5
Educational Systems

“People are hearing about overweight and obesity. So they’re trying to figure out how much food they should eat. How much is too much? They’re asking about calories, carbohydrates, vitamins, and fiber. They’re asking about salt, sugar, and portion sizes.

…As young medical students, you and I learned more about the pathophysiology of disease than we learned about answering these questions for our future patients.”

Vice Admiral Richard H. Carmona, M.D., M.P.H., F.A.C.S.

United States Surgeon General

American Medical Association House of Delegates Meeting

June 14, 2003

Over all, the U.S. educational systems offer a primary point of inter vention to improve the quality of literacy and health literacy. The educational systems discussed in this chapter are the K-12 system, the adult education system, and education for health professionals. Public educational systems in the United States are influenced by national policy and funding, but remain under the jurisdiction of and are funded by states and localities.



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Health Literacy: A Prescription to End Confusion 5 Educational Systems “People are hearing about overweight and obesity. So they’re trying to figure out how much food they should eat. How much is too much? They’re asking about calories, carbohydrates, vitamins, and fiber. They’re asking about salt, sugar, and portion sizes. …As young medical students, you and I learned more about the pathophysiology of disease than we learned about answering these questions for our future patients.” Vice Admiral Richard H. Carmona, M.D., M.P.H., F.A.C.S. United States Surgeon General American Medical Association House of Delegates Meeting June 14, 2003 Over all, the U.S. educational systems offer a primary point of inter vention to improve the quality of literacy and health literacy. The educational systems discussed in this chapter are the K-12 system, the adult education system, and education for health professionals. Public educational systems in the United States are influenced by national policy and funding, but remain under the jurisdiction of and are funded by states and localities.

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Health Literacy: A Prescription to End Confusion THE K-12 AND UNIVERSITY EDUCATION SYSTEMS Elementary, middle school, high school, and university education provide an opportunity to promote health literacy, to reduce health-risk behaviors, and to prepare children to navigate the health-care system. Effective health education programs should begin in early childhood and continually build on previous knowledge (NRC, 1999). Achieving health literacy in students is hindered by a lack of continuity in health education programs across the many age groups. K-12 Education Health Education Programs The School Health Policies and Programs Study 2000, conducted by the Centers for Disease Control and Prevention (CDC), indicated that most elementary, middle, and high schools require health education classes as a part of the curriculum (Kann et al., 2001). The majority of these states (75 percent) use the National Health Education Standards (NHES) as a framework to develop these programs (Kann et al., 2001). Box 5-1 displays the NHES and some background about these standards. Some states have made significant progress in establishing guidelines in accordance with the NHES. A lack of consistent, cross-grade health curriculums may reduce student health literacy. Although most elementary, middle, and high schools require students to take health education, classes in different grades tend not to build upon previous grades. The absence of a coordinated health education program across grade levels may impede student learning. Kann et al. (2001) report an increase in the percentage of elementary schools that require health education from 33 percent in kindergarten to 44 percent in grade 5. However, only 27 percent of schools require health education in grade 6, 20 percent in grade 8, 10 percent in grade 9, and 2 percent in grade 12. Teacher education may affect teacher effectiveness in implementing health and health literacy curriculums. National and international strategies developed to help schools implement effective policies and programs (e.g., Kolbe et al., 1997, 2001) are complicated by the fact that few health education teachers majored in health education (Collins et al., 1995; Hausman and Ruzek, 1995; Kann et al., 2001; Patterson et al., 1996; Ubbes et al., 1999). Only 10 percent of health education classes or courses have a teacher who majored in health education, or in health and physical education combined (Kann et al., 2001). Peterson and colleagues (2001) suggest that inadequate attention to teacher health literacy has impeded student health literacy. Many teachers feel that they are not prepared to teach specific health topics (Peterson et al., 2001). For example, a sample of 156

