The 2030 Healthy People Initiative and Framework

The 2030 Healthy People Initiative and Framework: Health Literacy’s Impact on Oral Health Promotion and Disease Prevention Objectives for the Nation

Dushanka V. Kleinman, DDS, MScD; Alice M. Horowitz, PhD; Rima E. Rudd, PhD; Donald L. Rubin, PhD; Kathryn A. Atchison, DDS, MPH; and Cynthia Baur, PhD

ABSTRACT Oral health is an integral part of the Healthy People initiative, a 40- year national health promotion and disease prevention effort that sets and monitors objectives with data-driven targets for each decade. The framework for the next decade, Healthy People 2030, includes new components and a focus on health literacy for the first time. This paper discusses oral health in the context of this framework and implications for supporting progress toward the new objectives.

The topic of oral health has been an integral part of the Healthy People initiative, a 40-year national health promotion and disease prevention effort launched by Surgeon General Julius Richmond’s landmark 1979 report “Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention.” [1] This report challenged the nation to do more collectively to improve the health of the population and highlighted the importance of setting science-based objectives with targets each decade to guide coordinated efforts and drive action. The development of Healthy People 2030 is now underway and includes a framework and new objectives with targets to chart the course for the coming decade. The framework explains the context and rationale for Healthy People 2030 and provides principles that underlie decisions about the initiative. In January 2019, the draft national objectives, including a number of oral health objectives, were circulated for public comment. The U.S. Department of Health and Human Services (HHS) is anticipated to launch Healthy People 2030, the fifth iteration of the initiative, in late summer of 2020.

The first section of the paper outlines the history and oral health components of the initiative. The second section describes new components of the Healthy People 2030 framework relevant to overall health and well-being, one of which is the inclusion of health literacy for the first time. It goes on to examine how oral health and health literacy fit within the framework. The discussion focuses on implications for oral health promotion and disease prevention and how the framework can inform oral literacy and support preparation for and progress toward the Healthy People 2030 objectives.

Section One: History of the Healthy People Initiative

The Healthy People initiative is federally led and stakeholder driven (FIGURE 1 ). HHS coordinates the initiative with the support of a federal interagency workgroup that includes representatives from each of the HHS agencies and other federal agencies. In addition, subject-matter experts from across HHS support the development, assessment and management of topic-specific objectives. Coordinators in each state further extend the reach of this initiative nationally and into local communities. From the beginning of the initiative, the critical role of multisector collaborations and concerted efforts at the local level to promote health was acknowledged. The 1979 surgeon general’s report recognized that progress will require “the commitment of people extending far beyond what we traditionally consider the health sector,” and that such action is possible only through “a partnership that involves the serious commitment of individual citizens, the communities in which they live, the employers for whom they work, voluntary agencies and health professionals.” [1]

FIGURE 1. Health People 2020: federally led, stakeholder-driven process. SEE FIGURE IN THE FULL ISSUE OF THE JOURNAL

At the time of the initial launch in 1979, the Healthy People initiative was innovative and unique in its design. It created a roadmap composed of carefully selected topics with quantifiable targets and provided a highly visible, data-driven report card of the nation’s health improvements and challenges. The approach, with its projection and monitoring of targets and reporting of progress at the middle and end of each decade, stimulated interest across the nation and in other countries. Now, 40 years later, this data- and evidence-based health promotion and disease prevention initiative continues to inform national, local, state and international initiatives (TABLE).

TABLE The Evolution of Healthy People SEE TABLE IN THE FULL ISSUE OF THE JOURNAL

Since 1980, specific national objectives have been established with targets to be achieved by the close of the decade. Throughout the decade for each iteration of the initiative, formal assessments of progress are conducted at various intervals, including topic-specific progress reviews, a mid-decade review and an end-of-decade final review. With each decade, the overarching goals have expanded in scope and emphasis and the number of Healthy People objectives and topic areas has increased. Two overarching goals guided the 1990 objectives: decrease mortality for infants through adults and increase independence among older adults. [2] By 2020, the scope of the overarching goals expanded the reach of the initiative: attain high-quality, longer lives free of preventable disease; achieve health equity and eliminate health disparities; create social and physical environments that promote good health; and promote quality of life, healthy development and healthy behaviors across life stages. [3] In addition to the overarching goals, the number of objectives and related topics grew from 226 objectives with 15 topics for 1990 to 1,300 objectives with 42 topics for 2020. This evolution reflects an increase in scientific knowledge and the interest of collaborating organizations and advocacy groups. It also speaks to the growing understanding of the multiple factors contributing to health and well-being.

