The Influence of Dr. Rima Rudd's Organizational Health Literacy Scholarship in Maryland.

BACKGROUND: This article analyzes and reflects on Dr. Rima Rudd's organizational health literacy ideas and tools and their influence on the field generally and on four projects over 12 years in Maryland specifically. OBJECTIVE: We present four organizational health literacy projects - two from oral health and two from COVID-19 vaccination - that used or were influenced by Dr. Rudd's the Health Literacy Environment of Hospitals and Health Centers. METHODS: In the oral health projects, we describe the organizational assessments we conducted, the assessment results, and the actions organizations took in response. In a Frederick, Maryland, COVID-19 project, we worked with multiple organizations in a single city to train them in the organizational assessment process, and we report the activities and results of this training. In the Baltimore, Maryland COVID-19 project, we provided general information about organizational health literacy and trained key health professionals in local organizations. KEY RESULTS: Our results confirm that Dr. Rudd's tools work mainly as intended because they help organizations or third-party evaluators identify health literacy barriers and create health literacy insights. Also, we observed that organizational health literacy tools can support organizations' interest in equity goals and increase their willingness to spend time on health literacy projects. CONCLUSIONS: Translating knowledge and skills to actions can require more time than organizations can commit or be more difficult than they can handle. In our projects, the four most positive examples were driven by a collaboration between our team and a change champion who had the power to institute new ideas and actions. While it can take time and money to gain traction, our Maryland work shows that organizational assessments are accessible, practical and tangible. We conclude that Dr. Rudd's influence extends beyond specific tools and is reflected in the field's acceptance of organizational and professional responsibility for health literacy as an equity and justice issue. [HLRP: Health Literacy Research and Practice. 2024;8(3):e151-e158.].

PLAIN LANGUAGE SUMMARY: This article discusses Dr. Rudd's original and foundational contributions to organizational health literacy and the influence her tools and methods have had on 4 projects over 12 years in Maryland. We describe implementations and results for organizational health literacy assessments and training activities and conclude with lessons learned about organizational health literacy approaches and Dr. Rudd's impact on the field.

An Almost Empty Scoping Review: State of the Research on Tobacco Prevention and Cessation Messaging Strategies for Black and/or Latine LGBTQ+ Youth and Young Adults.

Research has yet to offer strong recommendations for effective tobacco prevention and cessation messaging that can reduce tobacco-related health disparities among Black and/or Latine LGBTQ+ youth and young adults. As a result of predatory marketing strategies and community stressors, among other factors, LGBTQ+ youth and young adults use tobacco products at higher rates than their non-LGBTQ+ peers. These disparities are uniquely complex among Black and/or Latine youth and young adults within the LGBTQ+ community, but there has been little research addressing the communication strategies that can promote tobacco prevention and cessation for these groups. Given the promise and history of successful health communication campaigns for tobacco control, this research is crucial. We thus conducted a scoping review to identify trends and gaps in the empirical research published from 2002-2022 that analyzed tobacco prevention and cessation communication strategies for Black and/or Latine LGBTQ+ youth and young adults (ages 12-30) living in the United States. Despite an initial search query of 3,182 articles after deleting duplicates, only five articles were eligible for inclusion, three of which evaluated the This Free Life campaign. Accordingly, we view our scoping review as an almost empty review. Although our results offer preliminary insight into messaging strategies used in these campaigns, our larger contribution is to expose the scarcity of tobacco-related communication research being conducted among Black and/or Latine LGBTQ+ communities. Given the marginalization these communities face, we issue a call to action for researchers and campaign designers and offer a series of suggestions for future research.

How health literacy is taught and evaluated in dentistry, medicine, nursing, law, pharmacy, public health, and social work: a narrative review.

