Using the National Action Plan to Improve Health Literacy - Full Transcript - Health Literacy Discussion List - Literacy Information and Communication System(LINCS)

Using the National Action Plan to Improve Health Literacy

Full Transcript

Discussion Announcement | Guest Facilitator


Welcome to our discussion on Using the National Action Plan to Improve Health Literacy!

Julie McKinney 

Hi Everyone,

Welcome to our guest discussion with Cynthia Baur, the lead author of the National Action Plan to Improve Health Literacy! Cynthia has been dedicated to health literacy for many years, and is currently the Senior Advisor for Health Literacy, Office of the Associate Director for communication, Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services (HHS).

This Action Plan represents a national commitment to create a health literate society, and offers guidance to help each of us, from whatever angle we work, to participate in the process. I hope that each of us can see our health literacy efforts reflected in one or more the seven goals presented in this Action Plan, and that we can use this time with Cynthia to better understand the plan and how it can guide and support our work.

Please feel free to ask questions, to comment and to share your ideas and stories.

All the best,


Baur, Cynthia (CDC/OD/OADC)

Hello and thanks to Julie for the opportunity to spend a week discussing the new National Action Plan to Improve Health Literacy. The full plan is available at The Action Plan consists of a vision of a health literate society, 7 goals and the most important actions individuals and organizations can take to improve health literacy.

I usually get two questions when I talk about the Action Plan. One is, where is the money to implement the strategies in the Action Plan coming from? And two, who is leading implementation?

First, the money question. All of us who work in an organization - no matter how large or small - have budgets and human talent. Those budgets and human talent already are being spent to do something, most likely related to health and/or communication and education if you are on this listserv. We need to hold up a mirror and ask ourselves a very tough question:

Are our money and talent being spent to improve health literacy OR perpetuate and create health literacy barriers?

You can see the relevance and implications of the question the next time your organization (or mine) issues a fact sheet or set of recommendations for the public or medication/discharge instructions that are dense, technical and not actionable. If we challenge our organizations to meet the standard of health literacy improvement EVERY time using the resources we already have, then we would be well on our way to implementing the strategies in the Action Plan and meeting the seven goals. Fresh money and talent would reinforce and expand what already is underway.

Second, the leadership question. The U.S. Department of Health and Human Services (HHS) Health Literacy Workgroup led the development of the Action Plan. I and Dr. Linda Harris of the HHS Office of Disease Prevention and Health Promotion co-lead the group. Because HHS had the resources to pull together the Action Plan, we led the process. That does not mean, however, this a plan by government for government or a plan by government telling everyone else what to do.

The Action Plan applies to ANY organization - public or private - that creates and disseminates health information and services to the public. This includes government agencies, healthcare facilities, health insurance plans, schools, libraries, the mass media, foundations, patient advocacy groups - any group related to health is covered by the Action Plan. Is HHS going to enforce the Action Plan? No, it is not a law, regulation or policy. HHS agencies will encourage the adoption of the Action Plan as a framework for planning and action - for themselves as well as others. And any other organization can do the same.

For example, if there are hospitals that want to be leaders in cost effectiveness and patient safety, quality and satisfaction, then they can use the Action Plan to identify the health literacy goals and strategies that will help them in cost effectiveness and patient metrics.

If there are public health departments that want to contribute to the national health objectives in Healthy People, then they can use the strategies to improve the effectiveness of interventions in diabetes management, cancer screening, obesity reduction, infectious disease spread and any other public health priority.

If there are K-12 schools or adult basic education programs who want to help their students to access health care, understand what they need to do to stay healthy and take action to make that happen, then they too can use the Action Plan to integrate health literacy into their programs and partner with health programs.

In short, the resources and the leadership already sit with all of us. Each of us is responsible for doing whatever we can where we are right now to implement the strategies that will improve health literacy.

I know many of you on the listserv take these responsibilities seriously and demonstrate leadership daily in your organizations and try to influence others to improve health literacy. To all of you, the Action Plan is a call to double and triple your efforts because we must speed up and expand our impact. We have too many small-scale efforts that are not yet changing organizational practices.

To those of you who are new to health literacy or don't know how and where to start, the Action Plan provides the blueprint. It shows us where to focus our attention to achieve the vision of a health literate society.

Here is a set of questions to get you thinking about what you can do where you are today:

  1. What practices in your organization create a health literacy barrier?
  2. Which of the seven goal areas fit your organization's priorities?
  3. What is one thing you can do this week to use information from the Action Plan in your work?

During this week, you will hear from several organizations that already use the Action Plan. All of them are "early adopters" and they understand the power of "one plus" - no one is trying to go it alone. Each of them leads or is part of multi-sector coalitions and collaborations, which are essential to successful health literacy work. Please learn from them and ask all of us lots of questions. By the end of the week, I'd like as many organizations as possible accepting the action Plan challenge. Please share with all of us what your contributions will be.


Cynthia Baur
Centers for Disease Control and Prevention


Rob Simmons

I wanted to ask Cynthia and others about research on health literacy (Goal 6
in the National Action Plan).

What are important "research gaps" in health literacy and how are public and
private organizations addressing some specific gaps in knowledge of development, implementation, and evaluation of "best practices" in health literacy?



Matusow, Robin I.

As a person involved in adult ed, it seem that an easy way to get adult ed involved is to ask states to include health literacy courses or information in current state frame works for adult/vocational education. Vocational education courses often include various work place safety courses that might be ppropriate to include work place health literacy. Many opportunities would be developed by educational systems if "educational credit" were offered to the institutions.


Baur, Cynthia (CDC/OD/OADC)

Thanks Rob. I know there are many researchers on the list who can chime in about the sources of funding they use or have tried. The most established one I know about at the this point is the NIH/AHRQ/CDC Health Literacy Program Announcement. (Some HHS agencies do fund health literacy projects under contracts, and some of this work is research. Most is not.) This Program Announcement has been issued 3 times and during the last re-issue a NIH-led workgroup reviewed and updated the areas and questions of interest. This lists many of the gaps HHS agencies have identified.

You can find the Announcement for the R01 grants at and for R03 grants at

In addition NIH is supporting new research in behavioral and social sciences under its new OppNet initiative. Although this isn't health literacy specific, it can provide new funding avenues for researchers.

The Action Plan lists the gaps most frequently mentioned in the literature or at health literacy meetings. Earlier this year, Andrew Pleasant hosted a week long discussion on the research needed in the measurement of health literacy as well as health literacy outcome metrics. It provoked a lively debate on the list, and I recommend this discussion as a "pulse check" of the health literacy community on research gaps.

In addition, at the upcoming Health Literacy Annual Research Conference in Oct., there will be a session on basic health literacy research. We used the term "basic" intentionally in the Action Plan because there is a lot of work to be done on the underlying mechanisms that create the phenomenon we refer to as "limited health literacy." For example, the work coming out of Northwestern U. is looking at causal pathways related to cognition. They have begun to identify some factors. There are many other pathways related to public health, education, organizational performance and the like that we haven't really touched yet.

I hope others add to this discussion of gaps. We think we captured the biggest research gaps under Goal 6, but really any strategy in the Action Plan is a candidate for research, and especially evaluation.



Brach, Cindy (AHRQ)

The National Institutes of Health and the Agency for Healthcare Research (AHRQ) are sponsoring health literacy research under 3 program announcements entitled, "Understanding and Promoting Health Literacy." The program announcements state in general terms priority areas for research. In addition, each participating organization has written examples of research topics they are most interested in funding, which can be found at I have appended below what AHRQ views to be top priorities in health literacy research.

AHRQ is particularly interested in the development and testing of interventions designed to improve: 1) patients’ understanding of their health conditions, and 2) their ability to take appropriate actions. Such improvements will ultimately enhance informed decision making, health care, and/or health outcomes for individuals with limited health literacy. These include both patient/consumer-oriented and provider-oriented interventions. AHRQ is also interested in implementation research regarding health literacy interventions, such as the adoption of health literacy universal precautions. AHRQ encourages research in under-studied areas, such as verbal health literacy and numeracy. Ideally, all intervention studies would examine costs and cost offsets of the interventions.

