interested or do not want to listen, the tool will not help them. A key challenge now is to identify ways to empower and activate patients.

To move health literacy research forward, there needs to be a broader multidisciplinary group of researchers working on the problem. Clinician-investigators are not the best group to be developing strong interventions; their strength is in developing strategies for implementing solutions into routine care. Cognitive psychologists and people from the learning sciences are needed to develop interventions. Strategies are needed to bring these groups together.

In terms of causal pathways, it is now recognized that worse health outcomes for individuals with low health literacy are not simply due to inability to comprehend print, multimedia, and oral messages. Causes are multifactorial, including differences in background knowledge, community beliefs and norms, information-seeking behaviors, self-efficacy, and healthcare seeking behaviors. To explore causation, there needs to be outreach to such fields as sociology and medical anthropology to understand health and healthcare beliefs, healthcare seeking behaviors, community norms, and social networks.

A study of hospitalization rates on 3,000 Medicare patients found that rates were about 30 percent higher for patients with low literacy (Baker et al., 2002). After tracking the patients for 7 years, age-adjusted mortality for people with low literacy was 52 percent higher than for those with adequate literacy (Baker et al., 2007). Clearly, there must be other factors besides the health care system that are affecting longevity. The focus needs to go beyond the healthcare system. To explore these causal pathways requires partnerships with researchers from other disciplines.

Fostering a diverse new set of investigators who can develop effective interventions requires better educational tools and systems, including more use of lessons from the learning sciences and cognitive psychology, Baker said. For implementation science, communication needs to be hard wired into the healthcare system. The question is not one of whether to use multimedia or print. It is about designing a system of integrated education and reinforcement of key messages that can be applied in everyday practice and meet patients’ learning styles.

There are several avenues for bringing in other disciplines to health literacy research. HARC is one. A new summer institute, modeled after the American Heart Association’s epidemiology conference or the National Institutes of Health’s Office of Behavioral and Social Sciences Research summer research training conference, is another possibility. A summer institute could help junior investigators develop their knowledge and skill set. Applications could be required so that attendees come in with some level of preparation, and scholarships need to be provided.

Practice-based research networks offer a tremendous opportunity