During the recent anthrax scare, the United States Postal Service mailed millions of postcards to Americans listing ways to protect themselves from infection and to report suspicious mail. The idea was a good one during a time of unease. But Rima Rudd, lecturer on health education in the Department of Health and Social Behavior, poses a fundamental question: half of American adults have literacy skills that score below the eighth-grade level, so how many recipients could actually understand the mailing?

Rudd runs a number of projects under the umbrella of Health Literacy Studies (HLS) in the Department of Health and Social Behavior. HLS is the research program of the National Center for the Study of Adult Learning and Literacy (NCSALL), a research center focused on improving adult education. Rudd is the principal investigator for health and literacy studies at NCSALL. She was recently invited to deliver a Grand Rounds lecture at the Massachusetts Department of Public Health on health literacy and communication, which she called "Health Communication in Times of Calm and in Times of Chaos." The lecture was standing-room only.

"Do words matter? Yes. We live in a literacy environment," said Rudd in a later interview. "Some people feel attacked by the written word. We have to find ways to include them."

Even with the best intentions, public health officials do not always manage to clearly communicate to the public. About 200 studies over the last two decades have found that the reading level of most health-related materials far exceeds the reading ability of the average adult. The Canadian Public Health Association now requires that all health-related materials must be written in plain language.

One example of a fairly successful effort to communicate to the public was a mailing about HIV/AIDS sent by US Surgeon General C. Everett Koop in 1988. It was the largest mailing ever from the US government: 107 million American households received a seven-page brochure about the AIDS epidemic. The content was controversial because it talked directly about subjects such as sex and specific acts such as anal sex. Two years later, the brochures were assessed for how difficult they were to read. Researchers determined that people at a seventh-grade reading level should have been able to understand the brochure (Some sections were judged at higher levels. The one describing how someone gets AIDS was deemed a ninth-grade reading level).

Then, in 1992, the Education Testing Service undertook the first National Adult Literacy Survey and found that half of US adults read at levels between first and eighth grades. Nearly one-quarter of US adults read below fourth-grade levels, meaning they would have struggled with the AIDS brochure, even though it was considered well written.

"People with limited literacy skills are not well-equipped for modern society, where there is much emphasis on written words," said Rudd. The National Governors Association has said that Americans need to read at a level of at least ninth grade to meet the needs of most jobs in the US.

Literacy also affects health, a message that Rudd has doggedly pursued. Studies have shown that low literacy is associated with health behaviors such as less use of mammography services or delayed care for prostate cancer. Reading an appointment slip or directions on a prescription pill bottle are confusing tasks for some people. Lengthy informational material about illnesses may be too cumbersome for sick patients. Medical history forms can be intimidating, leading to inaccurate records that could adversely affect patient care. Even describing symptoms to a doctor–turning feelings into words–can be daunting for people with low literacy skills.

Only recently have experts begun to ask about the implications of limited literacy in health-related actions and outcomes, said Rudd. There are about a dozen rigorous studies of the question, but interest is growing. Rudd is working on about 10 small projects, including investigating how difficult it is to navigate health care systems, such as hospital hallways, as well as completing medical and insurance forms. For example, she is working with Anne Pereira, a former student of her’s and an HSPH graduate, in assessing the Medicaid application process. This project was, in part, inspired by the work of another HSPH graduate, Christine Molnar. (See below).

When Rudd spotted the US Postal Service’s anthrax-related postcard in the mail, she evaluated it and found it to be written at reading levels between the ninth and eleventh grades, above the known reading levels of half of American adults. She is writing a paper about her evaluation, including a systematic analysis of what could have been done better. One example: the postcard said to "notify local law enforcement" if suspicious. How about just saying, "call the police," asked Rudd?

"In public health, we have grown accustomed to talking about people who are ‘hard to reach’," said Rudd. "The issue is not that people are hard to reach. We may not have developed our communication skills so that we can effectively reach and talk to them."

Many professionals tend to use the jargon of their speciality when communicating with the public, and they often write for people like themselves rather than for the lay public, she said.

"We don’t pay enough attention to our words and to the structure of our writing," said Rudd. "It’s not evil or purposeful, but at this point, it’s unconscionable now that we know about the literacy levels of American adults."

The US Department of Education will undertake the next National Adult Literacy Survey in 2002, and, at the urging of Rudd and others like her, the survey will include health-related items such as reading a prescription bottle. Rudd was also involved in the development of Healthy People 2010, which now includes a focus on health communication and a health literacy objective.

For more information about the HLS, visit www.hsph.harvard.edu/healthliteracy, which offers a preview of a video the group produced.

The US government has launched a multi-million dollar campaign starring actor Leslie Nielsen to educate Americans about Medicare choices, but a recent report by National Public Radio described how many Americans, despite the campaign, remain unaware or confused (To listen to the report, visit www.npr.org). Medicare recipients have to choose their health plans this month and now will be locked into their choices for a year instead of having the option to change every month. Coverage choices have become manyfold. Since 1997, Medicare recipients have been able to pick among HMOs, traditional plans and Medigap plans, but private companies have been dropping Medicare patients at alarming rates. Easy-to-understand information is needed now more than ever.

That fact is well-known to Christine Molnar, MPH ‘94, who has worked on information campaigns on public health insurance programs such as Medicare, Medicaid and State Children's Health Insurance since the time she was an HSPH student. She now directs the Managed Care Education Programs at the Community Service Society (CSS) of New York, a non-profit organization that helps people navigate around system barriers.

Molnar wrote her own job description while at HSPH, although she didn’t know it at the time. She had been working with Rima Rudd, lecturer on health education in the Department of Health and Social Behavior (see above), when she accepted a summer internship at CSS. She proposed a program to educate New York City residents about upcoming changes to the Medicaid program using materials that would be based on adult-learning theories and varying literacy levels. When Molnar returned to HSPH that fall, CSS offered her the opportunity to run the program after she graduated.

Among her activities, Molnar directs an ombudsprogram that provides managed care enrollees with information and assistance with their health plans. She has designed and implemented multi-lingual, multi-cultural programs that provide education within communities to Medicaid beneficiaries on how to access health care services. She authored Knowledge Gap: What Medicaid Beneficiaries Understand–and What They Don’t–About Managed Care.

"We are trying to give people concrete tools to help them understand information useful to them," said Molnar. "We want to simplify the application process while helping people understand how the health care system works."

Molnar and her colleagues have broken down information for their clients into specific, action-oriented steps that are clear and to the point. For example, clients are given sample letters to use as templates when writing agencies for information.

Recently, Molnar won an achievement award for her work from the New York State Public Health Association.