SignedNBrittainKenney.pdf

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Abstract

Literacy and health are closely connected. Literacy impacts health directly by enabling

people to better read and interpret health information, a term we have come to call “health literacy”. Literacy also impacts health indirectly by affecting one’s educational attainment, job

opportunities, and other social determinants of health. Every day, we are learning more and more about the role that early literacy skills and school readiness play in childhood development and how these skills impact the rest of one’s life. This paper will discuss literacy’s direct and indirect

impacts on health and explore whether the field of public health, with its focus on disease prevention and health promotion, should put more energy into promoting early literacy, with an

emphasis on community literacy and school-readiness programs. It will also provide information about current literacy initiatives, with public health sector involvement, that set a precedence for additional programming. Specifically, it will analyze the specialized role local health

departments can play in promoting early literacy because of their access to low-income

populations, local leadership and partnerships, and experience in addressing health disparities. It is this paper’s position that health departments are especially equipped to be local leaders in

early literacy promotion and through this work reduce health disparities that are a result of poor literacy.

Key Words: Literacy, health, education, early reading, health department, social determinants of

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Background

In the spring of 2014, the Gaston County Department of Health & Human Services

partnered with First Book, an international organization that provides books to low-income children, and gave out 40,000 books to organizations that serve area youth. This was the first literacy-promoting initiative this local health department had undertaken and it left several staff

and community members wondering what else they could do to promote community literacy. I was fortunate to spend my Practicum experience working on this project. I had a basic

understanding of the importance of literacy to health, especially in the ways the presence or absence of literacy skills can help or hinder people trying to access healthcare. However, I was not familiar with community literacy or the critical importance of early reading on the brain,

childhood development, and to health in adulthood. Several of us began exploring what local health departments could do to promote early literacy which then impacts educational success, job opportunities, and improved health.

It is my hope that this paper will not only make a case for more public health involvement in early literacy promotion, but will reinforce my belief that local health

departments are especially equipped to address this issue at the community level.

Methods

For background on the connection between literacy and health, a literature search was conducted for “health outcomes” and “literacy” in PubMed and Google Scholar databases.

Abstracts were reviewed and screened to identify articles that were about general literacy and its connection to health outcomes. A search was conducted using a combination of the terms

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and screened for articles in the past four years (2010 to 2014) to find research into current trends in literacy and child development and how these are intersecting with health.

Finally, Google Scholar was used to search for the terms “social determinants of health”, “health equity”, “literacy”, and “evaluation” to find articles that explained current research into

the value of addressing root causes directly. General web searches also helped uncover examples of literacy interventions being conducted in the public health sector.

Literacy’s Impact on Health

The relationship between literacy and health outcomes is well established and has recently become a national and global priority. Numerous studies have evaluated the complex

relationship between literacy and health. In fact, an American Medical Association (1999) report reviewed 216 published articles and manuscripts and found that literacy was a stronger predictor of health status than education or any other social or demographic attribute (American Medical

Association, 1999). Regardless of the evidence, understanding the deep connection between these two concepts is complicated. Two models are provided to assist in understanding of this

issue.

 Three Connections between Health and Literacy/Education. An Issue Brief from the Virginia Commonwealth Center on Society and Health (2014a) presented a model (Figure 1) of the relationship between education and health based on a 2006 paper on the

same topic (Cutler & Lleras-Muney, 2006). While literacy and education are not interchangeable, this model helps summarize the 3-dimensional approach to

understanding the relationship between literacy and health. 1) Literacy skills can create

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and can prevent adults from supporting the literacy development of their children; and 3) The environment and other factors in people’s lives can affect both health and literacy.

(Virginia Commonwealth University Center on Society and Health, 2014a). While it is the first of these that is the primary focus of this paper, it is also important to remember

that children must be healthy to learn, that parental health is critical to help children learn and grow, and that outside factors influence both literacy and health daily.

