• Plenary Sessions
• Break Out Sessions
• Health Literacy Awards
  
  

The New Healthcare Landscape and the Role of Health Literacy
Richard H. Carmona, M.D., MPH, FACS
Jennifer Cabe, MA

Richard H. Carmona, M.D., MPH, FACS

Richard Carmona has spent eleven years preaching the gospel that health literacy involves cultural competency, and both are integral, not ancillary, to public health. To underscore the point, he joked that the degree he really needed, in addition to being an M.D., RN and having a Masters of Public Health, was in anthropology. But he is still pondering the question of how to operationalize that gospel. The question, he says, is not about the science. It is about how to capsulize information, translate it, and deliver it in a way that creates sustainable behavior change.

During his presentation, Dr. Carmona, 17th Surgeon General of the United States (2002-2006)  and President of Canyon Ranch Institute, offered several anecdotes that taught him in regards to execution and operationalizing. He described being at a fast food restaurant with his family. When he realized that many people recognized he was the Surgeon General of the United States, and that he was holding a French fry, he immediately dropped it.  There, he said, was a great opportunity for teaching and learning when he dropped that fry. 

He also recalled the time when he was a medic in Vietnam and treated a child from a Hills tribe. The young medic prescribed antibiotics. Later, the family thanked him for curing the child and for the gift he had given them—a necklace of 40 pills that had been of great benefit to the child, and would be worn by others to cure their illnesses. This is what we still call “non-compliance,” Dr. Carmona said, when in fact the situation indicts our “failure to communicate.”

As the Surgeon General, he wondered, for whom do we write the Surgeon General reports?  Are they peer-reviewed?  Or are they for the people? He realized that his grandmother who never spoke English would not be able to use the information in reports like a 900-page tome on smoking cessation. How, he wondered, does that information get to people so they can take action? As a result, his team created “The People’s Piece” to ensure that the best science available was offered in a way that was understandable and culturally appropriate.

Global strategies for health care have had similar problems. The 1978 Alma Ata Conference in Kazakhstan was the first international declaration of the importance of primary health care. The intent still resonates, says Dr. Carmona, but the execution lacked the emphasis in health literacy and cultural competence.  Understanding their role could 

Jennifer Cabe, MA

make us better purveyors.  Later, the UN Millennium development goals agreed to develop primary care by means of health literacy and cultural competency.

We can only be as prepared as our sickest people, said Dr. Carmona, and Katrina was a good example of that. A huge disaster happened in a place with people who are among the sickest, and have some of the lowest health literacy in the US. The initial disaster was terrible, but the lack of public health that followed was worse.  People did not  have the capacity to help with the solution, so 300,000 people were evacuated. Another example in the US is tribal reservations. Health status there is the worst of anywhere in the US.

We need to create resonant messages that change lives, to take what we know and get it out to all providers, said Dr. Carmona. So much of what we are trying to do is simple: wear a seatbelt, don’t smoke, walk a little. If we don’t have the ability to get the information to the people who need it, he says, we’re all going to pay. If we don’t  engage the public, we will perish. But, with the knowledge we have, we can do this.  This is an intergenerational project. What we teach today will emerge in the next generation.

Jennifer Cabe, Executive Director of the Canyon Ranch Institute stepped up to the podium to ask, how does this play out in light of the Affordable Care Act? It is, she says, a crack in the wall between people who need access to the system,  and the system. Though there are only five explicit mentions of health literacy in the ACA, it is infused throughout. However, there remains lots of work to do. Navigators are key to widening the crack in the wall. Accountable care organizations or ACOs, groups of hospital systems and physician groups working together to improve patient experience, care coordination, patient safety, and preventive health, will become the predominant form of health care. They need what you have, said Ms. McCabe, speaking directly to the audience of health literacy practitioners.

Why Are You Giving Me This Number? Accurate but Meaningless Health Data
Brian Zikmund-Fisher, Ph.D.

