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IMPROVING
HEALTH LITERACY
WITHIN A STATE
WORKSHOP SUMMARY
Maria Hewitt, Rapporteur
Roundtable on Health Literacy
Board on Population Health and Public Health Practice
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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the Gov-
erning Board of the National Research Council, whose members are drawn from
the councils of the National Academy of Sciences, the National Academy of Engi -
neering, and the Institute of Medicine.
This study was supported by contracts between the National Academy of Sciences
and the Agency for Healthcare Research and Quality (HHSP233200900537P),
Health Resources and Services Administration (HHSH25034004T), American Col-
lege of Physicians Foundation, Association of Health Insurance Plans, the East Bay
Community Foundation; GlaxoSmithKline, Johnson & Johnson, Kaiser Perman -
ente, Merck and Co., Inc., and the Missouri Foundation for Health (09-0290-HL-
09). Any opinions, findings, conclusions, or recommendations expressed in this
publication are those of the author(s) and do not necessarily reflect the view of the
organizations or agencies that provided support for this project.
International Standard Book Number-13: 978-0-309-21572-5
International Standard Book Number-10: 0-309-21572-2
Additional copies of this report are available from the National Academies Press,
500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202)
334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu.
For more information about the Institute of Medicine, visit the IOM home page
at: www.iom.edu.
Copyright 2011 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
The serpent has been a symbol of long life, healing, and knowledge among almost
all cultures and religions since the beginning of recorded history. The serpent
adopted as a logotype by the Institute of Medicine is a relief carving from ancient
Greece, now held by the Staatliche Museen in Berlin.
Suggested citation: IOM (Institute of Medicine). 2011. Improving Health Literacy
Within a State: Workshop Summary. Washington, DC: The National Academies
Press.
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“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
— Goethe
Advising the Nation. Improving Health.
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The National Academy of Sciences is a private, nonprofit, self-perpetuating
society of distinguished scholars engaged in scientific and engineering research,
dedicated to the furtherance of science and technology and to their use for the
general welfare. Upon the authority of the charter granted to it by the Congress
in 1863, the Academy has a mandate that requires it to advise the federal govern -
ment on scientific and technical matters. Dr. Ralph J. Cicerone is president of the
National Academy of Sciences.
The National Academy of Engineering was established in 1964, under the charter
of the National Academy of Sciences, as a parallel organization of outstanding
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bers, sharing with the National Academy of Sciences the responsibility for advis -
ing the federal government. The National Academy of Engineering also sponsors
engineering programs aimed at meeting national needs, encourages education
and research, and recognizes the superior achievements of engineers. Dr. Charles
M. Vest is president of the National Academy of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of
Sciences to secure the services of eminent members of appropriate professions
in the examination of policy matters pertaining to the health of the public. The
Institute acts under the responsibility given to the National Academy of Sciences
by its congressional charter to be an adviser to the federal government and, upon
its own initiative, to identify issues of medical care, research, and education.
Dr. Harvey V. Fineberg is president of the Institute of Medicine.
The National Research Council was organized by the National Academy of
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Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and
vice chair, respectively, of the National Research Council.
www.national-academies.org
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PLANNING COMMITTEE ON UNDERSTANDING WHAT
WORKS IN HEALTH LITERACY ACROSS A STATE1
SHARON BARRETTT, Health Literacy Staff Consultant, Association of
Clinicians for the Underserved
CAROLYN COCOTAS, Senior Vice President, Quality and Corporate
Compliance, F.E.G.S. Health and Human Services
JEAN KRAUSE, Executive Vice President and CEO, American College
of Physicians Foundation
RUTH PARKER, Professor of Medicine, Emory University School of
Medicine
DEAN SCHILLINGER, Professor of Medicine in Residence, University
of California San Francisco
1 Institute
of Medicine planning committees are solely responsible for organizing the
workshop, identifying topics, and choosing speakers. The responsibility for the published
workshop summary rests with the workshop rapporteur and the institution.
v
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ROUNDTABLE ON HEALTH LITERACY1
GEORGE ISHAM (Chair), Medical Director and Chief Health Officer,
HealthPartners
SHARON E. BARRETT, Health Literacy Staff Consultant, Association
of Clinicians for the Underserved
CINDY BRACH, Senior Health Policy Researcher, Center for Delivery,
Organization, and Markets, Agency for Healthcare Research and
Quality
CAROLYN COCOTAS, Senior Vice President, Quality and Corporate
Compliance, F.E.G.S. Health and Human Services System
ARTHUR CULBERT, President and CEO, Health Literacy Missouri
MICHAEL L. DAVIS, Senior Vice President, Human Resources, General
Mills, Inc.