Figure 1: Three Connections Between Education and Literacy

Source: (Virginia Commonwealth University Center on Society and Health, 2014)

 Conceptual Framework for Literacy and Health Research. Canadian research into health and literacy and the resulting policy and programmatic outcomes has provided an

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Program developed the Conceptual Framework for Literacy and Health Research, (Figure 2), which shows the indirect and direct effects of literacy on health status. In considering

the many ways literacy impacts health, exploring direct and indirect causes is a functional way of understanding the research and evidence; the next two sub-sections will explore

this in greater detail. Figure 2 also describes the actions that are needed to improve literacy, the factors contributing to literacy, and the different types of literacy that are involved in this issue, providing a simple yet thorough visual of the complexities of this

issue. (Rootman & Ronson, 2005).

Figure 2: Conceptual Framework for Literacy and Health Research

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Direct Impacts

Literacy has a direct impact on health outcomes through the concept of health literacy, an

idea that originated in the United States in the mid-1970’s (Mancuso, 2008). Health literacy is a term that encompasses the skills individuals need to function effectively in a health care

environment and make healthy choices in their daily lives (Berkman, Sheridan, Donahue,

Halpern, & Crotty, 2011). While the exact definition of health literacy is evolving, some of the key skills incorporated in this term are:

 Print literacy – the ability to read and understand health communications and correctly interpret and act on this information;

 Numeracy – the use of quantitative information used, for example, in understanding medication dosages, interpreting nutrition labels, and measuring glucose levels; and

 Oral literacy – being able to speak and listen effectively so patients can have productive and understandable conversations with health care providers (Baker, 2006).

It is sensible to conclude that persons who cannot read or write, or are limited in these areas, will be unable to read or understand written health materials and medication labels,

research medical conditions to guide decisions related to their health, and will likely have a harder time following their doctor’s advice or instructions, especially if this includes complicated

medical terms. Additionally, adults need literacy skills to make healthier choices outside the healthcare environment. Examples include being able to read warning labels on household products, interpret health-related information from news outlets and media, and determine

whether they qualify for health assistance programs like Medicaid.

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have limited health literacy. These rates are highest among the elderly, minorities, the poor, and those who did not complete high school. (Kutner, Greenberg, Jin, & Paulsen, 2006) This finding

highlights how groups that are already affected by such social and physiological factors as poverty, increased age, and minority status are further limited by their low health literacy.

In 2004, the American Medical Association published a report on literacy and health outcomes. A team set out to determine the exact effect of low literacy on health and to research available data to help prove and understand the causal relationship. Their initial report concluded

that low literacy levels impacted the way a person functions in the health care environment, affected the way patients and physicians communicated, and that the dynamics of their

interaction led to poor understanding of written and spoken medical advice, and might

inadvertently lead to inferior medical care. (Berkman, et al., 2004) A 2011 Systematic Review, which updated the 2004 paper, found evidence of the following trends in individuals with low

literacy: increased use of emergency care and hospitalizations; lower use of preventive services, including mammography screening and influenza immunizations; poorer skills in taking

medications appropriately; limited ability to interpret labels and health messages; poorer health status among elderly persons; and, higher all-cause mortality rates. These studies also associate, but with less supportive evidence, low literacy with more symptoms of depression and greater

severity in symptoms of HIV infection. (Berkman, Sheridan, Donahue, Halpern, & Crotty, 2011) While much research has studied literacy in adults, these skills are also important for

young people. A research study of middle school youth used a survey to assess preventive behaviors. The study found there were fewer preventive behaviors (dental check-ups and sunscreen use) among those youth who reported difficulties in understanding the survey. The

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health behaviors. (Zullig, Ubbes, & Mann, 2013) Literacy also has a direct impact on health outcomes for young people as they too need literacy skills to make healthy decisions and

navigate the healthcare system.

Indirect Impacts

Literacy also has an indirect impact on health outcomes through its role in improving

social and environmental conditions that allow for healthier behaviors and greater access to resources, including health resources. Below, some of the most well-known associations between

literacy and socioeconomic factors are identified and the potential implications of these relationships to health are explored.

