I'M ROB LOGAN, NATIONAL LIBRARY OF MEDICINE. I WELCOME YOU TO THE THIRD OF FIVE SESSIONS IN A SERIES THAT WE HAVE CALLED BETTER HEALTH, EVALUATING HEALTH COMMUNICATION LECTURE SERIES. MANY THANKS TO THOSE OF YOU WHO CHANGES VENUES A COUPLE OF TIMES IN ORDER TO FIND YOUR WAY OVER HERE TODAY. BY THE WAY T REASON WE MOVED HERE IS BECAUSE IT'S MUCH EASIER TO WEB CAST FROM HERE. AND WE'VE HAD VERY LARGE WEB CAST CROWDS AND SO WE FELT IT WAS IMPORTANT THAT WE TRY TO BE AS GRACIOUS AS POSSIBLE -- DR. KREZ WILL INTRODUCE DR. PLEASANT. NEXT TALK IS BRAD HESZ IS I FROM NATIONAL CANCER INSTITUTE ACROSS THE STREET IN NATIONAL LIBRARY OF MEDICINE BLISTER HILL AUDITORIUM ON THE 29th OF THIS MONTH AT 3:30 IN THE AFTERNOON. WE'LL RETURN TO LISTER HILL AUDITORIUM WHICH WASN'T ABLE TODAY. [LOW AUDIO]. ALSO WILLIAM SLAING WHO DIRECTS THE RAPID CYCLE EVALUATION GROUP CENTER FOR MEDICARE MEDICAID INNOVATION. WE NOW HAVE IT FROM HIM DIRECTLY THAT HE'LL BE HERE. WE'RE HAVING TROUBLE SETTING DATE BUT IT'LL BE EARLY TO MID MAY. IF YOU'RE NOT FAMILIAR WITH HIS WORK, THE CURRENT HEALTH AFFAIR HAS A ARTICLE ABOUT WHAT HIS INSTITUTE AND GROUP DOES. IT'LL BE PUBLISHED IN THE JOURNAL LATER BUT IF YOU GO TO HEALTH AFFAIRS.ORG YOU'LL FIND ARTICLE THAT DESCRIBES THE RAPID CYCLE EVALUATION. GARY KREPS HAS BEEN OUR TERRIFIC DISCUSSANT FOR ALL THESE MEETINGS. HE IS UNIVERSITY DISTINGUISHED PROFESSOR CHAIR OF THE DEPARTMENT OF COMMUNICATION AND DIRECTOR OF THE CENTER FOR HEALTH COMMUNICATION AT GEORGE MASON UNIVERSITY. DO YOU WANT TO COME UP AND INTRODUCE OUR SPEAKER? THANK YOU ALL FOR COMING. >> WELCOME BACK. IN A SMALLER ROOM YOU LOOK LIKE A BIG CROWD. IN THAT BIG AUDITORIUM OVER AT NATCHER OVER AT LISTER HILL LOOKS LIKE WE'RE A SPARSE GROUP, HERE I FEEL LIKE A WEIGHTY AUDIENCE. GLAD YOU'RE HERE TO HEAR AN DRU PLEASANT. I'VE KNOWN HIM FOR A NUMBER OF YEARS, ONE OF THE LEADING VOICES IN THE AREA OF HEALTH LITERACY BEEN DOING CUTTING EDGE WORK ON EVALUATING THE BEST WAYS TO ASSESS LITERACY AND THE WAYS TO TRY TO MAKE DECISIONS ABOUT HEALTH COMMUNICATION PROGRAMS BASED ON LITERACY. I'M REALLY QUITE EXCITED ABOUT HEARING WHAT HE HAS TO SAY BECAUSE I THINK THE ISSUE OF HOW LITERACY HAS BECOME ONE OF THE MOST CRITICAL FACTORS IN DETERMINING THE EFFECTIVENESS OF HEALTH COMMUNICATION PROGRAMS AND ALL TOO OFF PEOPLE JUST DO NOT UNDERSTAND THEOo: INFORMATION THAT WE'RE PROVIDING AND THE OLD ADAGE OF ONE SIZE FITS ALL DOES NOT SEEM TO BE WORKING VERY WELL. I THINK WE NEED TO START THINKING ABOUT WAYS TO HAVE -- OF TARGETING OUR INFORMATION. WE NEED TO UNDERSTAND WHERE THEY'RE COMING FROM. ANDREW PLEASANT. [APPLAUSE] >> THANK YOU. I'M REALLY EXCITED ABOUT WHAT HE'S GOING TO SAY TOO, I HAVE NO IDEA. IT'S GOING BE NEAT. [LAUGHTER] I'M SUPPOSED TO SAY WEB CAST PEOPLE, WHEREVER YOU ARE, I KNOW YOU'RE OUT THERE. SO I'M ANDREW, THEY SAY DOCTOR BECAUSE I DID EARN ONE OF THOSE DEGREES BUT I GO BY ANDREW. STOP ME AT ANY POINT IN TIME WHEN I SAY SOMETHING THAT MAKES ABSOLUTELY NO SENSE, REALLY, 'CUZ I MIGHT, 'CUZ I'M GOING TO TRY TO FIT IN A PRETTY LONG STORY IN A REAL RELATIVELY CONTAINED AMOUNT OF TIME BECAUSE IT'S IMPORTANT TO GET IT ALL TIED TOGETHER. I'M GOING THE START THE WAY THAT I USUALLY DO, SO, UM, 'CUZ I TALK ABOUT HEALTH [INDISCERNIBLE] WAY TOO OFTEN TO BE FRANK ABOUT IT. SO THOSE OF YOU WHO'VE SEEN THE FIRST FIVE SLIDES HOLD ON BECAUSE I PROMISE NO ONE HAS SEEN THESE BECAUSE I JUST MADE IT UP LAST NIGHT. -- I THINK I'M GETTING OLDER SO THEY DECIDED TO PUT FINNIER IN FRONT OF MY TITLE AND I'M FEELING THE YEAR TOOS. EXECUTIVE DIRECTOR JENNIFER AND PRESIDENT DR. RICHARD WHO USED TO LIVE AND WORK MUCH CLOSER TO WHERE WE'RE AT NOW IN THEIR PREVIOUS LIFE NONE OF THIS WOULD HAVE HAPPENED WITHOUT THEIR EFFORT OVER THE LAST FOUR YEARS WE'VE REALLY MANAGED TO TURN AN IDEA INTO AN EFFORT THAT'S REALLY HELPED HUNDREDS AND THOUSANDS OF PEOPLE AROUND THE WORLD NOW LIVE HEALTHIER LIVES. WE'LL GIVE YOU BRIEF INSIGHT INTO THAT. SO PLEASE ADVANCE SLIDE. THERE'S NOTHING LIKE STARTING A TALK WITH A LITTLE TECHNICAL DIFFICUL DIFFICULTY. I START OFF BY ASKING THIS, WHO ARE YOU? I KNOW ABOUT FOUR OF YOU IN THE ROOM SO GIVE ME LITTLE CLUE ABOUT YOUR INVOLVEMENT IN HEALTH LITERACY, WHAT YOU DO PROFESSIONALLY, WHERE YOU WORK -- YOU MIGHT ALL BE HERE AT NIH, THAT'S VERY LIKELY -- WHO WANTS TO JUMP IN FIRST? JUST SHOUT IT OUT. >> [LOW AUDIO]. >> THANKS, FRED, GOOD. I HOPE SO. WHO WORKS IN THE SAME AREA THAT FRED DOES, NATIONAL LIBRARY OF MEDICINE, JUST SHOW OF HANDS. ALL RIGHT. P WHO'S LEFT? WHO DOES SOMETHING DIFFERENTLY? I KNEW IT WAS GOING BEWHO'S LEFT? WHO DOES SOMETHING DIFFERENTLY? I KNEW IT WAS GOING BE YOU. [LAUGHTER] >> [LOW AUDIO]. >> ISN'T IT ABOUT TIME THAT PEOPLE ARE DOING THAT AND THE VIDEOTAPING'S REALLY PHENOMENAL. ANYBODY ELSE, ANOTHER SECTOR? BY THE WAY, YOU GUYS HAVE A GOOD PROFESSOR. YES. >> [LOW AUDIO]. >> WOULDN'T THAT BE LOVELY, TOO. THAT WOULD BE AN AREA THAT WOULD BE HELPFUL. YES, SIR, BACK THERE. >> [LOW AUDIO]. >> GREAT. THANK YOU. ONE -- YEP, SURE. >> [LOW AUDIO]. >> WOW. EXCELLENT. [INDISCERNIBLE]. >> [LOW AUDIO]. >> FANTASTIC. SO THAT BY THE WAY IS PRACTICING WHAT YOU PREACH, ALL RIGHT. THE FIRST AND GOLDEN RULE OF HEALTH LITERACY. NO WHO YOU'RE TALKING TO, INVOLVE THEM ADDS EARLY AND OFTEN IN YOUR EFFORTS AS YOU CAN. I ALWAYS LIKE TO GET A SENSE OF WHO'S IN THE ROOM. THIS STHOUB EASIEST ROOM TO ASK THIS QUESTION. YOU'RE ALL EXPERTS IN HEALTH IN VARIOUS WAYS, HEALTH LITERACY IN VARIOUS WAYS AND YOU'RE LAUGHING BECAUSE YOU PREDICT THAT I'M GOING THE GET DIFFERENT RESPONSES, RIGHT? I THINK SO TOO. I'M GOING GO FAIRLY QUICKLY THROUGH SOME OF THESE, BUT THERE IS A FEW RESPONSES TO WHAT IS HEALTH. DOES ANYBODY HAVE A DIFFERENT APPROACH ENTIRELY? OR JUST A MODIFICATION? OR DOES THAT SORT OF SUM UP YOUR PERSPECTIVES? I SEE THE PEOPLE ON THE WEB CAST ARE NODDING UP AND DOWN VIOLENTLY AND THAT ONE GUY IN THE BACK -- YES, PLEASE. >> [LOW AUDIO]. SURE. YEP, MORE INTEGRATIVE UH APPROACH CAN DEFINITELY BE FOUND AMONG NATIVE AMERICAN AND OTHER CULTURES AS WELL AS MODERN SOCIETY. SO THE POINT BEING RIGHT, H THAT THERE ARE MULTIPLE VIEWS OF HEALTH AND IT'S NOT NECESSARY L DETERMINED IDEA AND THE SAME IS TRUE FOR LITERACY, RIGHT? USED A LOT. PEOPLE SAY HEALTH, PEOPLE SAY LITERACY. WE TALK ABOUT THESE IDEAS AA LOT, IND P PENTLY BUT THERE'S MULTIPLE IDEAS OF LITERACY. IS IT LEARNING TO READ OR THE OTHER PART OF THAT CRITICAL TRANSITION WHEN YOU START READING TO LEARN OR IS IT THE ABILITY TO CHANGE THE WORLD, RIGHT, BY CONTROLLING HOW STORIES AND LITERARY TOOLS ARE USED AND SHARED AROUND THE WORLD. LITERACY JUST LIKE HEALTH HAS A LOT OF DIFFERENT CONNOTATIONS TO IT. NOT SO LONG AGO WITHIN ALL OF OUR LIFETIMES SH EASILY WITHIN ALL OF OUR LIFETIMES SOMEONE DECIDED TO PUT THE TWO WORDS TOGETHER AND CREATE WHAT IS NOW HEALTH LITERACY. WHAT HAPPENED AND THIS IS A QUICK OVERVIEW STORY OF HEALTH LITERACY. INITIALLY, PEOPLE THOUGHT HEALTH LITERACY WAS THIS, THESE EXAMPLES, RIGHT, OF EVERYDAY PROBLEMS, DEALS PEOPLE NEED TO DECODE THOSE, LANGUAGE-BASED, AND OFTEN FROM SOME PERSPECTIVE FRAMING THE PEOPLE T READER, THE PUBLIC INSTEAD OF CREATOR COMMUNICATION. HOPEFULLY EVERYBODY SEES A PROBLEM WITH THESE EXAMPLES ON THE SCREEN OR DOES ANYBODY THINK THERE'S SOMETHING THERE THAT'S PERFECTLY OKAY? BECAUSE FOR SOME REASON YOU STILL WALK THROUGH HOSPITALS IN THE UNITED STATES AND OTHER COUNTRIES AND THE SIGN ON THE WALL WILL SAY RADIOLOGY BUT YET TO HEAR A DOCTOR INSTRUCT A PATIENT THAT THEY NEED TO GO GET A RADIO BATH. HOW ON EARTH WILL PEOPLE KNOW TO GO TO RADIOLOGY? -- THAT'S PART OF HEALTH LITERACY AS WELL. SODIUM IS THE SAME THING. HAVE ANY OF YOU EVER SAID PLEASE PASS THE SODIUM. THIS COULD BE CLINICAL RESEARCHERS WHO HAVE SAID THAT HERE VOI TO BE CAREFUL. HEALTH LITERACY LOOKED AROUND THE WORLD AND STARTING SPYING COMPLEX EXAMPLES OF LANGUAGE AND MAPS AND DIFFICULT NAVIGATION. THIS IS A REAL-LIFE EXAMPLE FROM A HOSPITAL IN THE UNITED STATES. MAP IS SUPPOSED TO HELP YOU LEARN PARK IF YOU WANT TO GO TO OCCUPATIONAL HEALTH SERVICES. ANYBODY FIGURE IT OUT YET? IT'S ONE OF THOSE SLOW LEARNING CURVES. EVENTUALLY PEOPLE START SAYING, YEAH, I THINK IT'S ONE OF TWO PLACES. HEALTH LITERACY CAME ALONG AND SAID, YOU KNOW WHAT,? WE CAN FIX THIS JUST LIKE THAT, FLIGHT [LAUGHTER] ANYBODY WORRIED ABOUT BUDGET? THIS SA NO BUDGET, NO COST ABSOLUTE EASY FIX FROM HEALTH LATE LIT RA IS I PERSPECTIVE AND THAT'S TWO QUICK EXAMPLES OF HOW HEALTH LITERACY STARTED. THEN AS THE FIELD GREW AND PEOPLE BECAME SORT OF DIGGING DEEPER INTO THE IDEA, WHAT HAPPENS WHEN