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4
Panel Reactions
Following Ratzan’s presentation, three speakers were invited to pro-
vide comments on the commissioned paper which had been made avail -
able to them prior to this workshop.
Robert Gould, Ph.D.
President
Partnership for Prevention
Gould said he enjoyed the emphasis in Ratzan’s presentation on the
cost-effectiveness of prevention. One way to protect the prevention pro-
visions of various legislative actions is to understand that prevention is
a way to save costs in the health care system. Gould said he spends his
time in primary prevention, and, from a social marketer’s perspective,
defines health literacy as the effective engagement of the public in getting
and staying healthy. He has worked on social marketing projects such as
developing campaigns for hypertension, cholesterol, and the Food Guide
Pyramid. The prevailing attitude of those preparing the campaigns was
that if the public does not understand the message, then it’s not the pub-
lic’s problem, but rather it is up to the marketers to clarify.
In a campaign called the Healthy Older People Campaign, Gould said
he and his team recognized the importance of crafting a print media cam -
paign that the target audience could understand. Materials were printed
in yellow and black with sharp contrasts in order to accommodate elderly
populations that cannot see well. The campaign also made sure that the
13
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14 PROMOTING HEALTH LITERACY
reading level of all materials was appropriate for the audience. According
to Gould, social marketers already consider health literacy in their efforts,
though they define it as effective public engagement.
Gould’s concerns with the paper’s focus were in regard to behavior
change and using social marketing to improve equity and promote health.
Behavior, he said, is not determined solely by knowledge. Therefore, it is
important to focus on what other methods, in addition to fostering knowl-
edge, can be used to create the desired behavior. Many people understand
the messages and have the knowledge, but do not act on it due to other
barriers or beliefs. For example, a small subsample of teens known as high
sensation seekers understand the risks of smoking, and still engage in the
behavior despite this knowledge—some even enjoy taking the risk. The
Truth campaign (http://www.thetruth.com) targeted this population by
presenting tobacco corporations as manipulative and terrible, and leaving
the decision of smoking up to the consumer.
Gould expressed his support for the policy recommendations made
in the paper. Health literacy from Gould’s perspective is an umbrella term
that means effectively engaging the public. Such engagement is required
for prevention efforts to be successful, he said, and primary and clinical
prevention are key investments in the public’s health.
Charles J. Homer, M.D.
President and Chief Executive Officer
National Initiative for Children’s Healthcare Quality
Homer focused his comments on quality, which he defined gener-
ally as delivering the right care to the right person at the right time. In
Crossing the Quality Chasm (IOM, 2001), quality health care is defined as
having six characteristics: safe, timely, effective, efficient, equitable, and
patient-centered. Patient-centered or family-centered care means that the
care meets the needs of patients and families and is communicated in a
way that can be understood. This is particularly important in the areas
of chronic care and of prevention because in order to make care effective,
one must influence behaviors, and the only way to influence behaviors,
Homer said, is through patient- and family-centered care.
Quality is related to the construct of health literacy because meet -
ing the needs of patients and families requires clear communication.
Clinicians focus on reliable and effective delivery of care, and they are
increasingly turning to public health methods of quality measurement
and improvement to enhance performance.
The National Initiative for Children’s Healthcare Quality places a
major focus on childhood obesity and on applying the principles of qual -
ity improvement in both clinical and community settings, Homer said.
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This focus has lead to an examination of how one communicates with
patients about health behaviors for children, behaviors such as healthy
eating habits and active lifestyle. Unfortunately, the methods of com -
munication taught in medical school are wrong for effective communica -
tion. Doctors are trained to act as the experts and tell patients what to
do, whether they are interested or not. Similarly, clinicians have become
acutely aware of the limits of clinical prevention in affecting a problem
as broad as obesity—what is needed is a focus on change in the context
of the community.