Literacy and Education.The 2003 National Assessment of Adult Literacy found strong

correlations between literacy abilities and graduation rates. Individuals with the least educational attainment (finishing less than or some high school) accounted for the largest percentage of those

scoring Below Basic in their assessments. (Baer, Kutner, & Sabatini, 2009) A research study released by the Annie E. Casey Foundation (Hernandez, 2012) found ample evidence to reinforce the association between the inability to read proficiently and failure to graduate from

high school, concluding that students who do not read proficiently by third grade are four times more likely to not graduate. This report also showed the confounding effect of poverty on these

outcomes. (Hernandez, 2012)

The Virginia Commonwealth University (VCU) Center on Society and Health has reported that Americans with less education are not living as long as their peers and studies

estimate that the life expectancy gap between the most and least educated is 14 years in males and 10 years among females. Further, those with less education are also more likely to have

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without a high school education was 15% compared to 7% among college graduates. Additionally, adults with less education often have more risk factors for disease, including

smoking and obesity. Smoking rates in the population without a high school diploma or GED were 27% in 2011 but only 8% in adults with a Bachelor’s degree. (Virginia Commonwealth

University Center on Society and Health, 2014b)

The fact that literacy is such an important factor for educational success and is so closely associated with negative health outcomes is disturbing. But this relationship is further

exacerbated as it is also the foundation for many of the relationships and outcomes discussed in the following sections. It is straightforward to connect educational attainment to job

opportunities, economic status, and associated socioeconomic factors.

Literacy and Social/Psychological Benefits. With an established connection between

literacy and education, it is important to note the negative social and psychological consequences

resulting from a lack of education. The VCU Issue Brief on Education and Health (2014a) highlights positive social and psychological benefits gained from increased educational

attainment like reduced stress, greater self-esteem, stronger social skills and abilities to form relationships, and the ability to build social networks.

This brief also addresses the compounding effect that early stress has on infants and

toddlers. Citing a study on adverse childhood experiences (Felitti, et al., 1998), they explain how such experiences “can affect brain development and disturb the child’s endocrine and immune

systems, causing biological changes that increase the risk of heart disease and other conditions later in life” (Virginia Commonwealth University Center on Society and Health, 2014a, p. 7).

The relationship between education, stress, and health highlights the need for early intervention

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Literacy and Employment. The CDC reported that adults with less than a high school

education were three times more likely to be unemployed than those with a Bachelor’s Degree

(United States Bureau of Labor Statistics, n.d.; Brennan Ramirez, Baker, & Metzler, 2008). Individuals with no or limited literacy are not only unlikely to attain the higher education that

leads to many careers, but will likely find it more difficult to perform job-related tasks. Some examples include: developing a resume, filling out job applications and employment paperwork, reading and understanding work-related instruction manuals, and using computers and other

modern technologies. Today, there are few jobs that do not require at least basic literacy skills. The World Literacy Foundation’s report (2012) shows illiterate individuals earn 30%-42% less

than their literate counterparts and do not have the skills required to complete additional

education or training to increase their earning capacity. One study shows the incomes of persons with poor literacy typically do not increase throughout their working life, whereas individuals

with good literacy and numeracy skills see an increase of two to three times their starting salary (Cree, Kay, & Steward, 2012).

Those with less education are more likely to work in dangerous job situations and have fewer benefits. With better jobs, individuals are more likely to have health-promoting benefits like health insurance, paid time off, and pension or retirement plans. Higher wages also improve

access to health resources like gym memberships and healthier foods, flexibility to use time for exercise and stress-relieving activities, and pay for health services. (Virginia Commonwealth

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cancer. Additionally, these individuals more frequently experience mental distress. (Pleis & Lethbridge-Cejku, 2006)

Literacy and the Environment. VCU documented that low socioeconomic status is

negatively associated with health outcomes and having a low income often forces families to live

in less healthy neighborhoods. These neighborhoods are more likely to lack supermarkets with fresh and healthy food options, green space to promote exercise and activity, and high-quality schools. They also are more likely to have fewer jobs and higher crime rates (Virginia

Commonwealth University Center on Society and Health, 2014a). This VCU Issue Brief (2014a) also cites a previous review of environmental inequalities that found low-income neighborhoods

also are more likely to have higher levels of toxins (Brulle & Pellow, 2006). All of these environmental factors contribute to the health of those living among them.