AHRQ also supports the development of health literacy tools, such as health literacy measurement tools, pharmacy health literacy tools, health information technology health literacy tools. To view health literacy tools supported by AHRQ, go to: Applications to develop tools should include testing and validation of the tools. AHRQ also encourages research that addresses priority populations (minority groups, low-income groups, women, children, elderly, individuals with special health care needs - including individuals with disabilities and individuals who need chronic care or end-of-life health care). Research that could contribute to the reduction or elimination of disparities in health care or health disparities would be of great interest. For more information on disparities, see AHRQ’s National Healthcare Disparities Report at:

Cindy Brach


Julie McKinney

Rob and others interested in Goal 6: Health Literacy Research,

As Cynthia mentioned, we did have a rich discussion on the list about measuring and evaluating health literacy in March. To read this discussion, go to this link, and scroll down to post #4148 on March 8th:

The lack of comprehensive measures for studying and evaluating health literacy is a large barrier and needs to be addressed if any rigorous further research is to thrive. Therefore, research and development of measures is a first step. Also, to date, most of the research is related to the need for improved health literacy, which has already been established pretty well. What we need to do now is to study some of the "promising practices" so that we can prove them to be "best practices". Again, this is hard to do until we have accepted measures.

This is a very good question that Rob has brought up. I hope others will chime in!



Michelle Roberts

At Health Literacy Missouri, we believe the National Action Plan to Improve Health Literacy will shape the policy of our organization and organizations like it for years to come. Never has there been a more exciting time to rally behind this important mission and to do even more to improve the health literacy of our nation.

We are already working on several initiatives that address each of the seven primary goals for action in Missouri. Here, we have arranged each of our activities by where they fit into the stated goals of the action plan. We hope this list will spark ideas for how to help carry out the action plan’s objectives in communities everywhere. We welcome additional ideas and discussion.

Goal 1 - Develop and disseminate health and safety information that is accurate, accessible, and actionable

What we are doing:

  • HLM has developed the world’s first online library devoted entirely to health literacy. The collection contains more than 7,000 resources, including toolkits, and is accessible through HLM’s website,
  • The HLM News Service was created to provide localized health stories to more than 300 Missouri media outlets. Ready-for-print articles are written in a health literate manner, without industry jargon, making them easy to understand for the public.
  • Through a project funded by the Missouri Foundation for Health, HLM is producing a variety of videos to teach clear communication in health care. A 30-minute program on health literacy will air on HEC-TV, St. Louis’ leading producer of education, arts, and cultural television programming.
  • HLM is heavily engaged in social media efforts as part of a larger communications strategy. By utilizing the most popular social media tools, including Facebook and Twitter, HLM has been able to reach out to professionals, consumers and practitioners around the world and create a strong network of followers actively engaged in improving health literacy. Our efforts have improved our search engine ranking as well.
  • HLM has partnered with Public Health Television to produce videos and install video equipment in the reception areas of federally certified rural health clinics throughout Missouri. The videos will reach patients at the point-of-care with targeted, culturally tailored and linguistically appropriate health education, wellness and lifestyle information aimed at improving health outcomes.
  • HLM oversees an innovative project to introduce the Canadian website,, to middle and high school-aged children in Moberly, Mo. The website’s main goal is to promote health literacy in youth by becoming a daily presence in their lives. It offers relevant health content that also reflects community values and is culturally suitable for each locality. The website contributes to the early detection of mental health difficulties and encourages kids to seek help. Utilization data identifies which topics receive the most inquiries and gauges the severity of specific problems in particular school buildings. Over time, changes in health literacy can be tracked and analyzed.

Goal 2 - Promote changes in the health care delivery system that improve health information, communication, informed decision-making, and access to health services

What we are doing:

  • HLM is part of the Missouri Statewide Health Information Exchange Consumer Engagement Workgroup (MO-HITECH), a gubernatorial-appointed group charged with making electronic medical records (EMRs) more consumer-friendly and useful.
  • HLM provides walking tours to hospitals and clinics to gauge their health literacy environment. We look at the use of the written word inside buildings, programs and service agencies such as signs and postings, forms and information packets as well as the “talk” between visitors and staff, among staff and between patients and clinicians. The assessment identifies factors within the health center that help or hinder people as they access care and services, and offers advice on how those barriers can be removed.
  • HLM oversees Project Know at The Kitchen Clinic in Springfield, Mo. The clinic will provide 2,000 clinic discharge patients with a health literacy-trained registered nurse. Of those patients, at least 200 with multiple chronic conditions are being evaluated annually for improvement in knowledge, behaviors and health status indicators.

Goal 3 - Incorporate accurate, standards-based, and developmentally appropriate health and science information and curricula in childcare and education through the university level

What we are doing:

  • HLM oversees the Seed-to-Table Project at the Maplewood-Richmond Heights School District. The program was developed to provide a child-centered environment that helps students learn from the natural world around them and improve their health literacy. Goals of the garden curriculum include engaging children in hands-on exploration of food and nutrition, emphasizing healthy food and lifestyle choices, and promoting the value of cooperation, teamwork and responsibility.
  • The University of Missouri, in conjunction with HLM, is developing a Health Professional Health Literacy Curriculum program and will establish a certificate for undergraduate, non-physician health professional students using both traditional classroom curricula and online courses. The program addresses specific medical and non-medical issues that relate to the health literacy and health compliance of Missourians with chronic illnesses and disabilities. An estimated 300 health professional students will go through the program.
  • With a grant overseen by HLM, the St. Louis College of Pharmacy educates students, pharmacist and patients about health literacy. The curriculum uses approaches known to optimize the rate and extent of learning, including role-playing, simulations, and learning by doing.

Goal 4 - Support and expand local efforts to provide adult education, English language instruction, and culturally and linguistically appropriate health information services in the community

What we are doing:

  • HLM, in conjunction with the St. Louis Christian Chinese Community Service Center, is working to improve the health literacy of new immigrants, older adults and the needy in St. Louis’ Chinese community by developing culturally and linguistically appropriate health literacy materials and activities, including traditional puppet shows that center on health literacy messages.
  • HLM has paired with Nurses for Newborns to enhance patient-provider communication and cultural competency by hiring mothers from Bosnian and Hispanic communities to join agency nurses in providing home visits to new moms. Ninety families will receive 800 in-home visits, covering topics such as prescribed medication, immunizations and smoking.
  • HLM’s Promotoras de Salud project promotes and increases health literacy for underserved Latinos in Boone County, Mo., by improving access to primary care services and creating conditions that promote a healthy lifestyle.
  • Through HLM’s Literacy Investment for Tomorrow-Missouri (LIFT) Health Literacy Study Circle Pilot Project, a curriculum was designed for Missouri Adult Education and Literacy (AEL) Programs to teach adult learners health literacy lessons through traditional literacy lessons. The health literacy module was created and piloted in ten classrooms.
  • HLM works with a health literacy initiative in St. Louis that is designing materials to help people diagnosed with HIV/AIDS adhere to complex medication regimens.

Goal 5 – Build partnerships, develop guidance, and change policies

What we are doing:

  • HLM convened a group of more than 250 health care and literacy leaders from across Missouri for a health literacy summit in Columbia, Mo., on June 15, 2010. The first gathering of its kind in the state, the meeting provided an opportunity for a wide variety of stakeholders to hear about and share best practices around health literacy.
  • HLM brought together a growing group of statewide health literacy organizations and partners in Irvine, Calif. on May 5, 2010, the day before the Institute for Healthcare Advancement conference. More than 60 representatives from 22 states and the country of Singapore were in attendance. The goal was to share work being done across the country, assess the group’s needs and develop action steps to address those needs as a cooperative. The Midwest states: Iowa, Wisconsin, Minnesota, Arkansas, and Missouri agreed to create a formal cooperative, offering to share lessons learned as they move forward.
  • HLM teamed up with the St. Louis Collaborative and the St. Louis Business Journal to host a presentation by Dr. George Isham, Chair of the Institute of Medicine Health Literacy Roundtable, which focused on the business case for health literacy. More than 200 business leaders, healthcare providers, and community-based organizations attended the May 2010 meeting.
  • HLM is partnering with the Federation of Association of Schools of the Health Professions (FASHP) and the St. Louis College of Pharmacy to bring together the leaders of at least 12 national associations to develop health literacy core competencies.