ORAL HEALTH COMPONENTS OF HEALTHY PEOPLE

Targets for improvements in oral and dental health status, disease preventive measures and surveillance activities have been included in each decade since the inception of the Healthy People initiative. This has offered the opportunity for greater national visibility to oral health as an essential condition of overall health and well-being. Over the decades, the oral health objectives have grown in number and scope, reflecting the evolving structure of Healthy People as well as of the emerging professional and public health interests and issues. The objectives first appeared under the topic of “fluoridation and dental health,” but thereafter continued with each decade under the topic of “oral health.” With each decade, the number of oral health objectives has increased. The inclusion of oral health objectives addressing oral and dental health issues indicate increased diversification with additional disease targets, preventive services and infrastructure systems and reflect extension into dental-medical integration.

For 1990, 12 objectives addressed improving health status (dental caries and gingivitis in children and periodontal diseases in adults) as well as reducing risk factors (decreasing highly cariogenic foods and snacks in schools and wearing mouthguards during sports). [2] The initial oral health objectives called for increasing professional and public awareness by increasing schoolchildren and adults’ knowledge and awareness of dental disease risk factors and of the importance of fluoride and other measures to control disease. This includes increasing awareness of personal oral hygiene and the importance of professional care among adults as well as increasing personal oral hygiene and other preventive measures for schoolchildren. The objectives also included system-level changes such as improving services (access to community water supplies with optimum fluoride and provision of school water supplies with optimum fluoride when community water supplies are not possible.) Furthermore, the objectives addressed improving surveillance and evaluation systems, specifically, a system for periodic determination of oral health status, treatment needs and use of services as well as a system to determine coverage of all major preventive measures and actions to reduce consumption of highly cariogenic foods. The structure of these objectives paralleled that of other health objectives and followed the charge that these objectives were primarily designed for healthy individuals to reduce risks to future illness, not just for the early detection of existing diseases.

Oral health objectives continued to be expanded in number and scope for Healthy People 2000, 2010 and 2020. [3–5] In Healthy People 2020, the oral health topic area includes 33 objectives and represents a more detailed profile of targets that expanded the focus on early detection, systems of care and surveillance. [3] Objectives move beyond the profession’s and public’s increased awareness and knowledge of preventive measures and instead include measures of receipt of preventive services and measures of the inclusion of oral health components of school-based health centers, federally qualified health centers and local health departments. The addition of objectives to increase adults receiving oral and pharyngeal cancer screening, introduced in 2010, and for the testing and referral for glycemic control by dentists and dental hygienists reflect the continued emphasis on and the importance of integration of medical-dental practice. Expansions in measuring oral health status include untreated dental caries, tooth loss and oral-cancer detection. Expansions in surveillance and monitoring include the increase of state-based surveillance systems for oral and craniofacial conditions and for systems to record and refer infants and children with cleft lip or cleft palate to craniofacial anomaly rehabilitation teams. In addition, an objective was added to increase health agencies with a dental public health program directed by a dental professional with public health training. Healthy People 2020 also provides linkages among topic areas. For the topic of oral health, linkages with cancer, diabetes, tobacco use, access to care and others are highlighted.

The Healthy People initiative has provided the oral health community with a common roadmap to guide efforts at local, state, regional, tribal and federal levels with resources highlighting evidence-based interventions. It also has highlighted areas and gaps where additional investments are needed. For example, early in this national initiative, the need for access to timely, high-quality data to inform state and local prevention and health promotion efforts was identified. A concerted effort by the Association of State and Territorial Dental Directors with support from the Centers for Disease Control and Prevention’s Division of Oral Health established the National Oral Health Surveillance System. [6] This included the creation of oral health indicators and the inclusion of oral health questions in surveys, such as the Behavioral Risk Factor Surveillance System. Continued investments in surveillance efforts are critical to program development, assessment and redirection.

