Содержание
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HEALTH LITERACYWhat You Need To Know and What You Can Do About It
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Objectives
Demonstrate a basic understanding of key health literacy concepts. Communicate the importance of health literacy to colleagues, grantees, and contractors. Identify specific ways to integrate health literacy into your work. At the end of this presentation, you will be able to: 2
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Overview
What is health literacy and why is it important? Health literacy at HHS Strategies for improving health literacy Integrating health literacy into your work Resources 3
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What Is Health Literacy and Why Is It Important?
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What Is Health Literacy?
5 This slide contains video clips of patients discussing their health literacy experiences. Patients describe in their own words their difficulties reading medication labels, understanding informed consent forms, and following a drug regimen. In the words of one patient, "It's just a language that I'm not familiar with." The video is produced by the Academy of Educational Development in collaboration with the Institute of Medicine with special thanks to the American Medical Association Foundation and the National Center for the Study of Adult Learning and Literacy.
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Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. Health literacy is dependent on both individual and systemic factors: Communication skills of lay people and professionals Knowledge of lay people and professionals of health topics Culture Demands of the healthcare and public health systems Demands of the situation/context 6
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What Factors Affect Health Literacy?
Health literacy is dependent on the communication skills of lay people and health professionals. Communication skills include literacy skills (e.g., reading, writing, numeracy), oral communication skills, and comprehension. Communication skills are context specific. 7
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2. Health literacy is dependent on lay person and professional knowledge of various health topics. People with limited or inaccurate knowledge about the body and the causes of disease may not: Understand the relationship between lifestyle factors (such as diet and exercise) and health outcomes Recognize when they need to seek care Health information can overwhelm people with advanced literacy skills. 8
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3. Health literacy is dependent on culture. Culture affects: How people communicate and understand health information How people think and feel about their health When and from whom people seek care How people respond to recommendations for lifestyle change and treatment 9
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4. Health literacy is dependent on the demands of the healthcare and public health systems. Individuals need to read, understand, and complete many kinds of forms in order to receive treatment and payment reimbursement. Individuals need to know about the various types of health professionals and services as well as how to access care. 10
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5. Health literacy is dependent on the demands of the situation/context. Health contexts are unusual compared to other contexts because of an underlying stress or fear factor. Healthcare contexts may involve unique conditions such as physical or mental impairment due to illness. Health situations are often new, unfamiliar, and intimidating. 11
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What health literacy is NOT…
Health literacy is NOT… Plain Language. Plain language is a technique for communicating clearly. It is one tool for improving health literacy. Cultural Competency. Cultural competency is the ability of professionals to work cross-culturally. It can contribute to health literacy by improving communication and building trust. 12
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Why Is Health Literacy Important?
Health literacy is important because it affects people’s ability to: Navigate the healthcare system, including locating providers and services and filling out forms Share personal and health information with providers Engage in self-care and chronic disease management Adopt health-promoting behaviors, such as exercising and eating a healthy diet Act on health-related news and announcements These intermediate outcomes impact: Health outcomes Healthcare costs Quality of care 13
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Health Literacy and Health Outcomes
Persons with limited health literacy skills have: Higher utilization of treatment services Hospitalization Emergency services Lower utilization of preventive services Higher utilization of treatment services results in higher healthcare costs. 14
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Health Literacy and Quality of Care
Health literacy affects the quality of health care. “Good quality means providing patients with appropriate services, in a technically competent manner, with good communication, shared decisionmaking, and cultural sensitivity.”* * From IOM. Crossing the Quality Chasm: A New Health System for the 21st Century. 2001. 15
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Health Literacy and Shame
People with limited health literacy often report feeling a sense of shame about their skill level. Individuals with poor literacy skills are often uncomfortable about being unable to read well, and they develop strategies to compensate. 16
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Measuring Health Literacy
Health literacy is a new component of the 2003 National Assessment of Adult Literacy (NAAL). Nationally representative sample of more than 19,000 adults aged 16 and older in the United States Assessment of English literacy using prose, document, and quantitative scales 17
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Tasks used to measure health literacy were organized around three domains: Clinical: Filling out a patient form Prevention: Following guidelines for age-appropriate preventive health services Navigation of the healthcare system: Understanding what a health insurance plan will pay for 18
