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.

Educational attainment, severity and short-term prognosis of intracerebral haemorrhage.

Background: Educational attainment is a critical social determinant of health that impacts the risk and severity of incident ischaemic stroke, but less is known of its impact on intracerebral haemorrhage (ICH). The objective of this study is to determine whether educational attainment is associated with ICH severity and short-term prognosis. Methods: Subjects were enrolled in a prospectively ascertained cohort with primary ICH from 1994 to 2020 at Massachusetts General Hospital. Educational attainment, medical history of ICH risk factors, ICH volume and ICH score were obtained on admission. The primary outcomes were ICH volume and the ICH score. Results: Of 2539 eligible patients eligible, the median age of the sample was 74 (IQR 64-82) and 2159 (85%) had high school-only education. 1655 (65%) presented with an ICH volume less than or equal to 30 mL and 1744 (69%) presented with an ICH score less than 3. In multivariable logistic regression analyses controlling for age, income, employment history and prestroke diagnoses of hypertension and coronary artery disease, patients with high school-only education were more likely to have an ICH volume greater than 30 mL compared with college diplomates (OR 1.58, 95% CI 1.24 to 2.08) and more likely to have an ICH score of 3 or greater compared with college diplomates (OR 2.37, 95% CI 1.77 to 3.19). Discussion: Prestroke educational attainment is independently associated with ICH severity and short-term prognosis, with lower educational attainment associated with larger ICH volumes and higher ICH scores. Future studies should examine how educational attainment impacts exposure to traditional clinical risk factors.

Organizational Health Literacy as a Tool for Health Equity: Application in a High-Risk Infant Follow-Up Program.

BACKGROUND: Healthy People 2030 emphasizes personal health literacy (individual skills) and organizational health literacy-the degree to which organizations equitably enable individuals to find, understand, and use information and services to inform health-related decisions and actions for themselves and others. However, research on the latter is in the early stages. METHODS: This study describes an organizational health literacy assessment in a U.S. urban academic children's hospital. A variety of evidence-based health literacy assessments were used to assess patient information materials and the environment, including institutional practices, navigation, culture and language, and communication. Trained interviewers and analysts reached consensus for all assessments. RESULTS: Information Items: SMOG scores (n = 9) ranged from 7th- to 14th-grade reading level (average = 11.3). PEMAT-P scores (n = 9) ranged from 43.8% to 93.8% understandability and 0% to 80% actionability. CDC CCI scores (literacy demand) (n = 6) ranged from 18.2% to 58.8% (≥90% = excellent). SAM scores (suitability) (n = 6) fell in the "adequate" range (43.2-58.3%). The PMOSE/IKIRSCH scores (complexity) (n = 3) noted low-moderate difficulty. Apter's Hierarchy (n = 4) revealed three numeracy domains (50% = descriptive purposes and decision-making, 100% = interpreting information). Organization-level: Walking interviews highlighted organizational facilitators and barriers related to the pre-visit and visit environments. HLE2 domain scores ranged from 52% to 68%. CONCLUSIONS: Organizational health literacy demands far outweigh the average literacy skills of adults in the U.S. (patients and staff). Findings can be used to hone quality improvement and other processes to focus on structural solutions to increase health equity.

Participation in a national diagnostic research study: assessing the patient experience.

