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Health Lit Res Pract
Health Lit Res Pract
HLRP
HLRP: Health Literacy Research and Practice
2475-6024
2474-8307
SLACK Incorporated Thorofare, NJ

10.3928/24748307-20240814-01
10.3928_24748307-20240814-01
Original Research-Qualitative
The Influence of Dr. Rima Rudd's Organizational Health Literacy Scholarship in Maryland
Baur Cynthia PhD cbaur@umd.edu

Maybury Catherine MPH, PhD
Rosenfeld Lindsay ScD, ScM
Richey Leah MPH
From the Horowitz Center for Health Literacy, University of Maryland School of Public Health, College Park, Maryland (CB, CM, LRichey); Heller School for Social Policy & Management, Institute for Child, Youth, and Family Policy, Brandeis University, Waltham, Massachusetts (LRosenfeld); and Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts (LRosenfeld).

Grant: This project was funded by the Maryland Department of Health, Office of Oral Health with funding from DentaQuest Prevention and Early Detection of Dental Caries: the Maryland Health Literacy Model II; HealthEfficient, Networks for Oral Health Integration Within the Maternal and Child Health Safety Net grant, U.S. Department of Health and Human Services, Maternal and Child Health Bureau; City of Frederick, Maryland with funding from the Advancing Health Literacy to Enhance Equitable Community Responses to COVID-19 grant, U.S. Department of Health and Human Services, Office of Minority Health; and the Baltimore City Health Department, Maryland with funding from the Advancing Health Literacy to Enhance Equitable Community Responses to COVID-19 grant, U.S. Department of Health and Human Services, Office of Minority Health.

Disclosure: CB received consulting fees from the Baltimore City Health Department from the U.S. Department of Health and Human Services. CM received consulting fees from Johns Hopkins University. LRosenfeld received grants/contracts from Brandeis University and Harvard T.H. Chan School of Public Health; consulting fees from the University of Maryland, Horowitz Center for Health Literacy, the National Network of Public Health Institutes, MassGeneralBrigham/Massachusetts General Hospital McCance Center for Brain Health, and Thom Child and Family Services; payment/honoraria from Maryland Department of Public Health; support for attendings meetings from the American Dental Association. The remaining author has disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Cynthia Baur, PhD, Horowitz Center for Health Literacy, University of Maryland School of Public Health, 4200 Valley Drive, Suite 2387, College Park, MD 20742; email: cbaur@umd.edu.
7 2024
09 9 2024
8 3 e151e158
05 1 2024
20 6 2024
© 2024 Baur, Maybury, Rosenfeld et al.; licensee SLACK Incorporated.
2024
Baur, Maybury, Rosenfeld
https://creativecommons.org/licenses/by-nc/4.0/ This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International (https://creativecommons.org/licenses/by-nc/4.0). This license allows users to copy and distribute, to remix, transform, and build upon the article non-commercially, provided the author is attributed and the new work is non-commercial.

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.
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pmcOrganizational health literacy is a recognized concept in Healthy People 2030, the U.S. health goals and objectives for 2020 to 2030, and the achievement of health equity and the elimination of health disparities are tied to personal and organizational health literacy improvements (U.S. Department of Health and Human Services, n.d.). Healthy People defines organizational health literacy as “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” (U.S. Department of Health and Human Services, n.d.).

The roots of organizational health literacy are at least two decades deep in an edited volume of Healthy People 2010 health communication action plans (Baur, 2003). Health communication objectives, including the objectives to improve health literacy and increase patient satisfaction with provider communication, were new to Healthy People, and the action plans provided brief introductions to the literature, measures, and challenges to achieve improvements from 2000 to 2010, the time period for the objectives and action plans. Dr. Rima Rudd contributed an action plan for the health literacy objective and her mentor, Dr. Debra Roter, along with Dr. Gregory Makoul, wrote one on health care providers' communication skills (Roter & Makoul, 2003; Rudd, 2003). Both plans called for a shift from a patient literacy deficit model toward a health care organization and professional clear communication responsibility model. The Institute of Medicine health literacy report (National Academies of Sciences, Engineering, and Medicine, 2004) and the U.S. National Action Plan to Improve Health Literacy (U.S. Department of Health and Human Services, 2010) reinforced this focus on professional and organizational responsibilities to communicate clearly.