Literacy and Imprisonment. Cree, Kay, and Steward write, based on data provided by

The Literacy Centre Milford, Inc. (2012), “The link between illiteracy and crime is clear. In various countries around the world, studies show that a majority of prison inmates have poor

literacy skills. Also, amongst juvenile delinquents, up to 85% are functionally illiterate” (Cree, Kay, & Steward, 2012, p. 6; Literacy Centre Milford). In the United States, over 70% of inmates cannot read above a 4th grade level and once released, have a much greater chance of avoiding

future imprisonment if they improve their literacy (One World Literacy Foundation, 2013). There are a variety of poor health outcomes associated with incarceration. A Justice and

Health Connect Report (2013) highlighted some of the most prominent negative health outcomes including: hypertension, asthma, arthritis, cancer, hepatitis, HIV, syphilis, tuberculosis,

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While low literacy itself does not directly lead one to commit crimes, they are clearly related. The association between imprisonment and poor health are another reason to make early

literacy a public health priority.

The Need for Early Intervention

The groundbreaking Hart and Risley study (1995) reported that by age four, children

from families on welfare have heard over 30 million fewer words than children from families they categorized as “professional families” based on parent occupation and education. Follow-up

data collected on these children found that vocabulary use at age 3 was a strong predictor of language skills at ages 9-10. (Hart & Risley, The Early Catastrophe: The 30 Million Word Gap by Age 3, 2003) This study sparked a large amount of research into the prevalence and

importance of early reading, oral interactions between children and caregivers, and implications for literacy and language development. Reading aloud to children at a young age is a critical part

of the development of language and helps them learn skills like recognizing letters, knowing how to hold and use a book, manipulate sounds, and develop oral language skills. It also helps build parent-child relationships through reading as a shared experience and helps them develop

positive attitudes towards reading and literacy. (Duursma, Augustyn, & Zuckerman, 2008) Other research shows there is a consistent link between the onset age of parent-child reading and future

success with language; the earlier parents start the better (Karrass, VanDeventer, & Braungart-Rieker, 2003).

There is a problem, then, when parents with low literacy skills are not able to provide

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directly impact the health of their children, which in turn affects their children’s outcomes in educational/employment success and health. And as these children have their own families and

continue this cycle, they perpetuate the negative health and socioeconomic outcomes outlined above. I believe this concept is one of the most compelling arguments for public health to direct

its attention to supporting children and families in early reading and literacy.

Where Does Public Health Fit In?

Public health is already taking steps to address literacy, understanding the many ways

poor literacy skills limit health. A majority of this work has focused on health literacy and meeting the needs of patients with low health literacy. There are numerous studies, reports, trainings, guides, policies, conferences, and other resources that are dedicated to addressing

health literacy deficits. While these types of interventions are necessary and certainly a part of solution, it is less clear what public health’s role is in addressing early literacy and being part of a broader community approach to literacy.

Although there are not many tools available to local health departments to advise them on best practices in developing, undertaking and evaluating literacy initiatives, there is some

movement in public health towards supporting early literacy. Public health has taken measures to prioritize literacy and education which help highlight the need for programming and motivate health entities to take action. Public health has also been involved in promoting local and

national work that brings different sectors together to develop policies benefiting both education and health. Finally, there are examples of patient-centered and community-based programs

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involvement in literacy efforts that extend beyond the scope of health literacy and describe examples of this work through prioritization, policy, and programs.

Prioritization

Social Determinants of Health. In the past decade, a global focus on the concept of

social determinants of health has drawn attention to the root causes of health conditions by

considering the social causes of health inequities (WHO, 2014). The prominence of social determinants of health and the need to address disparities through public health policy and

practice has set a compatible framework for exploring collaborative literacy and education initiatives. Healthy People 2020, which sets national objectives for improving the health of Americans, has included the social determinants of health as a priority. Specifically, the

associated goal states, “Create social and physical environments that promote good health for all” and a key area of focus is education. (U.S. Department of Health and Human Services, 2014)

This prioritizes education and sets the stage for its inclusion in public health policies and

practice. Because of early literacy’s impact on educational attainment, this goal will lead to more attention given to literacy as well.