BENARD P. DREYER, Professor of Pediatrics, New York University
School of Medicine, and Chair, American Academy of Pediatrics
Health Literacy Program Advisory Committee
LEONARD EPSTEIN, Senior Advisor, Clinical Quality and Culture,
Health Resources and Services
DEBBIE FRITZ, Director, Policy and Standards, Health Management
Innovations Division, GlaxoSmithKline
MARTHA GRAGG, Vice President of Program, Missouri Foundation
for Health
LINDA HARRIS, Team Leader, Health Communication and eHealth
Team, Office of Disease Prevention and Health Promotion, U.S.
Department of Health and Human Services
BETSY L. HUMPHREYS, Deputy Director, National Library of
Medicine, National Institutes of Health
JEAN KRAUSE, Executive Vice President and CEO, American College
of Physicians Foundation
MARGARET LOVELAND, Global Medical Affairs, Merck & Co., Inc.
PATRICK McGARRY, Assistant Division Director, Scientific Activities
Division, American Academy of Family Physicians
RUTH PARKER, Professor of Medicine, Emory University School of
Medicine
YOLANDA PARTIDA, Director, National Program Office, Hablamos
Juntos, University of California, San Francisco, Fresno Center for
Medical Education & Research
1 Institute
of Medicine forums and roundtables do not issue, review, or approve individual
documents. The responsibility for the published workshop summary rests with the work -
shop rapporteur and the institution.
vi
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CLARENCE PEARSON, Consultant, Globabl Health Leadership and
Management
SUSAN PISANO, Director of Communications, America’s Health
Insurance Plans
ANDREW PLEASANT, Health Literacy and Research Director, Canyon
Ranch Institute
SCOTT C. RATZAN, Vice President, Global Health, Johnson & Johnson
WILL ROSS, Associate Dean for Diversity, Associate Professor of
Medicine, Washington University School of Medicine
PAUL M. SCHYVE, Senior Vice President, The Joint Commission
PATRICK WAYTE, Vice President, Marketing and Health Education,
American Heart Association
WINSTON F. WONG, Medical Director, Community Benefit,
Disparities Improvement and Quality Initiatives, Kaiser Permanente
Study Staff
LYLA M. HERNANDEZ, Staff Director
CHINA DICKERSON, Senior Project Assistant (until December 2, 2010)
ANGELA MARTIN, Senior Project Assistant (beginning November 1,
2010)
ROSE MARIE MARTINEZ, Director, Board on Population Health and
Public Health Practice
vii
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Reviewers
This report has been reviewed in draft form by individuals chosen
for their diverse perspectives and technical expertise, in accordance with
procedures approved by the National Research Council’s Report Review
Committee. The purpose of this independent review is to provide candid
and critical comments that will assist the institution in making its pub -
lished report as sound as possible and to ensure that the report meets
institutional standards for objectivity, evidence, and responsiveness to
the study charge. The review comments and draft manuscript remain
confidential to protect the integrity of the process. We wish to thank the
following individuals for their review of this report:
Martha Gragg, Medical University of South Carolina
John Gutierrez, University of California Los Angeles School of
Dentistry
Lauren McCormack, RTI International
Antronette Yancy, University of California Los Angeles Kaiser
Permanente Center for Health Equity
Although the reviewers listed above have provided many construc-
tive comments and suggestions, they did not endorse the final draft of
the report before its release. The review of this report was overseen by
Harold J. Fallon, Medical University of South Carolina. Appointed by the
Institute of Medicine, he was responsible for making certain that an inde -
pendent examination of this report was carried out in accordance with
institutional procedures and that all review comments were carefully
considered. Responsibility for the final content of this report rests entirely
with the rapporteur and the institution.
