Town Hall Meeting on Improving Health Literacy
A Vision for a Health-Literate Missouri

May 16, 2008
St. Louis, Missouri

Meeting Summary

Welcome

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 third 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 and the Missouri Foundation for Health (MFH).

James R. Kimmey, President and Chief Executive Officer, MFH, also welcomed the participants and expressed his appreciation for being able to co-sponsor the Town Hall meeting. Established in 2000, the MFH Board singled out health literacy as a priority area to develop statewide interest and structure in health literacy issues. Mr. Kimmey expressed confidence that the activities of the day would generate ideas to convert into programs to advance priorities in health literacy.

Highlights of Research Findings on Health Literacy

Rima E. Rudd, Senior Lecturer on Society, Human Development and Health, Harvard School of Public Health, presented an overview and key highlights of the 2006 Surgeon General's Workshop on Improving Health Literacy, where she was a presenter. The purpose of the workshop was to establish an evidence base to inform future actions in health literacy improvement. During the 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 workshop led to several conclusions:

Dr. Rudd added that much of the research supporting these findings comes from the clinical setting. She urged participants to consider research gaps and to think beyond the medical setting to public health, environmental health, housing, food production, policy, and other settings, as they take action to improve health literacy.

Proceedings from the workshop are posted on the Office of the Surgeon General's Web site (http://www.surgeongeneral.gov/topics/healthliteracy/toc.htm).

Panel 1: Health Literacy Across Missouri – Building a Statewide Health Literacy Enhancement Center

The health literacy initiatives described by the three panelists are part of the Missouri Health Literacy Enhancement (MHLE) program, an initiative of the MFH. As an introduction, Arthur J. Culbert, Senior Advisor to the MFH, described the work underway through MHLE, a program that targets efforts to strengthen individual and professional health literacy, and enhance consumer and healthcare provider communication across Missouri. In the 8 months since its inception, MHLE has begun a health literacy awareness campaign across Missouri and is creating a statewide health literacy surveillance system that defines health literacy and identifies measures for success. The panelists spoke about the work they do with the program.

Assessing the Need and Developing an Inventory of Resources

A primary activity of the MHLE effort is to identify health literacy needs and find and share health literacy tools among professionals working to improve health literacy in Missouri. Matthew W. Kreuter, Director, Health Communication Research Laboratory, Saint Louis University School of Public Health, described the work to date. Initially, a needs assessment that included 54 healthcare and public health professionals and educators revealed several key challenges. Patients do not understand disease processes and often find health forms difficult to complete. Moreover, providers lack the patient-friendly terminology, skills, and time to help patients understand, and the resources for non-English speakers are inadequate.

Noticing a gap in professionals' access to health literacy tools and resources already available, the Saint Louis University School of Public Health compiled an inventory of health literacy resources for health professionals. The database currently holds more than 10,000 resources, including tools, educational materials, scientific literature, surveys, and curricula. The easy-to-use system walks users through a series of steps designed to assist them in identifying resources. Each resource listed includes a description, user reviews, recommended resources, and evaluation and scoring information. Still in the development phases, the school hopes to obtain feedback on the prototype in the coming months.

Media in Action: Informing Smart Health Decisions

Glen T. Cameron, Health Communication Research Center, Missouri School of Journalism, spoke of the opportunities in informing the health decisions of Missourians through the media. The school recently completed two surveys with healthcare journalists and is finishing extensive open-ended interviews with 100 health literacy leaders. Preliminary findings show that 80 percent of journalists surveyed had no specialized training in healthcare journalism. That number jumps to 89 percent for those with fewer than 5 years of experience. The results demonstrate a significant gap in training and understanding in healthcare journalism. Nevertheless, these same journalists are strongly motivated to help people understand and make use of health information.

Many of the challenges for individuals in this profession lie in contemporary news values. Healthcare stories are often portrayed in a conflict/resolution style that can take away from the intended health messages. Journalists struggle to find balance between too much and too little information. Moreover, there are clear distinctions between how newspaper, magazine, and broadcast journalists view their role. The different media channels have different motivations toward healthcare information delivery and health literacy. The school is working on solutions through activities with MHLE to produce better healthcare journalism. Such journalistic changes will, in turn, make consumers more aware, more amenable to MHLE interventions and resources, and better equipped to make health decisions.

Identifying Hot Spots of Low Health Literacy in Missouri

Nicole Lurie, Paul O'Neill Alcoa Professor, Director, RAND Center for Population Health and Health Disparities, described efforts underway to develop a predictive model to map health literacy in Missouri and identify communities with people who have limited health literacy skills. The model incorporates common census variables, such as age, gender, race/ethnicity, education, income, marital status, and others, to identify areas in Missouri where poor quality care and low health literacy coexist.

Identification of the hot spots can help to clarify contributing factors and cost-effective interventions. Mapping will identify priority areas for intervention and bring together partners to develop interventions. Moreover, this shift in focus toward communities, rather than individuals, can have added benefits, such as helping communities take responsibility and leading to efficient resource use and a positive return on investment. Mapping data will be shared with agencies, health plans, and communities to be used when developing and testing interventions for pharmacy settings, provider offices, automated voice response systems, and others.

Discussion

At the end of the presentations, participants posed several questions to the panelists. The following issues were raised:

Panel 2: Initiatives in the Midwest to Advance Health Literacy

Panel members provided a range of perspectives on the initiatives underway to improve health literacy within communities in the Midwest. These promising practices exemplify the improvements possible in helping patients and consumers to more effectively navigate and negotiate the healthcare system.