INTRODUCTION: The Undiagnosed Diseases Network (UDN), a clinical research study funded by the National Institutes of Health, aims to provide answers for patients with undiagnosed conditions and generate knowledge about underlying disease mechanisms. UDN evaluations involve collaboration between clinicians and researchers and go beyond what is possible in clinical settings. While medical and research outcomes of UDN evaluations have been explored, this is the first formal assessment of the patient and caregiver experience. METHODS: We invited UDN participants and caregivers to participate in focus groups via email, newsletter, and a private participant Facebook group. We developed focus group questions based on research team expertise, literature focused on patients with rare and undiagnosed conditions, and UDN participant and family member feedback. In March 2021, we conducted, recorded, and transcribed four 60-min focus groups via Zoom. Transcripts were evaluated using a thematic analysis approach. RESULTS: The adult undiagnosed focus group described the UDN evaluation as validating and an avenue for access to medical providers. They also noted that the experience impacted professional choices and helped them rely on others for support. The adult diagnosed focus group described the healthcare system as not set up for rare disease. In the pediatric undiagnosed focus group, caregivers discussed a continued desire for information and gratitude for the UDN evaluation. They also described an ability to rule out information and coming to terms with not having answers. The pediatric diagnosed focus group discussed how the experience helped them focus on management and improved communication. Across focus groups, adults (undiagnosed/diagnosed) noted the comprehensiveness of the evaluation. Undiagnosed focus groups (adult/pediatric) discussed a desire for ongoing communication and care with the UDN. Diagnosed focus groups (adult/pediatric) highlighted the importance of the diagnosis they received in the UDN. The majority of the focus groups noted a positive future orientation after participation. CONCLUSION: Our findings are consistent with prior literature focused on the patient experience of rare and undiagnosed conditions and highlight benefits from comprehensive evaluations, regardless of whether a diagnosis is obtained. Focus group themes also suggest areas for improvement and future research related to the diagnostic odyssey.

To achieve equitable, integrated care for children, family-centered work must focus on systems.

Child health inequities are largely the result of entrenched, structural barriers created by racism, sexism, xenophobia, classism, and ableism that generally persist across the life course (Braveman & Gottlieb, 2014). The impact of such inequities may be magnified for those with complex needs who face considerable challenges in adulthood (Bethell et al., 2014), such as preterm infants, who experience threats to both short- and longterm health and development. Challenges in integrated care remain for all children, especially this population, despite extensive work across many decades to address such issues. The family-centered medical home has been the dominant pediatric care model in the United States for the last four decades (Stille et al., 2010). Despite emphasizing cultural humility and placing family at the care team core, the medical home model has not been able to deliver on securing equitable, integrated care for all (Bennett et al., 2012). (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Performing an Organizational Health Literacy Assessment in a Shelter Serving People with Mental Illness.

BACKGROUND: Health literacy research and practice are constantly evolving. Recent inquiry has highlighted the burdensome literacy demands faced by people with serious mental illness (SMI). Systems, organizational operations, and structures can play a role in decreasing literacy demand, thereby reducing unnecessary challenges for people with SMI. Brief Description of Activity: An organizational health literacy assessment was conducted to explore literacy demands in one mental health shelter and revealed best practice action steps for improving the literacy environment. IMPLEMENTATION: The assessment included an exploration of the shelter environment using The Health Literacy Environment Activity Packet, First Impressions & Walking Interview, and a commonly used shelter document using the Simple Measure of Gobbledygook (SMOG), Suitability Assessment of Materials (SAM), and Centers for Disease Control and Prevention (CDC) Index. RESULTS: The literacy demands of the shelter environment and a frequently used document exceeded the literacy skills of people with SMI. Environment assessment revealed environmental facilitators (e.g., welcoming atmosphere) and barriers (e.g., unclear signage). Document assessment also revealed facilitating factors and barriers. SMOG scores ranged from 11.25 to 11.80 (median: 11.38), meaning 11th to 12th grade-level reading skills are required to understand, use, and take action on the document's content. A SAM score of 50% (adequate) and a CDC Index score of 42.1 (revise and improve) reveal materials contain both facilitating factors (e.g., chunked sections) and barriers (e.g., jargon, mismatched graphics) to use. LESSONS LEARNED: The mismatch between system demands and the literacy skills of people with SMI is more profound than that of the general United States population. Organizational health literacy assessments are achievable and useful for both immediate and long-term action aimed at understanding and improving the organizational health literacy of mental health spaces. Further work is needed to explore the role of behavioral health services in addressing the institutional and programmatic literacy demands that inhibit treatment and recovery. [HLRP: Health Literacy Research and Practice. 2022;6(3):e167-e174.] Plain Language Summary: An organizational health literacy assessment reveals how system demands can be changed to better serve intended users. Engaging in mental health, recovery, and treatment services requires complex literacy skills. Generally, the U.S. adult population does not have the skills to meet such demands, and this is especially true among public mental health service users.

Prevalence and Predictors of Limited Literacy in Public Mental Health Care.