The Healthy People 2020 Midcourse Review oral health findings provide another example of how this initiative can be used to assess and inform our programmatic efforts and decision-making (FIGURE 2). [7] The report reveals positive progress: 16 of 33 oral health objectives had met or exceeded their 2020 targets and another three of 33 oral health objectives were improving. The Healthy People 2020 Midcourse Review further revealed that five oral health objectives had little or no detectable change — children with dental caries experience in their primary and permanent teeth (aged 6–9 years); adolescents with dental caries experience in their permanent teeth (aged 13–15 years); adults with moderate or serious periodontitis (aged 45–74 years); oral and pharyngeal cancers detected in the earliest stage; and federally qualified health centers with an oral health care program. One oral health objective was getting worse — children, adolescents and adults who visited the dentist in the past year (age-adjusted, percent, aged 2-plus years: from 44.5% to 42.1%) — and eight oral health objectives had baseline data only and progress could not be measured. The latter objectives highlighted the lack of data regarding: older adults (aged 75+ years) with untreated root surface caries; adults who received information on reducing tobacco use from a dentist; adults who received an oral cancer screening from a dentist; and adults who were tested or referred for glycemic control by a dentist and local health departments with oral health prevention or care programs. The Healthy People midcourse and final decade reports, like this one for Healthy People 2020, provide the health professions and policymakers with critical data to inform actions to be taken. These data serve as the initial stage to inform additional assessments into facilitators and barriers to achieve the objective targets and highlight gaps in needed surveillance and infrastructure.

With the anticipated release of the Healthy People 2030 final objectives in late summer 2020, oral health professionals can benefit from the Healthy People 2020 assessments and begin the process of alignment with the new Healthy People 2030 framework. The 2030 framework provides insight to the advance preparation and strategic approaches needed to support progress toward the newly formulated oral health and related objectives.

Section Two: Healthy People 2030 Framework

The framework for Healthy People 2030 provides a guide to the objectives and the implementation of initiatives. [8] The sidebar highlights select components of the framework: the vision, mission, foundational principles (new to the Healthy People initiative) and overarching goals. The health literacy component is a new and integral part of the foundational principles and of the overarching goals (attaining health literacy, eliminating health disparities, achieving health equity). In addition, several other concepts differentiate the framework for 2030 from that of Healthy People 2020. These include the cross-cutting emphasis on “health and well-being” throughout the framework as well as the principle that promoting the health and well-being of the nation is a “shared responsibility” among all levels and sectors. Included is attention to economic environments, in addition to the social and physical environments, to strengthen the potential to achieve health and wellbeing. Furthermore, the engagement of the public, key constituents and leadership to take action and design effective policies is highlighted. Research findings from health literacy offer insight for these additional concepts and can serve as a foundational component of Healthy People 2030 to “improve the health and well-being of all,” including oral health.

HEALTH LITERACY AS A FOUNDATIONAL CONCEPT

While the topic of health literacy is relatively new to the Healthy People initiative (introduced 20 years after the inception of Healthy People), its inclusion and evolution reflect the growth of the scientific research foundation and increased understanding of its role as a determinant of health. The topic was introduced at the turn of the century in the 2010 Healthy People objectives and was included in the 2020 objectives. The 2010 document defined health literacy as “the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions.” [5] The measure focused on health literacy skills of the English speaking population and noted that only 12% of this population was proficient. In addition, the definition of “oral health literacy” was included in the oral health chapter. However, no objectives specific for oral health literacy were included. For 2020, the health literacy objectives continued to address the health literacy of the population and added a measure of increasing “the proportion of persons who report that their health care providers have satisfactory communication skills.” This reflected a growing awareness of the evolution of the health literacy concept — one that is attentive to the literacy skills of the public along with the health literacy and communication skills of health professionals, the quality of health information and various attributes of the health care system.

SIDEBAR Healthy People 2030 Framework: Vision, Mission, Foundational Principles and Overarching Principles SEE SIDEBAR IN THE FULL ISSUE OF THE JOURNAL

ISSUE BRIEF ON HEALTH LITERACY

To clarify concepts included in the Healthy People 2030 framework, the Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2030 (Secretary’s Advisory Committee) prepared several issue briefs to inform the development and implementation of Healthy People 2030. [9] The issue brief on “health literacy” offers a review of this topic in the Healthy People initiative, provides a general overview of health literacy as a determinant of health and discusses the need for an expanded concept of health literacy. It offers a discussion of limited health literacy and its association with poor health outcomes, health disparities, reductions in health care quality and increased health care costs.

