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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

39251190
10.3928/24748307-20240819-01
10.3928_24748307-20240819-01
Perspective
Health Literacy for Healthy People: The Legacy of Dr. Rima Rudd
Koh Howard K. MD, MPH hkoh@hsph.harvard.edu

Brach Cindy MPP
Ochiai Emmeline MPH
Bishop Jennifer A. ScD, MPH
Blakey Carter BS
From Harvard T.H. Chan School of Public Health, Boston, Massachusetts (HKK); Agency for Healthcare Research and Quality, part of U.S. Department of Health and Human Services (HHS), Washington, DC (CBrach); HHS, Washington, DC (EO); and Office of Disease Prevention and Health Promotion, HHS, Washington, DC (JAB, CBlakey).

Disclosure: The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Howard K. Koh, MD, MPH, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Kresge 401, Boston, MA 02115; email: hkoh@hsph.harvard.edu.
7 2024
09 9 2024
8 3 e162e165
15 12 2023
25 6 2024
© 2024 Koh, Brach, Ochiai, et al.; licensee SLACK Incorporated.
2024
Koh, Brach, Ochiai
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.
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pmcFor so long, professionals and the public alike have urgently called for more scientific research and information. This has been especially true during the pandemic. During this time, however, Dr. Rima Rudd has sounded an equally important call: to understand and improve how people actually use that information to improve their health. Rather than focusing on the speaker and provider alone, Dr. Rudd has demanded that the health communication field pay more attention to the reader, listener, and user. This paradigm shift has changed medicine and public health in fundamental and profound ways. And in the process, Dr. Rudd has inspired a generation of public health and medical practitioners; she has not only identified the paradox that too many people are awash in information they are unable to use (Koh, & Rudd, 2015), but also devoted her career to fixing the problem. She has pioneered health literacy strategies to reduce barriers and burdens for both individuals and society at large.

We, longtime colleagues of Dr. Rudd at the U.S. Department of Health and Human Services (HHS) and the Harvard TH Chan School of Public Health (HSPH), are honored to describe how her lifelong commitment defined a field, shaped the arc of its evolution over several decades, and informed Federal policy and programs. We describe her impact on students, clinicians, organizations, systems, and the United States.

Scholarship

Dr. Rudd's trailblazing scholarship helped create and mold the health literacy field. After education professionals in the 1990s documented that many adults had difficulty using print materials to accomplish everyday tasks (National Center for Education Statistics, 1999), Dr. Rudd documented related barriers for individuals trying to navigate the health care system. She explained that personal health literacy—the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others (Santana et al., 2021)— involves not just print literacy (writing and reading), but also oral literacy (listening and speaking) as well as numeracy (understanding and using numbers). She was one of the first to not only describe how the health care system overwhelms those with limited health literacy, but also illuminate opportunities for improvement (Rudd et al., 2005).

Dr. Rudd led the first effort to estimate the prevalence of limited health literacy (Rudd et al., 2004). This work served as the critical precursor to HHS' use of the National Assessment of Adult Literacy to produce the only objective measurement to date of health literacy skills in the U.S. (Kutner et al., 2006). Moreover, she pushed many to appreciate that health literacy is a prerequisite not just for patient-centered care in the clinic but also more broadly for health equity and well-being in the community.

Clinicians

Clinicians generally assume that their patients understand what they are told, unless proven otherwise. Dr. Rudd exposed the utter fallacy of this assumption. She drew attention to the mismatch between people's actual skills and their understanding of nuanced concepts, such as risk and probability. She also deconstructed health literacy tasks so that clinicians would understand the complexities of what they were asking of patients.

Dr. Rudd and colleagues pushed clinicians to make changes so that patients with lower health literacy would not be left behind. This new paradigm—that clinicians should assume that patients may not understand, unless proven otherwise—led to a movement for health literacy universal precautions (Paasche-Orlow et al., 2006). HHS has embraced such precautions (Brach, n.d.), as more than one-third of adults have limited health literacy (National Institutes of Health, 2006) and so many more can face difficulties with understanding health information especially when they are sick, tired, frightened, and/or overwhelmed.

