Health Literacy Maryland: Strategic Thinking for Strategic Action

June 1-2, 2011

College Park, Maryland

School of Public Health Herschel S. Horowitz Center for Health Literacy

Advancing a Better State of Health…Through Health Literacy

Prepared by

Bonnie Braun, Horowitz Center Director Teresa McCoy, Assistant Director for Evaluation and Assessment,

University of Maryland Extension

September, 2011

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This event was made possible through the generous support of our sponsors!

Health Science & Human Services Library

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Table of Contents Forum Overview .............................................................................................. 4 Strategic Thinking Round 1 .............................................................................. 6 Strategic Thinking Round 2 .............................................................................. 7 Table 1: Measures of Central Tendency .......................................................... 8 Strategic Thinking Round 3 ............................................................................. 11 Closing Session ............................................................................................... 17 Commitment Cards ........................................................................................ 19 Conclusions & Recommendations ................................................................... 22 Acknowledgments .......................................................................................... 23

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Forum Overview

Health Literacy Maryland was launched June 1-2, 2011. Attendees, invited by the Herschel S. Horowitz Center for Health Literacy, came together to learn more about health literacy in the State of Maryland, to gauge interest in statewide action, and to determine what we might do to improve health literacy in Maryland. The Health Literacy Maryland launch was designed with the underlying belief that strategic thinking leads to strategic action.

Two days of dialogue, strategic thinking, and strategic action planning challenged attendees to explore the critical question: Are there sufficient reasons and will to establish Health Literacy Maryland? Approximately 100 targeted invitations were extended to people and organizations across Maryland. Out of the 100 invitees, 75 registered for the forum and attended various parts of the two day kick-off. Participants represented higher education, medical centers, hospitals, health providers and educators, public health departments, social workers, students and Extension educators. To stimulate strategic thinking for the Round I breakout session, forum participants were inspired by words of wisdom from two health-literacy scholars: Dr. Rima Rudd and Dr. Cynthia Baur.

Dr. Rudd is a senior Lecturer on Society, Human Development, and Health at the Harvard School of Public Health, and Senior Scholar in Health Literacy for the Horowitz Center on Health Literacy. She addressed the questions: Why a Focus on Health Literacy? Why Now? and Why a Health Literacy Maryland?

Dr. Cynthia Baur is Senior Advisor, Health Literacy, in the Office of the Associate Director for Communication at the Centers for Disease Control and Prevention, and she spoke with participants about the opportunities for Maryland to create a state action plan based on the National Action Plan for Improving Health Literacy.

During the launch, participants were divided into five working groups (with an assigned facilitator and recorder) for three strategic thinking rounds. The small groups reflected diversity in type of work, organization represented, and expertise. Reflecting on the speakers’ remarks and guided through a series of working sessions, participants:

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rated goals from the National Action Plan for Improving Health Literacy; identified factors that could help or hinder goal achievement; and, suggested actions to be taken to develop Health Literacy Maryland into a force

for change. At the end of the two-day launch, participants affirmed the proposed strategic vision that Maryland will become a leader in positive health outcomes through effective health literacy collaboration. Ten volunteers agreed to help with the next steps for Health Literacy Maryland. This report provides data from each of the three forum strategic-thinking rounds and the closing session that provides a foundation for the steering committee as it builds the discussions held at the launch of Health Literacy Maryland. It will be used to move the strategic thinking that was accomplished here into strategic action. Many people worked together to make possible the launch of Health Literacy Maryland. A list is included at the end of this report. Many donors provided support for the launch. They are acknowledged at the beginning of the report. Special thanks to Teresa McCoy for her evaluation expertise used to help craft the working groups, and collect and analyze the resulting data. To all who made the event possible, thank you. And to Linda Aldoory who will lead the next steps, it’s all yours.

Bonnie Braun, Ph.D. Former Endowed Chair and Director, Herschel S. Horowitz Center for Health Literacy 2008-2011

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Strategic Thinking Round I

June 1, Wednesday, 4:00-5:00 p.m. PURPOSE: Reflect upon what participants heard from the presenters in the general sessions, examine their individual perspectives, and prepare for more focused discussion in Strategic Thinking Round II. QUESTION: From your individual perspective, how important do you believe it is for the State of Maryland to respond collectively to the challenges and opportunities of health literacy? RESPONSES: Respondents used a scale of one to six, with one being not at all important; two, not very important, three, somewhat important; four, important; five, very important; and, six, of the highest importance, to respond to the question. Out of 41 responses, 31 responses were either very important or of the highest importance, representing 75% of the participants. In general, all participants believed there was some level of importance for the State of Maryland to respond collectively to the challenges and opportunities of health literacy. This type of affirmation is not surprising because forum participants self-selected to attend the forum and, most likely, already believed the issue is compelling and that it should be addressed in Maryland.