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Proficient: Can perform complex and challenging literacy activities. Intermediate: Can perform moderately challenging literacy activities. Basic: Can perform simple everyday literacy activities. Below Basic: Can perform no more than the most simple and concrete literacy activities. Nonliterate in English: Unable to complete a minimum number of screening tasks or could not be tested because did not speak English or Spanish. 19
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Percentage of Adults in Each Literacy Level: 2003
20 Source: National Center for Education Statistics, Institute for Education Sciences
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Nonliterate in English
21 Source: National Center for Education Statistics, Institute for Education Sciences
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Difficulty of Selected Health Literacy Tasks
22 Below Basic Basic Intermediate Proficient Circle the date of a medical appointment on a hospital appointment slip. (101) Give two reasons a person should be tested for a specific disease, based on information in a clearly written pamphlet. (202) Determine what time a person can take a prescription medication, based on information on the drug label that relates the timing of medication to eating. (253) Calculate an employee’s share of health insurance costs for a year, using a table. (382) Source: National Center for Education Statistics, Institute for Education Sciences 500 0 Average score: 245
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Percentage of Adults in the Below Basic Health Literacy NAAL Population: 2003
23 1 The “Did not obtain health information over the Internet” category does not include prison inmates. 2 Disabilities include vision, hearing, learning disability, and other health problems. Source: U.S. Department of Education, Institute of Education Sciences, National Center for Education Statistics, 2003 National Assessment of Adult Literacy (NAAL)
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Percentage of Adults in Each Health Literacy Level, by Self-Assessment of Overall Health: 2003
24 Source: U.S. Department of Education, Institute of Education Sciences, National Center for Education Statistics, 2003 National Assessment of Adult Literacy
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Sources of Health Information
25 Percentage of adults with Below Basic or Basic health literacy who get little or no health information from the following sources: Source: National Center for Education Statistics, Institute for Education Sciences
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The Bottom Line
Only 12 percent of adults have Proficient health literacy. In other words, nearly 9 out of 10 adults may lack the skills needed to manage their health and prevent disease. Fourteen percent of adults (30 million people) have Below Basic health literacy. These adults are more likely to report their health as poor (42 percent) and are more likely to lack health insurance (28 percent) than adults with Proficient health literacy. 26
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Measuring Health Literacy
Measures of health literacy at the individual level were developed in the 1990s: Rapid Estimate of Adult Literacy in Medicine (REALM) Test of Functional Health Literacy in Adults (TOFHLA and S-TOFHLA) 27
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Health literacy measures based on functional literacy do not capture the full range of skills needed for health literacy. Current assessment tools (for populations and individuals) cannot differentiate among: Reading ability Lack of health-related background knowledge Lack of familiarity with language and materials Cultural differences in approaches to health. 28
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Who Is at Risk?
The problem of limited health literacy is greater among: Older adults Those who are poor People with limited education Minority populations Persons with limited English proficiency (LEP) 29
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Many of the same populations at risk for limited health literacy also suffer from disparities in health status, illness (including heart disease, diabetes, obesity, HIV/AIDS, oral disease, cancer deaths, and low birth weight), and death. 30
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Health Literacy: Use of Preventive Services
Persons with limited health literacy skills* are more likely to skip preventive measures such as: Mammograms Pap smears Flu shots *As defined by these studies 31
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Health Literacy: Knowledge About Medical Conditions and Treatment
Persons with limited health literacy skills: Are more likely to have chronic conditions and less likely to manage them effectively. Have less knowledge of their illness (e.g., diabetes, asthma, HIV/AIDS, high blood pressure) and its management. 32
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Health Literacy: Hospitalization and Health Status
Persons with limited health literacy skills: Experience more preventable hospital visits and admissions. Are significantly more likely to report their health as “poor.” 33
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Health Literacy: Healthcare Costs
Predicted inpatient spending for persons with inadequate health literacy (measured by the S-TOFHLA) was $993 higher than that of persons with adequate health literacy. An earlier analysis found that the additional healthcare resources attributable to inadequate health literacy were $29 billion (assuming that inadequate literacy was equivalent to inadequate health literacy): This number would have grown to $69 billion if even one-half of marginally literate adults were also considered not health literate. 34
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Health Literacy at HHS
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Commitment to Health Literacy
Secretary Leavitt: Prevention and health information technology (IT) are two big priorities for the healthcare system. Secretary Thompson’s Workgroup on Health Literacy Prevention: A Blueprint for Action “It is critical that individuals have access to health information in a way they can understand and make appropriate health decisions.” 36