While urging clinicians to take more responsibility, Dr. Rudd also recognized that they must work as part of larger systems—clinics, hospitals, and health systems. Knowing that institutions have multiple levers for health literacy improvement, Dr. Rudd focused also on effecting organizational change.

Organizations and Systems

By keeping a spotlight on people with limited literacy, while rejecting the deficit model that blames people for their struggles, Dr. Rudd took an enlightened systems approach. Her vision has been broad, generous, and inclusive. She brought understanding to the challenges that people face, applauded their strengths, and partnered widely to build better health systems.

Dr. Rudd, the rare academic figure who has not only built evidence for broad application in peer-reviewed publications, also created practical tools for health literacy improvement. Her vision laid the foundation for the concept of organizational health literacy, “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (Santana et al., 2021, p. S259). Her research and action helped pushed efforts to create a national culture that featured organizations with health literacy norms and standards (Koh et al., 2013). Dr. Rudd and colleagues led the charge to make health texts, talk, and posts more accessible, simplify tasks people are expected to undertake, and identify and remove literacy-related barriers. For example, in the publication The Health Literacy Environment of Hospitals and Health Centers (Rudd & Anderson, 2006), not only was an audit tool represented to assess hospitals and health care centers for health literacy barriers but also an improvement tool for formulating an action plan. Since its publication, HHS and others have created organizational health literacy assessments (Brach, n.d.; Jacobson, 2007) that have accelerated the momentum.

Dr. Rudd always practiced what she preached. In developing materials and tools, she incorporated user-centered design before it was fashionable (Rudd & Comings, 1994). As she developed products, she engaged end users of health information and health services. Similarly, she recommended that health systems involve patients in improvement activities, such as asking them to tour facilities and to give feedback on how easy it was (or not) to find their way (Rudd et al., 2004).

Building on Dr. Rudd's work, HHS has promoted organizational health literacy throughout many of its agencies, with special attention for diverse populations. For example, the National Standards for Culturally and Linguistically Appropriate Services (Koh et al., 2014) includes health literacy in its principal standard for being responsive to diverse cultural health beliefs and practices, preferred languages, and other communication needs. HHS would never have made such progress without her. She noted that forging a better match between the expectations and processes of the system and the skills of U.S. adults can solve the problem of health literacy and reduce barriers to good health (Baur, 2010).

The United States

Dr. Rudd's work with HHS advanced national goals and aspirations. As HHS frequently invited her to give talks to inject a health literacy perspective into the agency's work, she educated countless Federal leaders. For example, she was a major national advisor and mentor to the authors and to Dr. Cynthia Baur, among others. She was also particularly helpful when one of us (HKK), after joining HHS as Assistant Secretary for Health, helped launch Healthy People 2020 (Koh, 2010)—the nation's health promotion and disease prevention agenda—and the National Action Plan to Improve Health Literacy (Baur, 2010). The goals in the latter report drew heavily on Dr. Rudd's work.

Dr. Rudd's influence has shaped the arc of Healthy People through several decades (Ochiai et al., 2021). This started with her leadership in identifying priorities for meeting the first health literacy objective in Healthy People 2010, noting that “Although the literacy and verbal skills of individuals are of critical importance, so too are the demands made by the health materials themselves, the communication skills of those in the health field, and the complicated nature of the healthcare and public health systems” (U.S. Department of Health and Human Services, (2003). She then supported Healthy People 2020's expanded vision for integrated systems, informed by health literacy, which went well beyond the walls of patient care institutions to include broad partnerships that reached so many people regardless of age or cultural background. Healthy People 2030 has elevated the importance of health literacy even further (Koh et al., 2021; Santana et al., 2021), especially by explicitly distinguishing between personal and organizational health literacy. Recognizing that health equity cannot be achieved without addressing health literacy, Healthy People 2030 has identified personal health literacy as a social risk, and organizational health literacy as a social determinant of health (Office of Disease Prevention and Health Promotion, 2023). In part, due to an Issue Brief co-authored by Dr. Rudd (U.S. Department of Health and Human Services, 2019), health literacy has joined health disparities and health equity as foundational principles and overarching goals for a healthier nation.