Brian Zikmund-Fisher, Ph.D, began his presentation with a barrage of numbers that patients have to deal with, including risk percentages, treatment success rates, blood test results, medication dosing charts, and nutrition labels. As an example of an objective numeracy measure, he asked the audience which represented the higher risk: 1-100, 1-1000 or 1-10.  Subjective measures of numeracy include the questions: “How good are you at working with fractions?” and “How often do you find numerical information useful?” He cautioned that, as with other kinds of literacies, numeracy does not equal education level. 

Problems with numeracy--the ability to understand, transform, and derive meaning from quantitative (health) information--can often come from the way the information is represented. Zikmund-Fisher pointed out that that objective question he asked the audience exemplified this problem. Because people assume that an increase in the denominator means an increase in risk, people may have been confused or doubted the right answer, 1-10, even if they got it.

Another example illustrated several common problems with health information and numbers. An imaginary patient, Robert, used an online risk calculator to calculate his heart disease risk and was told that his risk was 14.52%. But he was still confused and not informed. One problem was excess precision. Did Robert really need to know his risk to a hundredth of a percent? More decimal points are generally not more believable or more useful. And recall is significantly better for integers. Another problem is the numbers-only format of the presentation. Visual displays, or flags like “high” and “low” may be as or more informative. It’s reasonable to ask if numbers need to be used at all.

Zikmund-Fisher pointed out the dual nature of risk: there is the risk of occurrence, and then there is non-occurrence. Risk calculators tend to focus attention on the numerator (occurrence risk) and patients must do mental math to see the equivalent risk of non-occurrence. Bar graphs do a bad job of portraying this dual nature, but icon arrays or pictographs, do it well. Zikmund-Fisher showed several examples how icon arrays work.  Non-events are as salient as events and risk magnitude is represented in multiple cues, including counts (frequency), relative area, and height (each row = 10%). The website iconarray.com allows the creation of icon arrays very quickly and easily.

It’s important to ask what we want patients to know about risk.  Or, we can ask, what do our patients need to do? Zikmund-Fisher introduced the “harm anchor” as a practical concept:  it is the point at which something needs to happen.  Harm anchors may sometimes need to be the focal point of numerical information.

In order to overcome numeracy barriers, we need to provide context, know that less is more, and match the format to the need. We do not want to use “might want” or “need later” to figure out what to include in our discussions or materials. The ethical obligation for transparency cannot override the requirement to be actually useful in a given moment for a given individual. We must recognize why we are providing data before we provide numbers.

Health Literacy: The Missing Link in Public Health?
Andrew Pleasant, Ph.D.

Andrew Pleasant, Senior Director for Health Literacy and Research at the Canyon Ranch Institute, affirmed that “health literacy is the tool that can help people, and help health systems help people, to live a life of health and wellness and lower costs – regardless of socioeconomic status or other social determinants of health.”  It can help people use the skills they have instead of being daunted.  But, he added, though we talk about the power of health literacy correlated to health outcome and health status, we haven’t yet changed the world as much as we'd like. The health of the world continues to decline and the cost of health continues to rise. Our health care system absolutely requires proficiency, but 88% of us are below proficiency level. Female mortality rose in 42% of U.S. counties between 1992 and 2006.

Pleasant defined the task of public health as standing in front of millions of people and persuading everyone to move five steps to the left. Persuasion is one of four options available to public health. The others are regulation, technology development, and education. But, if you lose sight of the individual in the midst of the public context, it’s hard to create behavior change.

Tools of the trade for public health are knowledge, attitudes, beliefs and behaviors, and health literacy lies in the latter. Literacies, he says, are behaviors, and to improve literacy is to change behavior. But there are unanswered questions. Which literacies affect health in what ways? “We’ve measured document, prose, and numeracy literacies in a health context” said Pleasant, “to varied effect and validity questions abound. We have not tested any of the hypotheses/definitions of health literacy.” How do people take various literacies, prose, document and numeracy, and use them to improve health? How can health literacy be improved and applied in a manner that can be systematically tested in regards to improving individual, community, and public health? According to Pleasant this work begins with the Calgary Charter’s definition of health literacy, a theory of health behavior change based on the use of literacy behaviors. Pleasant neatly reframed the Calgary verbs, “find, understand, evaluate, communicate, and use,” into a logic model.