YOU PUT HEALTH AND LITERACY TOGETHER IS SORT OF ENCOUNTERED THE FACT THAT THERE ARE ALL THESE INEQUITIES AROUND HEALTH AND SOCIETY AROUND THE WORLD AND IT TURNS OUT HEALTH LITERACY PLAYS A PRETTY POWERFUL ROLE IN EITHER CREATING THOSE OR -- COME ON IN AND SIT DOWN THERE ARE SOME CHAIRS OVER HERE. YOU MIGHT HAVE TO SIT IN THE FRONT. IT'S LIKE UNDERGRADUATE NOBODY WANTS THE FRONT ROW UNLESS YOU'RE LATE. WHAT DOES IT LOOK LIKE TO SEE HEALTH LIT RAY IS IS INVOLVED IN INEQUITIES. THIS IS MY FAVORITE EXAMPLE. WE'LL ALL REMEMBER IT IF WE THINK ABOUT THE TROUBLED ASSET PROGRAM OTHERWISE KNOWN AS THE BANK BAILOUT A FEW YEARS AGO. THIS IS THE FORM THAT THOSE BANKS WERE REQUIRED TO FILL IN TO PARTICIPATE IN THE BAILOUT. THEY WERE ALLOWED TO ADD NO MORE THAN A SINGLE PAGE ADDENDUM TO THIS FORM, THAT'S IT. BY WAY OF COMPARISON, THIS IS THE CURRENT ARIZONA MEDICAID AND FOOD STAMP APPLICATION FORM, THE GREAT STATE WHERE I LIVE NOW NOT TO PICK ON ONE STATE ALONE THIS, IS UTAH. YOU'RE GOING TO SEE THE LAST FEW STATES I GAVE A TALK IN. THIS IS HO RIGHT HERE. YOU CAN SEE THEY'RE GETTING INCREASINGLY MORE COMPLEX AND LARGER. THE GREAT STATE OF TEXAS WHERE, AS MY FRIENDS IN TEXAS, I LOVE THE PLACE, EVERYTHING'S GOT TO BE BIGGER IN TEXAS THE, THEY'RE RIGHT. AND THEY SPLIT NIT HALF SO IF YOU WANT MEDICAID YOU HAVE TO FILL OUT THIS FORM F UH YOU WANT FOOD STAMPS TOO UH YOU HAVE TO FILL OUT ANOTHER FORM. P WHAT IS ALL THIS AS A WAY OF ILLUSTRATING, RIGHT, THAT WE OFTEN USE LITERACY, COMMUNICATION TOOLS, AS A WAY TO REINFORCE INEQUITIES OFTEN INVISIBLY AND UNCONSCIOUSLY BUT NONETHELESS IT STILL HAPPENS. SO BEING JUST THE SORT OF KI GUY I AM I HAD TO FIGURE OUT THE PER PAGE PAYBACK AND INEQUITY IS SIGNIFICANT AND REAL OVER TWO HUNDRED MILLION FOR THE BANKS WHEREAS 50-150 PER PAGE FOR PEOPLE WHO ARE IN REAL NEED, AND AS PALO FAIR A BRAZILIAN EDUCATION PHILOSOPHER -- SMART GUY, RIGHT -- HE SAY WHAT IS WE NEED TO DO WITH OUR LITERACY SKILL IS LEARN TO READ THE WORLD SO WHEN YOU READ THIS REALITY WHAT DOES IT SAY TO YOU ABOUT TRUST AND POWER AND DISTRIBUTION OF STATE RESOURCES AND PUBLIC GOODS AND HOW DO WE USE LITERACY AS A TOOL TO HELP REINFORCE SOME THINGS THAT NIGHT NOT ALWAYS BE GOOD? THE UPSIDE IS WE CAN USE LITERACY TO UNWIND SOME OF THOSE PROBLEMS TOO, WE JUST NEED TO WORK ON IT USUALLY FROM THE BOTTOM UP BECAUSE THAT'S WHERE THE NEED IS THE GREATEST BUT THERE ARE PEOPLE AT THE TOP THAT COULD USE A LITTLE HELP TOO. SO THE FIELD REALLY STARTED IN TWO CAMPS HISTORICALLY AND THE IDEA EMERGED SLIGHTLY DIFFERENT IN EACH OF THOSE FIELDS AS YOU WOULD EXPECT BECAUSE DOCTORS IS GOING TO LOOK DIFFERENTLY AT THIS THAN AN ADULT EDUCATION PROVIDER IS. OVER THE YEARS OTHER PEOPLE -- I SEE SOME OF YOU IN THE ROOM, MEDICAL LIBRARIANS FOR EXAMPLE -- HAVE STARTED TO FILL IN THE GAP AND PUBLIC HEALTH HAS PLAYED AN IMPORTANT ROLE IN HEALTH LITERACY. PEOPLE SOME OF WHAT I'M GOING TO TALK TO YOU NEXT IN TERMS OF EVALUATION OF HEALTH LITERACY REAL REALLY DEFLECTS THIS DIVERSION POINT OF VIEW FROM EARLY ON. THE ONE IMPORTANT THING THAT I SEED KNEAD SO SAY THIS @ THIS POINT IN TIME IS WHAT I'M GOING TO GO INTO NEXT IS GOING TO SOUND LIKE I DON'T THINK HEALTH LITERACY IS A GREAT FIELD BUT NOTHING COULD BE FURTHER FROM THE CASE. BUT I HAVE TO POINT OUT SOME FLAWS. WHAT IS HEALTH LITERACY? IT TURNS OUT THERE'S A LOT OF PERSPECTIVES ON THIS AND THEY DON'T ALWAYS AGREE. SO WE'RE GOING RUN THROUGH A NUMBER OF DEFINITIONS HERE. YOU DON'T HAVE TO READ EACH AND EVERY WORD BECAUSE POINT I WANT TO MAKE IS DIFRN BY THE TABLE THERE ACROSS THE BOTTOM AND WE'RE GOING START AGGREGATING THE COMPONENTS OF HEALTH LITERACY THAT HAS APPEARED IN A NUMBER OF DEFINITIONS OVER THE YEARS. THIS ONE FROM 1995 IS ONE OF THE EARLIER DEFINITIONS YOU'LL FIND IN THE LITERATURE. NEXT ONE IS MUCH SHORTER AND AGAIN IT CAME OUT OF THE PEER REVIEWED LITERATURE. ODDLY ENOUGH THESE EARLIER DEFINITIONS ARE FOCUSING ON USING INFORMATION. WHY IS THAT ODD? I'LL TELL YOU IN A LITTLE BIT BUT THAT'S CALLED FORESHADOWING. SO THE NEXT ONE FROM DONALD NUT BEAM OUT OF AUSTRALIA OFTEN WORKING IN THE U.K. OR AT THE WORLD HEALTH ORGANIZATION DEVELOPED A MORE COMPLEX DEFINITION AND HE STARTED TO THE DIVE INTO SOME OF THE FUNCTIONAL COMPONENTS OF WHAT HE SAW AS HEALTH LITERACY BEFORE PEOPLE GOT TO THAT USE STEP. FIND THE INFORMATION, UNDERSTAND THE INFORMATION. BOTH OF WHICH I THINK NO ONE WILL HAVE A DISAGREEMENT WITH. THIS IS THE DEFINITION THAT'S USED BY THE HEALTHY PEOPLE EFFORT AND THE INSTITUTE OF MEDICINEX HEALTH LITERACY. THE ASTERISK IS THERE BECAUSE THIS IS PROBABLY THE MOST CITED, MOST USED DEFINITION TO DATE AND THEY STARTED TO BREAK IT DOWN FURTHER INTO FUNCTIONAL CATEGORIES: OBTAIN, PROCESS, UNDERSTAND. THEY DECIDED THAT THE GOAL OF HEALTH LITERACY IN THIS DEFINITION WAS TO REACH AN APPROPRIATE HEALTH DECISION. THAT'S PROBABLY ONE OF THE MOST CRITICIZED ASPECTS OF THIS DEFINITION AND AS WE MOVE FORWARD YOU'LL SEE HOW THAT CHANGES. THE TABLE ALSO GIVES YOU THE PLACE WE'RE GOING SHIFT TO AN INFORMED DECISION. AS A MORE VIABLE OUTCOME AREK TOOK THAT DEFINITION AND HAD TO LIMIT IT TO A PATIENT P'S ABILITY. SO THEY'RE ALSO STARTING TO SEE SOME VARIATION IN WHERE HEALTH LITERACY RELIED IN SOCIETY. IS IT IN THE PUBLIC OR IS IT JUST IN THE PATIENT ROLE AND PEOPLE START TO EXPAND ON THAT HAS WE MOVE FORWARD. NATIONAL ASSESSMENT OF ADULT LITERACY DRIVEN BY THE FACT THAT THE NATIONAL ASSESSMENT OF ADULT LITERACY E WAS ENTIRELY ON PAPER, THEREFORE AS THEY DEFINED HEALTH LITERACY AS SOMETHING THAT WAS PRESENTED IN WRITTEN ENGLISH BECAUSE THEY DEFINED IT AS OUTSIDE OF THAT THEY'D HAVE HAD TO CHANGE THEIR ENTIRE METHODOLOGY AND MOVE AWAY PARTICIPATING. THERE ARE SOME REAL THINGS THAT START TO HAPPEN. THE AMERICAN MEDICAL ASSOCIATION, COMMITTEE ON HEALTH LITERACY DECIDED IT WAS A CONSTELLATION OF SKILLS WHICH I DON'T KNOW HOW TONESS THE CONSTELLATION SO I I DON'T PUT IT IN THE TABLE ACROSS THE BOTTOM AND IT'S THE ONLY TIME IT APPEARS ANYWAY. BUT H THIS MIGHT BE THE HIGHLIGHT OF WHEN PEOPLE ARE FOCUSING ON STILL SKILLS AS HEALTH LITERACY VERSUS SOMETHING ELSE. THE POINT IS, THERE ARE MANY DEFINITIONS AND THEY CONFLICT. THEY JUST DON'T AGREE. THIS IS THE DEFINITION OUT OF HERE STARTING TO GET LONGER AND ALSO STARTING TO LOOK AT NOTIONS LIKE EMPOWERMENT AND RESPONSIBILITY AND MOVING A LITTLE BIT AWAY FROM SPECIFIC SKILL SETS TO SOME EXTENT ANYWAY, STARTING TO MOVE TO THE SOCIAL AWARENESS LEVEL. THIS IS PROBABLY THE SHORTEST DEFINITION OF HEALTH LITERACY YOU'LL FIND. PEOPLE'S PRACTICAL ABILITY TO MAKE DECISIONS ABOUT THEIR HEALTH. AND MORE RECENTLY, A GROUP LARGELY BASED AT THE WORLD HEALTH ORGANIZATION BUT ALSO A FEW HEALTH LITERACY ORGANIZATIONS IN CANADA OFFERED THIS DEFINITION. THIS IS THE FIRST APPEARANCE OF COMMUNICATE IN A DEFINITION OF HEALTH LITERACY. AND THEY STARTED TO ADDRESS DIFFERENT CONTEXT AND ACROSS THE THE LIFE COURSE IN A BOOK WHICH I WAS A CO-AUTHOR ON WITH THE DEFINITION WE DEVELOPED SEVERAL YEARS AGO AND WE SAW IT AS SEEKING OUT COMPREHENDING, EVALUATING, USING HEALTH INFORMATION TO MAKE INFORMED CHOICES AND STARTING TO ADD ON SOME HEALTH QUALITY OUTCOMES TO THAT DEFINITION AND THE MOST RECENT NEW ENTRY INTO THE FIELD WOULD BE THE CALL VA IS I CHARTER ON HEALTH LIT RACY. ALLOWS THE PUBLIC PERSONNEL WORKING IN ALL HEALTH-RELATED CONTEXT TO FIND, UNDERSTAND, EVALUATE, COMMUNICATE AND USE INFORMATION THAT GOES ON TO LIST THE NUMBER OF OUTCOMES INCLUDING AN INFORMED DECISION-MAKING PROCESS. THAT IS ABOUT 15 YEARS IN ABOUT FIVE MINUTES. LIKE I SAID, THE POINT ISN'T REALLY THE DETAILS OF EACH DEFINITION, IT'S LOOK WHAT HAPPENED AT THE BOTTOM. WE REALLY HAVE MYRIADS OF CONSENSUS EMERGING, WE HAVE NEW THINGS EMERGING, COMMUNICATE ONLY A PERIOD OF THE LAST TWO BUT IT HAS POPPED UP ON THE HORIZON BUT BY IN LARGE THERE'S A LOT OF AGREEMENT HERE IN WHAT'S ACTUALLY INVOLVED. I THINK THE QUESTION IS THEN ONE OF WELL THERE'S SEVERAL QUESTIONS. ONE BECAUSE WE'RE LOOKING AT EVALUATION TODAY WHEN YOU HAVE MULTIPLE CONFLICTING DEFINITIONS, HOW DO YOU EVALUATE THE CONCEPTS THAT YOU'RE TRYING TO LOOK AT? WHEN FROM ONE PERS TECHIVE IT LOOKS AS IF NO ONE CAN ACTUALLY AGREE ON WHAT'S INVOLVED. FROM THE OTHER IT LOOKS LIKE MAYBE THERE'S SOME CONSENSUS BUILDING. THE ANSWER HAS BEEN THAT YOU DEVELOP MULTIPLE AND CONFLICTING MEASUREMENT AND SCREENING TOOLS. SO IN ESSENCE THE EVALUATION COMPONENT OF THE FIELD HAS FOLLOWED THE DEFINITIONAL COMPONENT OF THE FIELD IN SOME REALLY PRODUCTIVE WAYS BUT JUST NOT AS COORDINATED AND COMPREHENSIVE AS ONE WOULD LIKE. SO JUST OUT OF CURIOSITY HAVE