The brief provides evidence of how major national and international organizations have recognized the role of health literacy in reducing health disparities, improving quality of care and improving population health (World Health Organization, National Academies of Science, Engineering and Medicine, the Joint Commission and National Committee for Quality Assurance). The emerging perspective is that enhancing the population’s health literacy requires a systems approach and argues for a conceptual model of health literacy “as a process,” one that engages several contributing factors. The Secretary’s Advisory Committee concluded: “Health literacy occurs when a society provides accurate health information and services that people can easily find, understand and use to inform their decisions and actions.” “Society” includes health care providers, mass and social media, health care facilities and organizations and more. In addition, “people” includes individuals and communities, including health care providers. Furthermore, it notes: “Healthy People 2030 can catalyze new, systemwide health care and public health-oriented policies, standards and measures that strategically include attention to health literacy.” The brief concludes that “to attain health literacy, interventions targeting the complex factors contributing to or mediating health literacy are needed at all levels: individual, community and society.” The emphasis is placed “on aligning the information and services that society provides with the capacities of people” and that “this alignment is pivotal to eliminating health disparities and achieving health equity.”

Oral Health in the Context of the Healthy People 2030 Framework

The multidimensional aspects of oral health — the physical, psychological, emotional and social domains — are complex and require clearly communicated information to inform coordinated actions among sectors and settings. [10] The July 2019 Lancet review of the global oral health challenge echoes key messages from “Oral Health in America: A Report of the Surgeon General” that were highlighted 20 years earlier. [11,12] These messages reinforce that oral health is more than healthy teeth and highlight the integral role oral health plays for our overall health, well-being and quality of life. They also note that the disproportionate burden of oral diseases falls on society’s vulnerable populations. This occurs in the context of the existence of evidence-based interventions to prevent major oral health diseases and the sharing of risk factors, such as tobacco and alcohol, common to other diseases where interventions can have a magnified impact on overall health. Several essential aspects of the Healthy People 2030 framework magnify aspects of oral health that may not be as visible to the broader health and health policy community and add several key concepts not previously articulated. In addition, the framework provides an opportunity to view oral health through a health literacy lens.

First, we note that Healthy People 2030 added emphasis on health and well-being, which provides the opportunity to consider how the two states — health and well-being — relate to one another. Healthy People 2010 proposed that they should be seen as mutually reinforcing each other. The Secretary’s Advisory Committee’s Healthy People 2030 brief on health and well-being asserts that health and well-being can be defined as “how people think, feel and function — at a personal and social level — and how they evaluate their lives as a whole.” [9] For Healthy People 2030, well-being was added to the health-related, qualityof-life initiative and was viewed from a multidimensional perspective incorporating self-rated physical and mental health, the sense of overall well-being and a sense of participation in society.

Clearly, oral health and well-being can well fit into this construct. We have long considered oral health as the absence of disease. This view was reflected in the objectives and measures that had been used for the earlier Healthy People initiatives. However, we have also long understood the critical role of oral and craniofacial structures and health to our daily functioning — affecting our ability to speak, chew and smile — and its contribution to how we feel about our overall oral health and general health status. [13] Yet, conversations in the literature, at professional meetings and with policymakers tend to focus on health care services and treatment of diseases. An expanded oral health concept captures important quality-of-life measures as well as the importance of services and treatment.

Next, we note that the Healthy People 2030 framework has included economic environments in addition to social and physical environments to strengthen the potential to achieve health and well-being. The economic impact of oral health and well-being is given limited visibility, yet it is well-known that poor oral health undermines employment and productivity. Measures, such as days lost from work, oral health status factors that compromise employability and days lost from school, reflect that this aspect of our health warrants attention. [14,15] One frequently cited economic model estimated that improving health literacy could reduce an annual burden of $106 billion to $238 billion to the U.S. economy. [16] No doubt that estimate would be even higher were the impact of low oral health literacy adequately incorporated.

The framework explicitly connects health disparities, health equity and health literacy. Indeed, while many social determinants of health are very resistant to reform, health literacy appears much more tractable and therefore a promising route to reduce disparities. [17] The vicious bidirectional spiral that links poor oral health and social and economic fragility for many individuals in our society may be largely invisible to the general public. For example, individuals who are incarcerated in the criminal justice system are at high risk of poor dental health with little access to preventive or acute care. At the same time, the pain and distraction of acute dental disease may contribute to behavior patterns that put individuals at greater risk of incarceration. [18] Employing health literacy best practices with these fragile populations might prove an especially sound investment. [19]

The economic impact of oral health and well-being is given limited visibility, yet it is well-known that poor oral health undermines employment and productivity.

