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. The meeting, co-sponsored by the U.S. Department of Health and Human Services' Office of Disease Prevention and Health Promotion (ODPHP), the New York City Mayor's Office, and the Literacy Assistance Center (LAC), offered participants the opportunity to explore promising practices and lessons learned, while contributing to an agenda for health literacy improvement both in New York and nationally. The meeting is the first of four such meetings across the country over the next year that will likely culminate in a National action plan to improve health literacy.
Rima 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. Dr. Rudd was one of the Workshop presenters. During the Workshop, leading researchers from across the country presented the state-of-the-science in the field of health literacy from a variety of perspectives, including those of healthcare organizations and providers, the research community, educators, and communicators, to establish an evidence base to guide action steps.
The Workshop led to several conclusions:
Dr. Rudd added her insights and directions for future work in health literacy:
Proceedings from the Workshop will be posted on the Office of the Surgeon General's Web site in the near future.
Anthony Tassi, Director, Office of Adult Education, New York City Office of the Mayor, moderated a panel of representatives from three large-scale systems who spoke of their efforts to make systemic changes to improve health literacy and better reach those with limited health literacy skills within their constituent base. The panelists spoke of the accomplishments they have made and described the challenges they face for the future in reaching their health literacy goals more effectively.
The New York City Health and Hospitals Corporation (HHC) serves 1.3 million New York residents, 25 percent of whom are limited English proficient (LEP). As noted by Stephanie Trice, Assistant Vice President, Office of LEP/Culturally and Linguistically Appropriate Services, health literacy is a component of HHC's strategic plan and is managed through its central office. To meet the needs of those with limited health literacy,HHC's multifaceted approach includes a central repository of multilingual materials reviewed for literacy level; multilingual staff trained in the principles of plain language; patient-centric resources based on consumer studies; and gateway resources, such as interpreters and client navigators. HHC will consider the initiative successful if it sees a resultant reduction in healthcare disparities in the populations it serves. In the coming years, HHC will work to provide more staff training in health literacy and other language-related barriers; expand current community partnerships and build new bridges to reach communities; and expand the availability of multilingual patient education materials.
According to Joslyn Levy, Director, Clinical Systems Improvement, Bureau of Chronic Disease Prevention and Control, New York City Department of Health and Mental Hygiene, health literacy is a component of a broad quality improvement technical assistance strategy. As such, the office is uniquely positioned to partner directly with healthcare providers and staff to help them address health literacy within their communities. The office does evidence-based materials development and dissemination and offers onsite training to providers to better meet the needs of those with limited health literacy.
Currently, success is defined by the number of healthcare team requests for materials; provider self-reported material and tool use; provider self-reported increased confidence to engage and educate patients; and, ultimately, improved health status for New York residents. Future work will be done with consumers to obtain feedback on their need for materials and then incorporate these ideas in the materials development process. Also, given the time constraints of primary care visits, the office will work to identify new approaches for reaching its diverse populations, such as creating linkages with community organizations.
Maura Bluestone, President and Chief Executive Officer, Affinity Health Plan, described the multipronged approach to reaching the more than 210,000 members of its managed care plan. Affinity's goal is to embed health literacy concepts and practices into the organization's culture through knowledge and skills-based training for employees, members, and clinicians and their staff, and provide tools for community-based partners to help people navigate and access healthcare services. The health literacy initiative is driven by a corporate-wide Health Literacy Guiding Coalition that partners with community-based adult literacy experts.
Success will be demonstrated by:
The challenges Affinity faces include balancing competing organizational priorities; translating health literacy from concept to action; reducing high enrollment turnover and discontinuity of coverage; and developing meaningful, feasible metrics to track and evaluate program effectiveness.
In contrast to the large-scale systems described in Panel 1, Elyse Barbell Rudolph, Executive Director, LAC, moderated a panel of experts who spoke of the local partnerships and collaborations they created, despite minimal resources, to improve health literacy for the people they serve.
Diana Raissis, Instructional Facilitator, Mid-Manhattan Adult Learning Center, Office of Adult and Continuing Education, New York City Department of Education, and Ms. Rudolph introduced a videotape highlighting the work of a partnership between the Adult Learning Center, the LAC, the New York City Office of the Mayor, and Harlem Hospital Center. The partnership conducted a pilot health literacy study circle, an innovative new approach that infuses health literacy skills into an adult literacy curriculum. The health literacy study circles, developed by a team led by Dr. Rudd, enable participating instructors to integrate health literacy skills in three critical areas: navigating the healthcare system, managing chronic disease, and participating in prevention activities.