ANY OF YOU USED ANY OF THE EXISTING HEALTH LITERACY SCREENING TOOLS AND MEASUREMENT DEVICES? THOSE OF YOU IN THE ROOM K JUST RAISE YOUR HAND IF UH YOU HAVE? ONE OF YOU, TWO, THREE, FOUR, AND THEN FIVE. MY NEXT QUESTION OF THOSE FIVE OF YOU, WOULD YOU GIVE THEM A THUMBS UP OR DOWN? DOWN, MIXED, DOWN, AND A DOUBLE DOWN. ALL RIGHT. SO THIS IS WHAT HAPPENS ALL THE TIME WHEN WE TALK ABOUT HEALTH LITERACY MEASUREMENT. THAT RESPONSE WITHIN OUR PROFESSIONAL NETWORK BECAUSE YOU DON'T OFF PUBLISH THINGS THAT DON'T WORK OUT. IT DOESN'T APPEAR SO NAUVEN THE PEER REVIEWED LITERATURE WHICH IS A PROBLEM. THERE'S A LOT OF THEM. THERE'S A FEW FOR EVERYBODY'S HEARD OF, FEW THAT VERY FEW PEOPLE HAVE HEARD OF AND I'M NOT GOING TO INTO GO INTO DETAILS ON ALL OF THESE BUT I'LL SHOW YOU HOW MANY THERE ARE. THE FIRST TWO ON THE LIST ARE THE MOST WIDELY KNOWN AND USED AND I WILL SHOW YOU. [INDISCERNIBLE] WHICH WAS THE FIRST ONE WHICH WAS REALLY FORMALIZED AND PUBLISHED. THE TEST OF FUNCTIONAL HEALTH LITERACY IN ADULTS, THOSE ARE IN SORT OF ACADEMIC ACRONYM SPEAK CALLED THE REALM AND THE TOFLA. I PROBABLY WILL USE THOSE ACRONYMS. THE HEALTH ACTIVITY LITERACY SCALE. THE NEWEST VITAL SIGN IS NEWER, I'LL SHOW YOU ABOUT HA THAT. THE SOME OF THESE ARE MORE FROM LITERACY WORLD, SOME ARE FROM EDUCATION. THEY ALL HAVE A HEALTH COMPONENT TO THEM OF SOME SORT. NUTRITIONAL LITERACY SKILLS FOCUSES ON THAT DOMAIN OF KNOWLEDGE. THE SPANISH SPEAKING AADULTS, THERE'S A LONG RUNNING EFFORT TO GET SOMETHING IN SPANISH, FIRST TWO EFFORTS DIDN'T WORK AT ALL BECAUSE OF THE STRUCTURE OF THE LANGUAGE, BUT ACCORDING TO THE DATA THE AUTHORS ORG THAT THESE VERSION IS ACCEPTABLE. THE SUBJECTIVE NUMEROUS IS I SCALE WHICH IS A NAME I ALWAYS SORT OF CHUCKLE AT BUT THAT'S JUST ME. SHOULD NUMBERS BE SUBJECTIVE, YEAH, WHY NOT, IT'S OKAY. THERE WAS AN INSTRUMENT BUILT JUST FOR ADOLESCENCE IN CANADA. THERE'S TALKING TOUCH SCREENS THAT'S BEEN OUT THERE FOR A LITTLE BIT. VERY LARGE COMPONENT OF THE NATIONAL ASSESSMENT OF ADULT LITERACY AND THERE'S A HEALTH LITERACY SCALE IN MANDARIN NOW IF YOU'RE INTERESTED IN TALKING TO A MANDARIN POPULATION. AHRQ HAS HEALTH LITERACY SET. THE JOINT COMMISSION IS GOING TO DEVELOP HEALTH LITERACY STANDARDS AND YOU CAN TAKE THEM AS A WAY TO ASSESS PERFORMANCE, THUS ON THE LIST. THAT'S A QUICK OVERVIEW OF A NUMB OF THEM OUT THERE USED TO EVALUATE HEALTH LITERACY. HERE'S WHETHER WE START TO SEE WHETHER THIS IS ALL HOLDING TOGETHER OR NOT. WHAT'S HAPPENED IS THAT EVERYBODY HAS DEVELOPED A MEASURE OF HEALTH LITERACY AND VALIDATED AGAINST A MEASURE THAT ALREADY EXISTED AND SAY SEE, IT WORKS BETTER OR IT WORKS THE SAME OR IT'S THE SAME BUT SHORTER OR SOMETHING ALONG THOSE LINES. BUT WHEN YOU GO BACK AND LOOK AT THE INITIAL VALIDATION SAMPLES OF THE TOOLS WE HAVE OUT THERE YOU START TO SEE THERE'S PERHAPS A LITTLE MORE METHOD LOGICAL RIGOR THAT COULD HAVE BEEN APPLIED TO THE PROJECT. THE REALM, THE FIRST ONE WAS INITIALLY VALIDATED WITH A SAMPLE OF 207 PEOPLE, MAINLY BLACK WOMEN WITH VERY FEW YEARS OF EDUCATION. SO IT WORKED FOR THEM AND IT GOT PUBLISHED AND PEOPLE STARTED USING IT WITH DIVERSE POPULATIONS AND SOMETIMES IT WORKS, SOMETIMES IT DOESN'T. THE FUNCTION OF HEALTH LITERACY IN ADULTS MANY MAINLY WITH HISPANIC AND AFRICAN AMERICAN WAS LESS EDUCATION JUST HAPPENS. AS YOU GO THROUGH THE MOST RECENT ONES AND THE ONES MORE KNOWN THAN OTHERS THE SAME SORT OF PROBLEM FUNDAMENTALLY CONFRONTS USERS OF THESE TOOLS. IF YOUR POPULATION DOESN'T MATCH THEIR ARE YOU SURE IT'LL WORK. THANKS TO THE HEALTH LITERACY GROUP WORKING HERE, WE GET A PEEK AT WHO -- WELL NOT WHO -- BUT WHICH TOOLS THE PEOPLE WHO HAVE RECEIVED NIH GRANTS TO WORK ON THE HEALTH LITERACY ISSUE OF SOME SORT WHICH TOOLS DID THEY USE AND RIGHT THERE IT IS. REALM AND THE TOFLA ARE BY FAR THE TWO THAT HAVE BEEN USED THE MOST IN THOSE GRANT2 WHETHER THEY'VE BEEN SUCCESSFUL OR NOT IS ANOTHER QUESTION BUT THE PROPOSAL SAID WE'RE GOING TO USE THE REALM AND THE TOFLU. HERE'S THE REALM. BASICALLY WHAT YOU ASK PEOPLE TO DO -- SORRY THIS IS BIG AS I CAN MAKE IT ON A POWER POINT SLIDE -- YOU ASK PEOPLE THE TO READ THESE WORDS OUT LOUD. INFLAMMATORY, DIABETES, HEPATITIS, ANTIBIOTICS, PA TAS YUM, ADEEM YEAH -- POTASSIUM -- WHAT DIFFERENCE DOES IT MAKE IF YOU CAN SAY THOSE CORRECTLY. THEY JUST ASK, CAN YOU PRONOUNCE THAT CORRECTLY. I'VE YET TO SEE O WHAT YOU DO IF SOMEONE DOESN'T SPEAK ENGLISH AS A FIRST LANGUAGE. DO THEY GET A LEE WAY. THERE'S A SHORTER VERSION, I TRIED TO USE THAT ONCE, EVERYBODY GOT ALMOST EVERYTHING CORRECT. WHAT DOES THAT TELL YOU? FROM A RESEARCH PERSPECTIVE, NOTHING. EVERYBODY GETS AN A IT WAS EITHER EASY OR THERE WAS SOMETHING WRONG WITH THE CONTENT OR THE EVALUATION. IF EVERYBODY FAILS SAME STORY IN REVERSE. THAT'S THE REALM. THIS IS A PART OF THE TOFLA, TEST OF FUNCTIONAL HEALTH LITERACY IN ADULTS. IT USES ONE VERSION OF THE CLOSE METH PREVENTING MULTIPLE CHOICE RESPONSES THAT PEOPLE ARE SUPPOSED TO COLLECT THE CORRECT WORK FROM HERE AND HERE AND FILL IN THE FLANK. THIS RAY WILL... DIRECT RESPONSE IS -- HEY YOU ALL PASSED. FROM ONE TO THREE -- HOURS TO DO. WHY DO UH YOU KNOW THAT? 'CUZ YOU'RE SMART. [LAUGHTER] PU WHAT IF YOU DIDN'T KNOW THAT TWO WEEKS AGO BUT HAPPEN TO HAVE BEEN IN THE HOSPITAL AND HAD AN X-RAY, THEN YOU PROBABLY HAVE KNOWN THAT THROUGH LIED EXE EXPERIENCE IN A WAY YOUR LANGUAGE SKILLS MIGHT NOT HAVE SUPPORTED YOU GETTING THE CORRECT ANSWER. SOME OF THE TESTS OF LITERACY SKILLS MAY VERY WELL BE DRIVEN MORE BY PEOPLE WHO LIVE THE EXPERIENCE THAN THEIR LITERACY PER SE. HERE'S ANOTHER PART OF THE TOFLA MUCH MORE FAVORITE PART AND PENAL ARE ARE SUPPOSED TO LOOK AT THIS CLINICAL APPOINTMENT SLIP AND ANSWER THE TWO QUESTIONS BELOW. THE FIRST ONE, WHEN IS YOUR NEXT AAPPOINTMENT? THE NEXT ONE, WHERE SHOULD YOU GO ASSUMING THAT THEY KNOW FOR THE APPOINTMENT? IT'S FRAGMENT NOT COMPLETE SENTENCE, REALLY, BUT YOU TELL ME BASED ON THE INFORMATION IN THIS SLIP WHEN IS YOUR NEXT APPOINTMENT? >> [LOW AUDIO]. >> YOU ASSUME. THAT'S A BIT ODD BUT MAYBE IT'S A DOCTOR THAT ONLY SEES PEOPLE FOR TEN MINUTES AND REALLY MEANS IT, RIGHTING? SO IT'S 10:20 I CONCUR, YOU'RE PROBABLE LP IS IT A.M. OR P.M.? THE NEXT ONE, WHERE SHOULD YOU GO? THIRD FLOOR, AND YOU'RE RIGHT THAT'S THE CORRECT ANSWER. BUT WHAT IF SOMEONE SAID, I DON'T KNOW TO BOTH OF THOSE? SOMEONE REICH ME, WHO WANTS TO BE A SMART ELECT, RIGHT, I'M STILL RIGHT 'CUZ YOU HAVE NOT GIVEN ME THE SUFFICIENT INFORMATION TO REALLY ANSWER THE QUESTION COMPLETELY. I COULD SAY I DON'T KNOW BECAUSE I'M NOT SURE IF YOU MEAN IN THE MORNING OR EVEN AND NOW IN FACT IT'S VERY POSSIBLE TO SEE A DOCTOR IN THE EVENING. I DON'T KNOW BECAUSE THIRD FLOOR OF WHAT BILLING? THAT'S LIKE TELLING SOMEONE TO COME OUT OF THE NIH CAMPUS AND SAY I'LL SEE YOU ON THE THIRD FLOOR. NOT GOING TO GO SO FAR. YOU WON'T GET THROUGH THE GATEWAY, WILL YEAH? I TRIED ONCE TO DO ME E TA ANALYSIS OF ALL THE USES OF THE TOFLA AND ABOUT 60 PER SOPT WAY THROUGH IT, IT BECAME CLEAR THAT THAT WAS IMPOSSIBLE. MAINLY BECAUSE OF THE SECOND BULLET BECAUSE THERE'S NOT CONSISTENT WAYS TO REPORT IT. SOME PEOPLE USE DIFFERENT CULT POINTS ON THE SCORES. THEY TEND TO RECORD IT AS CATEGORICAL INSTEAD OF CONTINUOUS DATA BECAUSE THEY THINK PEOPLE WANT TO KNOW ABOUT EVERYBODY TALENT BELOW LITERACY LEVEL OR EVERYBODY ABOVE. GROUPS OF PEOPLE BUT THEY HAVEN'T DONE IT CONSISTENTLY SO WITHOUT ACCESS TO THE LAW DATA UH YOU CAN'T DO A META-ANALYSIS OF ALL THE DATA. THERE WERE 48 ARTICLES THAT ACTUALLY PEER REVIEWED JOURNAL ARTICLES THAT HAD RESULTS FROM THE TOFLA BUT GETTING AS FAR AS WE COULD WE FOUND THERE WERE OTHER ISSUES. REFUSAL PLUS EXECUTION WAS 40% ON AVERAGE ACROSS THOSE 48 -- THAT'S HUGE. THAT'S A REAL PROBLEM. FOR WHATEVER REASON PEOPLE ARE ARE SAYING I DON'T WANT TO HAVE ANYTHING TO DO WITH THIS TEST OF MY LITERACY SKILLS IN THIS CONTEXT AND SHAME AS AUSTIN BEEN AN UNDER LYING CONCERN WHEN IT COMES TO EVALUATING LIT VA IS I. SO BE CAREFUL HOW YOU DO IT. I'VE YET TO FIND A RANDOM SAMPLE. JUST 'CUZ I'M HERE AT THE NIH I'M GOING TO SAY IT AGAIN, I'VE YET TO THE FIND RANDOM SAMPLE OF ANY OF THE HEALTH LITERACY MEASURES IN THE UNITED STATES. THAT'S A PROBLEM. [INDISCERNIBLE] THEY'RE THERE ACROSS THE THE BOARD. SO, YOU KNOW, WE HAVE SOME WORK TO DO O. THE NEWEST VITAL SIGNS, ONE OF THE NEWEST ONES DOES ADDRESS SOME OF THOSISH HUES TO INCLUDE NUM RA IS I IN THE WAY OTHERS DON'T PERSONALLY BECAUSE I WORK AT AN ORGANIZATION THAT'S COMMITMENTED TO HUMANS. DO WE REALLY RANT TO BASE OUR MEASURE MS ON A PINT OF ICE CREAM? IT HAS WORKED FOR SOME RESEARCHERS