Roundtable chair Isham invited members of the roundtable to reflect on the day’s proceedings. Roundtable member Benard Dreyer reflected on the relevance of the adage, “all politics is local,” to health literacy and suggested that health literacy is also effectively implemented at the local level. He was extremely impressed with the accomplishments and success of the state-level coalitions and suggested that health literacy coalitions be broadly disseminated so they are present in every state. State-based health literacy coalitions are filling a vacuum that exists because state governments, health departments, and agencies that should be focusing on health literacy are not currently engaged. Furthermore, if the state coalitions ceased to exist, there would not be a statewide infrastructure to maintain health literacy activities, he said. There is a need, he said, to motivate the state agencies to incorporate health literacy efforts.
In reflecting on the workshop presentations addressing medical education, Dreyer stated there is much to be done to reach medical students, residents, and faculty members. He indicated progress likely could be made through organizations such as the Association of American Medical Colleges (AAMC) that focus on curriculum, and the Liaison Committee on Medical Education (LCME) and the Accreditation Council for Graduate Medical Education (ACGME) that address regulatory issues. Essential to improving the ability of clinicians to effectively communicate with patients are the experiences available to them while in training. He indicated the experiences medical students and other trainees have in Beck’s UCSD free clinic program can be life changing. Medical schools
and other clinical training programs need to make these sorts of opportunities available.
Finally, Dreyer said, changes are needed in the health system in order to improve health literacy because focusing on these systematic changes is more important than a misguided attempt at labeling the patient and trying to implement change at that level. But the workshop also affirmed the need to effectively help patients by empowering them to be able to take responsibility for their health care and to ask questions and interact in an empowered way with the healthcare system. Dreyer said the most effective way to improve patient knowledge is by reaching him or her through community outreach and not via the healthcare system. Health providers must work with community partners in a transdisciplinary fashion to achieve success.
Culbert mentioned that the work of Health Literacy Missouri takes place both inside and outside the healthcare system. He cited the importance of focusing on the individual, not in a way that points the finger at them, but rather one that empowers them. It is very important to begin early with individuals, whether they are new mothers, children, or medical students. Reinforcement must take place continuously throughout the life cycle. The state of health literacy will likely take a generation to make advances. Culbert said that progress can be made if there is a commitment to health literacy and efforts are based on good evidence. Knowledge is improving regarding what works at the community level and how to empower individuals so they can make good health decisions.
Roundtable member Winston Wong discussed the implementation of the Patient Protection and Affordable Care Act (ACA) and how health literacy may or may not be a mitigating factor toward the success of its implementation. The ACA will have its impact at the local level. Patient empowerment takes place both in clinicians’ rooms and in the community, such as within Head Start programs. There is a need to identify competencies of providers in terms of their ability to empower patients. More functional healthcare encounters would take place if patients were assertive and comfortable specifying their needs and expecting to be heard.
Wong mentioned that 90 percent of Americans do not see a physician or a nurse in any given year, and so much of the effort toward improving health literacy must be directed toward population management and wellness prevention efforts. Health literacy is a key element of how communities try to optimize health and wellness, aside from what happens during a clinical visit. There needs to be a focus on how health literacy is operationalized in terms of changing the trajectory of chronic disease and prospects for wellness and health in communities.
Roundtable member Cindy Brach mentioned that patient empowerment and self-management are focus areas of the AHRQ Health Literacy
Universal Precautions Toolkit. Patient empowerment can be thought of in terms of patients being able to take charge of their own health as opposed to taking charge of the encounter. Fostering patient empowerment is critical to achieving success, Brach said, because it is such a determinant of patient behavior beyond the clinical encounter.
In terms of provider education, Brach mentioned that a number of states have begun to require cultural competency training for licensure. She indicated that a study of the impact of these compulsory training requirements is needed. There are concerns that poor or ill-timed training may not have the results that are desired. Roundtable member Leonard Epstein mentioned the possibility of a collaborative study of these state requirements that would involve the Health Resources and Services Administration (HRSA).
Epstein stated that he was going to take several of the lessons he gleaned from the workshop back to HRSA’s various offices and bureaus that address the education and training of health professionals, the needs of mothers and children, and the provision of care in community health centers. There are potential implementation and research projects that could be initiated to further the work of the presenters. Mr. Epstein referred to a favorite saying of one of the early directors of the Bureau of Primary Healthcare, Marilyn Gaston, “Good primary health care is done community by community.”
Isham highlighted the importance of a national system of standards, discipline, and attention to health literacy at different levels of jurisdiction, national and state, in terms of health reform, and most importantly at the community level, where implementation occurs. It is not a matter of one versus the other, but the right mix of national, state, and community efforts. A major challenge is dissemination, that is, consistently applying model programs across the country.
Isham indicated that the workshop sessions provided examples of disseminating research findings from academia to clinical practices and community settings. There were also examples of incorporating research into clinical practices and offering clinical training in the community. The workshop included descriptions of innovative programs from North Carolina, Iowa, Missouri, and Louisiana that serve as models for other states to emulate. These types of integrative efforts are needed, Isham said. Challenges remain in terms of breaking down barriers between research institutions, clinical practices, and communities.
Isham also emphasized the need for theory-based interventions and for disciplined thinking. There are tremendous opportunities for a different kind of partnership between academics and practically minded people in the community. He also emphasized the importance of health literacy in addressing healthcare quality.