Canada’s National Literacy and Health Program. As mentioned previously, Canada

has done a great deal of work integrating literacy and health. With their establishment of the

National Literacy and Health Program in 1994, they framed literacy as a national health issue. What is different about their approach and that of the United States is their attention on general literacy and lifelong learning. While improving health literacy and creating health materials for

individuals with low literacy skills is part of this program, they also prioritize community development, policy changes, and are now closely looking at evaluation and examining the best

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(Rootman & Ronson, 2005) Their success with this national priority has set a precedence for other national public health entities to focus additional attention on early literacy and integrated

literacy efforts.

Florida Department of Health. This state public health agency has prioritized integrated

and collaborative health efforts to improve community health and eliminate health disparities and has focused its attention on literacy. Through their webpage, they endorse the value of literacy promotion and list several statewide literacy programs in which they support. The primary

components of their literacy initiative are Just Read, Florida, “a comprehensive and coordinated

reading initiative” operated by the Florida Department of Education under state-wide statute;

Reach out and Read, the clinic-based intervention that will be explained in greater detail below; and The Institute for Healthcare Advancement which provides information on issues that intersect literacy and health (Florida Department of Health, n.d.). Prioritizing literacy and the

simple act of promoting literacy on their webpage are big steps to set the standard for increasing early literacy and school readiness. Additionally, with the state health system’s support, local

health departments are more likely to embrace this issue.

Policy

Health in All Policies . The concept of “Health in all Policies” is a public health

movement that emphasizes the need for multi-sector collaboration in addressing social determinants of health. The Health in All Policies guidebook states,

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This encourages collaboration between education and public health sectors, and it is likely early literacy promotion will emerge as a policy priority.

Alliance for Early Success/Birth Through Eight. The Alliance for Early Success is a

group with a goal of influencing policies that lead to better life outcomes for children. Their

Birth Through Eight State Policy Framework provides a lens for public health and other sectors to influence state policy development in health, family support, and learning. The foundation for this program lies in the growing evidence of the connection between literacy and health. In turn,

the group is working to link their three priority issues and bring about policy change to enable children to thrive. (The Alliance for Early Success, 2014) This is a useful resource for public

health entities to use in policy collaborations with the education sector.

Place Matters. The Place Matters program is primarily a health equity intervention. Its

focus is to bring together different sectors to analyze and promote policies that benefit multiple

aspects of the community. The Almeda County Public Health Department, the local arm of this program, convenes public health and community partners to analyze local policies and

understand their effect in promoting or inhibiting community health. They then promote policies that will be most beneficial to local health and wellness. While they also address issues like economics and criminal justice, education is a key focus as it has great potential to impact health,

literacy, education, and other determinants of health. (Place Matters Overview, n.d.) This is a strong example of how local health departments can participate in health policy development.

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Practice

Reach out and Read. This evidence-based initiative is conducted by a network of

medical providers who promote early literacy and school readiness with their pediatric patients by providing children new books and giving advice to parents about the importance of reading aloud to their children. This program has been extremely successful, and has strong data to

corroborate its efficacy. (Reach Out and Read, 2013) Reach Out and Read children/participants read with their families more often (High, LaGasse, Becker, Ahlgren, & Gardner, 2000, p. 104),

enter kindergarten better prepared to succeed, and begin school with larger vocabularies and better language skills than non-participating children with similar backgrounds (Mendelsohn, et al., 2001). Reach Out and Read data from numerous independent, peer-reviewed studies show

that children scored three to six months ahead of non-Reach Out and Read peers on vocabulary tests (Reach Out and Read, 2014). The program serves 29% of all children living in poverty in

the U.S. as Reach Out and Read served 4.1 million children out of an estimated 14.7 children living in poverty in the United States in 2013 (Pear, 2014; Reach Out and Read, 2014).