Immigrant Health Literacy: Reaching Across Language and Culture

Daryl Gordon, Students Helping in Naturalization of Elders (Project SHINE), Assistant Professor, Adelphi University, described the Health Literacy Initiative, a program that engages college students in health literacy service for older immigrants and refugees. An initial needs assessment of immigrants, that included input from immigration, English as a second language (ESL), and senior service providers, revealed that needs of immigrant older adults are great. Many have difficulty understanding print material, such as instructions, prescription labels, and forms; communicating traditional practices to clinicians; and making healthcare appointments. To address these challenges, the health profession students (those in nursing, physical therapy, occupational therapy, therapeutic recreation, and medical interpreting) participated in health fairs, health education workshops, health screenings, and community needs assessments to provide ESL support.

The Initiative also engaged ESL teachers and adult learners to develop an ESL health literacy curriculum based on four quadrants of communicative competence, including language, sociolinguistic, strategic, and discourse competence. The curriculum is designed for immigrant older adults to use in ESL classes, tutoring sessions, or workshops and includes five topics—the doctor's office, the hospital, illness management, healthy aging, and medications.

Integrated Health Network—Regional Health Literacy Programs

The Integrated Health Network (IHN) is a group of 8 providers who serve over 200,000 uninsured and underinsured residents in St. Louis city and county. Brooke Sehy, Chief Executive Officer, and Lisa West, Health Coach, IHN, described the Health Education and Literacy Program, an IHN initiative that uses lay health coaches to reach uninsured and underinsured residents to empower them to take control of their health, communicate with providers, and become more confident in navigating the health delivery system.

Despite barriers to healthcare among this population, including transportation access, financial obstacles, and lack of trust in the healthcare system, results of a qualitative study to determine the effectiveness of health coaches were positive. Preliminary findings revealed a significant increase in the percentage of patients who had a primary care provider after working with a health coach (from 57 percent to 81 percent). Moreover, after working with a health coach, 27 percent of chronic disease patients (up from 1 percent) are now able to discuss their self management plan.

Twenty Years of Experience: The Adult Learner and Health Literacy

Archie M. Willard, founder, New Readers of Iowa, is an adult learner. He learned to read at the age of 54, after learning that he is dyslexic. In 1990, he and several other adult learners founded New Readers of Iowa, a group working to help people with low literacy skills navigate such arenas as the voting system and the healthcare system. Early in 2000, New Readers of Iowa hosted a health literacy conference that brought together adult learners and healthcare professionals to discuss the problems and solutions surrounding health literacy. The conference led to a partnership with the Iowa Health System.

Under partnership with the System, the New Readers of Iowa work to make healthcare more understandable to adult learners and others. Much of their work involves making small changes that have a big impact on improving access to and understanding of the healthcare system. For example, they review health forms, serve on committees, and participate in needs assessments, to offer the adult learner's point of view about health literacy. During his presentation, Mr. Willard reinforced the notion that each small step can have a large impact on improving health literacy. Mr. Willard urged participants to partner with adult learners and to listen to them to make a difference in health literacy.

Discussion

At the end of the presentations, meeting participants posed several questions to the panelists. The discussion centered on the following issues:

Histories of the Future for Health Literacy Improvement

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 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.

Characteristics of a Health-Literate Society

Within each breakout group, participants identified those characteristics that best describe a health-literate society. The following list is a compilation of all group sessions:

Prioritized Goals

Participants chose several goals on which to focus and identified strategies for achieving them. Below are the goals identified and their accompanying strategies

Orange Group (Timothy O'Dea, facilitator)

Goal: More affordable and accessible healthcare.

Red Group (Rob Logan, facilitator)

Goal: Highly literate society

Goal: Collaborative partnerships, valued by society, among all parties in the health care system: consumers and providers

Goal: Optimal access, well-designed, consistent, and consumer-friendly health care system services, information, and products

Goal: Person-centered healthcare systems with significant improved outcomes for all and elimination of health disparities

Blue Group (Elyse Barbell Rudolph, facilitator)

Goal: The population is proactively engaged in health promotion and a healthy community.

Goal: Health systems support consumers' health-promoting activities

Goal: The education system is a key driver of health literacy.

Yellow Group (Joanne Locke, facilitator)

Goal: Change healthcare focus to management of optimal health through prevention and wellness.

Goal: A diverse workforce is a priority.

Green Group (Sandra Hilfiker, facilitator)

Goal: People are knowledgeable and empowered to advocate.

In addition to the goals and strategies listed above, this group identified strategies for the Federal Government to begin the process of initiating change to improve health literacy.

Conclusion

Dr. Baur remarked on the tremendous impact the programs described during the meeting have on improving health literacy in Missouri and throughout the Midwest. Yet, the day's events also highlight the challenges we as a society still face, such as poverty, which is a factor related to health literacy. Rather than become overwhelmed by the enormity of the challenges, Dr. Baur offered that it is often the small, and sometimes unintentional, steps that are a springboard for change. She encouraged participants take one small step that can serve as catalyst for change in local healthcare and public health practices and relationships. For example, several of the presentations highlighted health literacy resources, many of which are under-utilized and not well applied. Participants can identify one small way the resources can be used in a slightly different way in their own situation and possibly start a cascade of change. She thanked participants for attending and encouraged continued discussions among the attendees.