Winston Lawrence, Senior Professional Development Associate, LAC, noted that activities such as tours of the healthcare facilities helped literacy instructors and students gain context for their work on health literacy skills and a stronger comfort level with the healthcare system. The healthcare organizations gained insight into the needs of low-literate and immigrant populations and began to improve the staff's ability to communicate with these populations. To date, over 200 teachers in New York City have been trained. The project plans to expand nationwide.
The Health Literacy Fellowship was initiated by the Mayor's Office in Adult Education to strengthen the health literacy training for future physicians; broaden the capacity of the education system to enhance the health literacy skills of adults; and promote collaborations among medical schools, healthcare facilities, and adult education facilities. In describing the program, Mr. Tassi noted that the fellowships provide the opportunity for first- and second-year medical students to strengthen health literacy skills through an immersion experience in adult learning as it applies to health.
Annery Garcia, Sophie Davis School of Biomedical Education, City University of New York (CUNY), participated as a fellow and offered her perspective on the experience, noting that it revealed to her the communication barriers between doctors and patients. She left the program feeling more capable of reaching patients by speaking to them in language they can understand in her future career as a physician.
Jane Levitt, Professor, Department of Health Sciences, Lehman College, CUNY, provided an overview of the Bronx Health Literacy Collaborative. The Collaborative was created to promote the importance of health literacy, encourage partnership building, and reach out to the Bronx community to improve health outcomes. The Collaborative consists of Bronx-based community healthcare providers, hospitals, literacy education providers, and CUNY campuses.
In the spring of 2006, the Collaborative hosted a conference to bring together close to 200 representatives from the Bronx community and encourage partnerships. During the conference, participants worked to define health literacy, understand how it impacts health outcomes, share strategies to help identify those with limited literacy skills, and provide a framework for networking and coalition building. The conference resulted in a forum to highlight two ongoing health literacy partnerships health providers and literacy educators. Forum members conducted hands-on interactive work to identify strategies to meet the increased demand for health literacy improvement given limited time, budget, and personnel resources.
Participants were randomly divided into groups and asked to address four questions related health literacy:
Discussions varied among each of the five groups. Two of the groups began with a conversation about their vision of improved health literacy among residents of New York. Their vision of the future included the following key factors:
Further discussions on the future vision and four questions prompted the following themes:
Dr. Christina Zarcodoolas, Associate Clinical Professor, Mount Sinai School of Medicine, and Dr. Rudd provided summary remarks, both emphasizing the need to look beyond the medical encounter to improve health literacy. Three factors, noted Dr. Zarcadoolas, suggest the timing is right to advance health literacy to the next level:
These three factors contribute to the need to change how we think about health literacy and to shift our understanding of health away from the patient-healthcare provider interaction. We must gain a better understanding of where the indigenous knowledge, lay epidemiology, and lay understanding of health are, and how people are using the health information that surrounds them and building on their knowledge to improve health outcomes.
Dr. Rudd echoed these comments, adding that we need to remember to focus on the voice of the public. We should improve our outreach, speak the language of communities, and speak with people rather than to people. Dr. Rudd asserted that if we talk to people in healthcare situations as we do in kitchens in our everyday lives, we will go a long way toward solving the complex problem of limited health literacy.
Dr. Rudd also urged participants to consider approaches in addition to those in traditional public health. These include:
Dr. Baur stressed the value in the programs and initiatives described during the day and emphasized the importance of working with each other to meet the health literacy challenges of our Nation. She reiterated Dr. Rudd's and Dr. Zarcadoolas's points, emphasizing the need to focus more on health literacy as it relates to people in their everyday lives, outside the healthcare provider's office.
Dr. Baur also noted a number of themes that emerged during the day and summarized them as an acronym, STEPP, where each letter refers to an important element in the effort to improve health literacy:
While the day provided the opportunity to share findings and begin new collaborations for people working in New York, it also served a broader purpose. The U.S. Department of Health and Human Services will work with local partners in three other cities to sponsor similar meetings during the next 12 months. The findings from these meetings will likely culminate in a national action plan for health literacy improvement.
Dr. Baur encouraged participants to visit the ODPHP's Health Communication Activities section of its Web site (www.health.gov/communication) to obtain updates related to this series of Town Hall meetings and additional resources on health literacy. She also encouraged participants to stay in touch with each other and continue the dialogue begun during the meeting.