BACKGROUND: This narrative review examined the published peer-reviewed literature on how health literacy is taught and evaluated in seven health professional and adjacent disciplines: dentistry, medicine, nursing, law, pharmacy, public health, and social work. The study objectives were to assess how students are educated about health literacy and how their health literacy education and skills are evaluated. METHODS: Study selection followed guidelines outlined in PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). We searched PubMed, CINAHL, SocINDEX (EBSCOhost), Lexis Advance and Public Health (ProQuest) for English-language publications of health literacy education studies across seven disciplines at U.S.-based institutions. Inclusion criteria included: 1) methods describing a primary health literacy educational intervention, 2) professional education in one or more of the seven disciplines, 3) educational institutions in the United States, and 4) articles published in peer-reviewed journals between 2000 and 2020. RESULTS: The searches yielded 44 articles. Health literacy education is evident in six of the seven studied disciplines, and varies widely in the quality, quantity, timing and mode of education and evaluation. Despite the presence of health literacy accreditation requirements, none of the seven disciplines has developed and implemented a standard, rigorous health literacy education program for students. CONCLUSIONS: Graduating institutions and professional accreditation organizations that set the standards for education must lead the way by implementing upstream changes in health literacy professional education. Teaching health literacy to students in health professions is one strategy to help close gaps in patient/client professional communication for graduates and those they serve.

Parental Health Literacy, Empowerment, and Advocacy for Food Allergy Safety in Schools: A Cross-Sectional Study.

BACKGROUND: Approximately 8% of elementary school-aged children in the United States have food allergies, a complicated health management situation that requires parents to use many types of health literacy, empowerment, and advocacy skills to work with school staff to protect their children. OBJECTIVE: This cross-sectional study examined (a) whether the highest versus lowest levels of functional, communicative, and critical health literacy are associated with higher perceived effectiveness of parental advocacy behaviors for safe food allergy management in schools [parental advocacy]; and (b) whether communicative and critical health literacy are more strongly associated with parental advocacy than functional health literacy. METHODS: A sample of parents of elementary school-aged children was recruited through 26 food allergy organizations and a research patient registry. Participants completed an anonymous online survey. Self-reported measurements of parental health literacy, empowerment, and advocacy were adapted and refined through pre-testing and pilot-testing. General linear model analyses were conducted to predict parental advocacy. KEY RESULTS: Participants (N = 313) were predominantly White, college-educated mothers with moderately high levels of food allergy knowledge, health literacy, empowerment, and parental advocacy skills. Parents who scored at the highest levels in the three dimensions of health literacy reported they engaged in more effective advocacy behaviors than parents who scored at the lowest levels. Parental advocacy was predicted largely by parental empowerment and the quality of the relationship with the school (B = .41 and B = .40, respectively). Functional health literacy and the child's diagnosis of asthma were smaller predictors. While accounting for covariates, functional health literacy was significantly associated with parental advocacy whereas communicative and critical health literacy were not. CONCLUSIONS: Interventions to impact parental empowerment and parent-school relationships, including a health-literate universal precautions approach of communicating food allergy school policies, may influence parental advocacy for food allergy safety in schools. Further research could use a performance-based multidimensional measure of health literacy. [HLRP: Health Literacy Research and Practice. 2023;7(3):e165-e175.].

PLAIN LANGUAGE SUMMARY: This online survey of parents of school-aged children in the U.S. examined health literacy predictors of effective parental advocacy behaviors for safe food allergy management in elementary schools. The results suggest that the parents' quality of their relationship with the school, parental empowerment, functional health literacy, and the child's diagnosis of asthma were associated with parents' reports of effective advocacy for food allergy safety, but communicative and critical health literacy were not.

The Benefits of Crowdsourcing to Seed and Align an Algorithm in an mHealth Intervention for African American and Hispanic Adults: Survey Study.

