Cynthia Baur, Director, Division of Health Communication and Marketing, National Center for Health Marketing, Centers for Disease Control and Prevention, welcomed participants to the Town Hall Meeting on Improving Health Literacy. This is the second of four Town Hall meetings created for participants to learn about significant activity in health literacy among communities and regions, share promising practices, and provide input for a national action plan to improve health literacy. This meeting was cosponsored by the U.S. Department of Health and Human Services' Office of Disease Prevention and Health Promotion (ODPHP), the California Department of Managed Health Care, and the Health Research for Action in the School of Public Health, University of California (UC), Berkeley.
Linda Neuhauser, Clinical Professor of Community Health and Human Development, School of Public Health, UC Berkeley, opened the Town Hall with a summary of the 2006 Surgeon General's Workshop on Improving Health Literacy. She had been one of the presenters at the 2006 Workshop. Leading researchers from across the country presented the state-of-the-science on health literacy issues from a variety of perspectives, including health services research, education, cognitive science, communication, linguistics, aging and health disparities. The purpose of the Workshop was to establish an evidence base to inform future actions in health literacy improvement.
The Workshop led to several conclusions:
Proceedings from the Workshop are posted on the Office of the Surgeon General's Web site (www.surgeongeneral.gov).
Representatives from three California state offices described health literacy initiatives underway at the agency level to reach more effectively their constituents with limited health literacy skills. Each panelist described the challenges and barriers among the populations they serve and solutions implemented to overcome them.
Lucinda Ehnes, Director, California Department of Managed Health Care (DMHC), described the gap between consumers' skills and the health sector expectations and demands. The trend, Ms. Ehnes noted, toward consumer-directed healthcare puts at risk people who lack enough consumer skills to navigate the healthcare system and get the information and care they need. For example, Ms. Ehnes reported the average reading level for Californians is seventh grade. In contrast, health plan and DMHC consumer materials are written at college or post-graduate levels, often by attorneys. Moreover, law requires that some health plan material content be verbatim from the statute.
The challenge for the DMHC has been in finding a balance between medical, legal, and healthcare industry terms and language that average consumers can understand. The DMHC is developing model documents for the insurance market to use that meet statutory disclosure requirements, yet are written at a ninth-grade reading level. They have revised DMHC consumer letters, complaint forms, and applications, as well as the consumer section of the DMHC Web site, applying best practices in health literacy. The materials are undergoing testing and will be adapted based on results. A new challenge is to revise the "required disclosures" language in the Knox-Keene Health Care Service Plan Act of 1975, the set of laws passed by the State Legislature to regulate Health Maintenance Organizations (HMOs) within the State, to meet literacy guidelines.
The California Department of Health Care Services (DHCS) finances and administers a number of individual health delivery systems, including California Medical Assistance Program (Medi-Cal), a managed care program. Vanessa Baird, Chief, Medi-Cal Managed Care Division, DHCS, described an initiative underway to help constituents make informed choices about enrollment and more effectively navigate the healthcare system. DHCS collected research to determine the languages spoken by program beneficiaries. The Department intends to translate materials into these languages and revise materials to the sixth-grade reading level. DHCS ensures that beneficiaries are informed of their healthcare options through in-person presentations, information materials, and a call center that includes translated materials and oral interpreter services.
In addition, Medi-Cal recently partnered with UC Berkeley, School of Public Health, Health Research for Action, to increase voluntary enrollment of seniors and persons with disabilities by raising awareness about Medi-Cal. Health Research for Action conducted a literature review, key informant interviews, and consumer interviews to develop content for a guidebook that explains enrollment options and benefits. The content is written at the sixth-grade reading level, is easy to understand for those who are limited English proficient (LEP), and includes accurate cultural adaptations. Pilot testing, via phone surveys among Riverside, Sacramento, and Alameda populations, revealed that beneficiaries display an increased understanding of enrollment options and an improved ability to make choices. DHCS hopes the guide will increase enrollment in Medi-Cal and provide better access and coordination of care.
The California Office of the Patient Advocate, Deputy Director Ed Mendoza explained, informs and educates consumers about their rights and responsibilities as HMO enrollees and teaches them to use the services effectively. Hoping to use current HMO materials to reach a diverse set of consumers, the office conducted an independent assessment in 2002 and found that almost half (49 percent) of HMO reading materials are at graduate school reading level; another 45 percent are at the college level.
Therefore, the Office of the Patient Advocate partnered with Health Research for Action to create two HMO guides, one for the general population and one for seniors, which could be used as resources for enrollment and healthcare decisions. The guides offer simple, personal, action-oriented messages for a diverse set of consumers with complex needs. A 2004 evaluation of the guides revealed that 73 percent of those who took them home had read or looked at some part of them. In addition, 19 percent said that information from the guides changed their thinking or caused them to do something different. The Office of the Patient Advocate continues to distribute the guides, participating in over 1,000 local events and making face-to-face contact with nearly 100,000 consumers last year.
At the end of the presentations, meeting participants posed several questions to the panelists. The discussion centered on several key issues.
Panel members provided a diversity of perspectives on the initiatives underway to improve health literacy within the communities of California. These promising practices exemplify the improvements possible in the interaction between individuals and the healthcare system.
According to Yolanda Partida, National Program Director, Hablamos Juntos, language diversity in California is greater than in the whole of Europe. Moreover, roughly 20 percent of Californians are considered LEP. To bridge the language gap, Hablamos Juntos created two tools to improve patient-provider interactions for persons who are LEP.