Goal 6 - Increase basic research and the development, implementation, and evaluation of practices and interventions to improve health literacy

What we are doing:

  • HLM and St. Louis University (SLU) are planning, implementing and evaluating health literacy policy changes in a federally qualified health center serving a high-need population in three rural Missouri communities.

Goal 7 - Increase the dissemination and use of evidence-based health literacy practices and interventions

What we are doing:

  • HLM created the “Straight Talk with your Doc” workshop that uses clinical simulations for medical practitioners and health professionals to develop and practice health literacy skills and techniques in real-life practice settings. A team consisting of physicians, an associate dean of education, and the chair of HLM’s education committee met over eight months to design the workshop curriculum and protocols.

Michelle Roberts
Director of Communications & Marketing
Health Literacy Missouri

Michelle Roberts

Hi all,

I wanted to add an exciting addendum to the list that I sent in earlier today. The Health Literacy Missouri News Service (which we operate through a contract with the University of Missouri-Columbia Journalism School) was created to provide localized health stories to more than 300 Missouri media outlets two times a month. The ready-for-print articles are written in a health literate manner, without industry jargon, making them easy to understand for the public. They have been published hundreds of times across the state and the web. While we have been able to measure how often the releases are reprinted, we haven't been able to measure their true impact on the health of Missourians.

We are now in talks with the Missouri Association of Local Public Health Agencies to find creative ways to expand the program. One idea is that we would provide the association members advance notice of our releases, plus include local contacts/places for people to go. In return, those agencies could report back to us whether people were "acting" on the information we provide in the releases, thereby giving us some form of public health measurement we currently don't have.

I would love to hear any other ideas about creative ways to measure the impact of these important public health messages.

Best, Michelle

Susan Centner

Hello -

We are currently conducting a series of workshops, in partnership with Missouri State Library, National Network of Libraries of Medicine and Health Literacy Missouri, on health literacy with public libraries and community health organizations throughout the state. We are using the National Action Plan To Improve Health Literacy as a framework for these sessions and have found it to be incredibly helpful in laying out a strategy for addressing health literacy.

We explored strategies for implementing the seven goals, often learning new things about each other, our organizations and the various roles each of us play in the health literacy continuum. One participant wrote the following on her evaluation "I will find ways to implement some of the ideas from today's sessions into my interactions with clients".


Susan Centner
Librarian Team - Health Literacy Missouri

sally sandy

With funding from Missouri Foundation for Health and support from Health Literacy Missouri and the Adult Education Section of the Department of Elementary and Secondary Education, Parkway Area Adult Education and Literacy in suburban St. Louis has developed a framework(not a curriculum) of resources to contextualize health literacy into every level of ABE/ASE and ESL instruction.

Health Savvy, our name for this very flexible framework, currently in its third and final pilot, gives teachers resources and lesson plans to use as they teach the same skills that they've always taught, but with a health literacy focus. We had high hopes from the beginning, but even we have been surprised how students become more engaged in the process of education when their own health is used as one the cornerstones of learning. Even though we have a month left in our final pilot the framework is out there at:

Sally Sandy
Parkway Area Adult Education and Literacy

Julie McKinney

Thanks, Michelle, for this impressive and comprehensive list of HLM's activities, and how they are mapped onto the action plan! It is amazing how much is happening in Missouri.

I am starting this thread to encourage other states and programs to share with us their own lists of activities and how they align with the Action Plan's seven goals. It would be great to end this discussion with a comprehensive chart that shows what everyone is doing for each of these goals.

I know that many other states are doing statewide health literacy initiatives, including Georgia, Wisconsin, New Jersey, Minnesota, Iowa, Arkansas, Rhode Island, Florida and many others. I would love to have people from those and other states write in with their own lists, mapped to the seven goals!

Thanks so much,


Baur, Cynthia (CDC/OD/OADC)

Yes, many of the states you list, Julie, are using the Action Plan. In addition to Missouri, I have worked already with the Wisconsin and Iowa initiatives. I know other state groups are thinking about to use the plan.

One of the discussion points at the meeting Health Literacy Missouri hosted in Irvine this year's (prior to the IHA health literacy conference) was getting a state coalition or initiative started. The Action Plan is a great tool for organizing. It provides a set of issues to focus on, sectors that need to be involved as partners and/or stakeholders and an outline of what a state or multi-organization plan would look like. You can do that by using the 7 goals and pulling out those strategies most relevant to your group.

It would be great to have a summary of each state's activities by goal to help stimulate thinking in states that are just at the beginning of the process. If you are in a state that doesn't have a coalition or initiative yet but your organization is using the Action Plan, please let us know that too.


Julie McKinney

Surely many coalitions and single organizations are addressing one or more of the goals, even though they were not consciously "using the action plan". We should include these efforts in our master list, too, so please submit them!

I also have a question:

How can it help your work to realize that the activities you have already been doing are now part of a "National Action Plan"? Does this give you more clout? Can it help to obtain funding or gain new partners? What else can this status do to help our efforts?


Michele Erikson

The 4th Biennial Wisconsin Health Literacy Summit April 11-13, sponsored by Wisconsin Literacy, Inc and the Wisconsin Research and Education Network (WREN) will contribute to six of the seven National Action Plan to Improve Health Literacy goals by achieving the following aims:

  1. Attract a national and regional audience of primary care physicians engaged in practice-based research (and other health care providers) that will be able to integrate health literacy research findings and tools into their medical practices (goal 1, 2, & 6).
  2. Attract a national and regional audience of leaders in community-based adult literacy education that will be able to integrate health literacy practices and interventions into their adult education programs. (goal 4)
  3. In collaboration with Health Literacy Missouri, conduct a pre-conference meeting of representatives from at least 25 state health literacy coalitions or initiatives to share experience and provide technical assistance for building statewide health literacy coalitions (goal 5).
  4. Discuss policy implications of health literacy as it relates to healthcare reform at the local, state and national levels (goal 5).
  5. Disseminate health literacy practices and interventions that can be used by the audience to address the National Action Plan goals in their personal work and within their organization (goal 7).
  6. 6) Continue the discussion on Health Literacy Measurement, led by Andrew
    Pleasant, Ph.D., that kicked off on the NIFL Health Literacy Discussion List in March and continued at the May IHA Health Literacy Conference. (goals 2, 6)

Using the methods of our three previous successful health literacy summits, we will target invitations to physicians, health care providers and literacy educators, invite national, regional and local speakers to summarize and communicate policy recommendations, research findings, evidence-based information, tools, and adult education interventions.

Our audience will include people within organizations that have the capability to use the information to improve the outcomes, quality, access to, cost effectiveness and utilization of health care services especially for low income and minority groups, women, children, the elderly and those living in rural areas.