He gave several examples of public health campaigns that, seen through the logic model, failed. The logic model illuminated the points at which the campaigns went wrong. Perhaps the most powerful example was the anthrax scare in the United States. Information was widely available and thus easy to find, but there was low public understanding due to complex government information sources. The public failed to evaluate the risk accurately, and assumed everyone was at risk. There was little communication or feedback between those giving information and those receiving it, and the result was that information was misused counter to public health benefits; in fact, antibiotic usage increased in every state in the nation.  Pleasant offered a detailed counter-example of the Canyon Ranch Institute’s Life Enhancement Program, which followed the health literacy “Golden Rule” of involving people early and often. It also included their whole lives in order to achieve prevention.  Improved health literacy leads to behavior change, which leads to improved public health and health system performance.

In summary, Pleasant said the Calgary Charter model provides us with a logic model supporting efforts beyond plain language efforts to improve health literacy, a two-sided framework for intervention design, and a basis for evaluating health professionals and health systems. Finally, it gives us a way to define, operationalize, and measure health literacy to improve individual, community, and public health.

Patient Engagement: Your Guide to Patient-Centered Care
Mary Jean Schumann, DNP, MBA, CPNP, FAAN

According to the 2013 White Paper from the Nursing Alliance for Quality Care, authored by Mary Jean Schumann and colleague Shoshanna Sofaer, “Patient engagement is the involvement in their own care by individuals (and others they designate to engage on their behalf), with the goal that they make competent, well-informed decisions about their health and health care and take action to support those decisions.” 

Why does patient engagement matter? It’s about getting to better health outcomes.  Moreover, the impetus to move towards a patient engagement model must come from health care professionals, specifically nurses. Even when you have patients who are highly engaged and energized, says Schumann, the system does not necessarily reward them. She offered a vivid video example of a patient who followed his doctor’s orders but the illness didn’t respond to the prescribed treatment plan. Health care professionals reacted with suspicion and judgment, until after a year, they realized they had given him the wrong diagnosis. Schumann encouraged the audience to think in terms of patient activation, not compliance. Activation differs from compliance, in which the emphasis is on getting patients to follow medical advice.

Schumann outlined nine guiding principles of patient engagement, beginning with partnership between providers, patients, and the families of the patients. At minimum there needs to be two experts in the room. Each has knowledge that the other needs in order to reach a good outcome. Patients know about themselves, their preferences values and resources, whereas the health care team member understands the medical evidence, including risks and relative odds of different outcomes.

The information exchange must be two-way, and responsibilities must be shared. At the same time, boundaries must be kept that protect both recipients and providers of care. Mutuality includes sharing of information, creation of consensus, and shared decision making. Providers must recognize the individuality of patients, in terms of their differing abilities to be engaged, and acknowledge and appreciate diverse backgrounds. Nurses and other health care providers must advocate for patients who are unable to participate fully.  Finally, health care literacy and linguistically appropriate interactions are essential.

Nurses and others must practice a person-centered approach to health care delivery and be willing to fully support patients as they encounter obstacles in the health care system. Healthcare professionals must also embrace and continuously support the belief that patients and families are or can become competent to engage fully in making informed decisions about their own health and health care. Schumann believes that a majority does not believe this and therefore a paradigm shift is necessary. This paradigm shift has to happen in all settings, from cradle to grave, except in hospital settings where people may be too sick to participate actively.

In order to make effective patient/provider engagement happen, says Schumann, we need to ensure that all nursing education emphasizes patient and family engagement. We also need to strengthen support for nurses as advocates in the care environments of patients, and this needs to happen in visible ways, via job descriptions and in performance evaluations. We must align incentives to encourage patient engagement in every aspect of the health care system, which means in part, changing budgets to support the time it takes to engage patients. Finally, as little has been done so far, we must intensify efforts to conduct and disseminate research and evidence on the effectiveness of patient engagement.