AND SOME CONTEXT DEFINITELY BUT I THINK QUESTION DO A BETTER JOB THAN THIS. OTHER RESEARCHERS AND THIS IS DRIVEN BY THE CLINICAL SIDE. WE'RE IN A CLINIC, WE DON'T HAVE TIME, WE NEED TO BOIL H THIS ALL DOWN TO ONE QUESTION SO TWO STUDIES LOOKED AT THESE THREE QUESTIONS. ONE STUDY SAID THAT THE SECOND BULLET WAS THE ONE THAT WORKED THE BEST WHICH WAS HOW CONFIDENT ARE YOU FILLING OUT FORMS BY YOURSELF. THE OTHER STUDY FOUND THIRD STUDY WAS THE MOST EFFECTIVE QUESTION. THAT WAS HOW OFTEN DO UH YOU HAVE SWN HELP YOU READ HOSPITAL MATERIALS? HOW DO YOU FEEL ABOUT THESE? SHAKING YOUR HEAD? I'M WORRIED YOU'RE GOING TO ASSESS SOMEONE'S HEALTH LITERACY WHAT IS REALLY AND TRULY A RICH AND POWERFUL TOOL THAT CAN CUT ASOMEONE'S LIFE BASED ON THE RESPONSE TO A SINGLE QUESTION LIKE THIS WHICH IS ESSENTIALLY SELF-REPORT I USE SELF-REPORT, MYSELF. THAT'S NOT REALLY ONE OF THEM. THAT'S STATE OF HEALTH LITERACY MEASUREMENT AND EVALUATION TO DATE. I'M SAD TO SAY BUT I'M GOING REMIND YOU SEVERAL TIMES THAT THESE TOOLS HAVE PRODUCED SOME PHENOMENAL DATA THAT HAVE SHOWN HOW POWERFUL HEALTH LITERACY CAN BE GIVEN LIMITATIONS THAT I'VE TRIED TO PICKLY POINT OUT. THERE'S ANOTHER PROBLEM THOUGH WITH THESE THAT NONE OF THEM WERE EXPLICITLY DEVELOPED TO EVALUATE ANY OF THOSE DEFINITIONS. THEY DON'T REFLECT EACH OTHER IN A ONE FOR ONE BASIS. SOMEONE IN AN ARTICLE WILL SAY MY DEFINITION OF HEALTH LITERACY IS FIND, ASSESS, APPRAISE BUT WHEN YOU LOOK AT THE SKILLS THEY'RE USING AREN'T INCLUDED IN THE EVALUATION. SO THEORY HASN'T BEEN TESTED IN THE WAY WE WOULD LIKE IT TO BE. WHERE DOES THAT LEAD US? THE STAGE HAS BEEN SET AND I HOPE IF WE'RE NOT IN AGREEMENT THAT'S FINE BUT IT'S CLEAR WE REALLY NEED TO DEVELOP A PLAN, WHAT ARE WE GOING TO DO NEXT? I E JUST DECIDED TO GIVE EXAMPLES IN THESE THREE PARTICULAR DOMAINS. ONE OF THEM'S REALLY QUICKLY. THE OTHER TWO IN DEPTH. CLINICAL PRACTICE IS THE FIRST ONE. THEN WE'LL TALK ABOUT WHAT YOU CAN DO WITH HEALTH LITERACY FROM AN INTERVENTION AND EVALUATION PERSPECTIVE IN A PUBLIC HEALTH CONTEXT AND INTERVENTION AND FINALLY WE'LL SAY WHAT DOES RESEARCH REALLY NEED TO TAKE ON TO MOVE FORWARD? THE FIRST ONE IS EZIEST AND QUICKEST ONE. 23 YOU'RE NOT A RESEARCHER -- IF YOU'RE NOT A RESEARCHER AND YOU'RE PROVIDING CARE TO PEOPLE IN A CLINICAL SETTING AND THIS IS THE THING UH YOU DO, YOU DO NOT NEED TO SPEND TIME EVALUATING SOMEONE'S HEALTH LITERACY. I KNOW WE'RE HERE TO TALK I BOUT EVALUATION AND IN THIS AREA MY RECOMMENDATION IS DON'T. IF YOU LOOK AT THE ASSESSMENT OF ADULT LIT VA RA IS I, ROUGHLY 88% OF AMERICANS ARE BELOW THE PROFICIENT LEVEL OF HEALTH LITERACY. IT'S REALLY 09.5% OF AMERICANS WHO ARE BELOW THE PROFICIENT LEVEL SO I'M SAFE TELLING CLINICIANS TO ASSUME HEALTH LITERACY IS A PROBLEM WITH EVERYBODY YOU MEET AND DEAL WITH THEM FROM THAT PERSPECTIVE. UNIVERSAL PRECAUTIONS. THERE ARE SOME TRICKS YOU CAN DO IF YOU'RE CURIOUS AND NEED TO KNOW, BUT THE POINT IS THAT PEOPLE WITH HIGHER LITERACY SKILLS IF THEY RECEIVE PLAIN LANGUAGE SAY BOY THAT WAS GREAT TOO. THEY UNDERSTOOD MORE, DIDN'T HAVE TO USE AS MUCH ENERGY TO GET TO TO SESSION AND THE HARDER PART FOR PHYSICIANS IS KEEPING PEOPLE IN THE ROOM 'CUZ THEY WANT OUT. THEY WANT TO DO YES AND NO ANSWER AND PLEASE LET ME OUT THE ROOM WITH A DIAGNOSIS AND CURE BECAUSE I DON'T FEEL WELL SO I DON'T WANT TO BE HERE ANYWAY. LOOK, WE ALL HAVE -- I'LL BET EVERYBODY IN THIS ROOM HAS OR IS ON THE VERGE OF RECEIVING AN ADVANCED DEGREE AND THINK OF YOURSELF WHEN YOU'RE SICK. YOU DON'T HAVE HIGH HEALTH LITERACY, YOU'RE SICK. CLINICIANS JUST NEED TO TAKE UNIVERSAL PRECAUTIONS AND MOVE FORWARD IN THEIR DAY. IN PUBLIC HEALTH IT'S A MUCH DIFFERENT STORY I'M GOING TO ARGUE. WHY? BECAUSE WORK PUBLIC HEALTH A LOT AND CLINICAL SETTINGS A LOT AND RESEARCH A LOT. YOU CAN USE HEALTH LITERACY BUT USE IT AS THE BASIS FOR YOUR INTERVENTION. THE CON UNDERPINNING OF WHAT IT IS YOU'RE GOING TO DOP DON'T NECESSARILY WORRY ABOUT PUTTING A YARDSTICK UP TO THE POPULATION YOU'RE WORKING WITH AND SEEING HOW MUCH THEIR HEALTH LITERACY MOVED BUT IF YOU HAVE ROOM IN YOUR METHODOLOGY YOU CAN DO INTERESTING THING AROUND THE EDGES AND START TO WALK BACKWARDS INTO A TRUE HEALTH LITERACY ASSESSMENT SHOULD LOOK LIKE. FIRST I'LL TELL YOU WHAT CONCEPT I USE. I AM A STRONG PROPONENT OF THE COG WAY CHARTER FOR HEALTH LIT RI SA DEFINITION AND APPROACH. I'M ONE OF THE PEOPLE THAT WROTE IT BUT NOT THE ONLY PERSON THAT WROTE IT. IT WAS WRITTEN BY A VERY LARGE ROOM FULL OF PEOPLE OVER A LONG PERIOD OF TIME. IF YOU TAKE IT AS FAR AS I DO BUT ADMITTEDLY NOT EVERYBODY DOES, IT BECOMES A THEORY OF HEALTH BEHAVIOR CHANGE WHICH IS VERY DIFFERENT THAN A PLAIN LANGUAGE OR A CONSTELLATION OF SKILLS. IT BECOMES A ROAD MAP TO BEHAVIOR CHANGE BASED ON THOSE SKILLS BUT THE IMPORTANT PART IS THAT IT FULLY OUTLINES THAT IF PEOPLE CAN FIND INFORMATION OR YOU HELP THEM FIND IT. IF THEY UNDERSTAND THAT INFORMATION AND YOU HELP THEM UNDERSTAND IT, THE INTERVENTION'S DONE. THEN IF THEY CAN EVALUATE IT AND SEE HOW IT FITS IN THEIR LIVES THEN YOU H HELP THEM DO THAT VIA YOUR INTERVENTION. THEN THEY GO TO THE NEXT STEP WHICH IS TO GO TO THEIR SUPPORT STRUCTURE AND COMMUNICATE IT TO OTHERS THAT IF THEY DO ALL THOSE STEPS THEY WILL THEN BE MORE LIKELY TO USE INFORMATION AND CHANGE BEHAVIOR AND THAT'S THE OTHER NEAT THING ABOUT HEALTH LITERACY RIGHT NOW. EVERY DEFINITION IS E SENT WAIT A HIGH POT SISZ TO BE TESTED. H THAT'S A STRAIGHTFORWARD HYPOTHESIS TO MY MIND THAT THIS IS A LOGIC MODEL TO TAKE PEOPLE TO BEHAVIOR CHANGE. YOU WORK IN PUBLIC HEALTH, YOU WANT BEHAVIOR CHANGE. ANYTHING ELSE IS SHORT OF THE MARK. YOU CAN INFORM PEOPLE ALL YOU WANT BUT IF THEY'RE NOT GOING CHANGE THEIR LIFE, YOU HAVEN'T REALLY UH LIVED UP TO WHAT YOU NEED TO DO IN PUBLIC HEALTH. SAME THING VISUALLY. TWO SLIDES SAME INFORMATION. THERE'S THE MAP, LEADS TO BEHAVIOR CHANGE. YOU ALWAYS HAVE TO BE AWARE OF THE BROAD DOMAIN OF LITERACY ACTIVITY WHEN YOU DESIGN YOUR INTERVENTION, RIGHT? THE LANGUAGE HA HAS TO BE AT THE APPROPRIATE LEVEL, SCIENCE HAS TO BE UNDERSTANDABLE AND RELEVANT. YOU CAN'T IGNORE CULTURE F YOU DO, YOU FAIL RIGHT OFF THE BAT AND YOU NEED TO ENGAGE AND EMPOWER PEOPLE. THAT GETS BUILT INTO YOUR INTERVENTION SO THAT THIS IS HOW HEALTH LITERACY IS NOT HEALTH EDUCATION. HEALTH EDUCATION BY IN LARGE UNFORTUNATELY AND I KNOW THERE ARE EXCEPTIONS AND I KNOW THIS ISN'T ALWAYS THE TRUE BUT NO MAKE THE POINT, HEALTH -- EDUCATION SAYS IF WE CAN GET THAT INFORMATION IN THEIR BRAINS IN THE SAME WAY WE GOT IT, THEY WILL DO WHAT WE WANT THEM TO DO. HEALTH LITERACY DOESN'T REALLY GO THERE. IT SAYS UNDERSTANDING IS PART OF IT BUT IT'S ALL THE WAY THERE. UH YOU WANTED TO ASK. E I CAN'T. THIS ONE RIGHT HERE. SURE. OKAY. YOU'RE GOING TO SEE THIS ABOUT SEVEN MORE TIMES BEFORE WE'RE DONE. >> [LOW AUDIO]. >> YEP. SO IN VARIOUS WAYS YOU'RE GOING TO SEE THOSE WORDS A LOT. I KNOW, THAT'S WHY I'M TELLING YOU. WE'RE WORKING TOGETHER ON THIS ONE HERE. THE OTHER THING YOU CAN DO AND I ENCOURAGE TO YOU DO THIS, I GIVE YOU A REALLY COMPLICATED WEB ADDRESS BUT YOU DON'T NEED IT. GO TO YOUR FAVORITE SEARCH ENGINE, ENTER IN CALVARY CHARTER HEALTH LITERACY, IT'LL TAKE YOU RIGHT TO IT. YOU CAN ADD YOUR NAME AS A CO-AUTHOR. WHY? BECAUSE WE'RE HEALTH LIT VA IS I, ENGAGE PEOPLE EARLY AND OFF. HERE'S AN EXAMPLE OF I'M GOING THE FIT INTO AND DO THEM QUICKLY BUT I'M GOING THE FIT THEM IN ANY WAY. THIS IS A PROJECT THAT WE DID RECENTLY IN PERU. WE TOOK HEALTH LITERACY, THE APPROACH I DISCUSSED, COMBINED IT WITH METH OF SOCIAL INTERVENTION CALLED THE PETER OF THE OPPRESSED. [INDISCERNIBLE] -- SO THE DIFFERENCE BETWEEN WA WE CALL FEEDER FOR HEALTH AND FEEDER OF THE OPPRESSED IS THAT WE BELIEVE THERE ARE SOME THINGS THAT ARE DISTINCTLY TRUE AND THAT'S CALLED EVIDENCE-BASED MEDICINE. THE COMMUNITY CAN'T ALWAYS BE RIGHT. THAT'S A HUGE DIFFERENCE BETWEEN THE METHODOLOGY'S ESSENTIALLY WHAT HAPPENS, YOU PROVE AN OPEN ENDED PERFORMANCE ON STAGE IN FRONT OF A COMMUNITY. THEY INTERACT WITH THE SCRIPT, LIVE, IN PERSON, AND PROPOSE SOLUTIONS TO THE ACTORS TO RESOLVE THE DILEMMA THAT THE STRUCTURE OF THE NARRATIVE PRESENTS. SO IT'S A NARRATIVE-BASED APPROACH. LITERACY, AN EMPOWERING TOOL THAT HELPS A COMMUNITY IDENTIFY A PROBLEM, SEE IT IN THEMSELVES, COMMUNICATE BACK TO THE ACTORS HOW THEY COULD POSSIBLY SOLVE IT IN THAT COMMUNITY AND THEN YOU TRY IT OUT ON THE STAGE FIRST SO IT'S A SAFE PLACE TO TRY OUT NEW IDEAS INCLUDING IDEAS THAT MIGHT NOT BE CULTURALLY ACCEPTABLE BECAUSE IT'S A PLAY, IT'S ALL FICTION. AND THE LOGIC MODEL FOR THIS IS YOU DO