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Health Literacy: A Prescription to End Confusion BOX 5-1 The National Health Education Standards In 1995, the Joint Committee on National Health Standards published the National Health Education Standards (NHES) subtitled Achieving Health Literacy (Joint Committee on National Health Education Standards, 1995). The standards describe the knowledge and skills essential for health literacy and detail what students should know and be able to do in health education by the end of grades 4, 8, and 11. The standards describe a health-literate person as a critical thinker and problem solver, a responsible, productive citizen, a self-directed learner, and an effective communicator. The National Health Education Standards: Students will comprehend concepts related to health promotion and disease prevention. Students will demonstrate the ability to access valid health information and health-promoting products and services. Students will demonstrate the ability to practice health-enhancing behaviors and reduce health risks. Students will analyze the influence of culture, media, technology, and other factors on health. Students will demonstrate the ability to use interpersonal communication skills to enhance health. Students will demonstrate the ability to use goal-setting and decision-making skills to enhance health. Students will demonstrate the ability to advocate for personal, family, and community health. The NHES identified obstacles that continue to impede health education programs, including: Lack of appreciation for the relationship between health status and success in academic and work performance, Low levels of commitment by school board members and administrators, Inadequately prepared teachers, Insufficient funding for resources and staff development, Overcrowded curricula with little or no time for health education (Pateman, 2002; Thackeray et al., 2002), Unconnected and seemingly irrelevant health instruction, Lack of recognition of the contribution made by health education to the achievement of the academic goals of schools, Failure to adequately document student performance in achievement of health literacy.

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Health Literacy: A Prescription to End Confusion elementary school staff from five schools in Philadelphia felt only “somewhat prepared” to teach health education (Hausman and Ruzek, 1995). These findings highlight the importance of professional development for teachers who provide classroom health education to young students. Many teachers are also required by state guidelines to include specific topics and standards within their curriculums, often in response to state-mandated tests. Even within good health education curricula, teachers cannot address all topics and issues at a single grade level. Although health education may be included within the required curriculum, it might not be included within state-mandated tests and therefore these topics will receive less attention in the classroom (Pateman et al., 1999). A call to strengthen school health education by health education with state assessment requirements was made soon after the NHES were published (Collins et al., 1995), but a low level of grant support for health literacy assessment persists. A national health promotion and disease prevention report recommends that the United States increase the proportion of middle, junior, and senior high schools that provide health education to prevent health problems in areas such as unintentional injuries; violence; suicide; tobacco use and addiction; alcohol and other drug use; unintended pregnancy; HIV/ AIDS and STD infection; unhealthy dietary patterns; inadequate physical activity; and environmental health (HHS, 2000). The World Health Organization (1996) has described several barriers that may impede the implementation of school health programs at local, state, national, and international levels. First, education, health, and political leaders, as well as the public at large, often do not possess accurate knowledge of modern school health programs and their potential impact on health. Second, many believe the most important function of schools to be the improvement of language, mathematical, and scientific skills. Third, some may not support modern school health programs because some elements of some programs may be controversial (e.g., school programs to educate about, and prevent, HIV infection, other prevalent STDs, and unintended pregnancy). Fourth, modern school health programs require effective collaboration, especially among separate education and health agencies. Unfortunately, among 38 states that participated in the School Health Education Profiles Study, the percentage of schools that required a health education course decreased between 1996 and 2000, as did the percentage of schools that taught about dietary behaviors and nutrition, and about how HIV is transmitted. During the year 2000, only 27 percent of schools required health education in grade 6, a number that fell to 2 percent in grade 12 (Storch et al., 2003). A similar pattern is observed in Canadian schools. In 1999, over 70 percent of Canadian school districts reported that health education was mandatory in grades 3 through 5, but only 20 percent