Reflecting on the paper, Homer commented that it points out
that there are multiple levels of prevention—primary, secondary, and
tertiary—some of which takes place in the community context and some
in a clinical context. He highlighted the concept of active agency—that is
that an individual takes an active step toward a health outcome such as
choosing either to exercise or not to exercise, or to wear a seatbelt or not
to wear a seatbelt. These actions can take place in either a conducive envi-
ronment or a hostile environment. For example, the message can be that
one should eat a healthy diet, but if the community lacks healthful food
options (a hostile environment), it is unlikely that the individual will eat
a healthful diet. Prevention efforts need to take into account the context
of the individual’s environment.
There are also passive strategies to influence prevention, which the
paper mentions only in passing. With passive strategies the individual is
not involved in making a decision or taking an action toward the preven-
tive measure. For example, policymakers have decided to put fluoride in
the water; the individual drinking the water does not decide to take that
step. The role of the individual is in influencing that community policy to
either support or not support the fluoridation of water. The importance of
health literacy in this context is to inform members of the public so that
they can influence policy decisions.
How, Homer asked, would enhanced health literacy improve preven-
tion-oriented behaviors in both the clinical context and the community
context? In the clinical context, health literacy can help primary preven -
tion efforts by helping people understand risks and benefits, understand
the actions they have to take, and potentially, enhance motivation. In
secondary and tertiary prevention, health literacy efforts can be aimed
at helping people prevent complications or worsening conditions. In sec -
ondary and tertiary prevention the kinds of actions required of people
are likely to be more complex as are the challenges of communication.
Therefore, the need for close attention to health literacy is greater and
may require the kind of interactive decision tools in which the informa-
tion presented is customized to individual risk.
The paper also mentions the need to decrease the complexity of the
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16 PROMOTING HEALTH LITERACY
health care system, Homer said. While this is certainly true, complexity is
not the main barrier to primary prevention. In obesity, what is particularly
helpful to is to have health navigators understand the complex set of com-
munity resources and help individuals access them, rather than helping
individuals obtain access to primary care services.
The issue of provider training is also addressed in the commissioned
paper and is absolutely essential, Homer said. Medical providers need to
be trained in communication in a more rigorous manner than just a course
in first-year medical or nursing school. Other health professions should
also be trained in health literacy and such education should be required
for certification or licensure, Homer stated. Furthermore, health literacy
should be incorporated into the public education system to help develop
informed health consumers, Homer said.
Additional strategies the paper could have commented on include
training consumers and youth in these types of issues, Homer said.
Another strategy would be to develop prevention specialists in the com -
munity who could work with multiple providers. The importance of lon-
gitudinal relationships cannot be overemphasized, Homer said. If one is
trying to change behavior, having a trusting relationship built over time
is a critical mediator. Another important area is payment reform. Our cur-
rent fee-for-service health care delivery system is completely at odds with
an emphasis on prevention.
Community change is critical in the preventive context, Homer
said. One focus of health literacy should be how to enhance prevention-
oriented behaviors in the community. This requires communicating to the
public about ways to be more effective in influencing public policy, both
at the national level and at the community level, where prevention issues
include which programs school boards will fund and whether streets will
have bike lanes and sidewalks. Successful prevention efforts at the com-
munity level are a matter both of understanding and prioritizing risk and
of balancing health with other priorities. Most people are not primarily
motivated by health; they are primarily motivated by wanting to do the
things that are important to them.
Homer commented on the specific strategies in the paper. He would
have liked greater elaboration on how to equip families with self-care
strategies. In terms of workplace wellness, while programs that encourage
healthy behavior in the workplace are important, there are some ethical
issues that cause concern, he said. Would employers make decisions about
hiring based on health behavior?
Homer also expressed skepticism about the health scorecard concept
because it is based on individual responsibility in the absence of com -
munity interventions, which can create blame for the individual. It is not
clear that scorecards would serve as appropriate individual motivation,
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and there is potential harm if they were to be used inappropriately in
guiding employment practices.
Overall, Homer concluded, it is important to clarify the scope and
focus of health literacy interventions, including general capacity, compe -
tency with specific preventive actions, and motivation and prioritization.
It is also important to decide if the individual interventions will focus pri-
marily on clinical prevention or community prevention even though there
is and should be interface between the two. It is also important, Homer
said, to address developmental issues of different life stages: parental/
early childhood stage, adult, and elderly.