FORMATIVE RESEARCH, HEALTH LIT RA ARE IS I, ENGAGE PEOPLE EARLY AND OFF IS ALMOST A REQUIREMENT THIS THAT YOU HAVE TO DO FORMATIVE RESEARCH BEFORE YOU LAUNCH AN INTERVENTION. WE INTRODUCE THE INTERVENTION, THEATER FOR HEALTH, PAYING ATTENTION TO THE FIND MENTAL, SCIENCE THE TIFK, CULTURAL LITERACIES IMBEDDED AND AS A HYPOTHESIS GOES, I TOLD YOU YOU WERE GOING TO SEE THIS AGAIN, RIGHT T COMMUNITY IS BETTER ABLE TO FIND, UNDERSTAND, EVALUATE, COMMUNICATE AND USE INFORMATION TO MAKE INFORMED DECISIONS BOUT THEIR OWN LIVES. DOES IT WORK? WELL, LET'S LOOK, RIGHT? BECAUSE OUR OUTCOMES SPECIFIED IN ADVANCE WERE ACTUALLY THE LAST BULLET THERE CHVS THE PRESENCE OF E. COLI OR WIS TIER YOO IN FOOD PREPARATION AREAS. ALMOST THE WHOLE COMMUNITY KNEW ABOUT THE PERFORMANCES BEFORE WE WERE DONE. E WE DID A BASELINE AND POST COMMUNITY-WIDE. ALMOST ALL OF THEM DEMONSTRATED KNOWLEDGE GAINS IN ONE OR SEVERAL AREAS OF KNOWLEDGE RELATED TO HOUSEHOLD HYGIENE. I'M JUST LUMPING SOME INDICATORS TOGETHER TO SAVE TIME. ALMOST ALL OF THEM SAID THE PERFORMANCES WERE RELEVANT TO THEIR LIVE WHICH IS WE TAKE AS AN TAND YEA KAY TOR OF THEY EVALUATED THE INFORMATION AND SAW WHAT WAS RELEVANT. THERE WAS AN INCREASE PREAND POST AND A NUMBER OF PEOPLE WHO SAID I HAD A CONVERSATION ABOUT HOUSEHOLD HIGH E GENE AND RELATED BEHAVIORS OVER THIS THREE MONTH PERIOD OF TIME SO THEY'RE TALKING ABOUT YOU. DID YOU CHANGE YOUR BEHAVIOR HALF OF THE COMMUNITIES SAID YES WE DO. THERE WERE GIVEN A NUMBER OF BEHAVIORS THAT THEY SAID THEY COULD HAVE CHANGED AND THEY CHANGED. SOME CHANGES ONE, SOME CHANGES SEVERALS, OTHER REPORTED THEY'D WITNESSED A LOT OF THINGS IN NAR COMMUNITY INCLUDING IN THEIR HOUSEHOLD. AS A RESULT, THERE YOU GO, YOU GET ABOUT A 30% DECREASE IN THE PRESENCE OF E. COLI AND WISTERIA. THIS WAS A SHANTYTOWN OF THE POOREST DEGREE SO TO GET ANYTHING CLEAN IN THIS COMMUNITY MEANT SOMEONE WORKED HARD BECAUSE MOST OF THE HOUSER WERE REALLY OPEN TO THE NATURAL ENVIRONMENT OP A STEADY BASIS, DIRT FLOORS, ANNUALS COMING IN AND OUT, RAIDING SOME ANIMALS WITHIN THE HOUSEHOLD, NO FORMAL SEWAGE, WATER DELIVERED IN TRUCKS ALREADY CONTAMINATED. YEP. PERU. THIS WAS IN PERU SO IT WAS ALL CONDUCTED IN SPAN NUSH. ON THE OUTSIDE SKIRTS OF LIMA UP IN THE HILLS. SO THOSE OF YOU WONDERING HOW TO DO THINGS LIKE THIS, THIS WAS ACTUALLY AN UNFROM ANDED INTERVENTIONING IN A COMMUNITY FUNDED BY THE GLOR ROKS COMP RAUGS WHO ALSO CONTRIBUTED [INDISCERNIBL [INDISCERNIBLE] TO THIS DAY, NO ONE KNOWS CLOROX FUNDED THIS. THANKS TO THEM FOR THEIR COMMUNITY OUTREACH EFFORTS. BUILT INTO THE METHODOLOGY WAS A SERIES OF HEALTH REPORTS JUST TO SEE WILL THE MODELS HOLD TOGETHER ANY TIME WHOOR? THESE ARE THE CORRELATIONS OF THE CHANGE PREE TO POST. YOU CAN SEE THE WHOLE MODEL IS STRONGLY AND POSITIVELY CORRELATED IN THE CHANGE OF THE NUMBER OF PEOPLE THEY TALKED TO ABOUT HOUSEHOLD HYGIENE AND HEFL EFFICACY. THE CONFIDENCE THAT THEY COULD ACTUALLY MAKE A A XHANG CHANGE IN THE COMMUNITY. THIS IS THE FIRST CARD SCIENTIFIC EVIDENCE THAT THE CALVARY CHARTER MODEL OF HEALTH LITERACY WORKS. YOU CAN E SEE THIS SCALE HELD TOGETHER VERY WELL. SO ANOTHER QUICK EXAMPLE, THIS IS [INDISCERNIBLE] PROGRAM. THIS IS A SHORT VERSION OF THE LOGIC MODEL, ESSENTIALLY. WE START WITH HEALTH LITERACY, WE TAKE AN INTEGRATIVE APPROACH TO HEALTH: MIND, BODY, SPIRIT, TO GET TO PREVENTION AND IN PARTICULAR PRESENT CHRONIC DISEASE. THOSE ARE THE GOLDEN TOOLS OF THIS PROGRAM. THIS IS THE SORT OF FORMAL LOGIC MODEL. THERE'S A LOT ON HERE BUT ESSENTIALLY JUST LIKE BEFORE WE START WITH FORMATIVE RESEARCH, LEARN ABOUT THE POPULATION WE'RE TRYING TO REACH, WE TAILOR THE INTERVENTION TO MATCH THAT COMMUNITY. THEN WE PUT THEM BOTH THROUGH GROUP SESSIONS TOGETHER, TALKING, LECTURES, TALKS ABOUT SPENS OF PURPOSE AND WE ACCOMPANY THAT WITH MINIMUM OF FOUR ONE-ON-ONE CONSULTATIONS FOR AN HOUR. WE'RE QUADRUPLING CONSULTATIONS. IT'S AGROULT THIS RANGE OF O SPECIALS -- WHENEVER WE SAY SPIRITUALITY IN A COMMUNITY PEOPLE THINK WE'RE TALKING ABOUT RELIGION SO WE'VE GONE TO SENSE OF PURPOSE, IT WORKS AS A PHRASE. INTEGRATED HEALTH MEDICINE, SOCIAL UH SUPPORT. AL OF THAT'S BUILT INTO HERE. IT INCLUDES LIKE A GROCERY STORE STORE AND YOU GOT TO GET UP AND MOVE YOUR BODY A LOT AND TRY TO MAKE IT A HABIT. AS THE HYPOTHESIS GOES WE IMPROVE THEIR HEALTH LITERACY, THEY CHANGE THEIR BEHAVIOR, WHEN WE DO ENOUGH PEOPLE IN A COMMUNITY IT STARTS TO PERCOLATE UP AND WE IMPROVE THE OVER YAWL COMMUNITY OF HEALTH WHICH THE HEALTHIER COMMUNITY ALSO MEANS MORE EFFECTIVE HEALTH CARE SYSTEM. LOW AND BEHOLD. WE DO DESIGN MOST OF OUR PROJECTS TO HELP INFORM WHAT THE HEALTH CARE SYSTEM SHOULD ACTUALLY LOOK LIKE TO BE A TRUE HEALTH CARE SYSTEM. AND NOT IN MY BOSS'S WORDS A SIX-CARE SYSTEM. THIS IS REALLY WHAT IT LOOKS LIKE. THERE'S PLENTY OF MATERIALS, PLENTY OF SUPPORT. WE DO A PRE, A POST AND PLUS ONE YEAR E EVALUATION ON THIS PROGRAM. WE DO WAIT FOR A POST PLUS THREE MONTHS TO DO BLOOD WORK AGAIN. WE DRAW BLOOD FROM ALL PARTICIPANTS THREE TIMES. JUST LIKE IN RUE WE'RE NOT STOPPING AT UNDERSTANDING OR KNOWLEDGE, WE'RE GOING TO -- RIGHT, THE GOLD RING -- WHICH IS PHYSICAL STATUS IN A WAY THAT PEOPLE CAN'T LIE, DECEIVE THEMSELVES, YOU'RE NOT CHANGING YOUR BLOOD WORK JUST BECAUSE YOULY ABOUT IT A LOT. THERE'S ED MAYBE YOU CAN UH BUT NOT AS MUCH AS WHAT WE'RE SHOWING. NOITH RIGHT NOW THIS HAS BEEN IN A HOST OF DIFFERENT CULTURES ACROSS THE UNITED STATES. WE'VE DONE IT IN PUERTO RICAN COMMUNITY. WE'VE GOT TWO PROGRAMS UP AND RUNNING IN TUCSON, CLEVELAND AND VERY SMALL TOUB YOU HAVEN'T HEARD OF UNLESS UH YOU GREW UP IN NORTH CENTRAL MISSOURI. IT'S A LOVELY PLACE BUT IT'S SMALL. DID IT WORK? SO THIS IS A GRAB BAG, ONCE AGAIN. ATTENDANCE OVER 60%. TO I WISH IT WAS BETTER? YES, AM I COMPLAINING? NOT REALLY. PEOPLE HAVE BUSY LIVES AND THIS IS THREE HOURS ONE TIME A WEEK SO IT'S A LONG SESSION. UNDERSTAND. AGGREGATING SOME KNOWLEDGE QUESTIONS AN THE EVALUATION TOGETHER WE'VE GOT 20% N INCREASE IN KNOWLEDGE. E EVALUATE N SOME CITIES IT'S 9%, OTHERS IT'S RUNNING UP IN THE 20s. WE ASK A LOT OF QUESTIONS. THIS IS A VERY BIG METHODOLOGY. IT TAKES PEOPLE AN HOUR TO GO THROUGH IT, PRE, POST, AND BASELINE BUT WE THINK IT'S WORTH IT. COMMUNICATE. WE ASK PEOPLE, YOU SHARING INFORMATION ABOUT THIS PROGRAM WITH ANYBODY? THE DATA STARTED COMING BACK IN AND THERE'S LIKE GOT TO BE A TYPO, EIGHT-AND-A-HALF OTHER PEOPLE ON AVERAGE THEY SAY THEY'RE SHARING IT WITH. I'M LIKE WHAT ARE THEY DOING? THEY HAVE GOT FAMILIES OF FOUR, FIVE, SIX, MAYBE SEVEN, WHY ARE WE GETTING UP TO 8.5? TURNS OUT PEOPLE ARE TAKING THE PROGRAM ON WEDNESDAY AND THEY'RE GOING TO THEIR CHURCH ON SUNDAY AND THEY ARE STANDING UP AND TELLING THE ENTIRE CONGREGATION WHAT THEY LEARNED IN THE HEALTH CLASS THIS WEEK. SO WE HAD PEOPLE VALIDLY THE TELLING US, I'M SHARING THIS WITH ABOUT 150 PEOPLE. YOU KNOW WHAT, YOU'RE RIGHT, YOU DID. SO THERE IT IS. 8-AND-A-HALF OTHER PEOPLE. ARE THEY USING IT? WE ASKED A LOT OF BEHAVIOR QUESTIONS OUR SELF-REPORTED BUT WE'RE FINDING SAME RESULTS CONSISTENTLY ACROSS ALL COMMUNITIES. MY FAVORITE SOMEONE THE DROP IN SODA CONSUMPTION OF 37% ON AVERAGE. SOME PEOPLE WILL LIE AND SOME PEOPLE WILL INFLATE BUT THIS IS STRONG ENOUGH I THINK WE CAN GET PAST ANY WORRIES ABOUT SELF-REPORTED BEHAVIOR. WHY? BECAUSE WHEN WE LOOK AT THE BLOOD INDICATORS WE'RE SEEING ACTUAL CHANGE BOTH STATISTICALLY CHANGE IN HEMOGLOBIN, CHOLESTEROL AND C E REACTIVE PROTEINS. ADDITIONALLY WE RUN A CIVIC ENGAGEMENT SCALE PAST PEOPLE JUST TO SEE ARE YOU REALLY GOING TO BE HEALTHIER AND HAPPIER AND THEN MORE ENGAGED IN YOUR COMMUNITY? IT'S A LITTLE EARLY ON THIS BUT WE'RE STARTING TO SEE A REAL INCREASE IN PEOPLE SAYING I'M GOING TO MORE MEETING, I'M GOING POLITICAL EVENTS, I'M GOING TO CIVIC ORGANIZATIONS AND I'M TALKING. >> [LOW AUDIO]. >> NO. WE HAVEN'T. SHE THE MAYOR OF NEW YORK CITY BUT WE WORK IN THE SOUTH BRONX AND THAT OFFICE AND THAT COMMUNITY ARE WORLDS APART IN REALITY. YEP. >> [LOW AUDIO]. >> THAT'S RIGHT. WE AGREE. >> [LOW AUDIO]. >> THE NEXT TWO STEPS OF THE LOGIC MODEL. WE DON'T STOP AT UNDERSTANDING, WE KWO TO EVALUATING -- GO TO EVALUATING AND COMMUNICATING. A KNOWLEDGE-ONLY PROGRAM WOULD JUST ASK, HAVE WE IMPROVED YOUR UNDERSTANDING PREPOST OF LET'S JUST SAY WHAT CHOLESTEROL MEANS? CAN YOU GIVE ME THE RIGHT DEFINITION? CAN YOU GIVE ME THE APPROPRIATE AL YOUS THAT MY BODY SHOULD BE @. THAT'S FOUNSING, IT'S KNOWLEDGE TRANSFER AND IT'S FINE. THIS IS KNOWLEDGE TRANSFER. STORY: IN INNER CITY CLEVELAND A WOMAN'S IN THE PROGRAM, SINGLE MOM, LOW INCOME, DROPPED OUT OF HIGH