Dr. Rudd has continued to elaborate the organizational health literacy concept, and other researchers have followed (Kaper et al., 2021). According to a 2021 scoping review (Bremer et al., 2021), Rudd and Anderson's (2006) first edition of The Health Literacy Environment of Hospitals and Health Centers (HLE) laid the foundation for a succession of organizational health literacy tools, such as the Health Literacy Universal Precautions Toolkit (Agency for Healthcare Research and Quality, 2020), the 10 Attributes of Health Literate Healthcare Organizations (Brach et al., 2012), and Building Health Literate Organizations: A Guidebook to Achieving Organizational Change (Abrams et al., 2014).

The first HLE toolkit reflected Rudd and Anderson's (2006) backgrounds in the conduct of adult literacy research and partnership building with adult literacy agencies and adult learners, and the Preface stated that health care organizations had hidden literacy barriers that were excluding and harming people seeking information and services. Their remedy was to systematically assess health care practices and tasks and call for actions to reduce literacy demands and facilitate patients' engagement in their health care.

The HLE second edition (HLE2) reflects Dr. Rudd's collaboration with the Health Literacy Task Force at the University of Tennessee Medical Center (Grabeel et al., 2022; Rudd et al., 2019). The HLE2 includes five sections with scoring rubrics: organizational policies, institutional practices, navigation, culture and language, and communication, which is subdivided into print materials, forms, web postings, and patient portals (Rudd et al., 2019). The scores for the criteria are yes/no or a five-point Likert scale, such as never to always. The directions recommend that a small team conduct the assessment, and the results can provide priority areas and action steps that the organization's administration and committees can take.

From 2011 to 2023, the HLE and HLE2 toolkits have influenced the University of Maryland Horowitz Center for Health Literacy researchers and provided best practices for our work in clinical and community settings. We have used HLE and HLE2 components to assess public health dental clinics, inform health care provider training, and build health literacy insights with local coalitions. To further characterize these approaches, we discuss the use of Dr. Rudd's HLE tools in four projects over twelve years in Maryland. First, we describe the projects, characterize implementation activities, and outline organizational assessment and training outcomes. Next, we look across projects to distill and report lessons learned in implementing organizational health literacy approaches in academic/community collaborations. These lessons include facilitators of and challenges to organizational health literacy improvements. Our analyses offer a critical synthesis of prior experiences in Maryland. They can help guide next steps in the complex work of creating organizational change to achieve health equity.

Background

Faculty at the Horowitz Center recognized Dr. Rudd's early and substantial influence on the health literacy field. The Horowitz Center created a named dissertation fellowship for Rudd that exists as of 2024 and invited her to serve as a visiting scholar and advisor. When Horowitz Center faculty explored organizational health literacy approaches, Dr. Rudd's HLE tools were a natural starting point. The Horowitz Center's first organizational studies were in the oral health topic area and measured public and provider knowledge and skills as well as organizational policies and practices (Horowitz et al., 2013; Horowitz et al, 2014; Horowitz et al., 2015; Koo et al., 2016; Weatherspoon et al., 2015). We have expanded our organizational health literacy assessments into many local settings, such as health departments, community coalitions, small non-profit organizations, and health care providers who serve low-income patients or pediatric patients, and topics, such as coronavirus disease 2019 (COVID-19), and added interventions in the form of training, materials review and design, and checklists and best practices guides. In addition to the HLE tools, we always apply the Federal Plain Language Guidelines (The Plain Language Action and Information Network, 2011) and the CDC Clear Communication Index (Baur & Prue, 2014) when we develop new health messages and materials or evaluate existing messages and materials to identify needed revisions. The Federal Guidelines are general, not health specific, statements about plain language techniques intended to make communication understandable the first time a person, reads, hears, or sees it. The CDC Index is a set of evidence-based health literacy techniques, including some plain language techniques, to enhance the clarity and usability of health messages and materials. Together, these two tools cover the key elements of clear health communication.