Mariela Yohe, M.P.H.
Program Director
Directors of Health Promotion and Education
Maxene Spolidor was unable to attend the meeting due to illness.
Mariela Yohe delivered her comments.
The Directors of Health Promotion and Education is an organization
that represents the directors of health promotion and education at specific
state and territorial health departments. The directors administer a wide
range of programs, dealing with issues from chronic disease and tobacco
prevention to injury prevention, and members have the skills to imple -
ment, evaluate and create public health and education programs.
Communication activities have been major components of state health
department programs funded by the Centers for Disease Control and Pre-
vention (CDC), many of which specifically address issues of literacy and
cultural linguistic appropriateness for interventions, outreach, education
and social marketing strategies. For example, in Massachusetts, a recently
funded program to improve breast and cervical cancer service delivery
through the WISEWOMAN program included a health literacy training
component for community health workers, who act as patient naviga -
tors or care coordinators for the patients receiving care through feder-
ally funded community health centers and safety-net sites. In another
effort, staff involved in the delivery of evidence-based health promotion
programs for people over 50 were trained in health literacy, ensuring
that patients receive care that is linguistically and culturally appropriate
with an added emphasis on literacy considerations. Health promotion
activities undertaken by the Massachusetts Department of Public Health
do not place the burden of understanding complex information on the
consumer. Rather, the department accepts responsibility for delivering its
services and messaging to all audiences, with an emphasis on literacy and
cultural/linguistic appropriateness.
Comments on the Ratzan paper included questions about who, spe-
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18 PROMOTING HEALTH LITERACY
cifically, would be responsible for funding, organizing, delivering, and
evaluating consumer education aimed at helping people understand com-
plex health conditions. How would continuity of education be ensured if
less-advantaged populations may move frequently and change providers,
Yohe asked? The advancement of health literacy cannot rely on the model
of the medical home, she said.
Yohe expressed hesitation about the scorecard as a motivator, sug-
gesting that members of a disadvantaged population may have greater
barriers to overcome than scoring well on scorecard indicators. She said
that perceived barriers to health care need to be lowered but the scorecard
may feel like a new, judgmental obstacle for some people. She agreed with
Homer that it is important to make sure that health education, which
could include health literacy, is available in schools, although it is already
difficult to keep current programs funded. Furthermore, telling individual
school systems what and how to teach is a daunting task.
Yohe said that she would rather see resources concentrated on keep-
ing health education as a core component of public education for all U.S.
children than set up scorecards and other devices that may throw the onus
of understanding complex information on the patient rather than on the
health provider.
The paper’s recommendation “to develop, test, and implement health
communication approaches to advance wellness and prevention so that
skills and abilities of the population can be aligned with the demands
and complexity of the tasks required for health” places an additional bur-
den on programs that are currently underfunded and understaffed, Yohe
said. Public health agencies are generally not concerned with educating
the public on health literacy, but instead such agencies are providing
interventions in the most appropriate health-literate vehicle that they can
design and implement. Ratzan mentioned flu as an example in his paper.
If one looks at the CDC website on flu (http://www.pandemicflu.gov)
one will find programs that address consumers’ needs and abilities to
understand complex information.
The second recommendation in the paper calls for the Office of the
Surgeon General or the Domestic Policy Council to convene and guide
agencies to fund and create a Health Literacy P-scorecard in each state.
But this requires a set of universally accepted indicators. Which govern-
ment agency would be charged with developing those indicators? Who
would collect, analyze, and disseminate the information?
Concluding her presentation, Yohe said she agreed with several of the
recommendations including
• the need for health care systems to develop programs that simplify
the demands and complexity of the system (recommendation 5);
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• that there should be a health literacy competency base for different
levels of education (recommendation 7); and
• that accrediting boards should incorporate primary and secondary
prevention health literacy into their requirements.
But, she said, it is not clear how a scorecard would facilitate these
recommendations. Also, it is not clear, she said, how quality standards
that reduce the demands and complexities of the health system (Recom -
mendation 6) improve health literacy.