SCHOOL, TWO DAUGHTERS, TEENAGERS, THAT'S IMPORTANT. NUTRITION PROGRAM COMES ON AND SHE'S LISTENING TO INFORMATION AND UNDERSTANDING EVERY LITTLE BIT OF IT AND SHE'S SUCKING IT UP AND WRITING IT DOWN AND TAKING NOTES AND GETTING EXCITED AND THINKING OF ALL THE THINGS THIS MEANS TO HER AND DOING A MENTAL INVENTORY SHE'S STARTING TO EVALUATE THIS INFORMATION BECAUSE SHE'S DOING AN INVENTORY OF HER FRIDGE AND PANTRY. WHEN SHE GOES HOME SHE BRINGS OVER THE TRASH KAN AND STARTING THROWING OUT ALL THE UNHEALTHY FOOD CHOICES AND INTO THE TRASH CAN. YOU WANT TO SAY, HALL HALL LIEU YEAH BECAUSE THERE'S BEHAVIOR CHANGE. GUESS WHAT HAPPENED THEN? THE WHAT? THE DAUGHTERS CAME HOME, THE TWO TEENAGE DAUGHTERS WHO HAVE 50% IF NOT MORE OF THE POWER IN THAT HOUSEHOLD AND WHEN THEY THAT SAME REE FRIDGE RAY TOR AND PANTRY THE FIRST WORDS OUT OF THEIR MOUTH WAS MOM, THERE'S NOTHING TO EAT, MORE OR LESS. AND THAT TURNED INTO A REAL FAMILY RIFT AND THE NEXT WEEK WHEN THE PROGRAM TEAM FOUND OUT ABOUT THAT AND HOW MUCH STRESS THAT HAD CAUSED ON THE MOM AND DAUGHTERS -- IT WAS A SERIOUS SIGNIFICANT EVENT IN THEIR LIVES. THEY SAID COME ON THE DAUGHTERS CAN SIT IN ON THE PROGRAM, THEY NEED TO HEAR THIS INFORMATION TOO AND THAT RIFT WAS REPAIRED BUT IF YOU DON'T DO THAT CRITICALLY IMPORTANT COMMUNICATE STEP -- ALANON FIGURED THIS OUT A LONG TIME AGO. IF YOU WANT PEOPLE TO CHANGE BEHAVIOR THEY NEED SOME KIND OF SOCIAL SUPPORT. THE ONLY WAY I KNOW TO GET SOCIAL SUPPORT IS TO TALK TO PEOPLE AND SAY HERE'S WHAT I'M THINKING ABOUT DOING. WHAT DO YOU THINK? CAN WE CHANGE THE FOOD IN OUR HOUSE TO A HEALTHIER SELECTION? AND IF UH YOU DON'T DO THAT, YOU MIGHT MAKE A BEHAVIOR CHANGE ON MONDAY BUT IT'S NOT LIKELY TO STICK BY THE NEXT WEEK. SO INFORMATION IS WE LIKE TO SAY REQUIRED FOR BEHAVIOR CHANGE BUT NOT SUFFICIENT FOR BEHAVIOR CHANGE AND THAT'S WHAT THE LOGIC MODEL TRIES TO H LAY OUT. THESE REALLY CLEAN STEPS OF HOW TO MOVE PEOPLE TO A SUSTAIN ABLE BEHAVIOR CHANGE, FIND, UNDERSTAND, EVALUATE, COMMUNICATE AND USE. YES, MA'AM. >> [LOW AUDIO]. TWO SEPARATE INTERVENTIONS. THIS LAST ONE IS IN U.S. SO FAR PERU WAS THE START OF A NEW METHODOLOGY AN INTERVENTION WHICH WE OF COURSE WILL WANT TO SCALE UP AND REPLICATE. >> [LOW AUDIO]. >> SURE. IT'S THE 36 HOURS OF PROGRAMMATIC SESSIONS AS A GROUP AND THE FOUR HOURS OF ONE-ON-ONE CONSULTATION WITH EACH HEALTH CARE PROFESSIONAL. IMAGINE IF WE WERE HERE THREE HOURS ONCE A WEEK FOR 12 WEEKS. BY THEN YOU KNOW EACH OTHER PRETTY WELL AND YOU JUST BECAME EACH OTHER'S SOCIAL SUPPORT STRUCTURE WHEN THE FOCUS IS ON BEHAVIOR CHANGE. THAT'S HOW THAT INTERVENTIONS WORK BUT THEY'RE BOTH BASED ON THE SAME CONCEPTUAL MODEL, JUST VERY DIFFERENT APPLICATIONS OF IT. SO THAT'S PUBLIC HEALTH, RIGHT. WHAT YOU CAN DO IS USE HEALTH LITERACY AS A BASIS FOR YOUR INTRERER INTERINTENTION, BUILD IN PRELIMINARY STUDY OF THE LOGIC STUDY. I HAVE ANY BIAS, THIS ONE WORKS. IT'S PRELIMINARY DATA AND SO WE'RE GOING TO MOVE TO RESEARCH NOW. THAT DATA SHOULD BE SEEN AS THE BASIS FOR THE APPROACH TO BUILD AN ACTUAL COMPREHENSIVE MEASURE BASED ON THE FRAMEWORK BECAUSE WE CAN SEE IT'S STARTING TO WORK AND WHAT DO WE NEED TO DO? HERE I COME FROM ARIZONA TO NIH AND SAY LET'S USE THE SCIENTIFIC METHOD. [LAUGHTER] THAT'S A SURPRISE, E YES. >> [LOW AUDIO]. >> IN FACT WE DO ALL OF THAT, SO THANK YOU. ON THE LIFE ENHANCEMENT PROGRAM I JUST DIDN'T WANT TO GET TOO INTO EACH PROGRAM, BUT WE DO GO BACK INTO THE ENTIRE EVALUATION AGAIN A YEAR LATER BUT THAT SOCIAL SUPPORT STRUCTURE TURNS INTO SOMETHING THAT WE DON'T HAVE A NAME FOR REALLY. WE CALL IT REUNION BUT IT'S DIFFERENT IN EVERY COMMUNITY. SOMETIMES THEY'LL FORM A WALKING CLUB. SOMETIMES THEY'LL GET TOGETHER AND DANCE AND BRING FOOD. WHATEVER FITS THAT CULTURE, THAT'S WHAT THEY DO. THE PLUS ONE YEAR DATA BECAUSE WE DON'T REQUIRE PEOPLE TO DO THE EVALUATION, WE ASK THEM TO -- ONE YEAR WE GET THE SAME RESULTS BUT IT'S A SMALLER END WHICH YOU TAKE THAT ONE OF TWO WAYS IT'S WORKER FOR PEOPLE WHO COME BACK OR O IT'S WORKING FOR OTHER PEOPLE AND THEY DON'T CARE TO COME BACK BECAUSE THEY'RE BUSY. WE CAN LOOK AT THAT DOWN THE ROAD. IN EITHER CASE, RIGHT, LET'S USE THIS METHOD TO SEE HOW TO ANSWER THIS PERFECTLY VIABLE AND VALID QUESTION AND IT'S FUNNY THAT THE BEST EXPLANATION OF IT CAME FROM BIOLOGY FOR KIDS, RIGHT. WHY NOT 'CUZ THEY KNOW HOW TO DO THIS, RIGHT? HYPOTHESES, EXPERIMENT, REFINE IDEA, DO IT AGAIN, COME UP WITH SOMETHING YOU THINK THAT WORKS ALONG THE WAY IN HEALTH LITERACY TERM TERMS ESPECIALLY. IT'S VERY IMPORTANT TO KNOW THIS DIFFERENCE. THYME I'M TALKING ABOUT A FULL FLEDGED MEASUREMENT TOOL. EVIDENCE-DRIVEN. THAT'S THE ONLY WAY WE'RE GOING TO KNOW WHAT WE DON'T KNOW FROM THE CURRENT EVIDENCE WHICH IS ACTUALLY HOW HEALTH LITERACY WORKS. I MEAN I JUST SHOWED YOU MY ASSUMPTIONS, MY DATA, WHAT I THINK IT WORKS BUT IF YOU LOOK AT THE DATA, YOU HAVE NO CLUE YOU JUST KNOW THERE'S AN ASSOCIATION. NONE OF THE TOOLS WERE BUILT TO TEST THE DEFINITION OF HEALTH LITERACY. NONE OF THEM REALLY INCORPORATE BEHAVIOR CHANGE. IN PUBLIC HEALTH, WHAT ELSE SHOULD E WE CARE ABOUT? BEHAVIOR CHANGE IS HOW YOU GET THE HEALTH STATUS CHANGE AND THAT'S WHAT WE ALL SHARE IN COMMON. MANY OF THEM ARE CULTURALLY INAPPROPRIATE. NONE OF THEM LOOK AT PREVENTION IN NO WAY SHAPE OR FORM DO THEY ADDRESS PREVENTION. I MYSELF WOULD BE VERY AFRAID TO SORT OF MRIEK BASE AN INTERVENGE ON THE GOAL OF INCREASING [INDISCERNIBLE] AND IN FACT I DON'T KNOW THAT ANYBODY'S DONE THIS, RIGHT? BECAUSE A REALM INTERVENTION IS WE'RE GOING TO TEACH UH YOU HOW TO PRONOUNCE NEEZ WORDS CORRECTLY. OKAY, GIST CAN'T GET BEHIND THAT. PART OF REASON PEOPLE ARE NOT WORKING IS PEOPLE ARE AWARE IT'S AN ARTIFICIAL TOOL NOT RELEVANT MY LIFE SO THEY DON'T WANT TO PARTICIPATE IN WHY YOU ASKING ME THESE QUESTION AND NOT ANYBODY ELSE? NONE OF THEM INCLUDE SPOKEN COMMUNICATION LITERACY SKILLS. THEY WERE ALL BUILT FOR CLINICAL RORLD. WE SHOWED YOU SOME OF THE WORDING IS AMBIGUOUS. s THERE MIGHT BE A NUMBER OFS WAYS THEY'RE BIASSED. FINALLY YOU CAN'T ADD THEM ALL UP. YOU CAN'T MAKE A LOT OF SENSE ACROSS THE STUDIES. THERE HAVE BEEN SOME WELL-DONE STUDIES THAT HAVE DRIVEN ADVANCEMENT OF THE FIELD AND IT'S TIME WE MOVE FORWARD AND DO SOMETHING NEW AND ADVANCE THE FIELD A LITTLE FURTHER BECAUSE THEY'VE PROVEN THIS, THIS IS UNIVERSALLY ACCEPTED THAT HEALTH LITERACY IS AN INDEPENDENT PREDICTOR OF ALL OF THESE POOR HEALTH OUTCOMES BUT THE STUDIES CAN'T TELL YOU WHY OR NECESSARILY WHAT TO CHANGE TO MAKE THIS GO AWAY TODAY AND TO ME THAT'S THE MORE IMPORTANT PART. SO IT GOES ALL THE WAY DOWN FROM POOR OVER OUR HEALTH, LESS LIKELY TO GO TO A DOCTOR WHEN YOU NEED TO. BOOM, BOOM, BOOM TO THE BIG ONE AT THE BOTTOM, PEOPLE DIE EARLIER. THESE TOOLS HAVE SUCCESSFULLY SHOWN US THAT, BUT -- AND I'M JUST ABOUT DONE -- IT'S TIME TO MOVE FORWARD. IN THE RESEARCH DOMAIN, BUILD A TOOL THAT TELLS US HOW LITERACY ACTUALLY WORKS. YOU'VE ALREADY WITNESSED THAT THE NON-PEER REVIEWED COMMUNICATION IN THE FIELD INDICATES THESE TOOLS AREN'T SUCCESSFUL AND WE NEED SOMETHING NEW, SO THAT'S WHY I SAY IT'S TIME TO MOVE FORWARD AND NOW IS AS GOOD A TIME AS ANY BUT NOW IS A REALLY IMPORTANT TIME, RIGHT. WE KNOW WITH THE GROWTH CLIMATE DISEASE THAT SELF-CARE AND SELF-MANAGEMENT IS EVEN MORE IMPORTANT AND PREVENTION EASTBOUND MANY MORE DESIRED. NOTHING BUT A HEALTHIER PUBLIC WILL BE ABLE TO DO THAT TO REACH THOSE GOALS. YOU'RE NOT GOING TO ENFORCE THIS. PEOPLE HAVE ADOPT BEHAVIORS AND STICK TO THEM AND THAT REQUIRES HEALTH LITERACY. WHY ELSE? WE HAVE THE ACA. WE HAVE JUST CREATED A BRAND NEW SYSTEM TO NAVIGATE THAT WE DON'T REALLY KNOW GOING TO LOOK LIKE YET BUT AISLE BET YOU ONE THING FOR SURE, IT'S GOING TO BE COMPLEX. ALL RIGHT. AND IT ALSO ON THE UPSIDE PRESENTS A DONE OF OPPORTUNITIES FOR HEALTH LITERACY BASED INTERVENTION. FOR THIS FIELD THE ACA IS PROBABLY THE BEST LEGISLATION WE MAY EVER SEE, SO IF WE DON'T SEE THE OPPORTUNITY AND ADVANCE THIS IN A SCIENCE-BASED COMPREHENSIVE METHOD NOW, WE'RE GOING MISS THE BOAT AND THAT IS SOMETHING I'D JUST A AS SOON AVOID. WE NEED A NEW MEASURE. WE DON'T HAVE TO THROW ALL THE OLD STUFF AWAY, WE D K DO WHAT WE DID WITH THE CALVARY CHARTER. ALL WE DID WAS BRING THE NICE COMPONENT THAT WORKED INTO EXISTENCE AND CALL IT A CALVARY CHARTER. YOU COULD SAY WE PLAGIARIZED FROM IT BECAUSE WE DID TAKE WORD-FOR-WORD IN SOME OF THE THINGS. KEEP WHAT WORKS, GET RID OF STUFF THAT DOESN'T, BASE A MODEL AND YOU'VE GOT IT. BUT WE NEED TO DO THIS WITH A RANDOM REPRESENTATION OF THE POPULATION OF THE UNITED STATES AND THAT'S NOT