Video Interaction Project/Building Blocks. The Video Interaction Project and Building

Blocks are more intense and supplementary programs compared to Reach Out and Read.

Understanding the success of Reach Out and Read, a randomized, controlled study performed by

Mendelsohn et al. (2011) aimed to determine whether additional pediatric primary care interventions improved parent-child interactions in low-income families. In addition to the fundamental parts of Reach Out and Read (giving children books during their appointments and

giving parents advice on reading to children), these programs incorporate the use of more

intensive activities. Through the Video Interaction Project, children attend additional 1-on-1 and

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meetings are videotaped and reviewed to improve parental interactions and families are given additional materials appropriate to the child’s developmental stage. The Building Blocks

intervention also encourages parent-child interactions through pretend play, reading together, and including these activities as part of a daily routine. Rather than taking place in the office,

supplementary materials like newsletters, learning materials (like a stimulating toy or book), and parent-completed questionnaires are mailed to families. These families are able to implement the intervention on their own time and in a style that suits their situations.

The study concluded that interventions like these further increased parent-child

interactions and have long-term positive effects on the children who take part in these groups.

(Mendelsohn, Huberman, Berkule, Brockmeyer, Morrow, & Dreyer, 2011) Video Interaction Project, Building Blocks, and Reach Out and Read programs have paved the way for additional literacy interventions in the exam room. Their success also supports the idea that public health

should give children books and talk to parents about reading to and with their children early in their lives and demonstrates this regular practice is both influential and worthwhile.

Community Literacy Initiatives. Many communities are recognizing the importance of

bringing community organizations across multiple sectors together to address literacy. Health departments and other health organizations are playing an important role in this by participating

in literacy coalitions, collaborating on literacy programs, and by helping to coordinate local training opportunities and conferences. For example, the Literacy Center of West Michigan

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equity to help communities understand what this means to literacy, education, and other social determinants.

Literacy Builds Health Initiative. The Literacy Builds Health initiativewas the name of the partnership between First Book and the Gaston County Department of Health & Human

Services (Gaston DHHS), previously mentioned in the background section of this paper. One of the ways First Book operates is to host large book distributions for teachers and youth-serving organizations so they can distribute them to low-income children. First Book became interested

in working with health partners by providing books for Reach Out and Read sites (discussed above) and in 2013 they began exploring strategies for partnering with the public health sector

(Creech, 2013). One outcome was a collaboration with the Gaston DHHS which hosted a community book distribution, making it the first health department in North Carolina to partner with First Book in this way. The local health department was able to engage pediatricians, health

educators, and health-related case management programs that would not normally seek free books for their low-income clients. It also demonstrated to health workers the importance of

early reading and has changed the way they prioritize this issue, as evidenced by the

establishment of a Literacy Workgroup that was formed following this collaborative initiative. This workgroup involves multiple sectors, with participation from the local Literacy Council,

library, public schools, childcare, and childhood development organizations. The community support earned by distributing free books has helped Gaston DHHS initiate this workgroup and

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Local Health Departments Can Do More

As evidenced above, there are good examples of how public health can promote early literacy, which encompasses the skills children need to prepare them for formal reading and

writing. While a multi-sector and multi-level approach is critical to this issue, it is my opinion that local health departments are especially well equipped to promote early literacy for the following reasons.

Access to at-risk populations

Most literacy efforts occur in schools, childcare centers, and through before- and after-school supplemental programs. While there are always gaps in services, the access health

departments have to at-risk populations can help ensure more children receive early literacy outreach services. Local health departments serve a wide range of community members and in

many areas provide primary care to a majority of the low-income population.

It can take time to build trusting relationships with others, especially those disseminating information about health and wellness. Capitalizing on the ongoing relationships that public

health nurses, doctors, social workers, and educators have with clients can help motivate families to take steps to improve family reading and literacy. The Reach Out and Read program

demonstrates how effective physicians are at promoting literacy. Local health departments that provide primary care to children can and should take advantage of this and other compatible programs like Video Interaction Project and Building Blocks. Those that do not can use their

maternity clinics, WIC (Women, Infants, and Children) offices, community health workers, and family case-management programs to deliver frequent and enthusiastic literacy messages.