DISCUSSION
George Isham, chair of the Roundtable, observed that each of the
speakers appeared to struggle a bit with the concept of health literacy,
with the definition of health literacy often varying across speakers. This
emphasizes the importance of properly communicating this concept to
key groups and also emphasizes the challenge of ensuring that health
literacy approaches are integrated into primary and secondary preven -
tion strategies.
Benard Dreyer of the Roundtable said he is not sure what to do about
the confusion about health literacy. It has been defined and discussed;
there are the minimalists and then there are the maximalists. At some
level there are people who insist it is just literacy; at other levels people
see and include the complexity of the health care system. Somehow, he
said, those two messages must be put together in some way. It’s not what
the provider does but what the patient is taking away from it. Those are
two very different things, and that connection is what health literacy is
all about at the health system-patient interaction.
In Ratzan’s presentation he said that most of prevention takes place
outside the health care system. So the question, Dreyer asked, is how does
health literacy play out outside of the health system? Food and exercise
are a large part of primary prevention, in addition to immunizations. And
that raises the issue of agribusiness and advertising. Just as there have
been prevention efforts that emphasized how tobacco companies push
an unhealthy product for their own gain, perhaps a similar thing needs
to be done with unhealthy food and those who produce and market it,
Dreyer said.
Ruth Parker, a member of the Roundtable said that the research and
intervention efforts of the past decade demonstrate that what people are
being asked to do is really difficult for a number of complex reasons that
relate to the environment, the culture, and the tasks of everyday living.
What, she asked, is the common ground for health literacy that all can
agree on? It takes a number of people from different perspectives coming
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20 PROMOTING HEALTH LITERACY
together to make sure nothing is left out, that efforts don’t alienate large
groups of people, and that there is some understanding of what must
be known and done to promote health. Noting that she works in a large
public hospital where there are many people with many different needs,
Parker said that a simple way of understanding how they are doing
would be welcomed.
RADM Slade-Sawyer said that perhaps the focus should not be on
communicating the need for good health simply for the sake of health
alone, but also because health is the number-one resource needed to live
one’s life the way one wants to live. Healthy People 2020 has broadened
its focus to include the social determinants of health, examining policies
in many domains that contribute to health such as transportation, labor,
and environmental domains. But the man in the street may not even con -
sciously understand that there are things he needs to know and do to live
his life well. Communicating to these individuals who don’t know what
to do and what they need to know is a very big issue. That, Slade-Sawyer
said, is the big challenge facing everyone in the field.
Gould agreed that health literacy requires effective engagement of
policy makers across the board—agriculture, labor, transportation, and so
on. If policy makers from multiple areas can be engaged effectively and
can be made health literate about the priority and impact on health of
their decisions, enormous progress can be made. Prevention is a combina -
tion of policy, education, and program intervention, he said, even in the
case of clinical preventive services. It is also important, he said, to have a
HEDIS1 measure of quality for prevention.
Isham brought up the Health In All Policies2 approach undertaken
by Finland. How might that be applied to what the HHS is considering
in its approach to the social determinants of health? Slade-Sawyer said
that one of the most important things will be to convince groups work-
ing in domains other than health, for example, agriculture, that they do
have an impact on health and that it is in their best interests to work with
HHS. One of the Healthy People 2020 advisory committee meetings is
going to discuss health in all policies and how HHS might move forward
with this. Gould said that if the effect of other sectors’ policies on health
1 “The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by more
than 90 percent of America’s health plans to measure performance on important dimensions
of care and service.” http://www.ncqa.org/tabid/59/default.aspx (accessed June 17, 2011).
2 Health in All Policies “addresses the effects on health across all policies such as
agriculture, education, the environment, fiscal policies, housing, and transport. It seeks
to improve health and at the same time contribute to the well-being and the wealth of
the nations through structures, mechanisms and actions planned and managed mainly by
sectors other than health” (Stahl et al., 2006).
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could be measured and demonstrated, that would be a useful tool to use
in engaging them.