Maryland is a unique environment for undertaking organizational health literacy projects. As of 2022, the Horowitz Center is the state's designated Consumer Health Information Hub with a legislative mandate to create guidelines and best practices and provide technical assistance in plain language and language access for state and local public agencies (Public Health – Consumer Health Information – Hub and Requirements, 2022). Also, Maryland's Total Cost of Care All-Payer Model, a health care transformation agreement with the U.S. Centers for Medicare and Medicaid, shifts financial incentives so that primary care services deliver comprehensive disease prevention and health promotion and care coordination services and reduce demand for hospital-based services (Maryland Department of Health, 2021). A coordinated primary care approach and reduced demand for hospital services should favor health literacy interventions that help patients with everyday information-seeking, engagement with prevention and care coordination, and communication with primary care providers and support services (Maryland Department of Health, 2021). In addition, the Center is situated in a land grant university school of public health and takes a broad public-facing, community-based approach to its health literacy work. The Horowitz Center has pursued its health literacy strategy with these policy and public health factors in mind.

Brief Project Descriptions

This section briefly describes four Horowitz Center organizational health literacy projects: two in oral health and two in COVID-19 vaccinations. The oral health projects were with organizations that serve adults and children, and one COVID-19 project was for adults and the other for pediatric patients and their caregivers. The target populations for the organizational health literacy work were health care administrators, providers and clinic staff, health department staff, and community leaders. Three of the projects explicitly applied Dr. Rudd's assessment tools and one was influenced by Rudd's approach and our experiences with prior projects.

Oral Health

We used the HLE and HLE2 to conduct health literacy environmental scans for two oral health projects. The goal was to provide guidance to oral health care delivery organizations' health care administrators, providers, and staff on how to implement health literacy practices to enhance access to oral health information and services, thereby increasing parents' knowledge, awareness and adoption of preventive oral health practices to improve oral health outcomes. The first project in 2011–2012 used the HLE to assess the characteristics of 26 Maryland community-based dental clinics that serve adults and children. The second project from 2019 to 2022 used the HLE2 as part of a demonstration project to improve access to and use of comprehensive, high-quality oral health care for pregnant women, infants, and children at high risk for oral disease. We assessed medical and dental clinics of six organizations in three states—Maryland, New York, and Virginia—and the District of Columbia.

COVID-19 Vaccinations

From 2021 to 2023, the Center supported two Advancing Health Literacy to Enhance Equitable Community Responses to COVID-19 projects funded by the U.S. Department of Health and Human Services, Office of Minority Health (n.d.). The projects were implemented in two Maryland cities, Frederick and Baltimore. The Frederick project, named Lifting All Voices, was a partnership with the City of Frederick, the Asian American Center of Frederick, and the Coalition for a Healthier Frederick County and was an opportunity to build health literacy capacity with multiple community organizations in the city. The Center assessed the health literacy issues for COVID-19 vaccinations in Frederick, wrote the health literacy plan and the project work plan required by the grant, and planned organizational health literacy educational sessions led by Dr. Rudd and a former student, Dr. Lindsay Rosenfeld. We also worked closely with community health workers and co-created COVID messages and materials for adult populations that used 1 of 9 target languages, and this work ran parallel with the organizational health literacy elements. The languages included Spanish, French, Burmese, Vietnamese, Chinese (Mandarin and Cantonese), Russian, Gujarati, Korean, and Urdu.

The Baltimore project, named Baltimore Vs. COVID, was directed by the city health department, and included local universities, the city school system, local non-profits, and pediatric clinical practices. The Center provided health literacy consulting services that included assessing the health literacy issues for COVID vaccine roll-out to school-aged children in Baltimore and writing the health literacy plan required by the grant.

Since the 2003 action plan, Dr. Rudd has emphasized that health information and service providers must have clear communication skills and use them every time with everyone. Bremer et al.'s (2021) scoping review found clear communication with patients and clients to be the most common criteria in organizational health literacy tools. Our COVID-19 vaccination projects exemplify these recommendations.

The Frederick and Baltimore COVID-19 projects aimed to increase the capacity of health information and services providers to deliver COVID-19 information aligned with health literacy best practices. In the Frederick project, a Center faculty member collaborated with a local physician to design and deliver three training sessions to a total of 30 health care providers and 20 students during January and February 2023. For the Baltimore Vs. COVID project, a Center faculty member provided four presentations, two on health literacy basics and two on organizational health literacy to the full project team during the standing monthly virtual team meetings. The same faculty member who delivered the Frederick sessions collaborated with the lead physicians for two pediatric clinics to deliver the training. The training has been delivered to 30 individuals—10 at the first clinic and 20 at new hire orientation for all employees of a Federally Qualified Health Center (FQHC). The first training session was in February 2023, and the FQHC began delivering the training to new employees in November 2023.