ix
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Acknowledgments
The sponsors of the Institute of Medicine Roundtable on Health Lit -
eracy made it possible to plan and conduct the workshop, Understanding
What Works in Improving Health Literacy Within a State. Sponsors from
the U.S. Department of Health and Human Services are the Agency for
Healthcare Research and Quality and the Health Resources and Services
Administration. Non-federal sponsorship was provided by the American
College of Physicians Foundation; the Association of Health Insurance
Plans; the East Bay Community Foundation; GlaxoSmithKline; Johnson
& Johnson; Kaiser Permanente; Merck and Co., Inc.; and the Missouri
Foundation for Health.
The Roundtable wishes to express its gratitude to the following speak-
ers for their thoughtful and stimulating presentations: Mary Ann Abrams,
Ellen Beck, Arthur Culbert, Terry Davis, Ariella Herman, Carol Mangione,
Alfred E. Osborne, Jr., Rima Rudd, Dean Schillinger, Pam C. Silberman,
Cynthia Solomon, and Eugene Washington. The Roundtable also wishes
to express its appreciation to the planning committee for their hard work
in putting together an excellent workshop agenda. Members of the plan -
ning committee are Sharon Barrett, Carolyn Cocotas, Jean Krause, Ruth
Parker, and Dean Schillinger.
xi
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Contents
1 INTRODUCTION 1
2 KEYNOTE ADDRESS 3
Opening Remarks and Introduction of Keynote Speaker, 3
Overview of the Role of the University in Improving Health
Literacy Statewide, 4
3 STATE-BASED MODELS TO IMPROVE HEALTH LITERACY 7
The Road to Regional Transformation: The North
Carolina Experience, 7
The Iowa Experience: Creating a Shared Vision for Health
Literacy in Iowa, 12
Discussion, 17
The Missouri Experience, 21
Louisiana Statewide Health Literacy Initiative, 24
Discussion, 29
4 THE ROLE OF THE UNIVERSITY IN IMPROVING STATES’
HEALTH LITERACY 33
How the University Can Advance State Health Literacy, 33
Workforce Training and Preparedness, 42
Discussion, 48
xiii
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xiv CONTENTS
5 IMPROVING HEALTH LITERACY AT THE COMMUNITY
LEVEL 51
New York City Mayor’s Initiative on Health Literacy, 51
MiVIA, 56
Empowering Parents, Benefiting Children, Creating Strong
Foundations for Health: Improving Health Literacy
Through the Head Start Program, 59
Health Literacy at the University of California, San Diego,
Student-Run Free Clinic Project and Fellowship in
Underserved Health Care: Learnings, 65
Discussion, 71
6 CLOSING REMARKS 75
REFERENCES 79
APPENDIXES
A ACRONYMS 83
B WORKSHOP AGENDA 85
C WORKSHOP SPEAKER BIOSKETCHES 89
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Tables, Figures, and Boxes
TABLES
2-1 Experience of Collaboration in Decision Making, Simulated
Model, 5
2-2 Groups Involved in Health Literacy: Definitions, 6
4-1 Results of Informal Survey of University of California Health
Professional Schools’ Health Literacy Curriculum, 45
5-1 Parents’ Sources of Help When a Child Is Sick, 63
5-2 Outcomes of 182 Diabetic Patients Seen at the UCSD Free Clinic and
Assessed at 1 Year, 68
FIGURES
5-1 HCI health improvement project, 61
5-2 HCI strategic implementation, 61
5-3 Overview of the Head Start intervention, 64
BOXES
3-1 Iowa Health Literacy Sponsors and Their Projects, 13
3-2 Iowa Health Literacy Steering Work Group Membership, 14
3-3 Principles of Health Literacy Iowa, 14
xv
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xvi TABLES, FIGURES, AND BOXES
4-1 Study Objectives, 37
4-2 Anticipated Study Outcomes, 37
5-1 Guidebook Outline, 55
5-2 Goals of the HCI Health Literacy Program, 60