Literacy is an important predictor of health care utilization and outcomes. We examine literacy among people seeking care in a state funded mental health clinic (Site 1) and a safety-net hospital clinic (Site 2). Limited literacy was defined as literacy at or below the 8th grade level. At Site 1, 53% of participants had limited reading literacy and 78% had limited aural literacy. At Site 2, 72% had limited reading and 90% had limited aural literacy. Regression analyses examined associations among limited literacy and psychiatric, neurocognitive and sociodemographic characteristics. Few associations among psychiatric and neurocognitive factors, and literacy were found. At Site 2, black and "other" race participants had higher odds for limited literacy compared to white participants suggesting that limited literacy may be an under-examined mechanism in understanding racial disparities in mental health. Work is needed to understand the relationships among literacy, mental health and mental health care.

The Impact of 1 Year of Healthier School Food Policies on Students' Diets During and Outside of the School Day.

BACKGROUND: In 2012, Massachusetts implemented both the updated national school meal standards and comprehensive competitive food/beverage standards that closely align with current national requirements for school snacks. OBJECTIVES: This study examines the impact of these combined standards on school meal and snack food selections, as well as food choices outside of school. In addition, this study examines the impact of these standards on nutrients consumed. DESIGN: The NOURISH (Nutrition Opportunities to Understand Reforms Involving Student Health) Study was an observational cohort study conducted among students from spring 2012 to spring 2013. PARTICIPANTS/SETTING: One hundred sixty students in 12 middle schools and high schools in Massachusetts completed two 24-hour recalls before (spring 2012) and after implementation (spring 2013) of the updated standards. MAIN OUTCOME MEASURES: Changes in school meals, competitive food, and after-school snack selection, as well as nutrients consumed outside of school were examined. STATISTICAL ANALYSES PERFORMED: Logistic regression and mixed-model analysis of variance were used to examine food selection and consumption. RESULTS: After implementation, 13.6% more students chose a school meal (70.1% vs 56.5%; P=0.02). There were no differences in competitive food purchases but a significant decrease in the number of after-school unhealthy snacks consumed (0.69 [standard error=0.08] vs 1.02 [standard error=0.10]; P=0.009). During the entire day, students consumed, on average, 22 fewer grams of sugar daily after implementation compared with before implementation (86 g vs 108 g; P=0.002). CONCLUSIONS: With the reduction in the number of unhealthy school snacks, significantly more students selected school meals. Students did not compensate for lack of unhealthy snacks in school by increased consumption of unhealthy snacks outside of school. This provides important new evidence that both national school meal and snack policies may improve daily diet quality and should remain strong.

Scoping Review: Social Determinants of Young Children's Participation in the United States.

Optimal child development is supported by services, policies, a social determinants of health (SDOH) frame, and meaningful participation (as defined by the International Classification of Functioning, Disability, and Health-Children and Youth [ICF-CY]). This scoping review describes the social determinants that may affect the participation of young children aged 0 to 3 years with developmental disabilities (DD) in the United States. Scoping review of studies including U.S. children with DD aged 0 to 3 years, from 2000 to 2016, were used. 5/979 studies met inclusion criteria. Two researchers independently coded studies to align them with both ICF-CY and SDOH. Studies found determinants of participation stemming from the child (e.g., individual) and multiple contexts: immediate, community, and policy. The emergent literature continues to primarily focus on child determinants but suggests participation of young children with DD is affected by social determinants stemming from the community and policy contexts. The literature underrepresents children from racial/ethnic minority backgrounds.

Product reformulation and nutritional improvements after new competitive food standards in schools.

OBJECTIVE: In 2012, Massachusetts enacted school competitive food and beverage standards similar to national Smart Snacks. These standards aim to improve the nutritional quality of competitive snacks. It was previously demonstrated that a majority of foods and beverages were compliant with the standards, but it was unknown whether food manufacturers reformulated products in response to the standards. The present study assessed whether products were reformulated after standards were implemented; the availability of reformulated products outside schools; and whether compliance with the standards improved the nutrient composition of competitive snacks. DESIGN: An observational cohort study documenting all competitive snacks sold before (2012) and after (2013 and 2014) the standards were implemented. SETTING: The sample included thirty-six school districts with both a middle and high school. RESULTS: After 2012, energy, saturated fat, Na and sugar decreased and fibre increased among all competitive foods. By 2013, 8 % of foods were reformulated, as were an additional 9 % by 2014. Nearly 15 % of reformulated foods were look-alike products that could not be purchased at supermarkets. Energy and Na in beverages decreased after 2012, in part facilitated by smaller package sizes. CONCLUSIONS: Massachusetts' law was effective in improving the nutritional content of snacks and product reformulation helped schools adhere to the law. This suggests fully implementing Smart Snacks standards may similarly improve the foods available in schools nationally. However, only some healthier reformulated foods were available outside schools.