Below are some of the recently funded projects Wisconsin Literacy, Inc has been working on that focus on goals 3 and 4 but touch on the other 5 goals as well:

  • Funded by the Centers for Disease Control and Prevention - Sub-award by WI Department of Health Services - Bureau of Communicable Diseases, Office of Preparedness. H1N1 Education Training Sessions to Vulnerable Populations. Wisconsin Literacy, Inc. is conducting H1N1 and Seasonal Flu Education Training Sessions statewide to its member literacy agencies and their local community partner organizations that serve vulnerable populations.
  • Funded by the Wisconsin Medical Society Foundation and the PIC Wisconsin Fund
  • Enhancing the Health Literacy of Wisconsin Parents and Families. This project focuses on the distribution and training in the use of the book edited by IHA, What to Do When Your Child Gets Sick to member literacy agencies and their community organization partners through out the state.
  • Funded by Wal-Mart State Giving Program
  • Health Literacy in Tutor Training. Wisconsin Literacy, Inc is incorporating fundamental health literacy awareness and implementing health literacy teaching resources into its member literacy programs and their partner community agencies serving vulnerable populations.
  • Funded by Safe Care Wisconsin: Medication Safety and Prescription Labels. This project centers on training literacy tutors and teachers how to teach medication safety to adult learners.
  • Funded by the American Academy of Family Physicians Foundation -Project Partner: WREN
  • Improving the Health Literacy Environment of Wisconsin Hospitals - A Collaborative Model. This study is a pilot project that teaches adult education students to be consultants to a hospital for improving the health literacy environment of the hospital.
  • Funded by the Southwest Wisconsin Area Health Education Center
  • Health Literacy 101 for Nursing Students and Nurse Practitioners. This pilot project introduced both future nurses at Western Technical College and current nurses at Franciscan Skemp - Mayo Health Systems in La Crosse, WI to health literacy issues and helped them identify and address patients' health literacy needs using a curriculum developed by Wisconsin Literacy staff.

Other recent activity that addresses the National Action Plan

  • We participated on a Health Literacy focus group for the Healthiest Wisconsin 2020 Plan (goal 5)
  • We contributed as reviewers to The Joint Commission's Roadmap to Hospitals on Advancing Effective Communication, Cultural Competence and Family- and Patient-Centered Care. (goals 2, 5)
  • Currently participating in meetings/discussions on Health Provider Payment Reform and Electronic Medical Records (goal 5)
  • We developed a Health Literacy Website dedicated to sharing resources for health care providers and literacy providers.(goal 1, 7)
  • We launched a monthly health literacy newsletter and adopted social media strategies to share information on our current health literacy efforts and those of other organizations. (goals 1, 7)
  • We support and lead 4 regional health literacy committees made up of health care and literacy providers that focus on health literacy interventions within their respective regions of the state. We were awarded a second grant by the Johnson Foundation to host a second Wingspread conference on strategic planning for Health Literacy in Wisconsin. (goals 1-5)

We hope you will consider attending the 4th Biennial Wisconsin Health Literacy Summit on April 11-13, 2011 to learn more about these initiatives and the many others that are underway around the country. Call for presenters will be coming out soon.

Michele Erikson
Executive Director
Wisconsin Literacy, Inc.

Winston Lawrence

Cynthia: Thank you for making yourself available to discuss the National Action Plan and also for your work in building consensus and producing this document In New York, we have shared the plan with members of health literacy collaboratives that we have organized in different boroughs. We have also shared the information in our health literacy and plain language workshop. The intention is for members of the collaboratives and participants in the workshops to share the information with their colleagues and supervisors.

We have also used the document in our health literacy planning meetings with a couple of hospitals, showing the administrators areas that they may want to address and strategies they may want to use.

Since my work is principally in adult literacy, I have used the document to highlight the importance of partnering between the health and adult education sectors. As the document points out, health literacy is everyone's business. And that's a great message coming from the plan. We have found that everyone is quite excited about the plan. People are delighted to know that health literacy is now a national issue. The challenge I think for many is where to start, how to start and how to fund whatever is deemed to be important.


Winston Lawrence Ed. D
Senior Professional Development Associate
Literacy Assistance Center

Pilisuk, Tammy (CDPH-CID-DCDC-IMM)

I'm unaware of an organized statewide health literacy effort in California, but if there is, I'd be interested to learn about it.

Just in my daily work I face many of the issues I hear others describe on this listserv. Primarily, those who must approve various communications are not aware of (or don't see the importance of) plain language principles.

Tammy Pilisuk

Elissa Director

Here's an update including a few highlights about our progress towards building a statewide health literacy coalition in New Jersey. This coalition has truly been a grassroots effort, with input from volunteers representing many diverse organizations and institutions. We are now beginning the critical task of securing sufficient funding to enable us to move forward with building a sustainable organization. The National Action Plan will certainly add validity to our initiative to create a statewide movement to improve communication with patients and make health literacy a priority issue on New Jersey's health care agenda.

April 2009 – New Jersey’s First Health Literacy Summit: Conducted by Literacy Volunteers of New Jersey. Attended by 175 people representing health care providers, hospitals, university and medical school faculty, community based and adult literacy organizations, state health associations, NJ state government, public health departments, pharmaceutical and health insurance companies.Produced outcomes that included increased awareness about health literacy and other state/national health literacy initiatives. Conference evaluations strongly endorsed the establishment of a NJ Health Literacy Coalition.

June 2009 - NJ Health Literacy Coalition Organizational Meeting: Attended by 50 individuals from organizations wishing to participate. Established 20 member Planning Board to define structure and specific goals of the Coalition

July 2009 to date. Established mission: A not-for-profit organization committed to improving health outcomes and increasing the efficiency of the health care system through better communication between health care professionals and the diverse communities they serve. Designed and conducted on line survey to identify New Jersey’s current health literacy programs and priorities for future initiatives. Received 91 responses (almost 50% response rate) from a wide range of organizations. 90% viewed improving health literacy as either an essential or important contributor to the accomplishment of their organization’s mission; more than half of respondents wish to participate in Coalition activities.

Presented seminar, “Improving Outcomes through Clear Communication”, for The Cancer Institute of NJ. Drafted by-laws, submitted 501 (c)(3) application to IRS, and began to explore funding opportunities.

Our Foundational Principles are:

  • Good health outcomes require clear communication between the medical professional and the patient.
  • Clear communication about health includes the written and spoken word and cultural competence.
  • Even highly educated patients may have difficulty with medical jargon and instructions.
  • Therefore, the primary responsibility falls on the health care provider to adopt a “universal precautions approach”, assuring that clear communication is the basis for every health information exchange.

We hope to have paid staff in place soon – so we can develop training and resources that will enable health care professionals in New Jersey to communicate health information more effectively.

Elissa Director
Health Literacy Consultant
Founding Member, New Jersey Health Literacy Coalition

Baur, Cynthia (CDC/OD/OADC)

Winston raises an important point about planning, which I have heard in other discussions. Developing a written strategic plan for an organization or a group of organizations may not be the first thing on people's minds when they get excited about health literacy. Our instincts are to jump in and start addressing the problems we see.

From where I sit, though, the planning and funding issues are tightly linked. When I take the time to make a plan, even a very brief and sketchy one, I am prepared when the funding opportunities come along. I have something written I can quickly pull out and use to provide a justification, a brief project description or even a short issue brief to make the case why I need funding to do X, W or Z.

Sometimes the idea of planning can be daunting. Perhaps "a plan" seems weighty and maybe even a little inflexible. Writing a plan may feel like we are taking time away from "real" work. What I have seen time and again though is that those programs I work with without a written plan aren't in the best position to take advantage of opportunities that serve their medium and long term interests. They may take whatever comes along but they don't really know why it might be good to pursue one opportunity and leave another one alone. From my experience in drafting and using the Action Plan so far, it helps bring clarity and focus to what I am doing and what I can get other people to focus on.

Planning doesn't have to be a massive task that brings everything else to a halt. At CDC, I am starting very modestly. I am condensing the introductory text of the Action Plan to a brief summary of why health literacy matters to public health, taking the 7 goals and pulling out a small number of strategies most relevant to CDC's work. This is all I am putting in a draft I will circulate to other communication staff at CDC. Their feedback will help to revise and fill out the draft.

Choosing and trying one strategy is all anyone needs to start. Once you do that, you are implementing the National Action Plan.


Julie McKinney

Choosing and starting one strategy. How simple!

Are some of you out there just beginning to incorporate Health Literacy into your work? In what ways does this Plan and Cynthia's advice help? Think about the question Cynthia posed in the opening post:

What is one thing you can do this week to use information from the Action Plan in your work?

Please share your ideas, even in a quick one-line post!