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Strategic Thinking Round II

June 2, Thursday, 10:00-11:00 a.m. PURPOSE: Sort through the national goals to make decisions about the importance, urgency, and level of difficulty of the goals for Maryland and prepare for discussion in Strategic Thinking Round III. TASK: Review and rank the seven national action plan goals according to importance, urgency, and difficulty for the State of Maryland. RESPONSES: Each national goal was ranked by participants on a scale of one to six, with one being not at all important and six being extremely important. Respondents in each group were asked to provide rankings at the beginning of the session, before any discussion ensued (pre-assessment) and after discussion (post-assessment). Responses from all groups were aggregated for the pre- and post-assessment. The mean, median, and mode were calculated for the aggregated responses for each goal. CONCLUSIONS: All seven goals, rated on importance,

urgency, and difficulty, were important or extremely important.

Goal II was consistently rated as important, urgent, and difficult.

Looking only at the mode, Goals I, II and V were consistently rated at six in both the pre- and post-assessments for importance, urgency, and difficulty.

Goal III was rated least difficult to accomplish in both pre- and post-assessments.

There were no substantial shifts in pre- and

post-assessment ratings.

National Action Plan to Improve Health Literacy Goals

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 decision making, 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

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Table 1: Measures of Central Tendency

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During Strategic Thinking Round II, participants were also asked to discuss these two questions:

What are the factors that could help achieve the goals? What are the factors that could hinder achievement of the goals?

Helping Factors The factors to help achieve the goals have been grouped by thematic categories (with the recognition that some items could be placed in more than one category). Communication

Input from communities involved Look at "communication" broadly Marketing and communication specialists input Seek input Using educational system (k-12 and higher) Integrate communication skills throughout curriculum Goal #1: good communication practices Plain language; white space Ensure all providers are trained in communication

skills Leadership

Identified leader or professional organization Framework: measurables/deliverables; change

evaluation steps Insurance industry: take responsibility! Need simple blueprint w/ objectives and goals that

everyone agrees on (ownership/buy-in; shared responsibility)

Center for Health Literacy at UMD - good to see leadership role

Curricula, Policy or System Change

Change curriculum Re-write materials Incorporate requirement into continuing education

across the health disciplines (i.e., use of standardized patients)

Change board requirements Information/Data

More Maryland-based data on public perceptions Centralizing information (e.g. Clearinghouse) More evidence - based info available/easily

available/locate easily Increase currency (oftentimes old data) of evidence-

based information

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Partnerships

Passion of people present Potential for vibrant partnerships (networking) Bring another partner to the table Capitalize on diversity (who’s doing what?) Articulate the resources among us (who’s got what?)

Hindering Factors The factors that could hinder achievement of the goals have been sorted into thematic categories (with the recognition that some items could be placed in more than one category). Communication & Technology

Cryptic legalese or medical terminology Poor communication Phones not user-friendly Websites aren't user-friendly Signage Language that doesn't "translate" Figuring out most appropriate message for different

audiences Different vocabularies

Information and Outreach

Reaching older adults Consent for treatment All materials Materials that weren't tested/filtered Scattered, possibly unreliable info on Internet Information overload/"media literacy"

Curricula, Policy or System Change

Change policy - different category Curriculum changes are arduous/difficult Bureaucracy makes change difficult Lack of standards across professions and across states State control of professions HIPPA Policies

Attitudes or Aspirations:

Lack of interest Sense of being overwhelmed Resistance to change Promoting sense of importance and why it matters Medical encounters Customer service is lacking

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Must be focused to get commitment/achievement Many players (social workers? Providers?) Who wasn't here? Differences among health care providers Different priorities Protected territories

Funding:

Funds (or lack thereof) Funding Money

Strategic Thinking Round III June 2, Thursday, 11:15-12:15 p.m.