Will Ross asked how behavior can be modified in the setting of
prevention-based interventions. There is a repertoire of interventions
from tobacco cessation to obesity reduction that rely on behavior modi-
fication, he said, and perhaps there is a tacit assumption that behavior
modification would also be playing a role in the actions discussed in the
workshop, but it was not mentioned explicitly. Gould responded that
getting consumers to understand the risk behaviors that one is trying to
change may be a part of the intervention. In that case, one would com-
municate those risks in the most effective and engaging way possible.
However, if the perception of risk is not sufficient or effective for change,
one must look at other options. Individuals may not be aware of why they
are making the choices they make. But if the environment is created so
that the healthy choice or behavior is the default condition—that is, the
easy choice—then that is behavioral economics at work. The issue may
not be one of consumer understanding and processing in order to make a
conscious decision. But, Gould said, no matter how one achieves behavior
change, primary prevention is about behavior and is the focus of social
marketing campaigns.
Homer said that in the field of pediatrics, practitioners are well aware
of the difficulties of prevention and behavior change. One example of
this relates to children’s car seats. Pediatricians and family physicians
thought they were doing a great job talking to families about risks and
benefits and why car seats were such a wonderful thing, but what really
changed behavior was the passage of legislation that required car seats.
This demonstrates that it is crucial, when talking about health literacy
and prevention, to include the need for an informed public that can make
policy choices that will influence positive behaviors. Such policies range
from absolute requirements, as was the case with car seats, to the creation
of default situations that lead one to pro-health behaviors.
Gould pointed out that the seat belt law is another example. There
is not a person in this room, he said, who would move his or her car in
the driveway without putting on the seat belt because it’s a habit, a social
norm. This demonstrates the interplay between engagement strategies
and policy strategies, Gould said.
Michael Davis of the Roundtable commented on the idea of a preven-
tion scorecard. Davis explained that General Mills uses a similar mecha -
nism which it calls a health number. The data stay with the doctor and are
never used for employment decisions. Once a year, General Mills brings
all the salespeople together for a national meeting. They can meet with a
nurse for a one-on-one consultation, have blood drawn, and have the 10
factors included in the health number scored. This provides the company
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22 PROMOTING HEALTH LITERACY
FIGURE 4-1 Health literacy framework.
SOURCE: Parker, 2009.
doctor with an opportunity to create a community health number. Davis
noted that if something isn’t measured, it cannot be managed. He said he
has been able to see improvement in the salesperson community with this
4-1 xed
technique. Employees appreciate the chance to meet with a professional
and are eager to see how they have progressed or regressed with respect
to their goals.
Isham commented on the diagram in Figure 4-13 which was included
in Ratzan‘s presentation and in the paper’s discussion of the social deter-
minants of health. Motivation and social determinants of health are
important in understanding how individuals act (the yellow arrow in
the figure) as well as how to simplify the demands and complexity of the
system (the red arrow in the figure). Therefore context or the social deter-
minants of health seem to be key. It seems important, therefore, to begin
to focus more on the social determinants of health when deciding how
to measure health, Isham said, and he noted that the IOM report, State of
the USA Health Indicators (2009) described efforts in this area. Perhaps, he
said, one could create a standardized method of measuring health that
could be used to engage employers and communities.
Another approach, Isham said, is to look at those health behaviors
that are most critical to change. McGinnis and Foege identified these
behaviors in 1993 and that study was updated in 2004 by Ali Mokdad.
3 This diagram was first presented by Dr. Ruth Parker at the Institute of Medicine
workshop, Measures of Health Literacy, held on February 26, 2009, and it was published in
the summary of that workshop.
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But a list of effective interventions to change those behaviors is needed,
Isham said.
For clinical preventive services, the U.S. Preventive Services Task
Force evaluates interventions for their effectiveness. Perhaps, Isham said,
a clinical practice guideline that defines the most important interventions
in terms of health burden would be useful for health care providers.
With developing health information technology, it should be possible to
develop decision support systems that take the guidelines into account.
The guidelines could also be used to ensure that health professional
training focuses on topics and interventions that relate to the behaviors
and actual causes of death, Isham said. Then this information could be
presented to the public as what should be expected from healthcare pro -
viders. The potential to do this is a tremendous opportunity for health
literacy.