Break Out Sessions

Cultural Competency Training – A Collaborative Project
Crystal Duran, MPH, MCHES

Crystal Duran began her session by humbly asking everyone to think about their experiences, and the population they work with. “I believe all of your experiences are much more valuable than the experience I speak from, so please keep them in mind throughout this session.”

Duran continued, “We as customers are evolving, and we expect much more from the services we receive now than we did ever before. Health care has a long way to go in meeting this demand. As a Cigna professional, people don’t think of trusting me as a reliable and safe source. It’s progressively getting better, but it’s safe to say that insurance people are equated to tobacco and big oil.” With that being said, “In order to serve our customers, we need to know them in a more personal way so that we can better meet their needs and expectations.”

Historically, 25% of individuals choose not to seek care when sick or injured, and 76% of individuals don’t understand how the health care system works. For example, Rose doesn’t follow her treatment plan because she cannot read and is embarrassed to tell her doctor. Maria needs kidney dialysis treatments three times a week, but she doesn’t speak English and has trouble scheduling appointments. “These are the people we deal with everyday, and it is a very confusing and frustrating system for patients to navigate themselves. That is why it is so important that patients can receive culturally competent care so that they better understand and can make informed decisions about their coverage and treatment plans.”

Unfortunately, not everyone in your workplace will feel the same way. “There is a lot of people internally who will think it’s the patient’s problem and they need to figure it out. Sadly, we want them to have access to preventive care and to be healthy, but there is unwillingness on the part of physicians to want to be trained in this area. Sometimes they don’t understand and they don’t want to understand. It can be a lose-lose.”

To combat internal opposition, Cigna had an open discussion with their physicians to understand what their needs and wants were. “We found that time, safety, quality, and money really were their major concerns,” shared Duran. Subsequently, Cigna offered “patient safety” training sessions that were designed to address physicians’ concerns and needs, cultural competency, and health literacy. “Never call it cultural competency training, but rather patient safety or equitable care training. Cultural competency training tends to be a turn-off for doctors,” claimed Duran.

Finally when leadership is fully on board and buys into the need, many of us find that there isn’t a budget to allocate for training purposes, unfortunately….just our time. Duran emphasizes, “This is when you’ll have to think outside the box in how to create your training.” Fortunately, there is some curriculum already out there for public use, such as the ‘Curriculum Cultural Response’ textbook that can be helpful in designing health literacy training.  There are also models for training that have already been done, and it would be beneficial to, “expand your literature, research, and partnerships as you acquire ideas on how to develop your trainings.” When you think about partners, some of you may be reluctant to reach out to your competitors…”But in this field, insurance companies are willing to come together for these values and mission,” assured Duran. “Step out of your comfort zone and make some time to phone one of your competitors to see what they having been doing for cultural competency health literacy training. You’ll be surprised!”

Creating Unbiased, Understandable Shard Decision Materials: Is It Possible?
Geri Lynn Baumblatt, MA

According to the website for the International Patient Decision Aids Collaborative, decision aids “prepare patients to make informed, values-based decisions with their practitioner.” Geri Lynn Baumblatt, who works with decision scientists, clinicians, and patients to create multimedia decision aids, gave a broad and detailed explanation of why they are being used now, what’s involved in creating them, and how to avoid bias.

Shared decision-making is a new practice, and increasingly important for several reasons. Patients may not be aware of multiple options, and understanding risk in the face of increasing amounts of data is a challenge. The patient’s quality of life may be significantly affected, and, as Baumblatt pointed out in an interesting study about breast cancer and mastectomy, practitioners are not particularly good at knowing what their patients want. In addition, most patients now, 71% as opposed to 51% in 2000, want to be involved.

In order for shared decision making to happen, more than one reasonable option, including no treatment, needs to be in place, and values recognized. Providers need to be open to the possibility that they may not agree with the patient’s choice. Allowing enough time for discussion is a factor, making the emergency room an inappropriate setting.