In addition, we note that promotion and maintenance of oral health demands an understanding of culture and society and a shared responsibility among several sectors: between individuals and professionals, among various professionals and among the lay public, professionals and health systems. Evidence-based interventions that promote oral health exist and can be applied by individuals, communities and professionals. These interventions range from basic self-care with a fluoride-containing dentifrice to programs such as community water fluoridation and school-based dental sealant programs. Public benefit will accrue through continual communication and education of entities at all levels (local, state, national and tribal) and sectors (public, private, not for profit).

One of the key challenges lies in the continual need to communicate oral health knowledge, new findings and benefits of practice. Communication with people, whether they are patients, providers, community residents or policymakers, must be developed and delivered in a manner that meets the needs of each group. This includes attention to people’s language and scientific understanding, as well as to the use of information for decision-making and action. This is closely aligned with the framework’s emphasis on the importance of engaging the public, key constituents and leadership to take action and design effective policies. Finally, this issue of communication brings us to the importance of drawing from findings and insights in health literacy.

The Secretary’s Advisory Committee’s health literacy brief provides a broader concept of health literacy than had been articulated earlier in Healthy People 2010. This health literacy lens now offers a focus on the literacy skills and ability of members of the lay public as well as on the health literacy and communication skills of health professionals; the reading skills of the public as well as on the quality of health texts; the communication skills of professionals and the norms of health and health care practices; and the navigation skills of the public and the facilitating factors and hindrances found in health and health care offices, institutions and systems. Health literacy research indicates that changes in texts, in communication practices and in the characteristics of health institutions and systems have the potential to improve health literacy and thereby influence health outcomes. FIGURE 3, adapted from the Institute of Medicine’s sentinel report “Health Literacy: A Prescription to End Confusion,” [20] provides a visual that highlights key factors influencing oral health literacy and ultimately contributes to oral health and well-being outcomes.

FIGURE 3. Potential points for intervention in oral health literacy. SEE FIGURE IN THE FULL ISSUE OF THE JOURNAL

HEALTH LITERACY, ORAL HEALTH LITERACY AND INTEGRATION OF HEALTH CARE

The year 2000 was a banner year for oral health literacy in that it was first mentioned in Healthy People 2010 and subsequently in “Oral Health in America: A Report of the Surgeon General.” [11] Oral health literacy first appeared in the Healthy People 2010 oral health chapter released in 2000, which included this definition of oral health literacy: “The degree to which individuals have the capacity to obtain, process and understand basic oral health information and services needed to make appropriate health decisions.” [5] Further, in 2003, “A National Call to Action to Promote Oral Health” was published, which further established the need for increasing oral health literacy to help ensure improved oral health for all, especially for vulnerable groups. [21] While great strides have been made in increasing oral health literacy, much more is needed to achieve the Healthy People 2030 objectives. Fostering improved oral health literacy at all levels requires significant education, training, research and resources.

Improved oral health literacy of patients, the public, health care providers and policymakers requires their understanding that science-based preventive regimens exist for most oral diseases. Yet these regimens are not routinely being applied by health care providers and a large proportion of the public and policymakers are unaware of them. Moreover, patients cannot request them personally and policymakers are unaware of the potential for improved health of the public. Most individuals, including health care providers, social workers and policymakers, are unaware of the importance and impact of oral health on general health and vice versa. To help educate the public and policymakers, all health providers and staff members who interact with patients need training about the interrelationship of common risk factors of oral and general disease. Joint accreditation for interprofessional continuing education currently excludes dentistry but includes other health professions. [22] Training is also needed on how to apply recommended communication techniques beginning at the undergraduate level and continuing throughout practice as new knowledge or clinical practice guidelines are created. Further, health care facilities need to ensure their practices or clinics are user-friendly. While there are various guidelines for assessing health facilities, none exist for dental facilities. The creation of dental facility guidelines is particularly important, as the predominant site of practice has been solo private practice.

