in real-world settings in different communities. Knowing the cost of the problem may help drive policy. Additionally, there is a need to drill down on issues that are not clear. For example, why is low literacy related to worse health outcomes? The impact of poverty, social disadvantage, and poor quality of care on outcomes has been documented, but what else is going on? What is health literacy a marker for? It is likely a key, but not the only key.

In addition, several crosscutting research themes offer exciting possibilities. These include health care redesign, health insurance reform, improving navigation and community-based participatory research, removing health literacy barriers to clinical trials, addressing disparities, health literacy measurement in national and other surveys, and pre K through 12th and adult education and health education. Davis said that one of her long-standing concerns involves the pervasive national problems with K-12 education. Currently it is estimated that 30 to 40 percent of sixth graders will not graduate from high school. The markers are known—school attendance, behavior, scores, and grades. These children need more than better health literacy. Evidence is emerging that student achievement improves if there are high expectations, impassioned teaching, provision of better reading and math skill building, more practice, and a lot of support. Attention to this challenging problem will also help address the health literacy of future adults and families.

Crosscutting research themes are interesting opportunities, but are crosscutting agendas possible? And if so, who will be the responsible agency? The bureaucracy of research makes collaborations difficult. Funding is offered largely by disease, and researchers most commonly function and publish in silos.

The good news is that health literacy research is evolving. The field has finally moved beyond assessing readability and individual literacy. Self-management interventions have moved beyond knowledge transfer to include patient behavior, support, and empowerment. Areas where work is still needed include outcomes research and identifying methods to make health numeracy more user-friendly. For example, in outcomes research focusing on preventive services utilization, patients’ completion of screening tests are most commonly self-reported and usually not tracked for more than 1 year. More longitudinal studies are needed. Another promising area is numeracy. Because of the work of Dr. Russ Rothman and others,1 it is now clear that numeracy is a pervasive problem even among younger adults with adequate reading skills. Ameri-


Dr. Russell Rothman and colleagues (2006) conducted a study that showed that those with low literacy and low numeracy skills have significant difficulties understanding food labels.

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