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health departments serve qualify these organizations to receive funding from agencies that traditionally have only worked with schools and libraries. For example, First Book has special

pricing at a fraction of the cost of Amazon or other book distributors. They also offer free books through community distributions.

Health departments can turn crowded waiting rooms and major public health events, like back-to-school vaccinations, into opportunities to promote literacy by giving out free books. This offers a unique opportunity to reach parts of the population that might be overlooked and

reinforce the importance of early reading in the most at-risk populations.

Community Leadership

Health departments are often seen as community leaders. With this role, they are in a key

position to prioritize literacy for their agency, other health and wellness organizations, and the community at-large. The Board of Health is typically made up of community members from a

wide range of fields, and with their leadership, they too can prioritize this issue.

Health departments typically serve as the lead group initiating community health assessments which set health priorities for their constituencies. By including questions about

literacy, they can identify gaps in literacy services, public perceptions of literacy and early reading, and establish target areas for improvement.

Public health’s involvement with literacy offers a chance for health departments to

strengthen their partnerships with other agencies and sectors. Working together closely for policy development, like those involved in the Place Matters program, and using an annual event to

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Creating formal collaborative relationships like a task force or council to address literacy is a start. But careful guidelines should be followed to ensure these groups achieve the goals they

set out to address and that meetings are productive and outcome-driven. Attempts should be made to incorporate a wide range of experts and use tools like the Birth Through Eight policy

framework that are effective and established (The Alliance for Early Success, 2014).

Evaluation and Quality

Public health knows the importance of evaluation, data, sustainability and quality

assurance. Among the problems with current interventions around social determinants of health - including literacy - is the need for more evidence to evaluate program efficacy and long-term effects (Rootman & Ronson, 2005; Baker, Metzler, & Galea, 2005). With literacy, especially, it

is difficult to show the direct line of causality from early literacy interventions to school performance, employment opportunities, and socioeconomic stability and the many protective

benefits afforded by this (American Medical Association, 1999).

Public health can play a critical role in the process of evaluating literacy programs because of its ongoing relationships with children and families. Whereas libraries or literacy

councils might have a hard time showing long-term program success because of their inability to follow participants for years, many health departments have relationships with families that span

generations.

Health departments are also adept at quality improvement activities which can benefit literacy programs. Over half of the nation’s local health departments (55%) conduct formal

quality assurance activities and most (76%) state health departments, which provide support to local health departments, have adopted formal performance management programs (Salinsky,

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Understanding and Addressing Social Determinants of Health

As previously mentioned, the field of public health has recently focused on identifying

and addressing the social determinants of health. Health departments have access to funding and training to implement programming aimed at reducing health disparities which is making them local experts in root-cause analyses. Leveraging this expertise and their capabilities to partner as

a member of interdisciplinary teams, public health departments can guide other organizations to develop policies and programs that address disparities in literacy and education rates among

differing populations.

The relationship between literacy and health is not a one-way street. Health status itself can impact literacy through the presence of disabilities that make it harder for one to learn to

read, such as dyslexia, vision impairment, cognitive skills, and attention disorders. Asthma and other chronic conditions might cause recurrent school absences and difficulty concentrating in

class. By considering how present health conditions impact reading skills, school attendance, and opportunities to learn, public health might promote literacy by creating healthier children that are ready to learn.

Conclusion

Public health involvement in literacy does not have to be expensive or time consuming.

Local health departments can integrate literacy-promoting activities into their clinics, programs, and waiting rooms. They can invite representatives from the education sector to meetings on health policies and collaborate in literacy workgroups. They can educate their communities on

health inequities and cultivate community support around literacy and education.

We should do this because public health is prevention. We offer immunizations to

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classes on healthy eating and exercise to educate the public and empower them to make healthier decisions. With all of the evidence demonstrating the protective benefits of literacy on health and

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