One such tool, Universal Symbols for Health Care, uses universally recognized graphic symbols, based on the Mexico subway system, to help LEP populations navigate health facilities. The Hablamos Juntos Web site offers a downloadable workbook that suggests ways to implement the symbols in the healthcare setting. The second tool, More Than Words Tool Kit Series, helps healthcare organizations become more proficient in ensuring quality health materials are produced for LEP patient populations. Drawing on lessons learned from studying translation errors, Hablamos Juntos developed and tested the Translation Quality Assessment tool to assess the quality of translated text.
The IDEALL (Improving Diabetes Efforts Across Language and Literacy) Project leverages telephonic technology and group medical visits to address the literacy and language needs of high-risk diabetes patients and to enhance self management. Dr. Dean Schillinger, San Francisco General Hospital, explained the project, noting that a three-arm randomized control trial was completed with patients who received weekly phone calls via an automated telephone diabetes management system, monthly group medical visits, or usual care. The trial demonstrated improvements in communication and self-efficacy with regard to health behaviors and functional status at a modest cost, especially among low-literate and LEP populations.
This innovative approach transforms the healthcare delivery system from reactive to proactive through the inclusion of surveillance, monitoring, tailored health education, and triggered call backs. An evaluation showed that IDEALL generated new knowledge about how to transform clinical and public health practice to benefit populations with the greatest needthose with limited health literacy. Four new projects using a similar methodology and technology are underway. Future efforts will be made to create more nimble software that can be adapted to meet nonprofit contexts and to link it to medication intensification to improve health outcomes.
Radio Bilingüe is the first and only Latino radio network in the United States. Through 24-hour public radio satellite, Radio Bilingüe reaches out to listeners in nearly 80 communities across the United States, Puerto Rico, and parts of Mexico. Zaidee Stavely, Associate Producer, described La Cultura Cura (translated "Culture Heals"), a radio campaign that promotes health and wellness for Spanish, Mixteco, and Triqui-speaking farm workers, their families, and their communities. The health needs of farm workers are many. Nearly 70 percent of farm workers in California lack any form of health insurance, and almost one-third of male farm workers have never been to a doctor or clinic in their lifetimes. Access to healthcare for this population is impeded by language and cultural barriers, and, in many cases, an inability to understand how to navigate the medical system.
The components of La Cultura Cura include talk shows, feature news reports, educational messages, and mini radio dramas, all designed to create health behavior changes, community action, and public policy changes at the local, state, and national levels. Although many challenges confront the station, including limited resources and competition from other radio stations and other commercial messages, an independent survey of the campaign revealed promising findings. Two out of three listeners have discussed Radio Bilingüe health programming with others. Moreover, the news reports have prompted new pesticide drift regulations, increased health official presence in the San Joaquin Air Pollution Control District, and prompted regulations that address heat-related illness and death in the California fields.
Dr. Winston F. Wong, Medical Director, Community Benefit, Kaiser Permanente, reinforced the notion that health literacy is more than words on a page. He described how Asian Health Services, a nonprofit clinic in Oakland, California that provides healthcare and education to Asian immigrant communities, uses cultural images, colors, and design elements to convey cultural relevance and cue patients to important messages. The cultural cues begin on the outside of the building with the use of Asian-inspired architecture at the entrance. Inside, patients see a variety of cues that convey the cultural competence of the healthcare organization, including linguistic inclusion and cultural integration; a welcome sign, color-coded patient literature, and medication instructions written in multiple Asian languages; pictograms, images, and visual cues reinforcing directions; photos of staff emphasizing the interpersonal atmosphere; and patient questions from clinicians written in several languages, allowing for increased patient-provider interactions.
Despite the numerous efforts of Asian Health Services, the clinic still faces challenges. Across the street lies a pharmacy that promotes its own, perhaps conflicting, health messages and draws consumers to its products. Asian Health Services continues to consider ways to re-engineer service delivery and make changes to improve the health literacy of its patients and providers.
During the afternoon session, participants in the Town Hall meeting were randomly assigned to one of four small groups and asked to develop goals for achieving a more health-literate society. Imagining that it is the year 2025, participants described the characteristics of a health-literate society. Based on those characteristics, each group selected several goals, strategies, and action steps to prioritize. Discussions ranged from broad overarching themes to specific action steps. The suggestions below reflect the comments of meeting participants and do not necessarily reflect the position of the U.S. Department of Health and Human Services or any of its agencies.
Goal 1: Integrated technology system
Goal 2: Patient (consumer)-centered healthcare system that is respectful of diversity and culture and responsive to family and care-givers
Goal 1: Training for providers
Goal 2: Empowering consumers
Goal 3: K-12 health education
Goal 1: Optimal health for entire population/elimination of health disparities. Overarching strategy: Establish a common language and understanding between providers and consumers
Goal 1: Robust healthcare delivery system that includes standardized health communication, healthcare teams, evaluation of messages, and trusted sources of health information
Goal 2: Get society to understand and demand health promoting policies through stronger funding; involvement from media, educators, and providers; trusted sources of health information; crafting and delivering messages; and healthcare education Strategies for reaching Goal 2 were not discussed due to time constraints.
Dr. Baur stressed the value in the sharing of significant activities underway in the area of health literacy improvement among California State, local, and community leaders. Each person and organization is capable of taking just one small step toward a more health literate society. Moreover, the meeting provided rich material for the development of a national action plan to improve health literacy, which will be undertaken later this year.
In closing, Dr. Baur reinforced the notion highlighted by one of the breakout groups, that if we begin today to educate our children and focus on improving health literacy, we have a generational window to achieve measurable progress. The Town Hall is a first step toward the goal of a health literate society. Dr. Baur encouraged participants to share with colleagues, managers, policymakers, and friends the discussions heard throughout the day and to engage people from diverse groups to address this important public health issue.
Dr. Baur also encouraged participants to visit the Health Communication Activities section of ODPHP's Web site (www.health.gov/communication) to obtain updates related to this series of Town Hall meetings and additional resources on health literacy.