Boegli, Suzanne

It probably falls under goal #2, but this is an example of just how "basic" the situation is that I'm dealing with on a daily basis.

I was in a meeting yesterday dealing with implementation of various perational changes stemming from the Health Reform legislation. (I work for a managed care company.) A draft disclaimer was presented (by a director) that will be used on explanation of benefits statements that go to members. The 6-7 line paragraph consisted of 2 sentences (first red flag). I asked if the readability had been checked (my one thing?), to which the director's reply was "I don't know how to do that." To make this long story shorter, it was a teaching opportunity for me. Several other directors present at the meeting "heard" my query (again). And before we're done the "14th grade" statement will become much more understandable before it goes to print. -shb

Suzanne H. Boegli, MBA, RHIT
Quality Improvement Project Coordinator III
Paramount Care, Inc.

Yolanda Partida

This falls under Goal 2 Promoting changes in health care systems to improve communication and Goal 4 Support and expand linguistically appropriate health information.

In 2003, inspired by the use of cultural icons for the Mexico City subway destinations, Hablamos Juntos began exploring the potential of graphic symbols to augment English signage used in health facilities serving linguistically diverse communities. Working with the Society of Environmental Graphic Design (SEGD) and wayfinding researchers we designed and tested (in the ten Hablamos Juntos Demonstration sites) images for 28 common health facility destinations. Symbols testing was conducted with volunteers from four different language groups in each community using procedures recommended by the International Organization of Standards (ISO).

This week we released 54 health care symbols which updates the original 28 and increases the number of clinical and administrative services symbols available. Attached is a poster displaying all the symbols. This work involved four university design schools (Department of Art & Design, College of Liberal Arts at California Polytechnic State University; Digital Design Program, College of Design, Architecture, Art and Planning at the University of Cincinnati; Graphic Design Program in the College of Design at Iowa State University; and School of Visual Communication Design at Kent State University) that designed and tested the images in their communities with linguistically diverse populations and four volunteer health facilities (Women & Infants Hospital in Providence, Rhode Island; International Community Health Services in Seattle, Wash.; Children's Mercy Hospital in Kansas City, Missouri; and Grady Health System in Atlanta, Georgia) that implemented new signage systems using graphic symbols (ours and others).

Go to our website (still being updated) to find several reports that describe different aspects of the project. The design school reports describe how symbols were designed and tested, and facility reports describe pre and post signage systems with photos and details of how symbols were incorporated into wayfinding programs. This work was funded by the Robert Wood Johnson Foundation.

Yolanda Partida, MSW, DPA
Director, Hablamos Juntos
Assistant Adjunct Professor
UCSF Fresno Center for Medical Education and Research

Gwen Ratermann

Most states throughout the country are in the throes of adopting a statewide electronic medical record system. Missouri has been in the process of doing this for over a year. Our state is the only one we know of that included a consumer engagement workgroup to make recommendations about adoption of the EMR from a consumer/patient perspective.

Health Literacy Missouri (HLM) was part of that workgroup. The workgroup reviewed five different states' consent forms for their possible use in our state. HLM offered to review those consent forms for their readability. The 10th grade level was the lowest grade level that any of the five were written. This information and our subsequent HLM example of a form written at the fifth grade level provided a real learning experience for this workgroup.

It also provided HLM with an opportunity to educate the group about health literacy principles and their use in all consumer communications.

The result of this learning experience was that the Missouri Statewide Health Information Exchange (MO-HITECH) has agreed to employ health literacy principles for consumer outreach and all consumer-related information, and has made that recommendation to the Office of the National Coordinator in regards to its communication efforts at the national level.

Gwen Ratermann
Director of Partnerships and Initiatives
Health Literacy Missouri

Margarete Cook

Planning is indeed an important part of the success of any group intending on taking on health literacy as an initiative.

In Wisconsin, our grassroots efforts have come out of regional committees that were set up at our second Health Literacy Summit. The northwest region began the work of health literacy in our part of the state by utilizing the Franklin Covey project planning model. Since one of our members was trained in this method, we spent the first meetings identifying our own mission, goals and strategies. This plan then helped to guide us through our activities. It was time consuming at the front end, but worthwhile in the long run. We have since then concluded most of the activities identified in our original plan and are looking forward to the statewide health literacy strategic planning session to be held at Wingspread in October. I imagine that as a result of the work done there, our committee will come back and develop our own regional plan again based on the statewide plan. We have found the planning to be a crucial part of getting ownership from a variety of stakeholders.

It is not easy to keep the enthusiasm going for any project, especially when it relies heavily on volunteer participation. Since our committee has concluded most of our awareness raising activities, we have floundered a bit to keep the enthusiasm and participation going. We do have high hopes for being re-energized after Wingspread. Perhaps the innovative attitude from Frank Lloyd Wright ( the architect for the Wingspread conference center) will rub off on us and we will be newly inspired. If nothing else, we will be awed by his creativity.

Margarete Cook
Northwest Regional Literacy Consultant
Wisconsin Literacy

Julie McKinney

I would love to talk more about how the Action Plan can help us to add validity to what can often be a hard sell to administrators and funders. How can health literacy's new status of being part of the "National Agenda" translate into more support and more funding?

See these examples below...

Elissa Director (NJ) says: "The National Action Plan will certainly add validity to our initiative to create a statewide movement to improve communication with patients and make health literacy a priority issue on New Jersey's health care agenda. "

Winston Lawrence (NYC) says: "We have also used the document in our health literacy planning meetings with a couple of hospitals, showing the administrators areas that they may want to address and strategies they may want to use."

Elissa and Winston,
Can you tell us any more about your partners' reactions when shown the Action Plan? Does it help to bring people on board in cases where they may otherwise have not deemed health literacy a pressing need?

Please others help us comment on this!

Shelly, Susan

Keep the faith, Suzanne. I've been doing the same thing for a years, and now other people involved in these kinds of projects are asking the questions only I used to ask. Sometimes its hard to see progress; it comes in baby steps.

Sue Shelly, Patient and Family Librarian
Banner Thunderbird Medical Center

Baur, Cynthia (CDC/OD/OADC)

Suzanne's and Gwen's posts are great examples of starting with one specific problem that needs to be solved as a way to educate others and support the Action Plan. The people you are interacting probably don't know about the Action Plan but your actions clearly support the Goal 1 strategy to "Ensure that all consumer health communication - including applications, benefits materials, rights and responsibilities, letters and health and wellness information - incorporate health literacy principles." You can reinforce their willingness to consider/support clear communication by letting them know they are in line with national goals.


Kuntz, Ellen E

This week's discussion is very interesting and helpful for me in starting an organization-wide health literacy movement at Highmark. Julie asked us to share one thing we've learned and how we plan to use it. I like Cynthia's advice to condense the National Action Plan into a document that makes sense for your organization. I plan to do this and review it with our newly-formed Health Literacy Task Force. We can use it to get everyone on the same page and direct our activities moving forward. I also plan to use the wonderful information Michelle Roberts shared this week about what Health Literacy Missouri is doing around each goal. It should spark good discussion among our task force. One activity that is already in the works is a 5-7 minute online training module on how to use the AHRQ Health Literacy Universal Precautions Toolkit. This training module will soon be available on our provider resource center and accessible to network providers 24x7.

Ellen Kuntz, MS
Health Equity & Quality Services

Baur, Cynthia (CDC/OD/OADC)

Thanks Ellen for sharing your process. Your description provides a realistic and actionable example for any organization that wants to get started.

Are there other organizations ready to try now that you have seen how others approach the "getting started" step?


Julie McKinney

Hi Everyone,

We have heard from some health literacy initiatives and coalitions about how they are using this Plan. Thank you! I am happy to hear from you all who are joining forces between health and literacy programs!

I would also like to hear from those of you who work on quality improvement and access to care, such as primary health care consultants. I know that a lot of what you do involves helping community health centers and hospitals to connect better with underserved populations, and creating strategic plans to improve the quality of care. Now that Health Literacy has been formally added to the national agenda and this plan is available to help focus the goals, I would love to hear if and how you all may use this in your work.