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Health Literacy: A Prescription to End Confusion reported that it was mandatory in grade 12 (McCall et al., 1999). When children are at an age when health risk behaviors increase (Smith, 1999), American schools require little education about health (Grunbaum et al., 2002). Unless health education is considered part of basic education, the quantity and quality of health education in U.S. elementary and secondary schools are likely to deteriorate further. A report from an Institute of Medicine Committee on Comprehensive School Health Programs in Grades K-12 (IOM, 1997) recommended that the United States improve its school health programs. A report from the World Health Organization (1997) made similar recommendations for all nations to take similar measures. Recent surveys show that school administrators, parents, students, and the public at large all want elementary and secondary schools to implement more comprehensive school health programs (The Gallup Organization, 1994; Marzano et al., 1998). Health professionals, such as school nurses, food service directors, health teachers, physical education teachers, and school psychologists, are already working in many elementary and secondary schools (Marx et al., 1998). Many state education and health departments also employ staff to help schools implement school health programs, as do many national nongovernmental education and health organizations (CCSSO, 2003). These programs provide a potential target for further intervention. Science Education Science education provides a clear opportunity for implementation of health literacy education programs and content. An example of this association is the Curriculum Linking Science Education and Health Literacy program. This project transformed inner-city children’s, teachers’, and parents’ or care givers’ experiences with food into an inquiry-based science program. Guidelines for science education include content standards for personal and community health (American Association for the Advancement of Science, 1993; NRC, 1996). Science teachers have indicated that scientist participation can strengthen science education. A survey called “The Bayer Facts of Science Education V,” conducted by Bayer Corporation and the National Science Teachers Association (1999), indicated that 98 percent of the science teachers believe that direct student–scientist interaction within classroom was important. These findings suggest an opportunity for science and health-care professionals to participate in school science and health education programs to improve the health literacy of pre-college students. In fact, more than half of 107 elementary school teachers at 31 schools reported wanting classroom visits by health professionals (Thackeray et al., 2002).

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Health Literacy: A Prescription to End Confusion Literacy Education The subject of literacy instruction and achievement in schools, particularly reading, is more conspicuous in the political and mainstream arenas than is health education. While health education holds promise in promoting full health literacy insofar as it leads to the acquisition of the necessary health-related knowledge, the issue of basic literacy is equally essential to full health literacy. As detailed in previous chapters, much of the research on health literacy documents the difficulties with printed health texts experienced by adults who are low in overall literacy skill. Two influential reports have been issued by the National Research Council (NRC, 1998) and the National Institute of Child Health and Human Development (National Reading Panel, 2000) addressing the failure of schools to produce adults who are sufficiently literate to participate in an increasingly information-driven and competitive economy. These reports, along with a collection of Congressional mandates, helped lead to the No Child Left Behind legislation,1 which is driving major instructional change designed to improve the levels of achievement in the schools. The major strategy of No Child Left Behind is to hold all schools accountable for ensuring that students achieve certain standards in subjects that comprise basic education, including language, science, and mathematics. It is too soon to report any results of these changes, but increasing numbers of schools and school districts are attending to the issues raised by the national concern with literacy achievement. College and University Health Education Nearly two-thirds of the 27 million 18- to 24-year-olds in the United States become college undergraduates (U.S. Department of Education, 2001). Unfortunately, relatively few of the nation’s 2- and 4-year colleges and universities currently require or provide education about health (Keeling, 2001; Patrick et al., 1992). In a summary from a symposium on health and higher education, the Association of American Colleges and Universities suggested that these institutions are well situated to address issues critical to health literacy, “… to discover the causes and cures for diseases and to explain how people can be engaged, individually and collectively, in the improvement of their own lives and the lives of others” (Burns, 1999). But a summary from their 2001 symposium noted that: “… as a nation, we have not made the health of college students a priority; we lack a strong commitment to addressing health on campus, a coordinated strategy to 1   No Child Left Behind Act of 2002. P.L. 107-110.

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Health Literacy: A Prescription to End Confusion improve health among students, and—most important—a focus on the capacity of students themselves to contribute to solving health problems” (Association of American Colleges and Universities, 2002). One of the National Health Objectives calls for the United States by the year 2010 to “increase to 25 percent the proportion of college and university students who receive information from their institution on each of the six priority health-risk behavior areas (injuries, tobacco use, alcohol and illicit drug use, sexual behaviors that cause unintended pregnancies and sexually transmitted diseases, dietary patterns that cause disease, and inadequate physical activity)” (HHS, 2000). In 1995, only 6 percent of 18- to 24-year-old undergraduates in the United States received information about all six topics (Douglas et al., 1997), despite the fact that these college students were substantially more likely to engage in most of these health risk behaviors than high school students (Kann et al., 1996). Neither standards nor instruments to assess their attainment have been developed to support critical health knowledge and skills that undergraduate students could acquire as part of their college education. Finding 5-1 Significant obstacles and barriers to successful health literacy education exist in K-12 education programs. Strategies and Opportunities in K-12 and University Systems Although the difficulties in addressing health literacy in education are considerable, targeted solutions can be developed if the factors that contribute to these difficulties are identified. State and local programs can use the educational system’s potential for addressing the issue of health literacy to produce change. St. Leger (2001) proposes that government investment into teacher professional development, research into school health frameworks, and wider dissemination of effective school health programs will improve health literacy. In addition to health education programs, opportunities for health literacy instruction exist that embed health literacy content into basic literacy teaching. In this section, these two types of approaches are described, issues with the assessment of health literacy in educational settings are explored, and examples of ongoing approaches are offered. Opportunities for Health Education Programs Many studies have provided evidence that school health programs can improve critical health knowledge, attitudes, and skills among elementary and secondary school students and the evidence suggests that school health programs can improve health behaviors and health outcomes (Kolbe, 2002). The CDC has initiated a project called “Programs-That-Work” to identify