Research is needed across all aspects of oral health literacy including determining the best ways to educate the public and train provider groups as well as what messages to use, their frequency and how they are delivered (i.e., using patient health record portals, after-visit summaries, brochures or texting). The role of health literacy in integrating dental and medical practice is an issue ripe for pursuing because this approach can potentially improve oral and general health. The 2019 National Academies of Science, Engineering and Medicine’s Health Literacy Roundtable workshop “Integrating Oral and General Health Through Health Literacy Practices” emphasized the need for research at all stages, including predoctoral interprofessional training, health system demonstration programs of various models (e.g., colocated physician and dentist practice), components of integration (e.g., effective referral practices between physicians and dentists) and the importance of developing meaningful outcome and systems measures. [23] This area of research especially is needed now with Healthy People 2030’s emphasis on health and well-being. Pivotal to all research is determining the impact of improving oral health literacy on oral health and general health outcomes.

Oral health literacy is now considered a young but established field in public health dentistry and one that needs to be addressed by all federal, state and local entities by supporting it educationally, administratively and financially. We believe the Healthy People 2030 framework serves as a call to action to integrate health literacy into our plans to address the oral health objectives.

California as Exemplar

The California Oral Health Plan 2018–2028 provides a carefully developed and targeted roadmap to improve oral health and is an example of one state’s approach to incorporate health literacy within a larger plan. [24] The plan’s five overarching goals are well aligned with the Healthy People 2030 framework given the focus on prevention, health literacy, social determinants of health and engagement of multiple sectors and stakeholders. The plan is based on addressing the outcomes of a detailed assessment of the burden of oral disease and related issues that have impeded oral health improvements and emphasizes strategies that support data-driven and evidence-based interventions with broad partnership involvement. Critical assets have been secured and include funds from the California Healthcare, Research and Prevention Tobacco Tax Act of 2016 and the Dental Transformation Initiative, part of the Medi-Cal 2020 Waiver, to improve the oral health of Medi-Cal children. Further, the plan is viewed as an essential component of the state’s Public Health 2035 vision “to reduce health care system dependence and improve health equity throughout California.” [24]

Conclusion

The Healthy People 2030 Foundational Principle “achieving health and well-being requires eliminating health disparities, achieving health equity and attaining health literacy” provides a call to action to incorporate health literacy interventions as an essential component of our work to eliminate health disparities and achieve health equity. This is an opportunity for those working on all topic areas including oral health. It requires integrating health literacy thinking and skills at all stages of our Healthy People planning and strategies: assessing population needs, selecting and implementing interventions, preparing the needed workforce and evaluating outcomes. We need to establish sufficient resources to support this integration, such as toolkits for practitioners and technologies for health care systems. Additionally, we need to create collaborative, coordinated efforts with key sectors, including but not limited to businesses, media, the faith community and education, that reinforce and complement these efforts. Our investment in oral health literacy will contribute to improved and sustained oral health and general health and well-being and can pave the way for the national collective effort to integrate health literacy to eliminate health disparities and achieve health equity.

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AUTHORS

Dushanka V. Kleinman, DDS, MS, MScD, is the principal associate dean and a professor in the department of epidemiology and biostatistics at the University of Maryland School of Public Health in College Park. Conflict of Interest Disclosure: None reported.

Alice M. Horowitz, PhD, is a research associate professor in the department of behavioral and community health at the University of Maryland School of Public Health in College Park. Conflict of Interest Disclosure: None reported.

Rima E. Rudd, PhD, is a senior lecturer in the health literacy, education and policy department of social and behavioral sciences at the Harvard T.H. Chan School of Public Health in Boston. Conflict of Interest Disclosure: None reported.

Donald L. Rubin, PhD, is an emeritus professor in the departments of speech communication and language and literacy education and in the program of linguistics at the University of Georgia in Athens. Conflict of Interest Disclosure: None reported.

Kathryn A. Atchison, DDS, MPH, is a professor in the division of public health and community dentistry at the University of California, Los Angeles, School of Dentistry and is jointly appointed in the UCLA Jonathan and Karin Fielding School of Public Health, department of health policy management. Conflict of Interest Disclosure: None reported.

Cynthia Baur, PhD, is an endowed professor and the director of the Horowitz Center for Health Literacy at the University of Maryland School of Public Health in College Park. Conflict of Interest Disclosure: None reported.