8

The Potential and Challenges of Highlighting Health Literacy

Jennifer Cabe, M.A.
Executive Director
Canyon Ranch Institute

The health in all policies focus mentioned by Slade-Sawyer earlier originally led to the interest and involvement of the Office of the Surgeon General in health literacy activities. Dr. Richard Carmona, 17th Surgeon General (2002-2006), identified health literacy as a topic of major importance, making it a topic of prominence for the Office of the Surgeon General. There was a realization that health literacy could have a major impact in the field of health communication and that it could affect health behavior and produce real physical and physiological changes not only in individuals but across a population. The question faced by the Office of the Surgeon General was how to infuse health literacy into every aspect of prevention, preparedness, and the elimination of health disparities.

While the reports from the Office of Surgeon General are wonderful reports that bring together the science on a topic, Dr. Carmona questioned who was reading and using them. This led to the idea of developing what he called the People’s Piece, an approach that has continued. Peoples Pieces are issued with full Surgeon General reports and Calls to Action. They are released online and in print, and are written at fifth- or sixth-grade reading levels. They have been translated into numerous languages and distributed by the government, by health insurers, and by states. Major magazines, such as Good Housekeeping, have published them in their entirety.



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8 The Potential and Challenges of Highlighting Health Literacy Jennifer Cabe, M.A. Executive Director Canyon Ranch Institute The health in all policies focus mentioned by Slade-Sawyer earlier originally led to the interest and involvement of the Office of the Surgeon General in health literacy activities. Dr. Richard Carmona, 17th Surgeon General (2002-2006), identified health literacy as a topic of major impor- tance, making it a topic of prominence for the Office of the Surgeon General. There was a realization that health literacy could have a major impact in the field of health communication and that it could affect health behavior and produce real physical and physiological changes not only in individuals but across a population. The question faced by the Office of the Surgeon General was how to infuse health literacy into every aspect of prevention, preparedness, and the elimination of health disparities. While the reports from the Office of Surgeon General are wonderful reports that bring together the science on a topic, Dr. Carmona questioned who was reading and using them. This led to the idea of developing what he called the People’s Piece, an approach that has continued. Peoples Pieces are issued with full Surgeon General reports and Calls to Action. They are released online and in print, and are written at fifth- or sixth- grade reading levels. They have been translated into numerous languages and distributed by the government, by health insurers, and by states. Major magazines, such as Good Housekeeping, have published them in their entirety. 57

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58 PROMOTING HEALTH LITERACY After leaving the position of Surgeon General, Dr. Carmona took the ideas and concepts he had been working with to the Canyon Ranch Insti- tute, a nonprofit organization whose mission is to help educate, inspire and empower every person to prevent disease and embrace wellness. The Canyon Ranch Institute views health literacy as • a tool for prevention and better care; • important for clinical, public health, K-12 education, adult literacy, care advocacy and navigation, and workplace wellness and work- force productivity; • including the skills and abilities that determine the extent that all people can find, understand, evaluate, communicate, and use health information; and • leading to informed choices, reduced health risks, better navigation of the existing health care system, reduced inequities in health, and increased quality of life. Health literacy is not about communicating health for health’s sake, Cabe said, but rather about communicating health in the context of what people need to know. This applies to individuals, parents, educators, health care professionals, health care systems, policy makers and policy brokers, government staff and officials, media, and community leaders. In the ongoing debate about health care reform there is an opportu - nity to make prevention as great a priority as treatment, and to recognize the contributions of health literacy to both. Investment in the avoidable causes of mortality, that is in prevention efforts, are dwarfed by our investment in medical care and biomedical research. Health care reform, Cabe said, is an opportunity to focus the system on prevention rather than sick care. Chronic diseases account for more than 75 cents of every dollar spent on health care in the United States. Yet most chronic diseases are pre- ventable or manageable with appropriate preventive efforts. If one were the chief executive officer of a company and realized that 75 percent of company spending was unnecessary, it would be time to determine how to stop the waste. Prevention can eliminate unnecessary spending as well as save lives and reduce and eliminate suffering from many diseases that are completely preventable, Cabe said. Health literacy can lead the way, she said, and she proposed some strategies: • Communicate at the appropriate literacy level for the audience. • Create health literacy courses in Adult Basic Education, in K-12, and in training of all health care workers. o Establish health literacy learning standards across the lifespan.