PURPOSE: Identify possible actions and prepare for ratings in closing general session. TASK: Create a list of possible actions for Health Literacy Maryland to undertake in the next 12-18 months. While the intent was to collect only the list of possible actions, the dialogue generated by the assignment was rich and insightful for understanding the actions. Therefore, a summary of that dialogue is included immediately following the suggested actions. Discussion and Suggested Actions

Group 1

AACCTTIIOONNSS:: Clearinghouse for evidence-based info including social media Build a prioritized awareness campaign

- Health professions can influence policy makers - Get info on health literacy out to health officers in country health

departments - Take advantage of health officer roundtables

Identify ‘end of game or goal’ coalition Learning and leveraging: look at other states, reaching out to other

states, enlist ‘heroes’ to help us get our message out (ex. Rep E. Cummings), widen coalitions members

Develop training curriculum for health professions

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Link health literacy to healthcare reform - Assess NHIS - Add health literacy questions to survey, and questions about

insurance form navigation Assess economic impact of low health literacy Have a health literacy conference on the East Coast that attracts a

broad audience Policy: adapted by difference organizations/localities for their own

use Idea: Video “I am Health Literacy Maryland and Here is What I’m

Doing” Raise awareness through the state to increase capacity Get info to county health officers and encourage staff training

BBAACCKKGGRROOUUNNDD DDIISSCCUUSSSSIIOONN:: Rationale for Creation of HLM:

Based on current environment Imperative to move rapidly Develop and implement a statewide coalition Driven by the state’s frontier work in

- Health care reform - Critical needs in health disparities - Budget challenges - Educational disparities - Rapidly growing, diverse population

These issues cut across all disciples and sectors of health care For the purpose of:

- Raising awareness - Giving visibility - Maximizing resources and efforts

Group 2

AACCTTIIOONNSS:: The coalition needs to conduct a needs assessment, create new or use

existing group Define missions statement and create specific organizational structure Ensure sustainability: Exist – Survive – Thrive BBAACCKKGGRROOUUNNDD DDIISSCCUUSSSSIIOONN:: Add credibility

Is there a need for a health coalition? Determine other states’ programs Sustainability plan Timeline

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Collaborate Involve those impacted Diverse groups: where are they? Faith-based organizations Greek society Identify groups: discuss how health literacy jives with them and

their missions Grease that wheel! Small health clinics: more outreach

Time Time is precious: add HL as a theme? Commitment from top: tangible steps, MOU Grass-roots approach Vision of successful coalition: end results? Specify

Necessity: Coalition is necessary: what is health literacy? Who is doing health

literacy? Come together and agree on importance, DEFINE Have a tight directed group where each person’s niche is

recognized to avoid burnout Involve clients and patients Similar definitions among policy makers and clients and patients Different health messages Develop real leadership – not volunteer position or volunteer

coalition Group 3

AACCTTIIOONNSS::

Define coalition composition and sustainable leadership Conduct a needs assessment/environmental scan regarding what’s

being done to capitalize/define what coalition should do Strategize regarding and raise awareness of health literacy to the

public, educators, providers, community leaders, and through policy

BBAACCKKGGRROOUUNNDD DDIISSCCUUSSSSIIOONN:: Who are we? What do key members look like?

Multi-leadership for coalition to reduce risk of too few plus sustainability

What’s important for a coalition to form? Legislation for state health literacy Capitalizing on what’s been done/what’s happening

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Needs assessment: What’s important to do? What data do you need? Is there a need for a coalition? What resources are available through the state, local

organizations, providers Raising awareness:

Develop PSA/Brochure regarding health literacy public awareness

Point professionals to health literacy resources (e.g.: Diversity Rx) Health insurance companies to educate clients Include health literacy in curricula – have CE database for

teachers, community leaders Emphasis on providers: school, medical, dental, social work

Partial Timeline 0-6 months:

Form coalition Identify and recruit members Create Coalition infrastructure

3 months: Raise awareness Conduct needs assessment Compare K-12 Education curricula with national standards Public health professionals including school nurses: how health literate are we in current health information Survey providers for awareness and practices of health literacy

Group 4

AACCTTIIOONNSS::

Establish a baseline for current statewide health literacy efforts and health literacy status Align with and learn from other state health literacy coalitions Focus resources where they will have the greatest impact Cultivate public-private partnerships Identify advocates and future allies in government and public/private agencies Develop an action plan with achievable goals and measurable outcomes based on learning from steps 1-5 Implement the action plan Evaluation BBAACCKKGGRROOUUNNDD DDIISSCCUUSSSSIIOONN:: Determine key population groups for messages -Kids for dental and general health -Baby boomers/Seniors for general health