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Office of the Surgeon General
Health literacy improvement is one of the Surgeon General’s seven public health priorities. “Health literacy is the currency of success for everything I am doing as the Surgeon General.” —Dr. Richard Carmona in his speech to the AMA House of Delegates, June 2003. 37
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Healthy People 2010 Health Communication Objectives
11-1. Internet access in the home 11-2. Health literacy 11-3. Research and evaluation of health communication programs 11-4. Quality of Internet health Web sites 11-5. Centers of Excellence in health communication 11-6. Provider-patient communication 38
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Healthy People 2010 Health Literacy Objectives
11-2. Improve the health literacy of persons with inadequate or marginal literacy skills. 11-6. Increase the proportion of persons who report that their healthcare providers have satisfactory communication skills. 39
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Funding
NIH program announcement: Understanding and Promoting Health Literacy Three annual submission dates 2004–2006 Thirteen sponsoring institutes and offices with AHRQ NIH spending in FY05 for these grants is close to $3 million, and it will total more than $8 million during the life of the awarded grants. HRSA provides funding to community-based organizations for health literacy activities and research. 40
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Health Literacy Coordination
Department health literacy workgroup Agency health literacy workgroups HHS health literacy intranet site Quick Guide to Health Literacy for HHS employees Health literacy action plan 41
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Strategies for Improving Health Literacy
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Four Strategies for Improving Health Literacy
43 Improve the usability of health information. Improve the usability of health services. Build knowledge to improve decisionmaking. Advocate for health literacy improvement.
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1. Improve the Usability of Health Information
44 Is the information appropriate for the users? Is the information easy to use? Are you speaking clearly and listening carefully?
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Identify the Intended Users of the Health Information and Services
45 Know the intended users of the health information and services: Demographics Behavior Culture Attitude Literacy skills Language Socioeconomic status Access to services Decide which channel(s) and format are most appropriate.
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Evaluation
46 Evaluate users’ understanding before (formative), during (process), and after (outcome) the introduction of materials. Test! Test! Test!
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Acknowledge Cultural Differences and Practice Respect
47 Accepted roles of men and women Value of traditional vs. Western medicine Favorite or forbidden foods Manner of dress Body language, especially touching or proximity
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What Is Cultural Competency?
48 Cultural competency is the ability of health organizations and practitioners to recognize the following in diverse populations to produce a positive health outcome: Cultural beliefs Values Attitudes Traditions Language preferences Health practices
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Use Plain Language
49 Plain language is a strategy for making written and oral information easier to understand. Key elements of plain language include: Using simple language and defining technical terms Using the active voice Breaking down complex information into understandable pieces Organizing information so the most important points come first
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Speak Clearly and Listen Carefully
50 Use a medically trained interpreter if necessary: For those who do not speak English well, plain English will not help. Ensure that all language access services, including translation, are in plain language. Refer to CLAS standards. Ask open-ended questions: Elicit cultural beliefs and attitudes: “Tell me about the problem and what may have caused it.” Check for understanding: Use the “teach-back” method: Have the person restate the information in his or her own words.
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Improve the Usability of Health Information on the Internet
51 People cannot find the information they seek on Web sites 60% of the time. Many elements that improve written and oral communication can be applied to information on the Web: — Plain language — Large font — White space — Simple graphics Don’t forget Refer to the Office of Management and Budget (OMB) Policies for Federal Public Websites for further guidance.
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52 Health literacy has implications for Web-based communication beyond written text. Consider the following strategies: Apply user-centered design principles and conduct usability tests. Include interactive features and personalized content. Organize information to minimize scrolling. Use uniform navigation.
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2. Improve the Usability of Health Services
53 Improve the usability of health forms and instructions. Improve the accessibility of the physical environment. Establish a patient navigator program.
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Health Forms and Instructions
54 Healthcare and public health settings rely heavily on forms and printed instructions: Medical history forms Insurance forms Informed consent forms Child immunization records for school Test results Directions to the lab or pharmacy Hospital discharge and home care instructions Clinical research protocols and announcements
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Improve the Usability of Health Forms and Instructions
55 Revise forms to ensure clarity and simplicity. Test forms with intended users and revise as needed. Provide forms in multiple languages. Offer assistance with completing forms and scheduling followup care.