Implementation of Organizational Health Literacy Elements

Oral Health

Maryland 2011–2012. In each of the 26 clinics, we identified institutional characteristics and provider practices that enhance or inhibit access to oral health information and preventive and treatment services. We used the HLE navigation and communication assessments to examine facility signage, on-site navigation, phone system, written communications including patient forms and print materials posted in the clinic, online, and distributed to clients. We provided each clinic a written report that synthesized our findings and recommended actions they could consider to better serve their patients and accommodate for varying levels of health literacy.

Maryland, New York, Virginia, D.C. 2021–2022. We used the HLE2 communication assessments to examine the phone system, patient forms and educational materials available through the patient portal. The assessments were conducted during the COVID-19 pandemic and thus we were not able to use the navigation assessment. We only assessed 6 of 12 planned clinics in 18 months due to the COVID-19 pandemic. Some providers declined to participate because they were focused on treating and vaccinating patients, and some organizations declined because of staff exhaustion, staff shortages and a backlog of appointments. We provided each clinic a written report that detailed our findings and included recommended actions to support organizational health literacy.

COVID-19 Vaccinations

Frederick project. To meet the health literacy capacity-building objectives for community organizations, the Center team consulted with Dr. Rudd and Dr. Rosenfeld to build a program that would introduce local health information, service providers and community-based organizations to an organizational health literacy approach. Participants included leaders of the Coalition for a Healthier Frederick County (the local health improvement coalition) and its member organizations; these included health entities, the public school system, multiple nonprofits, and representatives from coalition-supported local health improvement work groups and community-based organizations.

Dr. Rudd delivered live webinars (recorded for future viewing) to two cohorts of participants between March and December 2022. Webinar topics were the meaning and implications of health literacy, a task assessment and activity, introduction to the assessment process and a tool, and the Health Literacy Environment toolkit (HLE2). We offered one-on-one facilitated follow-up sessions to all participants during which they could ask questions and get personalized feedback, explore how to use the tools in their own organizations, or plan for and implement organizational health literacy best practices. Both cohorts were offered tools to plan and execute an Action Plan: A Guide for Developing an Action Plan (“Guide”), an Action Plan Outline (“Outline”), and planning meetings with Rosenfeld.

Both the Frederick and Baltimore projects included educational sessions for health care providers. The sessions were based on evidence-based best practices for communicating health information to patients or clients, which aligns with HLE2 and strategies from the National Action Plan to Improve Health Literacy (U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion, 2010). The Frederick training sessions focused on oral communication characteristics such as speech speed and the interactivity of conversations along with how to use plain language and confirm understanding with the Teach-Back method. The training sessions were delivered in person and virtually to providers associated with the local hospital and to nursing and public health students at a local college. The hospital recorded the virtual session and added it to their library of continuing medical education offerings.

Baltimore Project. The Center's primary implementation activities in the Baltimore project included participation in routine project team meetings and training sessions and presentations to project partners. The Center team participated in three types of meetings: monthly full project team, monthly workgroups with subsets of the project partner organizations, and ad hoc with the health department staff. In all three meeting types, we called out health literacy issues, such as jargon or overwhelming amounts of information in COVID-19 educational materials, and offered suggestions of how to use plain language and Teach-Back techniques. We gave two health literacy basics and two organizational health literacy presentations to the full project team and provided training sessions to health care provider partner organizations. The partner training focused on using plain language and the Teach-Back method and included scripted scenarios for participants to practice using plain language to explain health information related to vaccines and confirm patient understanding using the Teach-Back method. The training was initially delivered to a medical team at one adolescent health clinic. The module is now being delivered at a FQHC new hire orientation training for all employees. Also, the Center co-developed a health literacy module on clear communication for pediatric residents at an academic institution. This module covers plain language, Teach Back and motivational interviewing using vaccine examples. The module was implemented with residents in the fall of 2023.