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Get census data for population centers related to above ID public/private partnerships, and get a general consensus statewide on resource allocation focused on the above two Investigate what has worked/not worked for other state coalitions Identify what each conference participant is already doing to achieve the seven national goals Develop actionable goals and objectives

Group 5

AACCTTIIOONNSS::

Advocate for the role of health care “communicator” Create buy-in from top-level state agencies (first step in simplifying

the systems) Create and disseminate a database of best-practices and resources to

improve communication BBAACCKKGGRROOUUNNDD DDIISSCCUUSSSSIIOONN:: Make sure all agencies in Maryland are involved and supportive –

especially budget people At the state level, put together a database that has all health literacy

resources: cleaning house, evidence based best practices, what’s happening/not happening here and in other states

Disseminate what works to health care providers, health departments, and private providers through entire health care systems

Educate health care providers about clear communication – can do through continuing education once done with school

Increase public’s understanding of how to navigate the health care systems/public education systems and fix the system’s navigability

Advocate for clinical education regarding health literacy – accrediting bodies should be on board of schools

Practices need a health communicator/navigator (professional/para-professional) to help public through system (on site)

Simplify government info on health care (e.g. Medicare)

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Accomplishment Statements From these action steps, each group was asked to craft a statement of what Health Literacy Maryland should accomplish in the next 12-18 months. The five are:

Use the information garnered within the last 2 days to draft the outline of a state health literacy plan to be reviewed by this coalition.

Form a Health Literacy Maryland coalition with sustainable leadership to determine health literacy needs, gaps, and successes among a myriad of audiences. This will be used to construct a strategic plan of action and evaluation to increase health literacy in Maryland, mindful of Health People 2020 and Maryland Healthcare Reform Coordinating Council goals and initiatives.

- Establish a baseline for current statewide health literacy efforts and health literacy status - Align with and learn from other state health literacy coalitions - Focus resources where they will have the greatest impact - Cultivate public-private partnerships - Identify advocates and future allies in government and public/private agencies - Develop an action plan with achievable goals and measurable outcomes based on learning

from steps 1-5 - Implement the action plan - Evaluation

In the next 12-18 months, Health Literacy Maryland will highlight our membership, the ongoing activities throughout the state, and the overall goal of making Maryland healthier.

In order to reduce health disparity and improve health outcomes, a health literacy coalition must be established. The coalition’s tasks will be the following: 1. To conduct a needs assessment 2. Define a vision/mission statement and create a specific organizational structure 3. Ensure sustainability of the coalition

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Closing Session

June 2, Thursday, 1:00-2:00 p.m.

Dr. Alice Horowitz is a Research Associate Professor, Center for Health Literacy, University of Maryland’s School of Public Health. She explained how Maryland is leading the way with oral health literacy as an example of what could occur in a broader health literacy initiative.

Closing Responses Following Dr. Horowitz’ remarks, participants’ beliefs about the importance for the State of Maryland to respond collectively to the challenges and opportunities of health literacy were assessed. Three additional questions were asked about willingness to be involved in a health literacy coalition and to act upon one of the action goals. The assessments were collected using an audience response system or “clicker” technology. This technology permitted all attendees to see the results immediately.

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Commitment Cards

At the end of the final general session, participants were asked to complete a commitment card stating what they were willing to do as a result of participation in this launch. Twenty-eight commitment cards were received and a summary is below of the types of commitments offered.

Table 2: Health Literacy Maryland Comment Card Responses I’m willing to:

1. Participate in basic research 2. Participate in development of intervention. 3. Participate in development of appropriate health curricula 1. Promote changes in health care. 1. Help with research while working on my MPH 1. Provide accurate, accessible, actionable information 1. Advocate for education of health professionals to improve clear communication 2. Review drafts/contribute revisions 1. Help with development of coalition 2. Help with the needs assessment 3. Serve as a reform for materials -> personally and be recruiting reactors from appropriate target audiences; e.g. providers, clients 1. Develop curriculum for health professionals 2. Comment on draft documents 3. Coordinate basic research projects 1. Share results of our activities 2. Attend 2 meeting on a specific task (Coalition formation/Action/Promotion) 3. Contribute to “the Library” 1. Create and produce health literacy programs 2. Implement targeted health literacy programs 1. Help to make partnership connections with other stakeholders not present at conference 2. Assist with outreach efforts 3. Consider other opportunities to help develop the Initiative 1. Assist with development of Strategic Plan 2. Assist with needs assessment regarding best practices, experts, state leadership buy in 3. Additional support tasks if needed

1. Work on Coalition 2. Get other partners to join in HLM 1. Support qualitative research efforts that organizations/coalition undertake regarding needs assessments – focus groups, interviews and/or framing regarding how to organize/conduct/analyze – especially RURAL!