Personal Reflections

Dr. Rudd has profoundly and personally influenced us authors of this commentary. Several of us trace her influence to before we even worked together at HHS. I (HKK) first felt her wisdom early in my clinical career as a physician in academic medical practice when I regularly advised and cared for new patients referred for melanoma. I discovered then that instead of routinely starting each new patient encounter by reciting often dry facts about diagnosis, prognosis and treatment, I was far more effective in connecting to each person by asking, “What is your understanding of what you have and how are you feeling about it?” In hindsight, I now understand that I was putting into practice Dr. Rudd's longtime lesson that all health care providers should first listen before speaking. Later, after entering public service as the Massachusetts Commissioner of Public Health, I (HKK) found that Dr. Rudd's critical health literacy briefing to the Department during the 9/11 and anthrax attacks raised the quality of our risk communication efforts in a terrifying time for our state and nation.

Several of us (JAB, EO) first met Dr. Rudd as students at HSPH, where she transformed our views on health information and made us feel seen as whole persons. In challenging the assumption that providing health information alone was sufficient to promote behavior change, she opened our eyes to the power of advocating for plain language and accessible information for all.

Collectively, all of us have enjoyed decades of collaboration with Dr. Rudd at HHS and HSPH. With charisma and warmth, she let us ride on her coattails.

The Future

Dr. Rudd first exposed the chasm between people's capacity to process critical health information and the health profession's ability to deliver such information effectively, empathetically, and equitably. She then worked over a lifetime to narrow that chasm. Now, we all must build further on her life's work, especially since the pandemic has laid bare a host of new, yet familiar, communication challenges. Revitalizing public health for the future will require implementing and innovating on lessons that Dr. Rudd first taught us long ago. May her legacy continue to push health literacy further into the mainstream and foster healthier people for generations to come.
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References