Clifford Coleman

Hi All,

At Julie's suggestion/request, thought I'd weigh in with a somewhat different "primary care perspective" on the Action Plan.

First, let me say that I work in a unique setting of a Federally Qualified Health Center look-alike family medicine clinic attached to a large medical school. This arrangement comes with lots of resources typically not available to most primary care clinics. There are also unique challenges involved in being a teaching clinic, staffed by faculty members with diverse interests and expertise, family medicine residents at various stages of training, and a constant flow of other learners passing through. For these and other reasons, my perspective should not be considered representative of that of primary care in general.

Second, I'd like to acknowledge that as it currently stands, the primary care "system" in the U.S. is actually structured NOT to provide clear communication. While the field of primary care is full of very well-intentioned conscientious individuals who want all patients to be empowered and well, there are significant disincentives to providing clear patient-centered communication. Under current financial structure, I (we) get paid per office visit or per procedure, more or less. The more visits I can pack into a day, the more I (we) get paid. Hence the advent of the 15-minute visit (and in some cases 10 or 7 minute visits!). Now, we all know that it's difficult to have a rich patient-centered patient-provider discussion with shared decision-making in a 15-minute visit, even when the provider is using clear communication techniques, let alone when they're not. If I spend an extra 10 minutes with a patient to ensure that informed shared decision-making has occurred I can get paid a little more, but not as much as I would for seeing another patient during that time. My incentive, then, is to do the best I can in a short amount of time, and have my patient come back for another follow-up visit later (often to discover that something was not conveyed clearly the first time). If something goes wrong, and my patient needs to be hospitalized, I get paid for taking care of them in the hospital too. Of course, I don't get paid for helping anyone stay well! (Pay-for-performance may begin to change this in the future). So, with that background, we can start to see that many of the goals in the National Action plan will face systemic barriers to implementation in primary care settings. By the way, the financial incentive problem outlined here is even worse in specialty care settings.

Third, change is hard. Busy primary care clinics are typically working as hard as they can to maintain a status quo (whether it's good or not), and generally find it difficult to change the way something is done. For this and other reasons, change often requires an outside stimulus of some kind. Typically that means money to implement the change and evidence that change will produce tangible results.

From this vantage point, I see the National Action Plan having a number of important uses for the work we do here at my institution, and the work done in more traditionally arranged primary care settings (i.e., where the vast majority of Americans receive their primary care). Below are some comments on a few of the goals in the Action Plan:

This is a huge issue for us. Primary care providers often enjoy the role as educator, but lack adequate time for this role, and struggle to find quality print or other media resources they can trust without reading them themselves (which is often just not realistic in primary care, where we see every kind of problem). Having a single-source easy-to-use web-based resource for trusted low-literacy materials will benefit us all.

I think the disincentives mentioned above will be a huge barrier that we will need to overcome to make this goal a reality, ultimately. The Capitated care experiment of the 1990s could have helped here, but we saw how that failed...

In the absence of sweeping financial reform for primary care reimbursement, Pay-for-performance approaches (while distrusted by many) hold the potential to incentivize outcomes which might be linked to clear communication, such as avoidable hospitalizations, non-urgent emergency department utilization, uptake of routine recommended preventive services, improved medication adherence, etc. The question is whether payers will recognize that clear communication may the best "lever" for achieving such outcomes.

For this goal, I use an expanded definition of health literacy, which includes the roles of health care professionals (not the frequently cited patient-focused definition of HL). I see primary care settings as THE place where such research must be conducted. That's relatively easy where I work, but much more difficult for the majority of busy practices out there. Research collaboratives, such as the Oregon Rural Practice-based Research Network, can play a major role here. Clinics often lack personnel with research expertise, and those with expertise or interest often lack time or money to conduct original research. Folks working in the field of HL should look to partner with local clinics to help advance a national health literacy research agenda (yet to be fully defined).

First we need to build the "evidence base". This comes through clinical research (noted above). Once the benefits of a given HL practice have been demonstrated, one will be able to make a stronger business case for adopting the practice. Business cases can then be used to persuade payers to incentivize such practices among providers. Without such incentives to balance the current disincentive structure mentioned above, change will come slowly.

If you've read all the way to this point, I'm flattered.


Cliff Coleman, MD, MPH
Assistant Professor of Family Medicine
Oregon Health & Science University
Richmond Family Health Center

Wilson-Stronks, Amy

Yesterday Cynthia Baur presented the National Action Plan to The Joint Commission's Patient and Family Advisory Council. It generated some interesting discussion about how patient advocates can use the Action Plan to help health care organizations better engage patients and families.

The recent release of Joint Commission hospital accreditation standards for patient-centered communication makes health literacy more relevant for hospitals. However, "health literacy" as a term can be off-putting. We have also found the term "cultural competence" to be problematic. For this reason The Joint Commission is promoting both health literacy and cultural competence as dimensions of patient-centered communication.

If we work toward the goals of health literacy (as outlined in the Action Plan) and promote health literacy in the context of improved patient-provider communication we may find greater traction since the literature (as well as logic) tells us that communication impalcts safety and quality. Since health care organizations are challenged by so many competing priorities, it helps to present these issues as effective ways to meet quality and safety priorities.

The Joint Commission has a free resource, Advancing Effective Communication, Cultural Competence, and Patient- and Family-centered Care: A Roadmap for Hospitals available for free download at

We received tremendous support from many members of this list serve and other health literacy experts in crafting the recommendations in this resource to best promote health literacy. We see it as a terrific compelment to the National Action Plan since it provides some concreate "how- to" information for hospitals to improve quality and safety of care through improved patient-provider communication.

Kudos to everyone for all the work you do to improve patient care through improved health literacy!


Amy Wilson-Stronks
Tina Cordero
ccordero at

Abrams, Mary Ann A.

At Iowa Health System, we have been working in multiple areas of the Action Plan, and are leading development of Health Literacy Iowa, a statewide health literacy center whose mission is to promote and facilitate the ability of all Iowans to use effective communication to optimize their health.

We work from the premise that health literacy is fundamental to safe, high-quality, patient-centered care; that it applies to all areas of health—individual and population-based; and that collaborative partnerships are key to success. Here are some examples of how this fits with the Action Plan.

GOALS 1, 2, 5, 6, 7: We are striving to build system wide capacity in use of key health literacy-related strategies and interventions, including verbal and written communication. Health literacy is included in staff orientation, and additional education and training are available for those in specific areas, including nurses, other clinicians, non-clinical staff, and those involved with developing written materials for patients, families, and the public. To sustain health literacy strategies and interventions, we look for opportunities to incorporate them into standard operating processes, like competency assessments, adoption of health literacy-related policies and checklists, and triggers for and documentation of use of teach-back. We work with current and future partners to disseminate such strategies through Health Literacy Iowa.

GOALS 3, 5: We collaborate with Reach Out and Read Iowa to prepare young children for school success by partnering with doctors to prescribe books and encourage families to read together. By promoting literacy in primary care, the evidence-based Reach Out and Read model can open discussions with parents about literacy—their own as well as their children’s. It can be used for primary prevention of low literacy and low health literacy among children, and also for secondary prevention—to help providers explore parents’ reading comfort and respond appropriately by using plain language and other techniques to improve health communication, and through referrals to adult reading programs.

GOALS 4, 5: We collaborate with the New Readers of Iowa and the Iowa Department of Education to promote opportunities for adult learners and health professionals to work together to address health literacy. Examples include: conferences for health providers and adult learners with panel discussions and presentations, health screenings, medication reviews, and navigational interviews; New Readers participating on health literacy-related workgroups and committees of health professions organizations; co-presentations about health literacy for multidisciplinary audiences; written materials reviews; and a grant to build leadership skills among adult learners. The New Readers of Iowa and Department of Education are represented on Health Literacy Iowa’s Steering Work Group. Other Steering Group members contribute expertise in cultural and linguistic competence, and caring for diverse and underserved populations.