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1. Infrastructure activities such as helping write a quarterly communication to coalition members on tools, tips, successes 1. Research current health literacy coalitions 2. Assess the coalitions’ successes and failures 3. Assess/generate student interest in health literacy 1. Share and coordinate education (K-12) related activities 2. Assist with the formation of a coalition and work plan 1. Report on these two days to the MNA Board of Directors 2. Recommend to the MND Board that we join the Coalition 3. Be supportive of the Coalition and build partnerships 1. Help organize an East Coast conference on health literacy 2. Help educate healthcare providers about clear health coordination 3. Provide guidance on evaluating health information on the internet 1. Use my position, networks, and other opportunities to bring attention to health literacy, the Center, and a Health Literacy Maryland Coalition 2. Other as available, possible, etc, 1. Spread the word about the importance of health literacy 2. Participate in getting appropriate messages out to the general public 1. Return back to my workplace, report back to the powers that be and solicit feedback regarding support and understanding for health literacy goals in our work 2. Health literacy incorporated in our curriculum design as a community college nursing program 1. Support the School’s participation/role in HLM 2. Contribute to establishing and maintaining partnerships 3. Contribute to policy related activities Focus on Oral Health: 1. Identify and expand allies 2. Inform and educate dentists and legislators 3. Cultivate more private sector partnerships 1. Work with the Center for Health Literacy to develop an action plan to help create and move a MD state health literacy coalition forward 1. Participate in shaping strategy for health literacy 2. Participate in shaping policy 3. Integrate health literacy into the delivery of healthcare 1. Work to disseminate “early” summer 2. Assist in coordination of coalition members 3. Participate in a “needs assessment” 1. Approach at least one State of Maryland agency to clarify health information 2. Make opportunities to conduct interventions (at least 1) to improve workforce health literacy 3. Champion English as a Second Language instruction and fluency practice 1. Help coordinate future Health Literacy Maryland events

 

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Conclusion

The guiding question for the launch of Health Literacy Maryland was:

Are there sufficient reasons and will to establish the Health Literacy Maryland statewide initiative?

Answer:

The positive response of participants and the willingness of people to assist with next steps is sufficient evidence to move ahead with establishing Health Literacy Maryland.

Moving ahead: Responses to the importance, difficulty and urgency of the seven goals provide

priorities for action. The lists and statements of action provide a starting place to guide the initiative. The leadership of the Horowitz Center for Health Literacy in making real the

vision of Health Literacy Maryland was affirmed.

   

“Health literacy is the currency of success for improving emergency preparedness,

eliminating health disparities and preventing disease.”

U.S. Surgeon General Dr. Richard Carmona, 2004

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 Acknowledgments

SPH Office of the Dean Bonnie Braun Gloria Friedgen Barbara Gold Alice Horowitz Alison Kitchens Dushanka Kleinman Chris Kosecki Blakely Pomietto Sarah Radice Adam Shervanian Vanessa Springfield School of Public Health Departments Behavioral and Community Health Epidemiology and Biostatistics Family Science Kinesiology University of Maryland Extension Teresa McCoy & Brad Paleg Strategic Thinking Facilitators Wendy Child Wes Queen Carlessia Hussein Christine Lothen-Kline Blakely Pomietto Amanda Gintner Teresa McCoy Health Literacy Maryland Planning “Think Tank”

Health Literacy Maryland Planning “Think Tank” Michelle Clark – Maryland Rural Health Association Olivia Carter-Pokras – Department of Epidemiology Carlessia Hussein – Office of Minority Health, Department of Health and Mental Hygiene Joanne Locke – Center for Plain Language Christine Lothen-Kline – University of Maryland Extension, Howard County Monica McCann – Office of Minority Health, Department of Health and Mental Hygiene Katharina Pesquera – Kaiser Permanente Paula G. Raimondo, University of Maryland Health Science and Human Services Library Izione Silva – Primary Care Coalition of Montgomery County Strategic Thinking Recorders Kathy Sharp Quynh Tran Amanda Gintner Joanne Clovis Monica McCann

Student Volunteers Jenny Ahmed Andrew Herschelroath Anissa Marzuki Karla Stockford Paola Villaver Jasmine Vinh