Baur , C & United States Office of Disease Prevention and Health Promotion . ( 2010 ). National action plan to improve health literacy . U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion . https://health.gov/sites/default/files/2019-09/Health_Literacy_Action_Plan.pdf
Brach, C. (n.d.). AHRQ Health Literacy Universal Precautions Toolkit ( 3rd ed.). https://www.ahrq.gov/health-literacy/improve/precautions/toolkit.html
Jacobson , K. L. & United States Agency for Healthcare Research and Quality . ( 2007 ). Is our pharmacy meeting patients' needs? A pharmacy health literacy assessment tool: User's guide . U.S. Department of Health and Human Services, Public Health Service , Agency for Healthcare Research and Quality . https://www.ahrq.gov/sites/default/files/publications/files/pharmlit.pdf
Koh , H. K. ( 2010 ). A 2020 vision for healthy people . The New England Journal of Medicine , 362 ( 18 ), 1653 – 1656 . 10.1056/NEJMp1001601 PMID: 20445177
Koh , H. K. , Brach , C. , Harris , L. M. , & Parchman , M. L. ( 2013 ). A proposed ‘health literate care model’ would constitute a systems approach to improving patients' engagement in care . Health Affairs , 32 ( 2 ), 357 – 367 . 10.1377/hlthaff.2012.1205 PMID: 23381529
Koh , H. K. , Gracia , N. J. , & Alvarez , M. E. ( 2014 ). Culturally and linguistically appropriate services—Advancing health with CLAS. 371, 198–201 .
Koh , H. K. , & Rudd , R. E. ( 2015 ). The arc of health literacy . Journal of the American Medical Association , 314 ( 12 ), 1225 – 1226 . 10.1001/jama.2015.9978 PMID: 26247161
Koh , H. K. , Blakey , C. , & Ochiai , E. ( 2021 ). Flourishing after a pandemic: Healthy People 2030 . Journal of Public Health Management and Practice , 27 ( Suppl. 6 ), S215 – S217 . 10.1097/PHH.0000000000001415 PMID: 34559737
Kutner , M. , Greenburg , E. , Jin , Y. , & Paulsen , C . ( 2006 ). The Health Literacy of America's Adults: Results from the 2003 National Assessment of Adult Literacy . NCES 2006-483. In National Center for Education Statistics . ED Pubs . http://eric.ed.gov/ERICWeb-Portal/detail?accno=ED493284
National Center for Education Statistics . ( 1999 ). 1992 National Adult Literacy Survey: An Overview (Working Paper 1999–09a) . U.S. Department of Education . https://nces.ed.gov/pubs99/199909a.pdf
National Institutes of Health . ( 2006 ). Surgeon General's workshop on improving health literacy national institutes of health . Proceedings of the Surgeon General's Workshop on Improving Health Literacy . https://www.ncbi.nlm.nih.gov/books/NBK44257/
Ochiai , E. , Blakey , C. , McGowan , A. , & Lin , Y. ( 2021 ). The evolution of the healthy people initiative: A look through the decades . Journal of Public Health Management and Practice: JPHMP , 27 ( Suppl. 6 ), S225 – S234 . 10.1097/PHH.0000000000001377 PMID: 34016910
Office of Disease Prevention and Health Promotion . ( 2023 ). Healthy People 2030: Health literacy . https://health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/health-literacy
Paasche-Orlow , M. K. , Schillinger , D. , Greene , S. M. , & Wagner , E. H. ( 2006 ). How health care systems can begin to address the challenge of limited literacy . Journal of General Internal Medicine , 21 ( 8 ), 884 – 887 . 10.1111/j.1525-1497.2006.00544.x PMID: 16881952
Rudd , R. E. , & Comings , J. P. ( 1994 ). Learner developed materials: An empowering product . Health Education Quarterly , 21 ( 3 ), 313 – 327 . 10.1177/109019819402100304 PMID: 8002356
Rudd , R. , Kirsch , I. , & Yamamoto , K . ( 2004 ). Literacy and Health in America . Policy Information Report. In Educational Testing Service . Policy Information Center, Mail Stop 19-R, Educational Testing Service ETS, Rosedale Road , Princeton, NJ . http://eric.ed.gov/ERIC-WebPortal/detail?accno=ED486416
Rudd , R. , Renzulli , D. , Pereira , A. , & Daltroy , L . ( 2005 ). Literacy demands in health care settings: The patient perspective . In Schwartzberg J. G. , VanGeest J. , & Wang C. , Understanding health literacy: Implications for medicine and public health (pp. 65 – 84 ). American Medical Association .
Rudd , R. E. , & Anderson , J. E. ( 2006 ). The health literacy environment of hospitals and health centers: Partners for action: Making your healthcare facility literacy-friendly. National Center for the Study of Adult Learning and Literacy and Health and Adult Literacy and Learning Initiative , Harvard School of Public Health . https://files.eric.ed.gov/fulltext/ED508596.pdf
Santana , S. , Brach , C. , Harris , L. , Ochiai , E. , Blakey , C. , Bevington , F. , Kleinman , D. , & Pronk , N. ( 2021 ). Updating health literacy for Healthy People 2030: Defining its importance for a new decade in public health . Journal of Public Health Management and Practice , 27 ( Suppl. 6 ), S258 – S264 . 10.1097/PHH.0000000000001324 PMID: 33729194
U.S. Department of Health and Human Services . ( 2003 ). Communicating health . Priorities and Strategies for Progress . https://ia804608.us.archive.org/27/items/communicatinghea00unse/communicatinghea00unse.pdf
U.S. Department of Health and Human Services . ( 2019 ). Issue briefs to inform development and implementation of Healthy People 2030 . Secretary's Advisory Committee for Healthy People 2030 . https://health.gov/sites/default/files/2021-09/HP2030_Committee-Combined-Issue%20Briefs_2019-508c_0.pdf