BACKGROUND: The lack of publicly available and culturally relevant data sets on African American and bilingual/Spanish-speaking Hispanic adults' disease prevention and health promotion priorities presents a major challenge for researchers and developers who want to create and test personalized tools built on and aligned with those priorities. Personalization depends on prediction and performance data. A recommender system (RecSys) could predict the most culturally and personally relevant preventative health information and serve it to African American and Hispanic users via a novel smartphone app. However, early in a user's experience, a RecSys can face the "cold start problem" of serving untailored and irrelevant content before it learns user preferences. For underserved African American and Hispanic populations, who are consistently being served health content targeted toward the White majority, the cold start problem can become an example of algorithmic bias. To avoid this, a RecSys needs population-appropriate seed data aligned with the app's purposes. Crowdsourcing provides a means to generate population-appropriate seed data. OBJECTIVE: Our objective was to identify and test a method to address the lack of culturally specific preventative personal health data and sidestep the type of algorithmic bias inherent in a RecSys not trained in the population of focus. We did this by collecting a large amount of data quickly and at low cost from members of the population of focus, thereby generating a novel data set based on prevention-focused, population-relevant health goals. We seeded our RecSys with data collected anonymously from self-identified Hispanic and self-identified non-Hispanic African American/Black adult respondents, using Amazon Mechanical Turk (MTurk). METHODS: MTurk provided the crowdsourcing platform for a web-based survey in which respondents completed a personal profile and a health information-seeking assessment, and provided data on family health history and personal health history. Respondents then selected their top 3 health goals related to preventable health conditions, and for each goal, reviewed and rated the top 3 information returns by importance, personal utility, whether the item should be added to their personal health library, and their satisfaction with the quality of the information returned. This paper reports the article ratings because our intent was to assess the benefits of crowdsourcing to seed a RecSys. The analysis of the data from health goals will be reported in future papers. RESULTS: The MTurk crowdsourcing approach generated 985 valid responses from 485 (49%) self-identified Hispanic and 500 (51%) self-identified non-Hispanic African American adults over the course of only 64 days at a cost of US $6.74 per respondent. Respondents rated 92 unique articles to inform the RecSys. CONCLUSIONS: Researchers have options such as MTurk as a quick, low-cost means to avoid the cold start problem for algorithms and to sidestep bias and low relevance for an intended population of app users. Seeding a RecSys with responses from people like the intended users allows for the development of a digital health tool that can recommend information to users based on similar demography, health goals, and health history. This approach minimizes the potential, initial gaps in algorithm performance; allows for quicker algorithm refinement in use; and may deliver a better user experience to individuals seeking preventative health information to improve health and achieve health goals.

Some Psychometric Properties of the Brazilian CDC Clear Communication Index.

The Centers for Disease Control and Prevention (CDC) Clear Communication Index (CCI) was cross-culturally adapted to Brazilian Portuguese (BR). It was necessary to analyze the reliability and validity of the BR-CDC-CCI for its use in Brazil. This study aimed to evaluate the psychometric properties of the instrument in its Brazilian version. Four specialists in health education used the BR-CDC-CCI to evaluate a population-level health education material. Primary health care professionals (n = 105) evaluated the same health material using the BRCDC-CCI, and 30 professionals performed the retest 15 to 20 days after the first assessment. Cohen Kappa and area under the receiver operating characteristic (ROC) curve analyses were developed. Inter-rater agreement ranged from moderate to almost perfect, with 90% of the items almost perfect. The percentage of agreement ranged from 8.6% to 98.1%. For the analyzed questions, the area on the ROC curve was 0.9412 (confidence interval [CI] 95%; [0.8259, 1.000]). The BR-CDC-CCI had sufficient validity and reliability for its use in the evaluation of educational/informational materials in health in the Brazilian context. In view of the good results from this psychometric assessment, we anticipated the BR-CDC-CCI could contribute to improvements in Brazilian professionals' skills in developing health communication materials, thereby improving the quality of education and, possibly health outcomes. [HLRP: Health Literacy Research and Practice. 2022;6(2):e84-e87.].

Benefits of mHealth Co-design for African American and Hispanic Adults: Multi-Method Participatory Research for a Health Information App.