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59 HIGHLIGHTING HEALTH LITERACY • Establish health literacy centers of excellence for each state. • Incorporate health literacy in all health and medical certification courses. • Incorporate health literacy into national health surveillance efforts. o First, fund development of a comprehensive measure of health literacy. • Build demonstration projects specifically targeting reductions in health disparities by using health literacy. o Specifically target changes in cost, health status, equity, and sustainability issues as priority outcome areas. • Create and monitor standards for hospital operations (via Joint Commission). o Mandate local participation on evaluation teams. • Emphasize health literacy as a solution in Healthy People 2020 goals. As mentioned earlier, the study discussed by Crippen found that over 90 percent of health professionals in the study did not know anything about health literacy. Yet there are programs that are going on around the country and around the world to train health professionals in health literacy. Perhaps one of the things that should be done is to examine the outcomes of that training. Cabe also said that it is crucial to get health literacy into health professional certification and licensure tests. The Canyon Ranch Institute views the advancement of health literacy as crucial to creating a preventive care system. To highlight health literacy in prevention programs means more than just ensuring that programs are accessible to people with low health literacy. It means • designing programs to advance health literacy; • prospectively identifying and then measuring outcomes in health literacy, behavior, physical changes, and physiological changes; • measuring process and program effectiveness and adapting to the needs of all partners and participants; • preventing disease; • improving health and well-being; and • eliminating health disparities. The Institute organized an integrated health literacy training pro - gram, the Life Enhancement Program, at the Urban Health Plan, a com- munity health center in the South Bronx that serves 28,000 patients. One of the things needed was a place to hold the program so within the com- munity health center building a health and wellness center was designed and built. The curriculum, which contained information on nutrition,

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60 PROMOTING HEALTH LITERACY physical activity, integrative medicine, and social support, was taught first to the center’s staff and leadership and then to patients. Staff involved in the training included the chief medical officer, a nutritionist, a social worker, a physical therapist, an exercise physiologist, the person in charge of public health and continuous quality improvement, a psychiatrist, and the center’s chief executive officer. During the training, the health professionals learned how to com- municate key messages to their patients. They also learned that healthy messages have to be achievable. For example, if a patient is told to eat more fresh fruits and vegetables but does not have access to such food, it does more harm than good. Since that was one message that was going to be conveyed to patients, the center worked with a local bodega to get it to stock healthy foods in addition to the items such as chips and liquor that were its standard fare. Most of the people who participated in the program were not engaged in any sort of physical activity at the beginning. But they began to use the equipment in the health and wellness center. They also said they wanted to do something even closer to their hearts, and that is when the Latin dance program at Urban Health Plan was started and included as part of this program. The Institute measured outcomes of the program, Cabe said. At the community level many participants reported sharing the program guide (a book with information about nutrition, physical activity, and other health information) with their family members and their neighbors. It was in Spanish, and it was something that they liked, so they shared it. Changes in health literacy skills and behavior included improved nutri - tion habits, increased physical activity, and improved interaction among health care professionals and patients. Patients learned that they could prepare for a visit to the physician, that they could ask questions. Health outcomes included weight loss and stress reduction. Suggestions for improving the program included a desire for more time, more scientific information (e.g., how nutrition affects the body), and the use of more charts and graphs. At no time during the program did any of the health professionals or any of the patients say that they wanted incentives, such as pay- ment or gifts, in order to participate in the program, Cabe said. The first patient participants in the program were referred by their physicians. But referrals are no longer necessary to fill the program. Patients who have gone through the program are recruiting their family members and their friends to participate. Canyon Ranch Institute is beginning to look at making the business case for health literacy, Cabe said. It is also important to measure the sus- tainability of changes achieved. The scorecard idea is worth pursuing if

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61 HIGHLIGHTING HEALTH LITERACY it is used in the context of a community-based, integrative health model such as that of the institute or the Head Start program described earlier, but the scorecard must be uniform and reflect community needs. To succeed, Cabe said, health literacy efforts will need to engage in partnerships with invested stakeholders. Health literacy should be proac- tive, not reactive. Health literacy is prevention, Cabe said, and it can save lives and save money.

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