to the multiplicity of settings within which people take health-related actions. In so doing, the NAP is recommending a strategy that reduces barriers to information, to decision making processes, to action, to health care, and to community well-being.

The U.S. Department of Education’s 1993 and 2005 reports of literacy skills among U.S. adults give evidence of the strong links between literacy and social factors (Rudd, 2007). Analyses of the distribution of health literacy indicate that health literacy is related to health disparities. Everything we talk about when speaking of literacy and disparities, alone or together, must meld with the powerful issues of social justice.

Health literacy research offers evidence of links between literacy skills and prevention, early detection, chronic disease management, informed choice, illness, and early death. Social justice will not allow us to wait for the education systems to improve literacy skills of the public. At the same time, logic will not allow us to attribute health outcomes to individuals’ literacy skills alone. Literacy, as the 2004 IOM report noted, is an interaction between the skills of individuals and the demands of health systems. Barriers to information, to care, and to individual as well as community-level decision-making and action—contribute to untoward health outcomes. They must be identified and removed.

Policy makers need an evidence base for suggested change, Rudd said. There is already a strong foundation for some of these issues. For example, we know that there must be professional rigor applied to the development and delivery of health information. (Rudd suggested that it be made criminal to disseminate incomprehensible materials critical to health, to healthful action, and to health decisions.) We may well want literacy-related regulations that set standards for health and social service environments and institutions and literacy-related communication criteria for the testing and licensing of professionals. However, we cannot move this agenda ahead without the research to provide insight into needed change and program studies to determine what actions prove efficacious. The National Action Plan offers more than a call—with strategies and links to examples, it illuminates a pathway, Rudd concluded.

One of the major things we are trying to improve, said Dreyer, is how the health care system communicates with patients and gives them information. The NAP says this needs to be measured. But how does one measure how a health system communicates? Davis agreed that is the crux. More work is needed on how to measure whether a health care system is designed for patients. Isham added that the system with its complexity is a key target. We need research and implementation tools for