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Health Literacy: A Prescription to End Confusion effective health education programs that reduce health-risk behaviors (for review, see Collins et al., 2002). These health-risk behaviors are those stressed by the U.S. Department of Health and Human Services Healthy People 2010 program (2000). Lohrmann and Wooley (1998) have proposed that successful health education curriculums should meet the following criteria: Be research-based and theory-driven. Include information that is accurate and developmentally appropriate. Actively engage students using interactive activities. Allow students to model and practice relevant social skills. Discuss how social or media influences affect behavior. Support health-enhancing behavior. Provide adequate time for students to gain knowledge and skills. Train teachers to effectively convey the material. Health education programs have the opportunity to provide students with practice in negotiating the health-care system. Specific instruction might include such activities as roleplaying to become familiar with the many different interactions that occur between the health-care provider and the patient (Purtilo and Haddad, 1996). Arguably the most effective means to improve health literacy is to ensure that education about health is a part of the curriculum at all levels of education. Schools and colleges could incorporate health literacy education into a range of exiting programs and services such as health services, health education, food services, physical education, and counseling, psychological, and social services (Kolbe, 1986). Strategies for Health Literacy Instruction With the increasing pressure on schools today to include more and more academic content, educators are justifiably reluctant to add one more content area to their already overflowing plates. However, health literacy instruction can be embedded into existing science and health education, and even mathematics and social studies, as well as literacy instruction for children and adults. There is a sound justification for embedding health literacy instruction into existing literacy instruction for children and adults. Educational research for at least the last few decades has documented the impact of context and content on learning, retention, and transfer. This research has shown that learners retain and apply information best in contexts similar to those in which they learned it (Bereiter, 1997; Mayer and Wittrock, 1996; Perkins, 1992).

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Health Literacy: A Prescription to End Confusion Literacy practitioners and scholars have taken these findings and applied them to the vexing problem of why literacy skills learned in school are often not applied to literacy tasks in life. One obvious implication of this research is that reading and writing skills must be learned in the context of texts and literacy purposes that readers will encounter out in the world. Therefore, one needs to teach reading skills in those contexts. Health texts and purposes for reading them make up one of those real-life literacy domains. A survey conducted by Bayer and the National Science Teachers Association (Bayer Corporation and the National Association of Science Teachers, 1999) indicated that 98 percent of science teachers surveyed believe that direct interaction within classroom with health professionals was important. These findings suggest that the participation of health-care professionals in school health education programs would improve the health literacy of pre-college students. Embedding health literacy instruction can be done with the two types of literacy instruction needed to improve health literacy: basic print literacy instruction and literacy instruction in text types common to the field of health literacy. This latter type of instruction introduces the idea of teaching functional print literacy based on using and understanding real-life text types. Several studies, funded by the National Science Foundation and the Interagency Educational Research Initiative, have examined the outcomes of introducing more expository texts2 into primary-grade instruction during years typically devoted to basic literacy learning. One study looked at the effect on basic literacy growth of adding non-narrative texts to the typical mix of stories used by first- and second-grade teachers (Duke, 2000). Results indicate that students whose teachers diversified their materials learned as much as those who did not, confirming that this approach was not detrimental to the development of beginning reading skill and writing abilities. A longitudinal study, termed the TEXT study (Purcell-Gates and Duke, 2000), has shown that children as young as second and third graders can grow in their abilities to read and to write two types of texts often found in the health field: science informational texts and science procedural texts. Since individual unfamiliarity with different text types often used to convey health information is a health literacy challenge, this study is important in that it is the only one to date that addresses the teaching of text types specifically, and, in this case, the teaching of health literacy-significant text types. For this study, second- and third-grade teachers were randomly assigned to one of two conditions: (a) The Authentic Only condition, where teachers had their students reading science informational and science proce- 2   Expository texts are statements or rhetorical discourse intended to give information about or an explanation of difficult material.