Baumblatt covered a long list of factors that contribute to bias and confusion, including the web, media and action groups with agendas of their own. The interests and experiences of family and friends create pull in one direction or another, as well as the patient’s own assumptions. Less direct effects, like the false consensus effect (assuming that other people are more like us than they actually are) or immune neglect (underestimating our ability to adapt to changed circumstances, like having a colostomy) influence our choices. The list also included health literacy, numeracy and practitioners. Baumblatt pointed out that it’s difficult to keep up with studies and statistics, and it’s a skill to present them effectively.  Sometimes, no data is available.

Baumblatt finished with an in-depth and compelling set of strategies that can be used to create unbiased decision-making aids.  She included advice on presenting risks and comparisons: using whole numbers not decimals; using both sides of the equation (22 in 100 will have this. 78 in 100 will not), using icon arrays and option grids, and ways to communicate randomness. She spoke about choice architecture:  presenting options with equal time, space and level of detail, and paying attention to the order of information. The list also included content advice: acknowledging emotions, describing each treatment option and procedure, researching and addressing pre-existing biases with repeated key messages and avoiding narratives and testimonials.

In fact, it’s impossible to avoid influencing people’s choices. The goal when creating shared decision making tools is to create them in a way that’s most likely to help and least likely to inflict harm. There are always trade-offs, says Baumblatt. A decision-making aid is about presenting them in the least biased way and giving the patient an opportunity to compare and find the right balance.

How Do You Know They Know? Methods for Evaluating Teaching and Training
Sabrina Kurtz-Rossi, MEd.

Education is a core component of health literacy. We routinely rely on health curriculums that are valuable for students, but that also have measurable outcomes.  Measuring outcomes is a crucial tool for quality improvement and for seeking funding, as many health literacy interventions are funded by grants.

This session helped attendees better understand the principles of andragogy (adult education) and demonstrated techniques for andragogy that could be easily and readily measured. Adult learning theory has various schools of thought, ranging from those based on environmental shaping of learning and self-determined learning. Recent trends in education reflect the idea of multiple intelligences, which challenges the definition of intellect as inherent (i.e. IQ). In particular, within adult education it’s important to realize that: lived experience is rich resource, learning is often problem centered, and that adults seek immediate application of skills and knowledge. In other words, adults need to know why they need to know. In all approaches to teaching adult learners, the principles of effective adult learning should be considered.

The application of these theories to curriculum development is two-fold. First, the pros and cons of various curriculum development methods should be assessed and the appropriate method chosen for the context. Second, the objective of the education needs to be identified.

Curriculum development may be based on a traditional approach. Another method for curriculum development is a learner centered approach. Yet another method is based in the theory of Transformational Learning. This approach is conducive to social action, dialogue, problem solving, and the curriculum is not set, but emerges.

In setting curriculum objectives ask: what will participants know, and at what point will they know it? This question focuses on the audience, not on the curriculum. In order to create measurable observation criteria for evaluation, include action verbs in these objectives and target one expectation at a time. Match the goals to the learning activities and the learning strategy. Lastly, identify the indicator that the learning has been accomplished, making the objectives achievement based and measurable. Be careful to include only one indicator at a time!

The four components to writing a measurable objective are:

1. Set the Condition. What is happening? When? (e.g. After the training… After watching the video…)
2. Who is the objective for? (E.g. …the learner…   …the health professional…)
3. What is being performed? Use an action verb here! 
4. What is the criterion? What is a single indicator that the learning has been accomplished? What is actually being measured?

There are two main types of evaluation that can be used: formative evaluation and outcome based evaluation. It may include alternative assessments such as telling stories or “teach-backs,” portfolio review, self-assessment, or peer review. These are methods of goal-free program evaluation in which the evaluator does not know program goals, and related in particular to Transformation Learning theory.

Numeracy: Exploring Strategies to Convey Quantity, Time and Risk
Helen Osborne, MEd., OTR/L

What is health numeracy? Even the definition may sound terrifying to some people.  According to the article, “A Definition and Operational Framework for Health Numeracy,” in the American Journal of Preventative Medicine (Golbeck et. al), health numeracy is “the degree to which individuals have the capacity to access, process, interpret, communicate, and act on numerical, quantitative, graphical, biostatistics, and probabilistic health information needed to make effective health decisions.”