How do we actually put smarter snacks in schools? NOURISH (Nutrition Opportunities to Understand Reforms Involving Student Health) conversations with food-service directors.

OBJECTIVE: In autumn 2012, Massachusetts schools implemented comprehensive competitive food and beverage standards similar to the US Department of Agriculture's Smart Snacks in School standards. We explored major themes raised by food-service directors (FSD) regarding their school-district-wide implementation of the standards. DESIGN: For this qualitative study, part of a larger mixed-methods study, compliance was measured via direct observation of foods and beverages during school site visits in spring 2013 and 2014, calculated to ascertain the percentage of compliant products available to students. Semi-structured interviews with school FSD conducted in each year were analysed for major implementation themes; those raised by more than two-thirds of participating school districts were explored in relationship to compliance. SETTING: Massachusetts school districts (2013: n 26; 2014: n 21). SUBJECTS: Data collected from FSD. RESULTS: Seven major themes were raised by more than two-thirds of participating school districts (range 69-100 %): taking measures for successful transition; communicating with vendors/manufacturers; using tools to identify compliant foods and beverages; receiving support from leadership; grappling with issues not covered by the law; anticipating changes in sales of competitive foods and beverages; and anticipating changes in sales of school meals. Each theme was mentioned by the majority of more-compliant school districts (65-81 %), with themes being raised more frequently after the second year of implementation (range increase 4-14 %). CONCLUSIONS: FSD in more-compliant districts were more likely to talk about themes than those in less-compliant districts. Identified themes suggest best-practice recommendations likely useful for school districts implementing the final Smart Snacks in School standards, effective July 2016.

Alfabetización en salud: implicación en el sistema sanitario / Health literacy: Implications for the health system

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Healthier Standards for School Meals and Snacks: Impact on School Food Revenues and Lunch Participation Rates.

INTRODUCTION: In 2012, the updated U.S. Department of Agriculture school meals standards and a competitive food law similar to the fully implemented version of the national Smart Snack standards went into effect in Massachusetts. This study evaluated the impact of these updated school meal standards and Massachusetts' comprehensive competitive food standards on school food revenues and school lunch participation. METHODS: Revenue and participation data from 11 Massachusetts school districts were collected from 2011 to 2014 and analyzed in 2015 using multilevel modeling. The association between the change in compliance with the competitive food standards and revenues/participation was assessed using linear regression. RESULTS: Schools experienced declines in school food revenues of $15.40/student in Year 1 from baseline (p=0.05), due to competitive food revenue losses. In schools with 3 years of data, overall revenues rebounded by the second year post-implementation. Additionally, by Year 2, school lunch participation increased by 15% (p=0.0006) among children eligible for reduced-price meals. Better competitive food compliance was inversely associated with school food revenues in the first year only; an absolute change in compliance by 10% was associated with a $9.78/student decrease in food revenues over the entire school year (p=0.04). No association was seen between the change in compliance and school meal participation. CONCLUSIONS: Schools experienced initial revenue losses after implementation of the standards, yet longer-term school food revenues were not impacted and school meal participation increased among children eligible for reduced-price meals. Weakening the school meal or competitive food guidelines based on revenue concerns appears unwarranted.

Impact of Nutrition Standards on Competitive Food Quality in Massachusetts Middle and High Schools.