GOAL 6: We want to participate in research evaluating adoption of health literacy interventions into practice. Examples include evaluation of an Ask Me 3 intervention among the community-dwelling elderly and evaluation of a reader-friendly consent for surgery/procedures.

GOALS 1, 2, 3, 4, 5, 6, 7: As we establish Health Literacy Iowa, we are building on much work underway throughout the state. In 2008, over 100 participants representing 45 organizations participated in strategic planning resulting in consensus to establish a dedicated Iowa center for health literacy education and training, resources and tools, and collaborative research. A Steering Work Group of representatives from almost 20 public and private entities—health professional organizations, employers, payers, New Readers, education, public health—is guiding development and early projects of Health Literacy Iowa. Activities focus on: raising awareness about health literacy; making the policy and business case; empowering patients, families, and consumers to ask for and find clear health communication; providing education, training, and other services to assist health and other organizations in adopting health literacy-related interventions and promoting system change; sharing resources; participating in research; and collaborating with state and regional partners.

Mary Ann Abrams, MD, MPH
Iowa Health System
Center for Clinical Transformation

Michael Villaire

I'd like to add IHA's voice to the chorus of thanks to Cynthia and Julie for holding this discussion. I'm curious to know if anyone has a plan for hosting all these ideas (other than here in the NiFL Health Literacy listserv archives). I'm not aware of any. We are planning to launch a resource website sometime in October, and unless I hear from someone else that this exists and that we're duplicating effort, I invite my colleagues working in health literacy to consider submitting a recap of their efforts under the Plan, along with a link to their website for more information.

Those who are looking for models on how to effectively use the Plan have certainly been well-served this week by this discussion and the many outstanding examples of work done to date on this. I offer this soon-to-launch site as a reference site to contribute, browse, learn from and connect with colleagues to further this important work.

I'm a firm believer that our field gains visibility, cohesion, advancement and legitimacy with communal efforts such as the National Action Plan. The beauty of this tool, in my mind, is that it provides us with our own yardstick, motivation tool, and community resource for our efforts. It is not prescriptive, but rather a guided assessment for where we've been, what we've accomplished, and what remains to be done. Cynthia and all her collaborators are to be congratulated for their efforts on this project.

As an update, we are also looking at some ways we can continue the work
on the National Action Plan through our annual health literacy conference. Our Tenth Annual Conference is scheduled for May 5-6, 2011, in Irvine, Calif., and we will be issuing a Call for Breakout Session Presentations shortly. We're evaluating other ways that we can share information and activities on the National Action Plan at that meeting. Visit our website,, and go to the Health Literacy Conference page to sign up for information about our 2011 conference as it becomes available.

We are also working with the peer-reviewed publication Nursing Outlook to publish articles based upon some presentations from our 2010 conference. Articles are in peer review now, so it's a bit premature to share any specifics, but you can look for this special issue to come out early next year. We'll share copies with everyone at our conference.

Thanks again to Cynthia and Julie for this forum this week.


Michael Villaire, MSLM
Chief Operating Officer
Institute for Healthcare Advancement

Linda Neuhauser

Hello Colleagues,

I'm impressed with the excellent work described in your postings on the listserv.

Our group at Health Research for Action center at the University of California School of Public Health is engaged in many health literacy/clear communication activities that are relevant to the goals of the Action Plan. Briefly, our mission is to work in a highly participatory way with the intended users to create communication that is relevant to people's literacy, language, culture, access and functional needs and other factors. Through this process we co-create multi-media (Internet, print, audio, video, etc.) resources. We work with national, state, community government and non-profit programs, as well as with private sector organizations.

Some of our activities relevant to Action Plan goals include:

Goal 1 - Develop and disseminate health and safety information that is
accurate, accessible, and actionable

By adhering to health literacy principles in the Action Plan and user-centered design processes, we develop guides on many health relevant topics, including parenting education, physical activity and falls prevention, and navigating health care systems.

Goal 2 - Promote changes in the health care delivery system that improve
health information, communication, informed decision-making, and access
to health services

We have been working with California state departments of managed health care, and Medicaid to improve Website and other communications for consumers so that they are more relevant to people's literacy, language, and access and functional needs. We have also created a guide at a low reading level to help seniors and people with disabilities on Medicaid make health care choices.

We have worked with an HMO to assess health literacy issues for their members. Based on this study and recommendations, the health plan has made major changes to communications with its members. We are now working with other managed care plans to ensure that their communication is relevant to the needs of the people they serve.

The Action Plan is a useful document that highlights key clear communication issues and strategies. Because of the nationwide input into the Plan, it provides important, practical guidance that can encourage organizations to improve their communications with diverse populations.

Linda Neuhauser

Linda Neuhauser, DrPH, MPH
Clinical Professor, Community Health and Human Development
Co-Principal Investigator, Health Research for Action Center
School of Public Health

Alisha Ellwood

At the Minnesota Health Literacy Partnership (MHLP), our mission to improve health through clear communication is threefold. We strive to train providers in health literacy best practices, empower patients to ask for clear communication, and share resources.

Here are some things that we have been working on and how they align with the goals of the National Call to Action:

  1. Develop and disseminate health and safety information that is accurate, accessible, and actionable
  2. Promote changes in the health care system that improve health information, communication, informed decisionmaking, and access to health services.
  3. Incorporate accurate, standards-based, and developmentally appropriate health and science information and curricula in child care and education through the university level
  4. Support and expand local efforts to provide adult education, English language instruction, and culturally and linguistically appropriate health information services in the community
  5. Build partnerships, develop guidance, and change policies
  6. Increase basic research and the development, implementation, and evaluation of practices and interventions to improve health literacy.
  7. Increase the dissemination and use of evidence-based health literacy practices and interventions

In closing, I want to point out two things.

1) You may find that many of your activities can actually apply to more than one of the seven goals and

2) It isn't necessary to respond to each of the seven goals, but to respond to those that fit best with your organization's structure and mission. By working together and combining our efforts we can achieve the goals in the National Call to Action and ultimately improve health.

Alisha Ellwood, MA, LMFT
Chair, Minnesota Health Literacy Partnership
Project Manager, Health Care Improvement
Blue Cross and Blue Shield of Minnesota

Baur, Cynthia (CDC/OD/OADC)

First, I would like to thank everyone who shared what they are doing with the National Action Plan. You have provided motivational and concrete examples of the amount and variety of health literacy improvement work going on across the country. Please keep sharing with the listserv and your colleagues where you work. Michael, I like your idea of creating a "home" for this work and would like to talk with you and others about how we can make this happen.

Second, I wonder how many listserv members harbor doubts that the Action Plan can help them do their work and get better results. Maybe some of our members are thinking, The Action Plan is great for Organization X with all those resources, or Organization Y with such a great champion, or Organization Z in a big city with lots of partners to work with. I'm just one person in this small office with no support. I'm lucky if I can convince my boss to think about the reading grade level of a piece, let alone all those strategies. I'll never get anyone here to be interested in the ideas in the Action Plan.

I want to share a story from a documentary called "Emmanuel's Gift" that I watched this week. Although the DVD arrived in my mailbox over a week ago, I hesitated to watch it because the story sounded too heavy. It concerns Emmanuel, a disabled young man in Ghana who undertakes a one man campaign to change the stigma and discrimination experienced by disabled persons in his country. So, instead I watched the Braves games all week, which actually was more depressing. I finally popped the DVD in and was amazed and frankly awed by the story. Emmanuel, an orphan with a few years of formal education, one working leg and one partial leg that can't be used, writes to a foundation in the U.S. and asks for a bicycle so he can ride around his country and show people what disabled persons are capable of. The foundation, surprised that's all Emmanuel wants, sends him a bicycle, helmet and some riding clothes. Emmanuel then rides across his country and completely shocks his fellow countrymen and women by showing what is possible. He goes on to do more amazing things, not for his own glory but to change the lives of disabled persons in Ghana.