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Improve the Physical Environment
56 Settings with lots of signs and postings have a high literacy demand: Include universal symbols and clear signage in multiple languages. Promote easy flow through healthcare facilities. Create a respectful and shame-free environment.
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Establish a Patient Navigator Program
57 Patient navigators are health professionals or community health workers who help patients: Evaluate their treatment options. Obtain referrals. Find clinical trials. Apply for financial assistance. Congress recently passed the Patient Navigator Outreach and Chronic Disease Prevention Act of 2005.
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3. Build Knowledge to Improve Decisionmaking
58 Improve access to accurate and appropriate health information. Facilitate healthy decisionmaking. Partner with educators to improve health curricula.
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Improve Access to Accurate and Appropriate Health Information
59 Create new mechanisms for sharing and distributing understandable health education materials: Create audience or language-specific databases. Partner with adult educators. Identify new methods for information dissemination: Cell phones, palm pilots, personalized and interactive content, information kiosks, talking prescription bottles, etc.
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60 Form partnerships with civic and faith-based organizations trusted in the community. Work with the media to increase awareness of health literacy issues. Work with providers to ensure that the health information they share is accurate, current, and reliable.
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Facilitate Healthy Decisionmaking
61 Use short documents that present “bottom-line” information, step-by-step instructions, and visual cues that highlight the most important information: People process and use a limited amount of information when making a decision. Align health information and recommendations with access to services, resources, and support!
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Partner With Educators
62 Co-develop adult basic education lessons on health topics: Adult learners want information that is relevant to their lives; health content is likely to engage them. Construct lessons in which students use health-related texts, forms, and content from the Internet.
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63 The K–12 education system is a critical point of intervention to improve health literacy. Incorporate health-related tasks, materials, and examples into lesson plans. Design and disseminate health information to support existing state standards. Speak to students or help organize health-related field trips for local schools.
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4. Advocate for Health Literacy Improvement
64 Make the case for improving health literacy. Incorporate health literacy in mission and planning. Establish accountability for health literacy activities.
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Make the Case for Improving Health Literacy
65 Identify specific programs and projects affected by limited health literacy. Target key opinion leaders with health literacy information: Explain how health literacy improvement relates to your mission, goals, and strategic plan. Circulate relevant research and reports on health literacy to colleagues. Post and share health literacy resources.
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Incorporate Health Literacy in Mission and Planning
66 Include goals and objectives specifically related to health literacy improvement in: Strategic plans Program plans Educational initiatives Goals can be broad (e.g., Achieving Healthy People 2010 Objective 11-2) or specific to the mission of the office/program.
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Include Health Literacy in Grants, Contracts, and MOUs
67 Recommend that all products, materials, and forms be written in plain language and tested with the intended audiences.
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Establish Accountability
68 Include health literacy improvement criteria in program evaluation. Implement health literacy metrics.
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69 Sample metrics Our office will: Apply user-centered design principles to 75% of new Web pages created after January 2006. Ensure that all documents intended for the public are reviewed by a plain language expert. Provide all new employees with training in cultural competency and health literacy within 6 months of their date of hire.
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Integrating Health Literacy Into Your Work at HHS
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Integrating Health Literacy Into Your Work at HHS
71 Communicate with the public. Work with grantees and contractors. Conduct and promote research. Manage staff and programs. Work with external stakeholders and partners.
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Communicating With the Public
72 HHS communication functions include: Responding to public inquiries Developing public health messages/campaigns Developing materials, publications, Web sites Improving public access to evidence-based health information Promoting and disseminating messages, materials, recommendations, and guidelines Working with the media/press Acting as public liaisons Developing and implementing communication plans Providing health research results Speechwriting Contributing to professional and academic publications
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73 Example: Working with the media Write press releases aimed at the general public; use plain language. Provide journalists with access to health literacy resources: Create and post a health literacy “backgrounder” for journalists online (focus on data and news “hooks”). Highlight health literacy angle embedded in routine stories.
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Working With Grantees and Contractors
74 Require health literacy expertise as part of the skill set for the teams awarded contracts. Encourage grantees to address health literacy issues in their work plans and deliverables. Include health literacy improvement as a topic in all technical assistance and materials development grants.
