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The stars of theory

Updated: Jun 13, 2019

When an innovative new health literacy initiative needed a strong theoretical foundation, Will Ross was there for it. 10 years later, he still is.

When Will Ross, MD, MPH reflects on the beginnings of Health Literacy Media, he’s still amazed at the confluence of like-minded individuals and organizations that were in the right place at the right time.

“It’s like it was supposed to happen; the stars aligned,” he says, about the efforts that laid the groundwork for the statewide health literacy initiative known as Health Literacy Missouri (and now, Health Literacy Media).

A portrait of Will Ross, seated in front of medical textbooks, smiling
Will Ross, MD, MPH

More than a decade ago, Ross, who currently serves as Associate Dean for Diversity at Washington University School of Medicine, helped spearhead the effort to ensure Health Literacy Missouri would be built on a solid foundation of relevant theory.

As part of a budding health literacy initiative with the St. Louis Regional Health Commission (RHC), Ross and his colleagues from areas like public health, the nonprofit sector, and medical education saw the need for an overarching framework that tied together efforts to positively influence the complex mix of forces that influence health and health literacy.

“Ten years ago, health literacy was in its infancy. It was just something you did in terms of re-writing information for the patient-provider interface,” Ross says.

The RHC Task Force on Health Literacy, which Ross directed, looked to the theoretical bases of health education, health promotion program planning, and social psychology. This approach of weaving together relevant theory, informed by an ecological perspective, filled a void for the growing field of health literacy.

Health Literacy Missouri Program Logic Model. Assumptions: Health literacy is associated with a low quality of life. Low health literacy is a significant issue in Missouri. Low health literacy disproportionately affects marginalized and underserved populations. Responsibility in improving health literacy resides in the entire community.  Inputs: People of Missouri. Educational Systems. Faith –based Institutions. Social Service Organizations. Health and Medical Community. Industry. Academic Policy Centers. Government.  Activities: Needs Assessment. Resource Inventory and Development. Assessment and Triage of Community Resources. Health Professional Curriculum Development. Public Education Campaign. Strategic Communication Planning.  Outputs: Prioritized Needs of Missourians. Health Literacy Resource Repository. Public Education Campaign. Health Professional Training Program. K-12 College Health Literacy Curriculum.  Short term outcomes: Increased Public Awareness of Health Literacy. Increased Personal Satisfaction with Health Care. Increased Patient’s Health Communication Skills.  Medium term outcomes: Appropriate Use of Prevention Services. Increased Health Literacy Among Students. Increased Provider Health Literacy and Communication Skills. Increased Community Capacity.  Long term outcomes: Healthier Missourians. Reduced Health Care Costs. Improved Systems Infrastructure.  Evaluation: Data collection, Analysis, Reporting
Health Literacy Missouri Program Logic Model. Ross, Will, MD, MPH; Culbert, Arthur, PhD; Gasper, Charles; Kimmey, James, MD, MPH. A Theory-Based Approach to Improving Health Literacy.

Moving beyond the individual

When reviewing the literature on health literacy interventions, Ross found a mixed bag, in terms of effectiveness. But they observed that programs which addressed the bigger picture–the social determinants of health and health behavior–tended to move the needle more readily than programs that just focused on educating individual patients.

They knew they needed to break out of the walls of academia too, and through a series of town hall meetings, Ross says they were able to hear what people in the community saw as barriers to health and accessing healthcare.

With these inputs from the scientific literature, grassroots organizations, and community members, they constructed a logic model to inform strategic planning, implementation, and evaluation for health literacy programs.

Will it play in Oxford?

Like many states, Missouri is incredibly diverse when it comes to demographics, the physical and economic structures of communities, assets and challenges, and other so-called social determinants of health. This diversity underscored the importance of a robust theoretical framework to support evaluation efforts: to observe and measure the relationships between program activities and outcomes and find the ‘active ingredients’ for improving heath literacy.

But this perspective was new enough that Ross says he felt it needed vetting by his peers. So in 2006, he presented a conference paper to an International Health forum in Oxford, England.

“It was a wonderful opportunity to present this scholarly analysis to some of the brightest people in the world,” Ross says, and he characterizes the overwhelmingly positive response as “The most affirming thing that could happen; I was convinced that we got it right.”

It was time to go all in, he says, and along with his colleagues from the RHC, Ross put together a comprehensive set of recommendations for putting a path-breaking statewide health literacy initiative into action.

Part of these recommendations was to form a “sustainable infrastructure” to provide a centralized sources of expertise, support statewide activities, and serve as an exemplar for similar efforts. Thus was born the foundation of Health Literacy Missouri: to provide that infrastructure.

The stars align

In the wake of the landmark 2004 IOM report, health literacy had the attention of various health-related organizations, and the RHC wasn’t alone in its focus on the topic. The Missouri Foundation for Health (MFH) was investing energy and resources into the challenge of improving health literacy in its service area.

“Steve [Pu] and Jim [Kimmey] were having this conversation independent of what we were doing at the Regional Health Commission,” says Ross. “Its just interesting that we were all able to come together at the same table and make this thing happen. It really is a beautiful story.”

In its role as a grantmaker, MFH was also in a unique position to observe the great demand for health literate resources and programming when its grant reviewers looked across the range of applications from the community.

It was also in a position to bring resources to bear.

Ross is fond of quoting Louis Pasteur; “Chance favors the prepared mind,” and he knew the time was right to make a pitch to MFH to put financial support behind this idea. As chair of the MFH Board of Directors at the time, he was well-positioned to inform the rest of the board on the idea.

Still fulfilling the vision

The original vision of the Regional Health Commission recommendations is flourishing at Health Literacy Media, and not just in terms of infrastructure. Through our partnerships, we’re training community health workers, social service professionals, pharma, and medical students in health literacy, patient-centered communication, and teach-back. We’re leading in cultural competency with health insurance education materials in 6 languages, with a focus on accessibility. And whenever we can, we love to work with the community directly.

10 years later, Ross continues his dedication to health literacy as a member of our board of directors, and through his myriad roles as an advocate for health equity in the community.

After all, says Ross, “The seed was really started by people in the community talking about their difficulty accessing care.”


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