What Emmanuel has that makes him so powerful is his confidence in his cause. He knows he is right that disabled persons are as capable as anyone else and deserve to be treated as human beings rather than cast-offs.

I always have believed that one person with confidence and a good cause can make a difference. "Emmanuel's Gift" reminds me it is true sometimes on a scale we can't imagine. He had no movement behind him, no allies, no megaphones or mass media at his disposal. He had his confidence and his bicycle.

I think the Action Plan is our bicycle. It is our tool for saying, hey, we're here, we're not going away, and we are right that everyone deserves access to health information and services that work for them. If you lose confidence, the listserv is a great place to work it out. And of course, you are welcome to email me or call me and I'm happy to provide advice and whatever assistance I can on the Action Plan.

My email is Cynthia.baur at

Please keep sharing and keep riding.


Arthur Culbert

Cynthia thank you for your leadership and for sharing your bicycle. Health literacy will make the difference that we all envision through our collaboration and partnerships. Have good weekends. Arthur

Arthur J. Culbert, Ph.D.
President and CEO
Health Literacy Missouri

Lisa Bernstein


Thank you for this beautiful post, and all of your important (and very successful) work promoting health literacy. (By the way, sorry about the Braves.)

I am not going to post all of the ways that The What To Expect Foundation's Baby Basics Prenatal Health Literacy Program fits into the plan...because its just too long. But I want to tell you that as soon as it came out we organized our work into your framework so that it could clearly show how the program fits into the national health literacy agenda. It was and is very helpful and we move forward.

In the past we have organized our work into the Quality Improvement Framework as outlined by the IOM. And, as we work with Medicaid Managed Care Plans,Prenatal Care Providers, and Maternal and Child Health organizations, I have put our work into their systemic vision as well. I think its marvelous to see how the Joint Commission did the same thing. After all, health literacy really translates across all of healthcare, and is at the core of all health interactions.

And for that matter,creating a shared framework is at the basis of all communication, as well. So thanks. We have found it useful, and will continue to share it with our Baby Basics Initiatives in Los Angeles, Cleveland, Baltimore, Palm Beach, New York, and New Jersey.

I agree that it would great to have site where everyone could put up their health literacy plans...and perhaps there is a way to create a site like the AHRQ Innovations Exchange where there is a criteria involved in what is listed. That way organizations interested in starting health literacy programs can search to see what exists that is evidence based and replicable in health literacy programming.

Thanks again!
Lisa Bernstein
Executive Director
The What To Expect Foundation

Helen Osborne

Thanks Cynthia & Julie,

This has been an awesome yet sometimes overwhelming discussion about the National Action Plan to Improve Health Literacy. I especially appreciate Cynthia’s concluding story about the young man in Africa who made a difference riding his rickety bike.

This story reminded me of the discussion Cynthia and I had on a recent Health Literacy Out Loud podcast. We likened the Action Plan to a car’s GPS device. Cynthia said that it is like a GPS in that the plan can help us find major highway exits. But it does not have the level of detail to get to specific houses. That navigation is up to each of us. To hear our podcast, go to

In keeping with this travel theme, I’d like to share how I got started on the health literacy journey. About 15 years ago, when working on an in-patient psychiatric unit, I read a JAMA article about health literacy written by Williams et al. I was immediately bitten by the “health literacy bug” and knew that I somehow wanted to make a difference. So soon thereafter I left the “day job” and started my own Health Literacy Consulting business.

Talk about scary! I was traveling to an unknown destination (few health professionals knew that health literacy problems existed, much less wanted to fix them), without a road map (starting a consulting practice without any business background), and driving my car with little fuel (no grants or outside funding). But somehow this journey is working out. I’m still in business and still passionate about health literacy.

My message to all is that no matter whether you are riding a bike, driving a car solo, carpooling with others, or picking up hitchhikers, there’s room for us all along the health literacy highway. Now it’s time to park this travel metaphor.

Helen Osborne, M.Ed., OTR/L
Health Literacy Consulting,
Health Literacy Out Loud podcasts,

Julie McKinney

I, too, would like to thank everyone for their responses to the Action Plan, and to Cynthia's description of how it can work for us all. The bicycle theme is priceless!

One thing I really appreciate in the Action Plan is the way it ties in the basic education of our children and adults to the efforts of health systems to better serve them (goals 3 & 4). This reflects the two-way street on which the bicycle travels. And in encouraging partnerships (goal 5), it highlights how important it is t collaborate between health and educational programs. I hope that this will flourish! I want to quickly look at our original discussion questions and see what else we may address:

Discussion Questions:

1. Which of the seven goals in the action plan can you address in your work?
2. What specific ideas do you have to work towards this goal?
3. How can the action plan itself help support you in doing this work?
4. What kind of technical support will you need?
5. How can programs from around the nation work in a “linked and coordinated manner” on these goals?
6. How can each of us encourage new partners to join this effort?

I think we covered 1-3 pretty well, but does anyone have any more to say about 4-6? I like Michael's idea of a "home" for this information, and would love to help make that happen. But I think there is more that would help us to work in a “linked and coordinated manner”, a place where we could get and share the technical support we need. Does this list, as a community of practice, fulfill that need, or should there be something more?


Pilisuk, Tammy (CDPH-CID-DCDC-IMM)

I love the idea of a web-based repository of "state profiles" in health literacy efforts. Some sort of a grid comparing similarities and differences would also be awesome. My feeling is that the more we start filling-in this information for those states who are excelling, the more other states may look to this as a road map for action--or at least feel a little peer pressure! Having a contact for each state also would allow continued dialogue for states to learn from each other.

I know this might be a big undertaking, but I'm hoping that the brain trust of this group might have some brilliant ideas. :)

Tammy Pilisuk

  • Goal 1. Develop and disseminate health and safety information that is accurate, accessible, and actionable.
  • Goal 2. Promote changes in the health care system that improve health information, communication, informed decision making, and access to health services.
    • MHLP members serve as resources and champions within their own organizations, promoting and implementing health literacy best practices both in clinical practice and in written health education information
    • Members of MHLP will be facilitating a pre-conference workshop, Making Your Organization More Health Literate Using the AHRQ Universal Precautions Toolkit, for the Minnesota Alliance for Patient Safety Annual Conference in November 2010.
  • Goal 3. Incorporate accurate, standards-based, and developmentally appropriate health and science information and curricula in child care and education through the university level.
    • MHLP recently submitted a grant proposal in partnership with the University of Minnesota focusing on Evaluating a Health Literacy Skills Curriculum in an Interprofessional Framework The project aims to increase health literacy competencies for a broad range of health professionals. We are waiting to hear if our proposal has been accepted.
  • Goal 4. Support and expand local efforts to provide adult education, English language instruction, and culturally and linguistically appropriate health information services in the community
    • MHLP continues to have a strong relationship with the Minnesota Literacy Council (MLC). We piloted a health literacy program with an adult education ESL class offered through MLC with positive responses. We have also concluded an initial pilot of a health literacy program for adults called Take Charge of Your Health through the St. Paul Public Libraries.
  • Goal 5. Build partnerships, develop guidance,and change policies
    • MHLP was asked to be a member of the Advisory Committee for the The Minnesota Community Blueprint to Asian American and Pacific Islander Health Equity.The Blueprint is a structural map for strengthening the health care system of Minnesota with the goal of optimizing the health and well-being of the Asian American and Pacific Islander community.
  • Goal 6. Increase basic research and the development, implementation, and evaluation of practices and interventions to improve health literacy
    • The Health Literacy Program for Minnesota Seniors (HeLP MN Seniors) has successfully gathered evidence related to teaching health literacy skills to older adults through the use of formal evaluation tools, and has applied this information to the development of a model training program. The training guide is now available at Funding for HeLP MN Seniors was provided from the National Library of Medicine National Network of Libraries of Medicine under contract number N01-LM-6-3503.
  • Goal 7. Increase the dissemination and use of evidence-based health literacy practices and interventions.