefulness of health literacy to public health seems somewhat straightforward, what is not known is the extent to which, and how, public health organizations conceive of and operationalize health literacy; organize and train staff to address health literacy within their mission; and approach development of materials with health literacy in mind.
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and countless other organizations with the staff and expertise to support state and local public health departments. The goals and objectives of these Institutes vary, though some are proving to be valuable assets to public health departments' efforts to address challenges related to low health literacy.
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Staff at both the public health organization and the PHI noted that a significant barrier to implementing activities that addressed the challenges of low health literacy was the lack of a formal methodology for "how to do it." With the exception of social marketing, staff at both the PHI and the state health department agreed with this participant's view that, "To my knowledge, there is not a tried and true process for developing materials with this principle in mind. There's that Word program that can tell you the reading level, but that has a lot of limitations.
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Such partnerships, however, should not preclude development of internal capacity within public health organizations as it may also prove more efficient and cost-effective for those organizations to bring health literacy expertise into their staff over the longer term.
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The Nebraska Public Health System Nebraska's public health departments are diverse in terms of organization, funding streams, and services provided in their districts. While public health departments are a fairly new resource across Nebraska, public health and health literacy professionals recognize the important connection between public health and health literacy.
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126 FIGURE 1 Public health departments in Nebraska.
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The provider side needs to communicate in a way the general public understands." One participant pointed out that the health care system in the United States focuses on disease and illness rather than prevention and promotion. Moreover, the participant pointed out that public health professionals are taking the leadership role to focus on health literacy as a means to prevention by stating, "public health is the ‘paper clip' to hold all information together." In addition, participants provided examples of steps that their public health departments have taken to make health information understandable to the general public.
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It is a three-semester course and is the first in Nebraska." Reflecting on what health literacy best practices they might recommend to others, participants gave several pieces of advice primarily focused on public health organizations just beginning their efforts to address health literacy. One participant specifically stated, "You need a champion .
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In these words in their Assessment and Plan: "The problem of low health literacy is solved when the health literacy of the health care system is in balance with the health literacy of the patients it serves." Consistent with that belief system, the responsibility for addressing the health needs of Arkansans through a health-literate public health approach is at the heart of this state health department's view of its own purpose and
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Thus, in Arkansas, efforts are ongoing to improve health literacy across the lifespan of its residents, and in each of its 75 counties. To multiply the effects of this work in a state that suffers from poor health metrics, it is notable that the Arkansas Department of Public Health has taken up the partnership model for advancing health literacy by joining forces with other statewide units.
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Perhaps the broadest and most visible multi-sectorial approach to advancing health literacy in Arkansas was formed in 2009, and was catalyzed not only by Arkansas Department of Public Health staff and leaders, but also by volunteers, staff, and leaders of literacy organizations, universities, and health care organizations, as well as individuals who were not sponsored by or professionally affiliated with an organization, but who cared about health and health literacy. Today, the Partnership for Health Literacy in Arkansas is a true statewide coalition and has developed a state action plan with these seven goals, which are not listed in any particular order of importance:
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Public Health and Health Literacy: What's Happening? To further learn about the use, or lack of use, of health literacy within state, local, tribal, and territorial public health organizations, we set out to directly ask individuals working in public health about their attitudes and experiences regarding health literacy.
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Ten state departments of public health reported that they did not fit the Health Literacy Staff Member No Formal Health Literacy Efforts Reported Health Literacy Part of Work Health Literacy Point of Contact No Response FIGURE 3 Health literacy within state departments of public health.
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• The National Association of Local Boards of Health (NALBOH) • The Office for State, Tribal, Local, and Territorial Support at the CDC • The Arkansas Health Literacy Working Group In addition, we sent the invitation to participate to more than 400 individuals identified via the APHA member directory online whose titles and affiliations indicate they work at a state, local, tribal, or territorial public health organization.
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The overall response rate, nonetheless, is clearly exceedingly low, as we received 63 responses. Two responses had to be removed from the sample because individuals who worked at federal-level public health organizations responded to the inquiry, although our invitation specified that the effort was specifically targeted to public health officials at state, local, tribal, or territorial public health organizations.
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Thus, the small number of responses does represent a large and diverse array of public health organizations. Participants were asked how the public health organization where they are employed defines health literacy.
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On average, participants reported that 30.7 percent of the overall effort at the public health organization where they are employed is spent addressing health literacy in some fashion. The lowest response received was 0 percent and the highest was 100 percent, indicating a broad range of perceptions of not only the amount of effort directed at health literacy within public health organizations, but also likely indicating a broad range of understanding of health literacy.