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Health Literacy: A Prescription to End Confusion dural texts that were constructed similar to those found in the real world for real-world purposes of learning new science information or for actually conducting experimental procedures. They also wrote science informational texts and science procedural texts for real-world purposes of providing readers with information of providing written procedures that allow readers to conduct scientific investigations. (b) The Authentic-plus-Explicit conditions added explicit teaching of language features associated with each text type to the authentic reading and writing just described for condition (a). Examples of language features include (for science informational texts) generic nouns (whales rather than Willy the Whale) and timeless verbs (whales eat rather than Willy the Whale ate) and (for science procedural texts) a materials section before the ordered steps that are usually numbered. Analysis of the TEXT data indicates that the children in both conditions grew significantly in their abilities to read and write these science-related text types. Although no significant differences were found due to explicit teaching of the language features, their reading comprehension and writing ability of these two types of texts were significantly related to how authentic the reading and writing assignments were in each class. All of the students learned the features of these two text types commonly employed in the health field, and those students whose teachers used more ‘authentic’ texts and purposes for reading and writing them learned them to a greater degree. The fact that this can occur at such an early age implies that one does not need to wait until middle or high school to begin teaching about the different text types so commonly used to convey health information. This study was funded by the National Science Foundation and the Interagency Education Research Initiative. Several studies funded by the National Science Foundation and the Interagency Educational Research Initiative have examined the outcomes of introducing more expository texts into primary-grade instruction during years typically devoted to basic literacy learning. A study by Duke (2000) looked at the effect on basic literacy growth of adding non-narrative texts to the typical mix of stories used by first- and second-grade teachers. Results are showing that students whose teachers utilized different types of texts in the lessons grew as much as those who did not, confirming that children this young could read and learn from non-narrative texts and that this approach was not detrimental to the development of beginning reading skill and writing abilities. Assessment of Health Literacy in Educational Settings It is possible to evaluate basic literacy and functional print literacy, and it is important to be clear when conceptualizing and building valid assess-

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Health Literacy: A Prescription to End Confusion ments. Effective recommendations depend on clear, accurate assessments. But much work remains to be done on the specific and targeted issue of health literacy assessment in educational settings. Educational assessments generally include formative and summative components. Formative assessments are constructed so that test results can directly inform and shape ongoing instruction. They should provide feedback to teachers and to school systems regarding how well the instruction meets the learning needs of their students. The major effort of assessment should be devoted to informed formative assessment. Summative assessments are a part of instructional contexts, and serve primarily to rate, or grade, the student on how well they learned what was taught. Within the health literacy context, summative assessments can be used to make judgments about individual persons regarding their “level” of health literacy. Health literacy programs in schools and colleges can be designed to accomplish four distinct, but overlapping and interdependent, types of goals (Kolbe, 2002). First, such programs can be designed to improve health literacy; that is, improve important health knowledge, attitudes, and skills. The Council of Chief State School Officers (which represents the nation’s state school superintendents) established a State Collaborative on Assessment and Student Standards (SCASS) to assess student achievement in several context areas. To assess health literacy, SCASS created an Assessment Framework Matrix (Council of Chief State School Officers and State Collaborative on Assessment and Student Standards, 1998) that was used to develop test items within nine content areas3 and six core concepts and skills4 that reflect the NHES for elementary, middle, and high school students (Joint Committee on National Health Education Standards, 1995). The major purpose of the SCASS Health Education Assessment Project is to improve health literacy by guiding improvements in school health education planning and delivery (Pateman, 2003). Examples of Current Approaches Several state organizations have developed programs to address health literacy education in kindergarten through high school. Many examples of programs are detailed in the State Official’s Guide to Health Literacy 3   These nine content areas are: alcohol and other drugs, injury prevention, nutrition, physical activity, sexual health, tobacco, mental health, personal and consumer health, and community and environmental health. 4   These six core concepts and skills are: accessing information, self-management, internal and external influences, interpersonal communication, decision-making/goal-setting, and advocacy.