BACKGROUND: Participatory research methodologies can provide insight into the use of mobile health (mHealth) apps, cultural preferences and needs, and health literacy issues for racial and ethnic groups, such as African Americans and Hispanics who experience health disparities. OBJECTIVE: This methodological paper aims to describe a 1-year multi-method participatory research process that directly engaged English-speaking African American and bilingual or Spanish-speaking Hispanic adults in designing a prevention-focused, personalized mHealth, information-seeking smartphone app. We report design team participants' experiences with the methods to show why our approach is valuable in producing apps that are more aligned with their needs. METHODS: Three design sessions were conducted to inform the iteration of a prevention-focused, personalized mHealth, information-seeking app. The research team led sessions with 2 community member design teams. Design team participants described their goals, motives, and interests regarding prevention information using different approaches, such as collage and card sorting (design session 1), interaction with the app prototype (design session 2), and rating of cultural appropriateness strategies (design session 3). RESULTS: Each design team had 5 to 6 participants: 2 to 3 male participants and 3 female participants aged between 30 and 76 years. Design team participants shared their likes and dislikes about the sessions and the overall experience of the design sessions. Both African American and Hispanic teams reported positive participation experience. The primary reasons included the opportunity for their views to be heard, collectively working together in the design process, having their apprehension about mHealth reduced, and an opportunity to increase their knowledge of how they could manage their health through mHealth. The feedback from each session informed the following design sessions and a community-engaged process. In addition, the specific findings for each design session informed the design of the app for both communities. CONCLUSIONS: This multi-method participatory research process revealed 4 key lessons learned and recommendations for future research in mHealth app design for African Americans and Hispanics. Lesson 1-community partnerships are key because they provide the chain of trust that helps African American and Hispanic participants feel comfortable participating in app research. Lesson 2-community-based participatory research principles continue to yield promising results to engage these populations in mHealth research. Lesson 3-interactive design sessions uncover participants' needs and development opportunities for mHealth tools. Lesson 4-multiple design sessions with different methods provide an in-depth understanding of participants' mHealth preferences and needs. Future developers should consider these methods and lessons to ensure health apps in the marketplace contribute to eliminating health disparities and achieving health equity.

The Value of Community Health Literacy Assessments: Health Literacy in Maryland.

OBJECTIVE: Community health assessments have typically not measured health literacy at the community level. We developed the Community Health Literacy Assessment (CHLA) framework to describe county and regional health literacy activities, assets, gaps, and opportunities in Maryland. METHODS: We implemented the CHLA framework in Maryland from January to August 2018. We conducted an environmental scan of Maryland's 24 counties to identify community resources, health indicators, and organizations. We targeted local health improvement coalitions and health departments for interviews in each county. We conducted qualitative interviews to understand what key community organizations throughout Maryland are doing to implement health literacy best practices and policies. We used summative content analysis to review, quantify, and interpret interview data. RESULTS: We conducted 57 interviews with participants from 56 organizations representing all 24 counties in Maryland. We captured data on multiple dimensions of health literacy and identified 3 main themes: health literacy assets and activities, health literacy gaps, and health literacy opportunities. The most cited asset was collecting data to inform health literacy practices, the most cited gap was using jargon with community members, and the most cited opportunity was increasing public awareness of existing health programs through improved outreach and teaching health information-seeking behaviors. CONCLUSION: A systematic community health literacy assessment is a feasible way to collect a large amount of health literacy data, which can inform strategic planning, determine community interventions, and ultimately lead us toward a health-literate society. We recommend that others replicate the CHLA framework to operationalize health literacy as a health indicator and include it as a community health assessment measure.

Re-Prioritizing Digital Health and Health Literacy in Healthy People 2030 to Affect Health Equity.

The U.S. Healthy People 2030 health objective-setting process has taken place in an inequitable social structure with significant implications for health literacy, health equity, and population health. The draft 2030 objectives have greatly reduced the number of digital health and health literacy objectives, meaning our national agenda is poised to capture only a fraction of what will evolve in digital and health literacy between 2020 and 2030. This paper synthesizes two decades of Healthy People data on health literacy and digital health objectives, highlights the digital health and health literacy trends and disparities that persist and proposes remedies to ensure that health literacy and digital health issues receive the attention they deserve in the next decade. These remedies can inform policies, research, and interventions that touch health communication and digital health issues.

What Must Health Literacy Stakeholders Do to Build a Public Health and Population Health Agenda?