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ticipants reported that rewriting plain-language materials was the most frequently adopted health literacy activity. Many expressed a view that this was also a very effective strategy for public health organizations to employ.
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(39.1%) literacy skills.
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For some reason, however, this core activity has not been adopted widely by the public health organizations where this study's participants are employed. Inquiring further as to how participants' public health organizations were responding to health literacy as a potential tool to improve public
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Finally, we qualitatively explored the health literacy activities and perceptions of health literacy at the public health organization where participants are employed. Themes in the responses indicate that when health literacy is addressed within public health organizations, it is being approached in a piecemeal fashion often limited to one individual or a small group versus instituted in an organizationwide and coordinated fashion.
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This is a very difficult concept for public health professionals who are not ‘communicators' to understand. We learned that well-chosen HPV [human papillomavirus]
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• Launch an educational campaign to health professionals empha sizing the need for improvement in addressing health literacy to improve public health outcomes. • Launch an educational campaign to the public to empower them to demand clear, concise, and understandable information from public health organizations and professionals.
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within public health departments to specifically address health literacy of the population the organization serves. • Make departments and staff accountable to a requirement to address health literacy effectively.
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on what is feasible within the timelines and resources of public health organizations. The Calgary Charter on Health Literacy, mentioned earlier in this article, may present a useful framework for public health agencies.
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That logic model can be used to design effective programs, critically evaluate, and inform both sides of the health literacy equation -- the supply from individuals and the demand from health systems and professionals.4 To hopefully help illustrate the potential benefits of health literacy to public health, we will employ the Calgary Charter's logic model of health literacy as a path to behavior change as an analytic framework (Coleman et al., 2009)
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(Many other definitions agree in whole or in part with that logic model; it is the author's preference based on experience to use the Calgary Charter model for this analysis.) By employing health literacy as an analytical tool, public health departments could identify where and how to alter the design of programs and interventions to increase effectiveness.
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Research has indicated that inmates in jails and prisons have lower health literacy, are poorer financially, are in greater need of health services than the non prison U.S. population, and have disproportionately higher incidence of chronic health conditions and poorer health outcomes compared to the general popula lytical framework to evaluate public health efforts is possible through the campaign titled "This Is Public Health." This campaign is sponsored by the Association of Schools of Public Health to "let people know that public health affects them on a daily basis and that we are only as healthy as the world we live in." In brief, the core activity of this campaign consists of providing stickers (see Figure 4)
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The U.S. inmate population presents an unprecedented opportunity to ad vance health literacy, reduce health disparities, achieve health equity, and improve public health.
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Overall, it seems clear that a good injection of health literacy into the "This Is Public Health" campaign could help redesign the effort by building a structure into the campaign to help individuals find, understand, evaluate, communicate, and use the information provided to make an informed decision about public health and about the particular characteristics of their lived environment that influence public health. We note that this sort of a public health campaign -- a fairly shallow effort to draw attention to an issue, but not helping people make an informed decision about public health behaviors -- is unfortunately quite common.
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The outcome of this mismatch between the supply of health literacy and the demand for health literacy resulted in a failure to follow the logic model proposed by the Calgary Charter on Health Literacy as the path to informed decision making. People made uninformed or misinformed decisions based on the little information or misinformation they possessed.
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The most likely conclusion we can draw from this experience seems to be that the relationship between health literacy as a field of practice, research, and action and the efforts of local, state, tribal, and territorial public health organizations remains in its infancy. On the positive side, this situation indicates that the field of health literacy faces a great opportunity to improve public health practice, research, and health outcomes.
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The potential benefits of embedding health literacy into public health organizations in the United States apparently have not been made sufficiently evident to the key public health decision makers within those organizations. That is the only acceptable explanation for why the research, critical perspective, and best practices of health literacy have not fully informed efforts to improve public health in this country.
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population. To fulfill that vision, public health organizations must work to ensure that either individuals have the necessary health literacy to navigate the public health and health care systems or that those same systems successfully reach out to accommodate those people who have less than proficient health literacy.
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• Engage with public health organizations such as APHA, ASTHO, NACCHO, NALBOH, and The Society of Public Health Educators to mandate training and evaluation of the health literacy awareness and skills of all public health professionals. • Build and actively promote an open-access and evidence-based repository of the best practices of health literacy that have been proven to improve public health.
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2009. Calgary charter on health literacy.
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Health literacy efforts outside of the United States. Washington, DC: Institute of Medicine.
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2006. Advancing health literacy: A framework for understanding and action.
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