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Health Literacy: A Prescription to End Confusion Green and Kreuter (1999) reported that simple acquisition of knowledge does not necessarily produce change: there may be motivational and informational gaps. In other words, “getting the message out” does not mean that people will act on the information. There is a need for better understanding of how people learn, as well as what factors influence information-seeking and how literacy contributes to health behaviors. Theories of learning and health education principles can offer explanations for health behaviors and actions and can point to promising ways to create meaningful messages (Meade, 2001). Learning theories can aid in recognizing the mechanisms whereby knowledge, attitudes, and behaviors can be potentially modified and adopted (Bandura, 1977; Becker, 1974; Becker et al., 1977; Bigge, 1997; Hochbaum, 1958; Pender, 1996; Rosenstock, 1966). Freire (1973) suggests that knowledge about health issues can be gained through participatory methods. This approach, called problem-solving education, encourages learners to be critical thinkers about health issues: the process encourages ongoing learner participation and input. This perspective of involving consumers in the educational process is consistent with literacy solutions that value the voice of the people. Incorporating Health Content into Adult Education Programs Most classes for adults studying for their high school equivalence are narrowly focused on the requirements of the GED test or other certification system. However, health content has always been part of basic skills and English language services. About 10 years ago, a number of professionals in the field became interested in expanding health content in the ABEL curriculum. This interest arose out of a need to find content that was compelling for adults so as to increase their motivation to practice the language, literacy, and math skills learned in class, and health is a topic of high interest to almost all students. Initial efforts focused on specific diseases, such as breast cancer, and traditional school health topics, such as nutrition. Work by NCSALL has expanded this focus to include the issues of access, navigation, prevention, screening, and chronic disease management (Rudd, 2002). Adult literacy researchers have begun to empirically examine the effects of using authentic (real-life) materials and activities for teaching adults to read and write. For example, Howard-Pitney et al. (1997) tested the effect of dietary intervention for low-literacy, low-income adults and found an increase in nutrition knowledge. A federally funded study, using a nationwide sample of adult literacy classes and students, found that students whose teachers incorporated texts for real-life purposes (like reading newspapers to learn the news rather than underline the verbs) began to read and write more often in their lives and to read and write more complex texts

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Health Literacy: A Prescription to End Confusion (Purcell-Gates et al., 2000, 2002)7 In contrast to these findings, Murphy et al. (1996) reported no significant change in nutrition knowledge or self-reported consumption behaviors. These findings are beginning to be incorporated into adult literacy teaching. For example, a handbook has been published for teachers who wish to begin to use more real-life texts and literacy activities while still teaching their students the skills of reading and writing (Jacobson et al., 2003). Teachers are encouraged to identify the types of life activities their students engage in that require more advanced reading skills. The domain of health and health maintenance is one obvious topic. Within this type of instruction, teachers obtain typical health-related texts like prescription labels, consent forms, health history forms, and health-related Internet sites and construct lessons in which students learn not only how to decode and comprehend health-specific words but also what information is being conveyed by different texts and why it is important. The students are taught measurement terms, commonly used abbreviations, how to keep track of vaccinations and medications, and so on. Reports from existing programs for adult health literacy instruction have been positive (Doak et al., 1996). Building on students’ present needs and experiences may add to already existing programs to bring more relevancy and meaning to the instruction (Perkins, 1992; Purcell-Gates et al., 2000). Findings from national surveys indicate that both state directors of adult education programs and adult education teachers are interested in and supportive of an integration of literacy skill development and health-related tasks and content (Rudd and Moeykens, 1999; Rudd et al., 1999). Finding 5-2 Opportunities for measuring literacy skill levels required for health knowledge and skills, and for the implementation of programs to increase learner’s skill levels, currently exist in adult education programs and provide promising models for expanding programs. Studies indicate a desire on the part of adult learners and adult education programs to form partnerships with health communities. EDUCATION FOR HEALTH PROFESSIONALS There are many demands for time and space in the curricula of health professional schools, including schools of medicine, dentistry, pharmacy, nursing, and public health. Further, continuing education efforts compete with thousands of topics for the attention of busy health-care providers. Regardless, improved education in health literacy is critical to the develop- 7   The reading and writing of more complex texts is associated with higher levels of literacy as defined by the NALS assessment.