Helen Osborne outlined overall strategies to increase understanding for patients who struggle with numeracy. They included knowing the science (or the study design), knowing and understanding the data, and knowing what your audience may or may not know. It’s important to know why you are using numbers as well as to know that there can be multiple reasons to use them, to persuade, inform or compel recognition of danger or to make sense out of conflicting data. It might be possible that you don’t need to use numbers at all.

She stressed that as conveyors of health information we need to understand the science of the studies from which we retrieve data, including the difference between cause and effect, and correlation. The gold standard for showing cause and effect is the randomized control trial. Studies that are preliminary too often get reported in the media as conclusive.

Osborne also offered sets of specific strategies for conveying quantity, time and risk and comparison data. When it comes to quantity, it’s important to confirm the measurement system you’re using, as a slide showing different sizes of spoons clearly demonstrated. She mentioned a number of visual comparisons, including the compartmentalized plate, the Wong Baker Pain Scale, and comparisons with common objects like ping pong balls. She cautioned that mathematical symbols can be a form of jargon, and suggested that if you are meeting in person, you can actually do the math with the client. For conveying time, she suggested creating schedules that revolve around a person’s daily habits, rather than the clock, and including visuals representing time, such as sunrise and sunset, as exemplified by the AHRQ pill card.

Teaching numerical terms such as “risk” and “frequency” can be a good place to begin when talking about risk data. Providing context, such as giving cholesterol numbers for an individual compared to ideal or normal numbers is helpful. Graphics that compare data are useful in different ways: line graphs tell story over time, bar graphs compare differences in a series and pie charts indicate proportion.

Osborne concluded the session with an exercise that paired a set of instructions requiring some kind of numeracy with an imagined client. The exercise gave participants the opportunity to employ some of the strategies and provoked lively discussion.

Enhancing Health Literacy Across a Health System
Terri Ann Parnell, DNP, RN
Joanne Turnier, MS

Terri Ann Parnell and Joanne Turnier focused on the optimization of health literacy programs and education in health care settings. Strategies for improving patient-centered care using health literacy in the North Shore LIJ Health System were shared.

A video was shown to demonstrate the low levels of health literacy among the general population. People on the street were asked the meaning of common medical words, such as hypertension, angina and stethoscope. Every response in the film had incorrect responses, which implies that health literacy is not just an issue for vulnerable populations, but one for many people. In this same video, people were also asked about their relationship with their doctor. They each gave answers that referred to lack of communication, respect and not having enough time to get the information they need from their doctor. Parnell and Turnier say that there needs to be a basic expectation that patients understand their doctors, and this is the goal of the health literacy campaign in the North Shore LIJ Health System.

The scope of their program includes 5 counties in New York, and is the 3rd largest for-profit health care system in the nation. Their campaign focused on diversity, developing patient-centered and individualized care, and recognized that health literacy is a key component of improving their health care system. In 2010 – 2011, they conducted an in-depth needs assessment and in 2013 they began to integrate programs and the process of outcome measurement. They engaged stakeholders across sectors, involved clinicians, medical students, public health workers, administration and people in marketing & advertising.

The overall process of operationalizing a broad scope health literacy intervention at the program level required the work of many dedicated individuals. Buy-in from stakeholders was key and particular focus was paid to the inclusion of diverse cultures and health needs. The process started with a rigorous needs assessment and progressed by developing resources and standards. The resources were not only delivered to the appropriate people, but there was also a focus on teaching and training around health literacy. Training and practice of health literacy for patient care was made mandatory where possible, and subsequently taken to the bedside for integration. Measurement and assessment were initiated, and quality improvement is continuous.

IHA 2013 Health Literacy Awards

IHA, a non-profit healthcare organization and a leader in the health literacy field, received nominations from the nation's foremost health literacy authorities and researchers. Winners were selected in the categories of Research, Innovative Programs, and Published Materials.