Isham said that Ratzan’s scorecard idea was a good start toward
this goal. Homer responded by emphasizing a developmental approach
to prevention. The way that messages are constructed and delivered is
important in prevention, he said. Communicating messages to individu -
als at different stages of the life course (e.g., children, adolescents, young
adults, and the elderly) require different strategies, perhaps even differ-
ent messages. Dreyer supported the developmental approach saying that
prevention messages and interventions in childhood and adolescence are
key to health at later ages. Isham agreed that thinking about prevention
across life stages is critical.
Linda Harris, Roundtable member, noted that health literacy is not
static. The discussion, she said, seemed to assume that once a message
is perfectly formed, with perfect clarity, that the message will be good
forever. It is important, she said, to think about health literacy in the
age of such information technology as Wikipedia, in which definitions
are changed rapidly, not by professionals and experts at the National
Institutes of Health (NIH) but by people who in the past were recipients
of messages but who have now become the creators of messages. These
social interactions, both mediated and unmediated, are changing the land-
scape of what health literacy needs to consider, she said. Harris suggested
that the Roundtable should examine new media and what they imply for
a group trying to present authoritative and clear information.
Dreyer said that several people had mentioned that the education
system has a role to play in health literacy but, he asked, what is it that the
education system should be asked to do? Slade-Sawyer responded that
the Healthy People Curriculum Task Force has been working to introduce
public health education into the school system. The effort has been under
the leadership of Richard Riegelman, who advances the concept of the
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24 PROMOTING HEALTH LITERACY
educated citizen. The goal is to integrate health education into curricula
from kindergarten through college.
Clarence Pearson, Roundtable member, said that he is concerned
about the enormous task of engaging the 14,000 independent school
districts in the United States. Homer noted that districts are currently
required to have health plans into which health literacy could be incor-
porated. Introducing the concepts of health literacy into the plans has the
potential to improve them. Early childhood education is another area in
which health literacy needs to be integrated.
Becky Smith, executive director of the American Association for
Health Education, said that the National Health Education Standards K-12:
Achieving Health Literacy was established in 1995. The standards identify
health literacy skills and abilities as well as assessments for determin -
ing how well students have attained those skills. The challenge is how
to engage the education community in the health-literacy effort, espe-
cially in these difficult economic times. The past two years have seen a
decrease in the amount of health education in the classroom. Decisions
to eliminate this education have been based on economic choices, not on
health choices about quality of life. What, she asked, can be done to engage
local school districts, school administrators, school boards, and the Depart-
ment of Education in supporting health education?
Linda Crippen, a nurse anesthetist, asked whether the group was
aware of how few health care providers know about health literacy. For
her master’s program, Crippen surveyed health provider coworkers and
found that 92 percent of staff had never heard of or been educated about
health literacy issues. She emphasized that it will be important to educate
providers about health literacy, about communication skills, and about
effective ways to teach patients.
Sharon Barrett, Roundtable member, said the assumption is made
that people will change behavior because they understand what their
health or health conditions are. She reiterated Gould’s point that behavior
change, not just increased knowledge, needs to be emphasized. Further-
more, it is important to figure out not only how to get individuals to
change specific behaviors, but how to get individuals to focus on their
health. Alice Horowitz from the University of Maryland School of Public
Health said that education in health literacy and good communication
should be integrated into the medical school curriculum from year one
all the way through residency.
Ratzan said that one thing that concerns him is illustrated by the say -
ing, “The perfect is the enemy of the good.” Implementing health literacy
into prevention strategies cannot and should not wait until we have per-
fect knowledge about what works. But what can be done now? What are
the options for advancing health literacy? Perhaps Healthy People 2020
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is a place to start, he said. Using behavioral economics is an option, as is
using social marketing. Isham pointed out that there is real opportunity
for integration with the six priorities of the National Quality Forum and
the National Priority Partnership. These priorities are patient and family
engagement, population health, safety, care coordination, palliative and
end-of-life care, and overuse.
Isham concluded the session by extending his thanks to Ratzan and
the panelists for a stimulating and important discussion.
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