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Health Literacy: A Prescription to End Confusion ment of competent physicians and other health-care providers who can help to improve health literacy and to limit the negative effects of limited health literacy among patients. Furthermore, research should investigate whether increased health literacy skills in care providers such as medical assistants, home health-care workers, and home health aides could contribute to improved health-care quality and reduced medical errors. Approaches to education for health professionals should include both curricular and continuing education to reach the greatest number of providers at all stages of career development. The approaches described below may provide a starting point for increased integration of health literacy concepts and skills into professional and continuing education programs. Further information on the relationship of health literacy to health-care quality for all categories of providers could help to develop future directions for such integration. Curricular Approaches Few official requirements or curricula address health literacy in schools of medicine, public health, nursing, dentistry, or pharmacy. Health literacy issues may be addressed under topics such as patient communication, but they are generally not systematically included in these topics. Plomer and colleagues (2001) reported on the development and implementation phases of a project to improve medical students’ communication with limited literacy patients by incorporating literacy content into the medical student curriculum. In this study, the use of standardized patient cases regarding cancer screening was implemented and results revealed that group discussion about literacy was prompted. There are a few examples of courses or curriculums that should be noted. In 1995, the Harvard School of Public Health initiated an ongoing graduate course for students in public health that focused on health literacy studies, research, theories, and implications (NCSALL, 2001). In addition, the Harvard School of Public Health provides a web site (http://www.hsph.harvard.edu/healthliteracy) about health literacy for researchers and practitioners that includes a video slide show, curriculums, literature reviews, annotated bibliographies, and policy initiatives. Another curricular approach took place at the University of Colorado Medical School in Denver where a course on health literacy for medical students was developed and taught during 2000 as part of a grant. This was a temporary initiative however, and was not made a permanent part of the curriculum. A more formal approach has been instituted at the University of Virginia School of Medicine (Dalton, 2003). This curriculum includes an introductory lecture for first-year medical students, departments, residents, and external institutions that request a presentation on health literacy. A faculty development handbook is given to all faculty teaching courses in

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Health Literacy: A Prescription to End Confusion the first and second year, which provides background information and a list of available health literacy materials. Health literacy concepts are also integrated into other courses in the medical school curriculum; for example, patient case studies are presented in the second-year “Clinical Problems” course in which patients experience barriers related to communication misunderstandings and language issues. Also in the second year, the required community preceptorship includes a health literacy component. A fourth-year elective focusing on health literacy issues and including a service component is currently in development and will likely be offered in the spring of 2004. The University of Virginia (UVA) School of Medicine also provides a web interface to help other institutions develop health literacy curricula. It is made up of three main groups of information which can be individually tailored to the needs of an institution: (1) an outline on how UVA established its curriculum, with reference materials that include a faculty development handbook and examples of written cases used at various points of the curriculum; (2) an introductory health literacy lecture, examples of illustrations, and a bibliography and resources list; (3) standardized patient cases that illustrate work with patients with limited literacy, that also show how to work with interpreters for the deaf and for non-English-speaking patients; some of these case studies also integrate cultural competency issues. Continuing Education Approaches Most health literacy training for health professionals is done under continuing education umbrellas. Continuing medical education (CME) consists of those educational activities that serve to increase knowledge, skills, and performance of health professionals. They often are intended to update health professionals on new techniques as well as to expose them to new ideas and concepts relevant to their daily practice (ACCME, 2002). The Accreditation Council for Continuing Medical Education (ACCME) reports that over 45,000 directly sponsored CME courses were offered in 2002 to both physician and nonphysician participants (ACCME, 2003). The Coalition for Allied Health Leadership (CAHL) formed a health literacy team during their 2003 meeting to assess health literacy practices of allied health professionals at the national level. The CAHL team developed a survey to assess further the current level of awareness of the allied health community and to develop materials to help the allied health community better meet their needs. The survey was electronically sent to members of the Health Professions Network and the National Network of Health Career Programs in Two Year Colleges. Approximately one-third of the respondents were unaware of the issues surrounding health literacy, or un-