This chapter argues that although the health literacy field has many frameworks and conceptual models, it lacks core components necessary to address health literacy as both a pressing public health and population health matter. Health literacy stakeholders need to develop three sets of activities that can provide the infrastructure for large-scale health literacy improvement. First, the field needs an 'epidemiology of health literacy' so we have a sustained and robust mechanism to collect and report data on multiple health literacy dimensions. Second, stakeholders should agree on standards to educate and train health professionals; develop health materials; and conduct organizational assessments. Third, the field should adopt a Health Literacy in all Policies stance and prepare to conduct health literacy impact assessments so previously hidden or minimized health literacy effects from health, education, and social polices become visible and measurable.

Section Two Summary: Taking Stock of Health Literacy Practices.

This summary of the brief reports notes common themes, activities, and directions in health literacy practices across diverse settings, organizations, and populations. The summary also discusses how a 'best practices' approach could help build an evidence base, solidify evidence of impact, and advance the use of health literacy techniques.

Cross-cultural adaptation of the Clear Communication Index to Brazilian Portuguese.

OBJECTIVE: To perform a cross-cultural adaptation of the Clear Communication Index instrument from the Centers for Disease Control and Prevention (CDC-CCI) from English to Brazilian Portuguese. METHODS: This study comprised initial discussion about the conceptual equivalence of the instrument by a committee formed by experts on health education. We performed translations, synthesis of translations, back-translations, revision by the committee, and linguistic revision. Semantic equivalence was obtained by analyzing the referential and general meaning of each item by the committee, resulting in a pre-final version of the instrument. Subsequently, thirty professionals with health sciences degrees performed a pre-test. These professionals used the pre-final version of the instrument to assess a health education material. A questionnaire was applied to evaluate the acceptability of the instrument, the understanding of each of the 20 items, as well as the individual and professional variables. We analyzed the scores attributed to the health education material, the variables related to healthcare professionals, the proportions of the acceptability of the instrument, and the comprehension of each item. RESULTS: After we obtained the conceptual equivalence of the instrument, the committee of experts, the instrument's main author, and the linguist produced the pre-final version using two translations, a synthesis of the translations, and two back-translations. A general equivalence was maintained in 15 of the 20 items (75%), four of the items were slightly altered (20%), and one item was very altered (5%). Nineteen items presented referential equivalence or near equivalence (95%). We then carried out with the pre-test, in which the professionals used the pre-final version. Two items in the domains of "risks" and "main message" were unclear and needed to be revised. CONCLUSION: The process of cross-cultural adaptation of the Clear Communication Index provided an adapted version to the Brazilian Portuguese language.

Patient and Family Engaged Care: An Essential Element of Health Equity.

In this paper, we emphasize and explore health equity as an integral component of a culture of patient and family engaged care (PFEC), rather than an isolated or peripheral outcome. To examine the role of PFEC in addressing health inequities, we build on the 2017 NAM Perspectives discussion paper "Harnessing Evidence and Experience to Change Culture: A Guiding Framework for Patient and Family Engaged Care." Informed by both scientific evidence and the lived experience of patients, their care partners, practitioners, and health system leaders, the paper by Frampton et al. introduced a novel Guiding Framework that delineates critical elements that work together to co-create a culture of PFEC, while also depicting a logical sequencing for implementation that facilitates progressive change and improvement toward the Quadruple Aim outcomes of better culture, better care, better health, and lower costs. In this paper, the authors highlight the need to integrate addressing health and health care disparities and improving health equity as core components of the framework to ensure the culture and policy changes necessary to meaningfully engage patients, health system staff, families, and communities.