Results of Organizational Health Literacy Activities

Oral Health

The HLE and HLE2 tools were valuable in finding and describing the health literacy issues in dental and medical clinics. Although the two assessments were conducted 10 years apart in different states, the results were similar. Many of the educational materials were written at reading levels that exceed the reading skills of average high-school graduates. The materials had attributes that made them hard to understand including jargon, dense text, little whitespace on the page, small font and unclear images. We examined several forms from each clinic—consent, health intake, or post-treatment instructions. The majority scored lower than 50% because they used complex dental and legal terminology instead of common words, the text was written in small font and had little white space on the page, and the forms lacked adequate white space for write-in responses. Collectively, the patient consent forms were rated between 9th- and 17th-grade reading level, far above general recommendations to aim for an 8th-grade level or lower.

From both projects, only three clinics reported back the actions they took because of the health literacy assessments. The clinics created plans to address the recommendations. Their key activities were to review and select different oral health education materials designed for low literacy audiences that are provided in person and in the patient portal; use video and online sources of oral health educational materials; and review and revise selected consent forms.

COVID-19 Vaccinations

Frederick Project. Dr. Rudd's personal involvement and the tools she provided, including the HLE2, created a rigorous yet accessible process that participants reported to be valuable and engaging. Across the two cohorts between March and December 2022, a total of 17 organizations joined the sessions; 74% (n = 35) of participants attended two or more sessions. We provide examples from Cohorts #1 and #2 to show the types of results.

Cohort #1 Solo Provider

The Center team met five times with the provider over a nine-month period. The provider focused on patient navigation, from arriving at the website to first appointment scheduling to first appointment completion. The provider was diligent, persistent, and completed an assessment and action plan. They had a drive to do the work and made time in a busy practice and other commitments. The key was the rhythm and support of the one-on-one facilitation. The provider planned to measure before and after changes with a survey and was able to pivot with help as issues arose. The provider indicated plans to continue on their own.

Cohort #2 Workgroup of the Local Health Coalition

The workgroup focused on a particular community health issue and was invested in the health literacy work from the start. This energy particularly came from an active community volunteer. Two members of the workgroup met regularly with the Center team, and they requested a multi-part training series to learn about health literacy information assessments. They applied what they learned to a flyer and quiz for awareness-raising activities. The workgroup indicated plans to address needed changes in the materials.

The Coalition for a Healthier Frederick County's support was a clear facilitator for the implementation and results the project achieved. Coalition leadership embraced the activities and encouraged member organizations to work with and learn from the Center team. Barriers to implementation seemed to focus on finances and manager or director prioritization of the work. The Coalition received project funds to participate, but individual member organizations did not. It could be that invited participants had difficulty dedicating time to attend webinar sessions and complete the activities. Of note, smaller organizations seemed to have an easier time incorporating the activities than did larger organizations. This is likely because the latter have more complex leadership structures, requiring cooperation and buy-in from multiple organizational entities to participate.

The Frederick project also included provider training sessions led by a different Center team member. For these sessions, one live and one virtual, we had 27 attendees from multiple departments including Service Excellence, Interpreting Services, Nursing, Home Health, Cultural Awareness and Inclusion, Accreditation and Regulatory Compliance, and Administration. The overall feedback was positive. Results from the post-training evaluation indicated that participants increased their knowledge about communication practices such as using plain language instead of jargon and using the Teach-Back method to confirm patient understanding, and they were very likely to use these practices in the following 30 days.

Baltimore Project. Although we did not conduct organizational assessments in the Baltimore project, our focus on presentations and training aligns with Rudd's approach to ensure administrators and providers know about health literacy issues, put procedures in place, and develop the knowledge and skills to communicate clearly. The first provider communication training session was delivered to the team at an adolescent medical clinic. We did not do a pre-test/post-test for this training. The FQHC received a customized training that is being delivered to all employees at their new hire orientation training. The organization did not evaluate the 2023 session, but the Center team is working to add one or two evaluation questions to the new hire assessment.

Lessons Learned About Dr. Rudd's Approach to Organizational Health Literacy

The Horowitz Center's experience with Dr. Rudd's organizational health literacy tools—HLE and HLE2—adds to the body of knowledge about how the tools perform in the field. Our results confirm that the 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. This was true no matter the organization size or who the change champion was. The organizations we worked with have expressed gratitude for our help and the health literacy knowledge and skills they gained.