The winners of the three 2013 IHA Health Literacy Awards are:

Research: Co-winner

Canyon Ranch Institute Life Enhancement Program (CIR LEP)

The Canyon Ranch Institute Life Enhancement Program (CRI LEP) is an evidence-based, multi-disciplinary, integrative program that increases health literacy while preventing, diagnosing, and addressing chronic diseases. The CRI LEP is a powerful guided experience designed to help participants make an enduring personal commitment to their health and wellness. The 40-hour CRI LEP consists of: 12 three-hour facilitated participatory group classroom, fitness and stress-management exercises; food preparation demonstrations; a grocery-shopping excursion; and individual planning sessions for setting health-related goals. This is accomplished through a rigorous research protocol and through seven core program elements, including 1) Nutrition, 2) Physical Activity, 3) Behavior Change, 4) Sense of Purpose, 5) Integrative Health, 6) Stress Management, and 7) Social Support and Follow-up. The CRI LEP is tailored to each community with a multi-disciplinary team of local health professionals. The team includes physicians, nutritionists, exercise professionals, social workers, registered nurses, behavioral health specialists, and spirituality professionals. Each member of this team receives 90 hours of training from CRI to integrate their efforts as a team of professionals who can effectively deliver the CRI LEP curriculum. A unique and essential characteristic of the CRI LEP to addressing health literacy skills is four one-to-one consultations between each participant and a behavioral health expert, a nutritionist, and a fitness/exercise expert, participants: review their own health assessment information; are helped to understand this health information using the Teach Back method; apply that information in relation to their own lives; improve their skills in navigating the health system; and establish clear, achievable personal health plans. The CRI LEP group sessions provide participants with tools to make healthy changes, but the one-on-one sessions with health professionals define what is needed as they are based on a rigorous physiological and social assessment of each participant’s own health status. CRI and the health care organizations that offer the CRI LEP follow a rigorous evaluation that begins at baseline and is repeated at post program, with the exception of the blood work which is repeated at +3 months. The entire evaluation protocol is repeated again at +1 year. The evaluation consists of a fitness assessment, blood work, a physical assessment, and an extensive knowledge, attitude, and behavior survey. The program has been ongoing since 2007.

“We approach each person and community as equal collaborators, drawing on our respective strengths to realize a whole is greater than the sum of its parts,” stated Jennifer Cabe, Executive Director & Board Member for Canyon Ranch Institute.

Research: Co-winner

“Picture This” – mobile technology to help improve health literacy and outcomes

Christine Kennedy, RN, PhD

University of California, San Francisco

Dr. Kennedy designed and oversaw implementation of “Picture This.” The objective of this three phase study was to develop a mobile phone application (mHealth app) to help healthcare providers to promote more physical activity and less sedentary behavior among patients. Yet, there is a need to bridge the challenges of low health literacy in this effort. Mobile phones offer a unique opportunity to address low health literacy and health disparities because of their widespread use in the population and as a platform that can provide visual content with minimal text.

“Picture This” is a pilot research study that investigates the possibility of leveraging mobile health (mhealth) technology to further health literacy research and practice to bridge ethnic and racial health disparities. In a world driven by technological innovation and the inherent market tendency to design for the wealthy as opposed to the segment of ethnic and racial minorities with low health literacy, “Picture This” aims to create new opportunities for mhealth technology and health literacy professionals/practioners to guide individuals through the complexity mobile health informatics by testing a new mode of visual communication for health.

“Although this study is specific to sedentary behavior and physical activity, the applicability of impacting the field of mobile health communication at large is inevitable. Visual mobile apps could be a complete game changer in the way we, as healthcare providers, share and receive knowledge, strengthen dialog with our patients and improve health outcomes,” Kennedy states.

Innovative Programs

Peer Language Navigator (PLN) Project

Rhonda Johnson, DrPh and Polly Smith, MA, Co-Chairs

The Alaska Health Literacy Collaborative (TAHLC)

The goal of the Peer Language Navigator projects is to create a support network that bridges the many cultural differences and language barriers to provide limited English proficient populations with important health care information and to increase provider awareness of low health literacy barriers to effective care. In response to identified and shared concerns about health literacy, TAHLC initiated PLN project that identified ethnic community members primarily from recent immigrant and refugee communities who would be interested in working with health and adult education providers in developing health messages and materials that are culturally competent. Extensive training and respectful discussion to develop a message that is understandable and culturally relevant was required. PLNs have assisted in bringing health messages and information in their own language to their ethnic community.