CHEAP. SOMEONE ORGANIZATIONALLY NEEDS TO STEP UP AND SAY, YES, WE AGREE THAT'S A PRIORITY, WE'RE GOING TO MAKE THAT HAPPEN AND HOPEFULLY AND SO AND THE OTHER THING THAT NEEDS TO BE BUILT INTO THE PROCESS IS A VALIDITY CHECK IN A LOT OF CULTURES TO MAKE SURE WHEN YOU MOVE THE BAR ON THIS HEALTH LITERACY MEASURE IT CORRELATES WITH HEALTH IMPROVEMENT, THAT IT'S NOT JUST A TEST AND IT ACTUALLY HAS REAL MEANING AND THAT IS EVERYTHING THAT THAT E I CAME HERE THE TO SAY. [APPLAUSE] I'M HAPPY TO LISTEN NOW. GARY IS GOING TO RUN THE SHOW. IF I DON'T LIKE IT THEN I'LL PASS IT BACK TO HIM. >> THANK YOU VERY MUCH SH ANDREW. WHAT I'M GOING TO DO IS RESPOND TO WHAT YOU HAD TO SAY AND GIVE YOU MY TAKE ON SOME OF THESE THINGS AN OPEN IT UP FOR CONVERSATION. I'VE GOT TO LET YOU KNOW THAT I FEEL AMBIVALENT A LITTLE UNSETTLED. WHILE I'M REALLY ATTRACTED TO TO WHOLE ISSUE OF HEALTH LITERACY BECAUSE IT MAKES SO MUCH SENSE TO ME THAT PEOPLE ARE JUST NOT GETTING IT AND THAT'S A CRITICAL PART OF COMMUNICATION PROCESS, I WORRY THAT THE FOCUS ON HEALTH LITERACY MASKS A MUCH LARGER SET OF ISSUES ABOUT THE COMPLEXITY OF THE COMMUNICATION PROCESS. AND SO I WANT TO TRY TO USE HEALTH LITERACY AS AN ENTRY POINT TO EXAMINE THE ISSUE OF EFFECTIVE HEALTH COMMUNICATION MORE BROADLY, BUT I DON'T WANT TO GET CAUGHT UP IN LITERACY AS THE ONLY PIECE. IT SEEMS TO ME THAT LITERACY IS ONE PART AND IF YOU ONLY LOOK AT THE WORLD THROUGH THE LITERACY PIECE YOU'RE MISSING SO MUCH ELSE. I THINK OF THE OLD ADAGE ABOUT THE BLIND MAN TRYING TO UNDERSTAND AN ELEPHANT BY FEELING THE TRUNK TOR LEFT LEG AND THIS IS WHAT AN ELEPHANT IS AND I HAVE A FEELING THAT IF WE LOOK AT HEALTH COMMUNICATION FROM THE HEALTH LITERACY THING WE SEE ONLY THAT PART AND THE REASON WHY I THINK THAT WE DON'T UNDERSTAND WHY IT THERE'S THIS CONNECTION BETWEEN HEALTH LITERACY AND ALL THESE DIFFERENT OUTCOMES, WE SEE THERE'S A RELATIONSHIP IS BECAUSE THERE'S A LOT MORE GOING ON. SO WHAT I WANT TO DO IS COMPLEX FIE -- IS THAT A WORD? I WANT TO COMPLEX FIE OUR THINKING ABOUT THE PROCESS AND RECOGNIZE THAT OUR ABILITY TO UNDERSTAND AT LEAST ONE PIECE OF THE PROCESS BUT THERE'S A LOT OF OTHER PIECE THERE IS AS WELL. OUR MOTIVATION, OUR CULTURAL BACKGROUND, OUR ORIENTATION, OUR RELATIONSHIPS, OUR PLACE LIFE. A WHOLE RANGE OF FACTORS ARE HISTORY WITH HOW WE INTERACT, THE DIFFERENT CHANNELS THAT WE USE TO GET INFORMATION. SO I WANT TO LOOK AT THIS IN A MUCH BROADER WAY. I DON'T THINK THAT A BETTER MEASURE HEALTH LITERACY IS GOING THE TO SOLVE OUR PROBLEM AND ALLOW US TO COME UP WITH BETTER HEALTH PROGRAMS ALONE. I THINK IT WILL BE ONE PIECE OF A LARGER MORE COMPREHENSIVE APPS. THE THING WE GOTq ARE VARIETY OF OTHER FACTORS. FIRST OF ALL I THINK WE HAVE TO UNDERSTAND THE WHOLE ISSUE OF HEALTH LITERACY. WE'VE BEEN THINKING ABOUT READING LITERACY WHICH IS REALLY A VERY SMALL PIECE OF WHAT GOING ON IN HEALTH COMMUNICATION, PARTICULARLY AS WE MOVING AWAY FROM A TEXT-BASED VIEW OF THE WORLD TO A MORE INTERACTIVE. IS IT LISTENING LITERACY, SPEAKING, SCIENTIFIC? YES, IT'S ALL OF THOSE THINGS. I THINK WE NEED TO LOOK AT LITERACY IN A MORE COMPLEX WAY. MOST OF THE TOOLS THAT HAVE BEEN DEVELOPED TO EVALUATE HEALTH LITERACY ARE GOOD FOR RESEARCH BUT ARE NOT SO GREAT FOR PRACTICE BECAUSE THEY'RE CUMBERSOME. THEY TAKE A WHILE. AND THEN WE COULDN'T UNDERSTAND WHETHER OR NOT -- AND I THINK ANDREW POINTED TO THIS, WHERE THE LITERACY IS A TRADE THAT PEOPLE HAVE OR A STATE THEY ARE APART OF BECAUSE OF THE SWAGSZ SITUATION THEY'RE IN? MY THINKING IS HEALTH CARE SYSTEM OFTEN CAUSES PROBLEMS WITH HEALTH LITERACY BECAUSE IT IS SO MIND NUMBING AND FRIGHTENING THAT WE GET CONFUSED. WHAT'S GOING ON HERE? THEN THE PROCESS OF BEING CIRCUMSTANCE MAKES IT MORE DIFFICULT TO UNDERSTAND. SO IF WE'RE NOT MEASURING LITERACY AT THE POINT WHERE PEOPLE ARE HAVING THE PROBLEM WE'RE GOING BE MISSING THE BOAT. SO WHAT I WANT TO RECOMMEND IS A PROCESS OF GETTING TO UNDERSTAND THE COMMUNICATION PROCESS MUCH MORE FULLY. UNDERSTANDING BETTER PEOPLE WHO WE'RE COMMUNICATING WITH AND BUILDING MORE ACTIVE CONNECTIONS WITH THEM. THE LAST LECTURE NANCY AND LINDA TALKED ABOUT USER CENTER DECYBERAND PARTICIPATORY APPROACHES TO DEVELOP HEALTH COMMUNICATION MATERIALS. I LOVE THAM APPROA -- THAT APPROACH OF WORKING TOGETHER BECAUSE IT'S RELATIONAL. THAT'S ONE THING WE NEED TO DO WITH HEALTH LITERACY IS MAKE IT MORE CONNECTED. HEALTH LITERACY IS NOT JUST A RECEIVER-ORIENTED THING. IT HA HAS A LOT TO DO WITH THE WAY WE'RE COMMUNICATING. IT'S A RELATIONSHIP BACK TOR. TOO OFTEN WE'RE THINKING ABOUT HEALTH LITERACY A S A PROBLEM THAT THESE POOR PEOPLE HAVE. RATHER THAN RECOGNIZING THIS IS PART OF A BAD SPROEZ OF PROVIDING INFORMATION AND THAT WHAT WE NEED TO DO IS WORK MORE COLLABORATIVELY TOGETHER TO BUILD SYSTEMS THAT ARE ADAPTIVE AND CHANGING THE EVOLVING OVERTIME. WE NEED TO BUILD TRUST BETWEEN PEOPLE WHO ARE DROOIFDING THE INFORMATION AND PEOPLE WHO WANT TO GIVE THE INFORMATION. YOU NEED TO UNDERSTAND WHAT OTHER MOTIVATING FAK TORZ WILL GET THEM TO ACCEPT AND USE THE INFORMATION THAT'S BEING PROVIDED. WHAT I'M SAYING IS LET'S USE HEALTH LITERACY AS A STARTING POINT TO BETTER UNDERSTAND THE AUDIENCES WE'RE WORKING WITH AND BUILD UPON IT BY CONNECTING WITH THEM IN A MUCH MORE PERSONAL, EVOLVING AND ADAPTIVE WAY SO THAT WITH CAN WORK TOGETHER TO EVOLVE HEALTH INFORMATION AND COMMUNICATION SYSTEMS THAT MAKE SENSE THAT, FELT INTO PEOPLE'S LIVES AND ARE REALLY ACTION NAHABLE IN TERMS OF GETTING PEOPLE THE TO DO WHAT WE WANT TO DO. IT'S NOT JUST A MEASURE, IT'S A WAY OF CONNECTING IN A MORE PERSONAL WAY. SO WHAT I'M ADVOCATING IS DEVELOP K HEALTH INFORMATION SYSTEMS THAT ARE MORE HUMANE, THAT ARE MORE RELATIONALLY CONNECTIVE AND MORE ADAPTIVE OVERTIME. ONE WAY TO DO THAT IS MAKING THEM MORE UNDERSTANDABLE BUT THERE ARE OTHER FACTORS INVOLVED TOO. MAKE THEM EASY TO USE, MAKING THEM FIT INTO PEOPLE'S LIVES, MAKING THEM FIT THEIR CULTURES AND MOTIVATIONS. I THINK WE NEED TO START THINKING ABOUT UH WAYS WE CAN SHAPE PROGRAMS ON A NUMBER OF DIFFERENT KOE DOMAIN WHERE IS HEALTH LITERACY IS ONE PIECE OF THE PUZZLE BUT LET'S NOT PUT ALL OUR MONEY IN ONE BASKET AND THAT'S ALL I GOT SAY. LET ME OPEN UP TO THE AUDIENCE AND SEE WHAT YOU HAVE TO SAY ABOUT ALL THIS. >> E [LOW AUDIO]. >> THANKS, FIRST OF ALL FOR BOTH SETS OF COMMENTS. IT SORT OF TAKES OFF FROM THE COMMENTARY WHICH IS, IT STRIKES ME THAT WHAT YOU DID WAS VERY SUCCESSFUL BY USING CALVARY MODEL AND I DON'T REALLY COMPLETELY UNDERSTAND WHY YOU FEEL A NEW MEASURE NEEDED. WHY CAN'T OTHER PEOPLE DO WHAT YOU DID? WHY CAN'T THAT BUILD YOU HAVE THAT, BUILD INTERVENTIONS AND BORROW THE BEST CONCEPTS THAT THEY FIND? >> SURE. MAINLY BECAUSE WE BUILT THOSE PROJECT-SPECIFIC. SO THERE ARE QUESTIONS WE ASKED ABOUT [INDISCERNIBLE] -- IMPROVE NOT THE SAME UP WITHES WE ASK ABOUT THE LIFE ENHANCEMENT PROGRAM BECAUSE THEY'RE TAILORED TO THE INTERVENTION. PEOPLE COULD CERTAINLY TAKE THE CONCEPTUAL FRAMEWORK BUT WHAT I'M SUGGESTING IS THAT WE NEED A UNIFIED MEASURE THAT YOU CAN USE ACROSS CONTEXT. THAT'S OUR DATA IS JUST PRELIMINARY AND NO ANYWHERE NEAR WHAT YOU WOULD WANT TO SAY TO SOMEONE, OH, SURE, YOU CAN USE THIS METHODOLOGY FOR YOUR INTERVENTION AND N FLORIDA ABOUT VACCINATION. IT JUST WOULDN'T BE THE SAME, WOULDN'T BE RELEVANT. SO THAT'S WHY. WE STARTED BUT WE HAVEN'T FINISHED. >> SO, YES, THANKS TO YOU BOTH. IT SEEMS TO ME THAT THE COMMENTS THAT GARY MADE JUST NOW AND YOUR LOGIC MODEL ARE CERTAINLY NOT EXCLUSIVE OF EACH OTHER, AND IT SEEMS TO ME THAT THE LOGIC MODEL IS NICE AND MODULAR AND SOME OF THE THINGS THAT GARY RAISED COULD BE MAPPED ON TO THAT, THESE DIFFERENT DIMENSIONS COULD BE MAPPED ON TO THAT MODEL. I'M WONDER WLG YOU HAVE USED -- I PRESUME YOU'VE USED THIS MOD UNTIL OTHER STILL OTHER STUDIES AND WHETHER THIS H HAS BEEN DONE SO THAT SOME OF THE THINGS THAT GARY RAISED -- I'VE GOT THIS PICTURE IN MY MIND OF ALL THE MODULES AS YOU WERE TALKING GARY I WAS SEEING HOW IT WOULD RELATE TO THE COMMUNICATE, TO ALL -- I MEAN -- I JUST ASK THE QUESTION IF YOU USE IT AS A PLUG-AND-PLAY MODEL ADAPTING TO DIFFERENT CIRCUMSTANCES. >> TO THE EXTENT THAT WE HAVE YES BUT IT'S STILL BEEN TAILORED AT EACH TURN. SO IT'S NOT CONSISTENT YET. AND YOU KNOW IN REGARD TO GARY'S OBSERVATIONS APART OF ME TOTALLY AGREES WITH YOU THAT WE'RE ON THE SAME PAGE BUT PART OF HIS COMMENTS WERE DIRECTED AT THE OLD HEALTH LITERACY. WHAT I PROPOSE VIA THE CALVARY CHARTER AND ESPECIALLY MOVE TO THEY ARE RYE AND BEHAVIOR CHANGE REALLY THE COMPLEXITY HE'S LOOKING FOR IS THERE, WE JUST HAD AN HOUR AND HALF, GIVE HIM