Cross-cultural adaptation of the Clear Communication Index to Brazilian Portuguese

ABSTRACT OBJECTIVE To perform a cross-cultural adaptation of the Clear Communication Index instrument from the Centers for Disease Control and Prevention (CDC-CCI) from English to Brazilian Portuguese. METHODS This study comprised initial discussion about the conceptual equivalence of the instrument by a committee formed by experts on health education. We performed translations, synthesis of translations, back-translations, revision by the committee, and linguistic revision. Semantic equivalence was obtained by analyzing the referential and general meaning of each item by the committee, resulting in a pre-final version of the instrument. Subsequently, thirty professionals with health sciences degrees performed a pre-test. These professionals used the pre-final version of the instrument to assess a health education material. A questionnaire was applied to evaluate the acceptability of the instrument, the understanding of each of the 20 items, as well as the individual and professional variables. We analyzed the scores attributed to the health education material, the variables related to healthcare professionals, the proportions of the acceptability of the instrument, and the comprehension of each item. RESULTS After we obtained the conceptual equivalence of the instrument, the committee of experts, the instrument's main author, and the linguist produced the pre-final version using two translations, a synthesis of the translations, and two back-translations. A general equivalence was maintained in 15 of the 20 items (75%), four of the items were slightly altered (20%), and one item was very altered (5%). Nineteen items presented referential equivalence or near equivalence (95%). We then carried out with the pre-test, in which the professionals used the pre-final version. Two items in the domains of "risks" and "main message" were unclear and needed to be revised. CONCLUSION The process of cross-cultural adaptation of the Clear Communication Index provided an adapted version to the Brazilian Portuguese language.

Community Health Literacy Assessment: A Systematic Framework to Assess Activities, Gaps, Assets, and Opportunities for Health Literacy Improvement.

BACKGROUND: The National Action Plan to Improve Health Literacy makes the case that a wide range of organizations and professionals must work together to improve health information and services to achieve a health literate society. The context and framework for this collaboration and action, however, have yet to be well-articulated. We report on our use of a community health needs assessment model to describe county and state health literacy activities, gaps, assets, and opportunities. This approach combines the public health best practice of learning about communities through systematic assessments and the emerging health literacy best practice of studying organizational behaviors. BRIEF DESCRIPTION OF ACTIVITY: A community health literacy assessment was implemented from January 2018 to April 2018. The purpose was to collect information about county and state-level health literacy activities, gaps, assets, and opportunities. We used this information to characterize the status of health literacy in Maryland and establish an initial baseline for county and state strategic planning work and future collaboration. IMPLEMENTATION: An environmental scan of each county in Maryland identified health indicators, community resources, and health organizations or professionals. Organizational representatives participated in interviews about their health literacy work. Interviews were analyzed to identify themes as well as summarize and quantify perspectives by county. We convened a forum, disseminated preliminary findings, and performed member checking to assess agreement with the results. RESULTS: The team interviewed 56 individuals from 49 organizations. Themes of health literacy definitions as well as organizational ranking on the use of health literacy best practices are discussed in this article. Forty public health professionals, including 10 interview participants, attended the forum. Member checking assessed interview participants' agreement with results and interpretations, which were found to be accurate portrayals of their responses. LESSONS LEARNED: Lessons learned include being flexible with the interview approach, performing member checking, and allowing participants to self-define health literacy. Our experience shows a small team can perform a large-scale assessment that provides actionable information at state and county-levels. The results can influence future interventions, inform strategic planning and collaboration, and lead us toward a health literate society. [HLRP: Health Literacy Research and Practice. 2019;3(4):e216-e226.]. PLAIN LANGUAGE SUMMARY: A systematic community health needs assessment framework was used to collect information about health literacy activities, assets, gaps, and opportunities at the state and county level. Participant feedback showed the team accurately captured the activities, assets, gaps, and opportunities to improve health literacy practices. A needs assessment framework is feasible for describing community health literacy.

The U.S. National Action Plan to Improve Health Literacy: A Model for Positive Organizational Change.

This chapter presents the U.S. National Action Plan to Improve Health Literacy and its unique contribution to public health and health care in the U.S. The chapter details what the National Action Plan is, how it evolved, and how it has influenced priorities for health literacy improvement work. Examples of how the National Action Plan fills policy and research gaps in health care and public health are included. The first part of the chapter lays the foundation for the development of the National Action Plan, and the second part discusses how it can stimulate positive organizational change to help create health literate organizations and move the nation towards a health literate society.