OBJECTIVES: To examine changes in competitive foods (items sold in à la carte lines, vending machines, and school stores that "compete" with school meals) in Massachusetts middle and high schools before and after implementation of a statewide nutrition law in 2012. METHODS: We photographed n = 10 782 competitive foods and beverages in 36 Massachusetts school districts and 7 control state districts to determine availability and compliance with the law at baseline (2012), 1 year (2013), and 2 years (2014) after the policy (overall enrollment: 71 202 students). We examined availability and compliance trends over time. RESULTS: By 2014, 60% of competitive foods and 79% of competitive beverages were compliant. Multilevel models showed an absolute 46.2% increase for foods (95% confidence interval = 36.2, 56.3) and 46.8% increase for beverages (95% confidence interval = 39.2, 54.4) in schools' alignment with updated standards from 2012 to 2014. CONCLUSIONS: The law's implementation resulted in major improvements in the availability and nutritional quality of competitive foods and beverages, but schools did not reach 100% compliance. This law closely mirrors US Department of Agriculture Smart Snacks in School standards, suggesting that complying with strict nutrition standards is feasible, and schools may experience challenges and improvements over time.

Implementation of Competitive Food and Beverage Standards in a Sample of Massachusetts Schools: The NOURISH Study (Nutrition Opportunities to Understand Reforms Involving Student Health).

BACKGROUND: During 2012, Massachusetts adopted comprehensive school competitive food and beverage standards that closely align with Institute of Medicine recommendations and Smart Snacks in School national standards. OBJECTIVE: We examined the extent to which a sample of Massachusetts middle schools and high schools sold foods and beverages that were compliant with the state competitive food and beverage standards after the first year of implementation, and complied with four additional aspects of the regulations. DESIGN: Observational cohort study with data collected before implementation (Spring 2012) and 1 year after implementation (Spring 2013). PARTICIPANTS/SETTING: School districts (N=37) with at least one middle school and one high school participated. MAIN OUTCOME MEASURES: Percent of competitive foods and beverages that were compliant with Massachusetts standards and compliance with four additional aspects of the regulations. Data were collected via school site visits and a foodservice director questionnaire. STATISTICAL ANALYSES PERFORMED: Multilevel models were used to examine change in food and beverage compliance over time. RESULTS: More products were available in high schools than middle schools at both time points. The number of competitive beverages and several categories of competitive food products sold in the sample of Massachusetts schools decreased following the implementation of the standards. Multilevel models demonstrated a 47-percentage-point increase in food and 46-percentage-point increase in beverage compliance in Massachusetts schools from 2012 to 2013. Overall, total compliance was higher for beverages than foods. CONCLUSIONS: This study of a group of Massachusetts schools demonstrated the feasibility of schools making substantial changes in response to requirements for healthier competitive foods, even in the first year of implementation.

Integrating racial/ethnic equity into policy assessments to improve child health.

The US child population is rapidly becoming more racially and ethnically diverse, yet there are persistent racial/ethnic gaps in child health. Improving and expanding policies to reduce these gaps is increasingly a mandate of government agencies. Identifying effective policies requires a rigorous approach, yet there is a lack of information about which policies improve equity. This article introduces the Policy Equity Assessment, a framework that combines policy assessment and rigorous equity methods to both synthesize existing research and identify and conduct new analyses of policies' ability to reduce racial/ethnic inequities. We applied the Policy Equity Assessment to three policies: Head Start, the Family and Medical Leave Act, and a federal housing assistance program known as Section 8. Our results show racial/ethnic inequities in access to benefits and substantial data and evidence gaps regarding the impact of policies in improving racial/ethnic equity. These results should motivate policy makers to strengthen equity analysis.

Iterative evaluation of a web-based health information resource.

This article presents the research process and methods used to evaluate and improve a web-based health information resource, called "Community Connect to Research," intended for the public. The research process was iterative and involved collaboration with many partners. Two formal evaluations were conducted in 2009 and 2010 using key informant interviews, usability interviews, focus groups, an online survey, and readability and suitability assessment tools. These methods provided users' perspectives on the overall design, content, and literacy demands of the website as well as valuable feedback on their interaction with the website. The authors subsequently redesigned Community Connect to Research, making significant improvements on the basis of what they learned from the evaluation. The second evaluation revealed that the redesign addressed many issues found in the first evaluation and identified additional areas of possible improvement. Overall, both evaluations suggested that participants believed that the website was useful and valuable, indicating that Community Connect to Research is a health information resource that provides patients and families with accessible, relevant, and high-quality information. Regular formal evaluation is an essential tool for effective ongoing enhancement of health information resources meant for the public.