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75 Example: Ask Funding Opportunity Announcement applicants to explain how their projects will contribute to meeting the health literacy objectives in Healthy People 2010.
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Promoting Research
76 Integrating health literacy into research agendas: Review research portfolios. Convene research agenda-setting meetings for your topics: Include colleagues from across HHS who share responsibility for these topics. Identify health literacy research questions. Communicate research findings to health professionals and the public (shared function with Communication staff).
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77 Example: Make presentations at scholarly meetings. Organize symposia and sessions on health literacy at annual professional association meetings. Publish in professional journals.
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Managing Staff and Programs
78 Incorporate health literacy improvement into performance plans, GPRA, and PART. Include health literacy activities in budget requests. Communicate the importance of health literacy improvement to staff.
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79 Example: Conduct a senior-level briefing at your office or agency: Include formal presentation and handouts. Tie health literacy improvement to your specific mission, goals, and objectives. Make specific recommendations.
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Working With External Stakeholders and Partners
80 External stakeholders and partners include: Healthcare professional organizations Patient advocacy and support organizations Consumer advocacy organizations State, local, and tribal governments Federal departments and agencies Academic institutions Industry trade organizations Media vendors and associations
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Working With External Partners
81 Arrangements may be: Formal (e.g., Collaborative Research and Development Agreements and signed letters of agreement) Informal collaboration In both cases, agencies can encourage partners to: Conduct user-centered research. Evaluate the impact of enhanced understandability.
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Working With External Stakeholders
82 Include representatives from your target population in planning, implementation, and evaluation. Be sure to include organizations that represent/serve populations with limited literacy skills.
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Working With External Stakeholders and Partners
83 Examples: When you are soliciting proposals for presentations at HHS-sponsored events, state your interest in receiving presentations that address health literacy issues.
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Who Is Responsible for Improving Health Literacy?
84 A health literate America is a society in which health systems and institutions take responsibility for providing clear communication and adequate support to facilitate health-promoting actions based on understanding. —Institute of Medicine, 2004
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85 Our job as HHS employees is to protect the health of all Americans. Healthcare providers, public health professionals, health policy makers, and health administrators are all responsible for improving health literacy.
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86 We are!
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Resources
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AHRQ Report—Literacy and Health Outcomes (2004): www.ahrq.gov/clinic/epcsums/litsum.htm Healthy People 2010 (2000): www.healthypeople.gov Healthy People 2010 Health Literacy Action Plan—Communicating Health: Priorities and Strategies for Progress (2003): http://odphp.osophs.dhhs.gov/projects/healthcomm/objective2.htm IOM Report—Health Literacy: A Prescription To End Confusion (2004): www.iom.edu/report.asp?id=19723 88
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NIH Improving Health Literacy Web page: www.nih.gov/icd/od/ocpl/resources/improvinghealthliteracy.htm NIH/AHRQ program announcements—Understanding and Promoting Health Literacy:http://grants.nih.gov/grants/guide/pa-files/PAR-04-116.html; http://grants.nih.gov/grants/guide/pa-files/PAR-04-117.html Prevention: A Blueprint for Action (2004):http://aspe.hhs.gov/health/blueprint/ 89
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AHRQ Health Literacy and Cultural and Linguistic Competency Web page: www.ahrq.gov/browse/hlitix.htm NLM Bibliography—Understanding Health Literacy and Its Barriers (2004): www.nlm.nih.gov/pubs/cbm/healthliteracybarriers.html CDC—Scientific and Technical Information: Simply Put:www.cdc.gov/communication/resources/simpput.pdf CDCynergy (CD-ROM): www.cdc.gov/communication/cdcynergy.htm NCI—Making Health Communication Programs Work (the “Pink Book”): www.cancer.gov/pinkbook 90
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Dynamic search of health literacy articles in PubMed: http://phpartners.org/hp/health_comm.html HHS university plain language course: http://lms.learning.hhs.gov/CourseCatalog/index.cfm Plain language Web site: www.plainlanguage.gov A Family Physician’s Practical Guide to Culturally Competent Care: http://cccm.thinkculturalhealth.org/ National Standards for Culturally and Linguistically Appropriate Services in Health Care:www.omhrc.gov/templates/browse.aspx?lvl=2&lvlID=15 91
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