PROMOTING
HEALTH LITERACY
TO
ENCOURAGE PREVENTION
AND WELLNESS

WORKSHOP SUMMARY

Lyla Hernandez and Suzanne Landi, Rapporteurs

Roundtable on Health Literacy

Board on Population Health and Public Health Practice

INSTITUTE OF MEDICINE
                      OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.

www.nap.edu



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PROMOTING HEALTH LITERACY TO ENCOURAGE PREVENTION AND WELLNESS WORKSHOP SUMMARY Lyla Hernandez and Suzanne Landi, Rapporteurs 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, the American College of Physicians Foundation, GlaxoSmithKline, Johnson & Johnson, Kaiser Permanente, Merck & Co., 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 organiza - tions or agencies that provided support for this project. International Standard Book Number-13: 978-0-309-21577-0 International Standard Book Number-10: 0-309-21577-3 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. Promoting Health Literacy to Encourage Prevention and Wellness: 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 engineers. It is autonomous in its administration and in the selection of its mem - 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 Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in pro - viding services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the 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 PROMOTING HEALTH LITERACY TO ENCOURAGE PREVENTION AND WELLNESS: A WORKSHOP1 Cynthia Baur, Ph.D., Director, Health Communication and Marketing, National Center for Health Marketing, Centers for Disease Control and Prevention Benard Dreyer, M.D., Professor of Pediatrics, New York University School of Medicine, and Chair, American Academy of Pediatrics Health Literacy Program Advisory Committee Margaret Loveland, M.D., F.R.C.P., F.C.C.P., Global Medical Affairs, Merck & Co., Inc. Scott Ratzan, M.D., Vice President, Global Health, Johnson & Johnson 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 LITERACY 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 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 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 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 vi

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AMY WILSON-STRONKS, Project Director, Division of Standards and Survey Methods, and Principal Investigator, Hospitals, Language, and Culture Study, The Joint Commission WINSTON F. WONG, Medical Director, Community Benefit, Disparities Improvement and Quality Initiatives, Kaiser Permanente Study Staff LYLA M. HERNANDEZ, Staff Director SUZANNE LANDI, Senior Project Assistant (until November 1, 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: Carolyn Cocotas, F.E.G.S. Health and Human Services System Norma Kanarek, Johns Hopkins Medical Institute Michael Villaire, Institute of Healthcare Advancement Louise Wessel, Association of Clinicians for the Underserved Although the reviewers listed above have provided many construc- tive comments and suggestions, they were not asked to endorse the final draft of the report before its release. The review of this report was overseen by Harold J. Fallon, University of Alabama at Birmingham. Appointed by the National Research Council the Institute of Medicine, he was respon - sible for making certain that an independent 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 authors and the institution. ix

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Acknowledgments The Roundtable on Health Literacy wishes to thank its sponsors for making it possible to plan and conduct the workshop on integrating health literacy into prevention programs. Sponsors of the workshop were the Agency for Healthcare Research and Quality, American College of Physicians Foundation, GlaxoSmithKline, Johnson & Johnson, Kaiser Permanente, Merck & Co., and the Missouri Foundation for Health. The Roundtable expresses its appreciation to Scott Ratzan for prepa - ration and presentation of the commissioned paper on integrating health literacy into primary and secondary prevention strategies. Thanks also go to the expert speakers whose presentations provided insightful infor- mation and stimulated interesting and thoughtful discussions. These speakers are Jennifer Cabe, Jennifer Dillaha, W. Douglas Evans, Robert Gould, Jeffrey Greene, Juli Hermanson, Charles J. Homer, Patricia Molino, John Montgomery, Linda Neuhauser, Arnold Saperstein, Penelope Slade- Sawyer, and Mariela Yohe. The Roundtable also wishes to thank the planning committee mem- bers for their work in developing an excellent workshop agenda. Members of the planning committee were Cynthia Baur, Benard Dreyer, Margaret Loveland, and Scott Ratzan. xi

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Contents 1 INTRODUCTION 1 2 THE ROLE OF HEALTH LITERACY IN PRIMARY AND SECONDARY PREVENTION 3 3 COMMISSIONED PAPER ON INTEGRATING HEALTH LITERACY INTO PRIMARY AND SECONDARY PREVENTION STRATEGIES 7 4 PANEL REACTIONS 13 Discussion, 19 5 INTERSECTION OF HEALTH LITERACY AND PUBLIC HEALTH PREVENTION PROGRAMS 27 Incorporating Health Literacy into the Healthy People Focus on Social Determinants of Health, 27 Integrating Health Literacy into State Prevention, Wellness, and Health Care Programs, 29 How Have the Concepts of Health Literacy Been Incorporated into Local Prevention and Wellness Programs? What Are the Successes and Challenges?, 31 Discussion, 34 xiii

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xiv CONTENTS 6 HOW DO INSURANCE COMPANIES FACTOR HEALTH LITERACY INTO PREVENTION PROGRAMS AND INFORMATION FOR ENROLLEES? 37 Discussion, 42 7 INDUSTRY CONTRIBUTIONS TO PROVIDING HEALTH LITERATE PRIMARY AND SECONDARY PREVENTION 47 Discussion, 53 8 THE POTENTIAL AND CHALLENGES OF HIGHLIGHTING HEALTH LITERACY 57 REFERENCES 63 APPENDIXES A WORKSHOP AGENDA 65 B WORKSHOP SPEAKER BIOSKETCHES 69 C COMMISSIONED PAPER 77 FIGURES 3-1 Determinants of health: The 21st century field model, 8 3-2 Health literacy scorecard, 9 4-1 Health literacy framework, 22 5-1 A framework for obesity prevention, 29 5-2 Potential points for intervention in health literacy, 32 C-1 Health literacy framework, 83