Through trainings, direct instruction and developing Peer Language Navigators who bridge the cultural and language gaps that arise in health education, TAHLC is changing the quality of life for hundreds of underserved and overlooked adults. The PLNs are recruited from the emerging ethnic communities within Anchorage. The content of the instruction and trainings for PLNs is determined by community assessment and interest in learning about a specific health issue or topic. TAHLC has just received a National Network of Libraries of Medicine Pacific Northwest Region Outreach grant to expand the knowledge of PLNs in accessing health information and bringing that information using WiFi enabled tablets to their communities in other setting such as homes, places of worship or workplaces.

“The PLN project helps our community by providing culturally relevant health information and resources, as well as improving health literacy of limited English speakers.”  - Polly Smith

Published Materials

WIC Nutrition Program Handouts: “I’m 1, I’m 2, I’m 3, I’m 4”

Poppy Strode, MS, MPH, RD, Public Health Nutrition Consultant

California Department of Public Health Women, Infants, and Children (WIC) Nutrition Program

The California Department of Public Health WIC (Women, Infants and Children) Supplemental Nutrition Program developed a series of handouts (“I’m 1”, “I’m 2”, “I’m 3”, and “I’m 4”) for parents of toddlers and preschool children.
These parent handouts were designed in alignment with the California WIC Program’s adoption of participant-centered education. The materials are not only easy to read, but are also designed to support an interactive approach during individual nutrition education. Staff engage parents in reading and working with each handout, so there is more participation during the session and parents are more likely to keep and use the handout at home. Also, the circle chart designed in each handout allows parents to choose a particular topic to focus on in discussion with WIC staff.

The handouts contain updated information for the four age groups, and follow the recommendations in the US Dietary Guidelines for Americans, MyPlate, and other evidence-based sources. Each handout includes a food guide; a sample menu; and information about: trusting the child to eat the right amount, family meals, healthy snacks, food safety, age-appropriate plan and normal development. In addition, each handout invites the parent to create a sample menu for his/her child, mark play activities to do together, and write down a healthy change his/her family will make. Encouraging parent involvement supports participant-centered education, and personalizing the handout encourages the parent to continue using it at home.

“These handouts support our parent participants by providing concrete “how to” information for good health and nutrition, that’s easy to understand and implement. The knowledge that participants gain, empowers them to be good role models, to offer healthy foods, and to trust their children to eat the right amount.” – Poppy Strode.

Presented to Andrew Pleasant, Ph.D.

Andrew Pleasant was presented with IHA's Health Literacy Hero Award. This award was created several years ago to honor individuals in the health literacy field who have made significant contributions to the health literacy field, and who have been strong supporters and loyal friends of IHA. The inscription on the award for Dr. Pleasant read: "For Demanding the Very Best From the Health Literacy Community and Never Failing to Deliver the Same.”

Leonard Doak Memorial Scholarship in Health Literacy

From left, Michael Villaire, MSLM, Chazz Glaze, Cecilia Doak, MPH

Presented to Chazz Glaze, Salud Family Health Centers

Chazz Glaze is the first recipient of the Leonard Doak Memorial Scholarship in Health Literacy. The scholarship was set up by Cecilia Doak to honor her late husband and longtime colleague, Leonard Doak, who passed away in July 2012. The scholarship pays all expenses for one individual to attend the Health Literacy Institute in Maine. The winner also works with a mentor for a year to achieve the projects they listed for themselves in their application. Glaze's mentor for the year is Cecilia Doak. 

The Institute for Healthcare Advancement donated $5,000 to the scholarship fund. Canyon Ranch Institute and the California Department of Public Health, WIC Program donated their $500 awards to the scholarship fund as well.