AND I 15 MORE MINUTES SOMEWHERE TONIGHT LATER AND I THINK WE'LL BE ON THE SAME PAGE IT'S JUST THAT HE'S ABSOLUTELY RIGHT IN UH HOW HEALTH LITERACY AS HISTORICALLY BEEN APPROACHED AND TREATED. YOU'LL NOTICE NEVER ONCE DID I SAY THAT WE NEEDED PEOPLE TO READ BETTER TO ACHIEVE THOSE OUTCOMES, RIGHT. ? THERE'S A LOT OF WAYS TO DO THAT AND MOST OF THAT EVALUATION DATA WAS COLLECTED VERBALLY. IN FACT, ALL OF IT WAS. SO READING AND WRITING WASN'T OUR PRIMARY OUTCOME. >> THANK YOU VERY MUCH FOR THAT WONDERFUL TALK. I ALSO GOT A SENSE THAT WHAT YOU WERE SAYING AND I'M THINKING THAT IN YOUR DECISION THE WORD LITERACY ALMOST BECOMES A METAPHOR SO BECAUSE IN YOUR INTERVENTIONS YOU INCLUDE THINGS THAT HAVE DO WITH SELF-EFFICACY AND SOMETHINGS THAT HAVE TO DO WITH COMMUNITY SUPPORT AND THIS IS GREAT THE ONLY THING I'M DOING YOU THE TERM FOR HEALTH LITERACY OR IS IT JUST HEALTH? >> THAT COMES UP FROM TIME TO TIME, IT REALLY DOES. MY ONLY RESPONSE TO THAT IS -- IT'S ALL RIGHT I'LL GIVE IT TO THE NEXT PERSON -- I DON'T KNOW OF A MORE APPROPRIATE TERM AND I'D ALSO HATE TO LOSE THE HISTORY BECAUSE THE TELLING OF THE STORY THIS IS WHERE HEALTH LITERACY STARTED -- GO BACK AND LOOK AT THE BEGINNING OF SELF-EFFICACY OR COMMUNICATION AS A DISCIPLINE AND YOU'LL FIND THE SAME PROCESS AND THAT'S HOW SCIENCE WORKS. SO AS HAVE WE OUTGROWN THE TERM? I THINK IT'S THAT WE DIDN'T HAVE A FULL UNDERSTANDING OF THE TERM TO BEGIN WITH AND WE'RE JUST GETTING THERE. >> THIS IS SORT OF A TWO-PART QUESTION. FOR THE PUERTO RICAN COMMUNITY THAT YOU WORKED WSHG WHAT KIND OF ADJUSTMENTS DID YOU MAKE TO THE DIFFERENT PARTS OF YOUR MODEL AND IF THOSE ADJUSTMENTS WERE LARGE ENOUGH, HOW DID THAT, HOW DID YOU EVEN ANALYZE THE DATA ACROSS THOSE DIFFERENT POPULATIONS? >> OKAY. DO YOU WANT TO DO THAT PART FIRST? THAT'S FINE. SO THANK YOU. I SOMETIMES GIVE PEOPLE A DOLLAR FOR ASKING THE QUESTION I HOPE THAT THEY -- AND YOU'RE THE ONE! [LAUGHTER] I'LL GIVE YOU A DOLLAR LATER. BUT, UH, SO HERE'S WHAT WE DO AND THAT'S THE DIFFERENCE. I SAY USE HEALTH LITERACY AS THE BASIS FOR YOUR INTERVENTION. THE EVALUATION PROTOCOL STAYS THE SAME FOR THE LIFE ENHANCE PROGRAM PRO TOE WHERE. WE TAILOR THE BRITEN MATERIALS THAT PARTICIPANTS RECEIVE AND WE TAILOR SOME OF THE TRAININGS THAT WE GIVE TO THE CORE TEAM BECAUSE I'M NOT IN THE ROOM IN ANY OF THOSE PLACES, IT'S LOCAL HEALTH CARE PROFESSIONALS, SO WE TRAIN THE TRAINERS. EVERYBODY GETS A PARTICIPANT GUIDE IN THE LIFE ENHANCEMENT PROGRAM AND IT'S RELATIVELY BOOK THAT TALKS ABOUT HEALTH AND PEOPLE AND CHOICES THEY'VE MADE IN THEIR LIVES. EMBEDDED INTO THAT PARTICIPANTS GUIDE ARE A SERIES OF NARRATIVES THAT DESCRIBE A REAL PERSON'S LIVES. WE BASE THOSE ON REFORMATIVE RESEARCH IN EVERY COMMUNITY. I CAN TELL YOU THAT THOSE STORIES ARE ALWAYS ABOUT CHANGE AND THEY'RE ALWAYS ABOUT ADDRESSING HEALTH NEED BUT THE NAMES CHANGE, THE LOCATIONS CHANGE T CULTURAL REFERENCES CHANGE, THE AGES CHANGE, THE SPREAD OF GENDERS CHANGE. WHY? TO REFLECT THE PEOPLE WHO WE'RE GOING BE SERVING IN THAT COMMUNITY, BUT TE EVALUATION STAYS EXACTLY THE SAME. AND THAT'S, I THINK HOW HEALTH LITERACY SHOULD BE TREATED ACROSS ALL INTERVENTIONS TALKED ABOUT IN PART TWO. THIS MIGHT COST ME ANOTHER DOLLAR. >> YOU HAVE TO RAISE YOUR RATES. $10. >> DID YOU EVER -- WELL, YOU SAID THAT I KIND OF MISSED THE BEGINNING OF YOUR LESSON, LECTURE, BUT DID YOU SAY THAT YOU USE COMMUNITY OUTREACH WORKERS OR DID YOU USE ONLY HEALTH PROFESSIONALS? >> ALL OF THE ABOVE. DEPENDING ON WHO OUR LOCAL PARTNER IS AND WHAT SKILL AND RESOURCES THEY HAVE. SO INTERESTINGLY ENOUGH, WE'VE WORKED WITH TWO FEDERALLY QUALIFIED HEALTH CENTERS, SMALL RURAL ACCESS HOSPITAL, A VERY LARGE URBAN HOSPITAL THAT STARTED ITS OWN [INDISCERNIBLE]. ONLY ONE OF THOSE HAS HAD ALL OF THE SKILLS AND CAPACITIES REQUIRED TO GIVE THE LIFE ENHANCEMENT PROGRAM WHEN WE FIRST MET THEM. INEVITABLY WITH THE EXCEPTION OF ONE THEY'VE HAD TO GO TO THE COMMUNITY TO LEAD THE EXERCISE PART OR THE SPIRITUALITY COMPONENT. THIS THAT TELLS YOU IN A SMALL LITTLE NUGGET THE DIFFERENCE BETWEEN AN INTEGRATIVE APPROACH TO HEALTH AND THE SKILLS IMBEDDED WITHIN OUR CURRENT HEALTH CARE SYSTEM. IT CHANGES BASED ON WHO WE WORK WITH. >> THIS IS NOT A WELL FORMED QUESTION BUT IT WAS STIMULATED BY THING THAT IS BOTH OF YOU SAID. BY MY OWN EXPERIENCE ALSO. I WOULD OBSERVE THAT ONLY ONE OF YOUR DEFINITIONS OF HEALTH LITERACY TALKED ABOUT THE HEALTH LITERACY OF THE HEALTH PRACTITIONER. SO I WORKED IN HOSPITALS FOR MANY YEARS AND I HAVE SEEN MANY, MANY PATIENT EDUCATION COMMITTEES, FEW OF WHOM ADDRESSED ANYTHING RELATED TO HEALTH LITERACY AND SOMEWHERE IT SEEMS LIKE THEY SHOULD RELATE. >> I AGREE. THAT'S WHY THE CALVARY CHARTER IS THE ONLY ONE OF THOSE DEFINITIONS THAT EXPLICITLY HAD BOTH SIDES OF THE EQUATION BUILT INTO THE DEFINITION. IT SAYS AND PERSONNEL WORKING IN HEALTH CARE SYSTEM. SO NONE OF THE OTHERS DID. THEY DID DO EXACTLY WHAT GARY SAID. THEY BLAMED PATIENTS, BLAMED THE PUBLIC, BY IN LARGE FOR NOT HAVING THE SKILLS THAT THE HEALTH CARE PROFESSIONAL THOUGHT WAS REQUIRED. AND WHAT I WOULD SAY WE CAN DO IS -- AND I JUST CHOOSE TO SAY WE SHOULD BUILD THE MAJOR BASED ON THE CALVARY CHARTER FOR PATIENTS IN FUB LICK FIRST BUT IF YOU PROVE IT WORKS THERE THEN YOU BUILD COMPLEMENTARY TOOL FOR HEALTH CARE SYSTEMS. YOU BASICALLY FLIP THE QUESTIONS SO THAT THEY'RE APPROPRIATE FOR THE PROVIDERS OF INFORMATION AND THE RECEIVERS OF INFORMATION AND THEN YOU DO THE SAME THING IN SPANISH AND THEN TO YOU THE SAME THING FOR STRUCTURE SO THAT YOU CAN TAKE THAT SAME EVALUATION BASED ON THAT CONCEPTUAL FRAMEWORK AND WORK OUT OF THE HOSPITAL AS A STRUCTURE AND SAY ARE YOU REACHING OUT TO THE USERS OF THIS FACILITY IN A APPROPRIATE MANNER? THAT COULD TEND THE PRINT MATERIALS AS WELL AS SIGNAGE AROUND THE HOSPITAL T ACTUAL BUILT DISEASE OF THE HOSPITAL, IS IT TRULY USUALLY FRIENDLY AND PARTICIPATORY 'CUZ THAT'S WHAT THE CALVARY CHARTER CALLS. SO I AGREE. IF THEY GET TO HEALTH LITERACY, THEY GET LITERACY AND SAY SIXTH GRADE LEVEL AND THAT'S ABOUT IT. >> [INDISCERNIBLE] NANCY, I THINK IT'S NOT ONLY BETWEEN THE PROVIDER AND THE CONSUMER BUT AMONG THE PROVIDERS THERE ARE TREMENDOUS PROBLEMS OF UNDERSTANDING AND COMING FROM DIFFERENT PERSPECTIVES AND OFTEN EVEN CONTEMPT WHERE THE DIFFERENT PROFESSIONALS FROM DIFFERENT BACKGROUNDS, DIFFERENT SPECIALTIES, DIFFERENT AREAS OF PRACTICE DON'T AGREE WITH EACH OTHER, DON'T SHARE INFORMATION, DON'T UNDERSTAND EACH OTHER AND THERE IS TREMENDOUS PROBLEMS WITH MISCOMMUNICATION INTERPROFESSIONALLY. WHEN WEAPON THINK ABOUT UNDERSTANDINGISH UH SHOE, WE NEED TO THINK ABOUT WIDE RANGE OF PARTICIPANTS AND THE HEALTH CARE SYSTEM IS GETTING MORE COMPLEX ALL THE TIME WITH MORE PARTICIPANTS INVOLVED. THIRD PARTY PAYERS NOW INVOLVED, GOVERNMENT REGULATORS INVOLVED, MEDICATION DEVELOPERS ARE INVOLVED, CLINICAL TRIALS PEOPLE ARE ARE INVOLVED. UH YOU GOT ALL THESE DIFFERENT CULTURAL AND COMMUNICATION PERS PERKTIVES THAT NEED TO BE MEDIATED AND SO WE HAVE TO UNDERSTAND BETTER WHERE THESE PEOPLE COMING FROM AND HOW DO WE SPEAK IN LANGUAGE THAT EVERYBODY CAN UNDERSTAND AND HOW DO WE GET EVERYBODY TO BE AT THE TABLE TOGETHER WORKING TOGETHER IN A COOPERATIVE WAY? HOW DO WE BUILD HEALTH CARE TEAMS THAT REALLY WORK LIKE TEAMS AND THAT'S A BIG ISSUE. >> AND THAT'S ALL WE NEED. [LAUGHTER] >> IT CAN BE DONE. >> YES, IT IS. >> UNFORTUNATELY WE'RE GOING TO HAVE TO GO IN A MOMENT BUT I WOULD JUST ADD THIS BEFORE WE GO THAT FIRST IF THERE HADN'T BEEN THE KIND OF HISTORY, FLAWED AS IT IS THAT ANDREW REFERRED TO IN HIS TALK, WE WOULDN'T HAVE SOME OF THE ELEMENTS SUCH AS THE JOINT COMMISSION TO ACTUAL ENCOURAGE MEDICAL CENTERS ACROSS THE UNITED STATES TO SET SOME STANDARDS ABOUT THIS AREA AND ACTUALLY DO SOMETHING BEYOND WHAT USED TO BE PATIENT EDUCATION. IT DOESN'T MEAN IT'S IMPERFECT BUT THERE ACTUALLY HAS BEEN SOME HONEST MOVE NMENT THE LAST FIVE, SIX YEAR WHICH IS IS IMPRESSIVE. IT'S YET TO BE SEEN/DETERMINED HOW EFFICACIOUS IT IS BUT THERE ARE BITS. I MADE A MISTAKE EARLIER WHEN I TALKED TO YOU. BRET'S SPEECH IS ACTUALLY THE BALCONY B WHICH IS A FLOOR ABOVE HERE. THOSE TO HAVE YOU COMING BAG ON 29th, ACTUALLY YOU'LL COME BACK TO THIS ROOM AND TO ALL THE FOLKS WHO ARE HERE, WE APPRECIATE YOU COMING. WOULD YOU THANK GARY AND ANDREW? [APPLAUSE] WE THANK THOSE OF YOU WHO SAW US ON THE WEB CAST. I BELIEVE THAT BOTH GARY AND ANDREW ARE VERY GOOD AT HANGING AROUND A LITTLE BIT AND ANSWERING INDIVIDUAL QUESTIONS THAT WE DIDN'T GET TO. I KNOW A COUPLE OF YOU HAD THINGS YOU WANTED TO SAY SO COME UP AND ASK THEM, OKAY?