However, translating knowledge and skills to actions that lower or remove barriers can require more time than organizations are willing to commit or be more difficult than they can handle. In our projects, the four positive examples (three from Frederick and one from Baltimore) that demonstrated the most progress were driven by a collaboration between our team and a change champion who had the power to institute new ideas and actions.

Our findings about organizational shortcomings in making health literacy a strategic priority and developing concrete plans align with the findings from the Kaper et al. (2021) review of 24 organizational health literacy studies. Per Kaper et al. (2021), the critical factors for organizational health literacy success are a daunting list: leadership support, an organization-wide approach, an innovation culture, a change champion, commitment and adequate capacity of staff, and patient engagement. Although we have pursued organizational health literacy projects for a dozen years, we have yet to find a health information or services provider in Maryland that can line up these six critical factors and complete the full organizational change cycle, even with expert facilitation. In our projects, one or more change champions seems to be the necessary but not sufficient ingredient for visible progress.

To our knowledge, the 2011–2012 oral health study was the first to conduct an environmental scan of community-based dental clinics, and it confirmed the feasibility of conducting such assessments in community-based dental clinics. We applied similar assessments for the second study to improve oral health literacy in organizations with integrated medical and dental practices. The findings provided insight into clinic and provider characteristics, practices, and environment that can be modified to make them more accessible to all patients. Although our findings could have helped administrators and practitioners with these modifications, only a few sites moved to action planning.

In the Frederick project, individual organization work was productive, at varying levels of time and intensity. For those that were able to invest the time, gains were made in providing clear information and reducing the burden of systems navigation for patients/participants. Four of six organizations who began facilitated sessions with the Center team were enthusiastically continuing the organizational health literacy work at the project's close. The organizational health literacy framework became part of their perspective in developing and reviewing current information and processes. Although the two organizations “on hold” described the work as “useful” and “important,” project leaders had trouble finding the time, despite initial enthusiasm and dedicated time originally set aside for project work.

Challenges for all the organizations included finding time to start the work and execute plans, even for organizations that received project money. Other challenges included easily linking health tools and standards to their current work, integrating staff who did not participate in the training or facilitated discussions, and involving community stakeholders in the work. The Center team discussed and emphasized such issues, but organizations generally lacked capacity to bring these pieces together.

The Baltimore project results exemplify that group presentations and training on health literacy issues are often an entry point for organizations. In our projects, organizations were willing to provide an hour or two for “what is health literacy” presentations or specific skills sessions, such as how to use Teach Back. Because we will continue to work with many of the organizations once the specific grants end, we are optimistic that we can leverage these basic sessions and expand their interests into other areas of organizational health literacy assessment and improvements.

Conclusion

During the last 20 years, Rudd's work created and nurtured a multilayered understanding of health literacy as complex interactions of skills, tasks, texts, and context. Her impact is evident in the field's acceptance that health professionals and organizations bear primary responsibility for shaping these interactions in a positive way to reduce patient burden. To put Rudd's approach into practice, the Horowitz Center and the field at large have used the HLE, HLE2 and other tools to undertake organizational health literacy studies and projects. Our Maryland work with Rudd's tools shows that organizational assessments are accessible, practical and tangible. While it can take time and money to gain traction, organizations that make small and large changes over time find increased satisfaction among staff and patients/participants as well as progress toward equity goals, among other priorities.

On their own, Dr. Rudd's HLE tools are a substantive contribution, but they are only one piece of her contribution. She helped birth the health literacy field, and her impact persists across its growth and development. Rudd's powerful storytelling, focus on individual dignity, and conception of health literacy as more than individual reading skills infuse the health literacy research and practice standards we know today. Her continued influence and legacy are visible in the field's exploration of health literacy change across all its component parts, whether it be patient engagement, professional interactions with the public, physical and online wayfinding and navigation, or organizational and public policies. The Maryland work is but one example of Rudd's praxis firmly connected to original thinking about how to manifest social justice in health.

The authors recognize the seminal contributions of Dr. Alice M. Horowitz as the principal investigator on the oral health literacy studies discussed in this article.
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