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Health Literacy: A Prescription to End Confusion aware of its impact on patient care. In addition, the same percentage also reported a lack of any institutional policy within their organization addressing health literacy or no assessment of the effectiveness of existing policies (Brown et al., in press). The American Medical Association (AMA) has developed several programs in professional continuing education in health literacy since adopting a policy in 1998 that recognized that limited patient literacy affects medical diagnosis and treatment. The AMA and the AMA Foundation have since raised awareness and shared best practices about health literacy. In 2003, the AMA Foundation, American Public Health Association, the National Council on the Aging, and other public health organizations formed the Partnership for Clear Health Communication, a coalition to increase awareness of health literacy and its impact on the nation’s health, and introduced a solution-oriented program that includes the “Ask Me 3” program that promotes communication between health-care providers and patients (AMA, 2003b; Ask Me 3, 2003). In conjunction with California Literacy, Inc., and the California Medical Association (CMA), the AMA and AMA Foundation developed the California Statewide Health Initiative that promotes provider–patient communication as a basis for patient understanding (AMA, 2003a). The AMA Foundation, with support from Pfizer, Inc., also links organizations across the country through Health Literacy Coalition, and provides grants to health literacy community service projects. The AMA Foundation has developed and distributed educational kits to physicians and health-care professionals. This program, “Health Literacy, Let Your Patients Understand,” includes a CD-ROM for use by providers in a continuing education curriculum. The 2003 Health Literacy Educational Kit is the Foundation’s primary tool for informing physicians, health-care professionals, and patient advocates about health literacy. The 2003 Health Literacy Educational Kit is an expanded version of the kit introduced in 2001. Included are a manual for clinicians, a new video documentary, reprintable information, guidelines for continuing medical education credit, and additional resources for education and involvement. The AMA Foundation provides these kits free to AMA Alliance chapters and state, county, and specialty medical societies that make a formal commitment to launch health literacy educational programs of their own, and to that end provide an extensive “train the trainer” program with a faculty guide to the clinician workshop and guidelines for local implementation planning. Finding 5-3 Health professionals and staff have limited education, training, continuing education, and practice opportunities to develop skills for improving health literacy.

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Health Literacy: A Prescription to End Confusion Finding 5-1 Significant obstacles and barriers to successful health-literacy education exist in K-12 education programs. Finding 5-2 Opportunities for measuring literacy skill levels required for health knowledge and skills, and for the implementation of programs to increase learner’s skill levels, currently exist in adult education programs and provide promising models for expanding programs. Studies indicate a desire on the part of adult learners and adult education programs to form partnerships with health communities. Finding 5-3 Health professionals and staff have limited education, training, continuing education, and practice opportunities to develop skills for improving health literacy. Recommendation 5-1 Accreditation requirements for all public and private educational institutions should require the implementation of the NHES. Recommendation 5-2 Educators should take advantage of the opportunity provided by existing reading, writing, oral language skills, and mathematics curriculums to incorporate health-related tasks, materials, and examples into existing lesson plans. Recommendation 5-3 HRSA and CDC, in collaboration with the Department of Education, should fund demonstration projects in each state to attain the NHES and to meet basic literacy requirements as they apply to health literacy. Recommendation 5-4 The Department of Education in association with HHS should convene task forces comprised of appropriate education, health, and public policy experts to delineate specific, feasible, and effective actions relevant agencies could take to improve health literacy through the nation’s K-12 schools, 2-year and 4-year colleges and universities, and adult and vocational education. Recommendation 5-5 The National Science Foundation, the Department of Education, and the NICHD should fund research designed to assess the effectiveness of different models of combining health literacy with basic literacy and instruction. The Interagency Education Research Initiative, a federal partnership of these three agencies, should lead this effort to the fullest extent possible. Recommendation 5-6 Professional schools and professional continuing education programs in health and related fields, including medicine, dentistry, pharmacy, social work, anthropology, nursing, public health, and journalism, should incorporate health literacy into their curricula and areas of competence.

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