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2 Keynote Address OPENING REMARKS AND INTRODUCTION OF KEYNOTE SPEAKER Alfred E. Osborne, Jr., Ph.D., M.B.A., M.A. Anderson School of Management Osborne emphasized the importance of health literacy and noted that the U.S. Department of Health and Human Services (HHS) has made improving the nation’s health literacy a national priority. In his view, having the Anderson School of Management cosponsor a workshop on health literacy with the Institute of Medicine (IOM) is consistent with the school’s mission of enhancing the administrative skills of leaders within organizations that are addressing the needs of underserved communi - ties. For example, the school’s Health Care Institute (HCI) has experience training Head Start Program leadership, staff, and participants. HCI also has a relationship with the Health Resources and Services Administration (HRSA) in its work with community health centers. Osborne welcomed roundtable members, speakers, and the audience to the UCLA campus and introduced the keynote speaker, Eugene Washington. 3

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4 IMPROVING HEALTH LITERACY WITHIN A STATE OVERVIEW OF THE ROLE OF THE UNIVERSITY IN IMPROVING HEALTH LITERACY STATEWIDE Eugene Washington, M.D., M.Sc. UCLA Health Sciences and David Geffen School of Medicine at UCLA Washington addressed four questions pertaining to health literacy in his presentation: Why is health literacy important? Who must under- stand its importance? How can its importance best be conveyed? What is the role of the academic community in addressing the needs of health literacy? Washington pointed out that the focus of the workshop is state- based approaches to health literacy, but he emphasized the global nature of the problem of low health literacy. He suggested that what is learned from local and statewide efforts could be translated to affect care around the world. The transitive property states that, “If a = b and b = c, then a = c.” This formula is used in philosophy, especially in the understanding of logic. Using the transitive property in the context of health literacy and quality health care means that if the quality of health care (a) depends on effective patient provider communication (b) and effective provider communica - tion depends on understanding the health literacy level of the patient (c), then the quality of care depends on understanding the patient’s health literacy level. In short, the quality of care depends on both the patient’s level of literacy and the effectiveness of provider communication. This transitive property can also be applied in the context of population health. The ability to improve the overall health status of a population or a com - munity depends on the effectiveness of communication with the entire community. And that, in turn, depends on understanding the health lit- eracy level of the population. The IOM report, Crossing the Quality Chasm, stated that health care should be safe, effective, patient centered, timely, efficient, and equitable (IOM, 2001). If care is patient centered, individuals leave their clinical encounter with the understanding that their specific needs have been met. Timely care means that necessary interventions are available and the processes of care are efficient. Washington observed that poor communi- cation is often what leads to medication errors. A clinician may choose the wrong therapy for a patient because he or she did not understand what the patient was saying. Alternatively, a patient may not take medications appropriately because the clinician did not give specific instructions. In early research that examined the elements of patient-provider com- munication and shared decision making, episodes of care were video - taped with the provider knowing that the encounter was being recorded. Patients and providers rated the encounters in terms of whether “part-

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5 KEYNOTE ADDRESS TABLE 2-1 Experience of Collaboration in Decision Making, Simulated Model Shared Decision Making Positive Negative Present True partnering False partnering 22% 38% Absent Assumed partnering Unwilling partnering 21% 19% SOURCE: Adapted from Saba et al., 2006. nering” in care occurred. True shared decision making occurred only 22 percent of the time while simulated shared decision making occurred 38 percent of the time (Table 2-1). When thinking about improving health literacy, Washington said, it is important to understand the perspectives of the various parties that listen to health literacy messages. The reaction to the message will depend on the role in which the recipient views him or herself. Yet the deliverer of the message often views the recipients as uniform. Various roles of the recipient are those of audience, customer, constituent, partner, and stake - holder (Table 2-2). Those that need to be engaged to effectively understand and com- municate the importance of health literacy include patients, providers, employers, payers, policy makers, communities and populations, com - munity leaders, researchers, educators, and communicators and dissemi - nators. When developing messages it is important to distinguish who is the primary audience, customer, constituent, partner, or stakeholder. It may also be necessary to think about whether particular groups are the primary, secondary, or tertiary audience. There is value in partnering with the communications industry because of its great expertise in using media to communicate effectively, Washington said. This key group, which has not been given sufficient attention, should be viewed as a principal partner and a major stake - holder in both education and research efforts. Members of this group can also be involved in efforts to intervene and improve health status. In terms of the academic community, health sciences centers, schools of education, and schools of communication have a major role to play in conveying the importance of health literacy and furthering health literacy practice. The academic community more broadly has a key role to play in teaching and expanding the relevant workforce and in advancing research methods and knowledge of what works. Projections of health professional shortages in California made by HRSA can provide opportunities insofar as they represent positions for

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6 IMPROVING HEALTH LITERACY WITHIN A STATE TABLE 2-2 Groups Involved in Health Literacy: Definitions Audience The group of spectators at a public event; listeners or viewers collectively, as in attendance at a theater or concert. A regular public that manifests interest, support, enthusiasm, or the like; a following Constituent A person who authorizes another to act on his or her behalf, as a voter in a district represented by an elected official Customer A person who purchases goods or services from another; buyer; patron Partner A person who shares or is associated with another in some action or endeavor; sharer; associate. A player on the same side or team as another Stakeholder A person or group not owning shares in an enterprise, but affected by, or having an interest in its operations, such as the employees, customers, and local community SOURCE: which individuals will have to be trained. Newly trained health personnel should be educated to understand the importance of health literacy and provide care that is linguistically appropriate, Washington said. Educational institutions have played an important role in furthering the use of multidisciplinary, community-based, participatory research. Such research should include schools of business, engineering, education, and communication, along with the traditional disciplines in health sci - ences. Another area for involvement of the academic community relates to interventions to improve health literacy. Researchers in academic insti - tutions are furthering the science of establishing what interventions are most effective. Interventions include communication strategies both at the individual level, and for populations at large. The development of meth - ods, measurements, and standards are critical to understanding what works and to determine whether or not providers, institutions, organiza - tions, and communities are providing care and messages that are at the appropriate health literacy level. The educational enterprise must embrace the idea of a continuum of lifelong learning, not only for individuals and patients, but also for health- care providers. Such an approach is needed in order to fully appreciate the dimensions of low health literacy and the opportunities to intervene and ensure high-quality health care. Low health literacy is not simply a local, state, or even a national problem. It is a global problem. The outcomes of forums such as the IOM workshop have broad implications with the potential for improving health worldwide, he concluded.