Understanding and promoting health literacy.

The participating institutes, centers, and offices of the NIH and the Agency for Healthcare Research and Quality (AHRQ) invite investigators to submit research grant applications on health literacy. The goal of this program announcement (PA) is to increase scientific understanding of the nature of health literacy and its relationship to healthy behaviors, illness prevention and treatment, chronic disease management, health disparities, risk assessment of environmental factors, and health outcomes including mental and oral health. There is a need for increased scientific knowledge of interventions that can strengthen health literacy and improve the positive health impacts of communications between health care/public health professionals (including dentists, health care delivery organizations, and public health entities) and consumer or patient audiences that vary in health literacy. Applicants may propose secondary goals of modeling the potential impact of new interventions on future national trends and/or determining the impact of targeted cancer control interventions on population outcome (i.e., evaluating optimal cancer control strategies).

Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. Many factors affect individuals' ability to comprehend, and in turn use or act on, health information and communication. Proficiency in reading, writing, listening, interpreting, oral communication, and visual analysis is necessary as the modern health system typically relies on a variety of interpersonal, textual, and electronic media to present health information. Individuals and families both must be able to 1) communicate with health professionals; 2) understand the health information in mass communication; 3) understand how to use health-related print, audiovisual, graphic, and electronic materials; 4) understand basic health concepts (e.g., that many health problems can be prevented or minimized) and vocabulary (e.g., about the body, diseases, medical treatments, etc.); and 5) connect this health-related knowledge to health decision making and action taking.

Too often, people with the greatest health burdens have limited access to relevant health information. In addition, health care providers may not communicate effectively with individuals with limited levels of literacy. Low health literacy is a widespread problem, affecting more than 90 million adults in the United States. Low health literacy results in patients' inadequate engagement in and benefit from health care advances, as well as medical errors. Low health literacy is likely to be a major contributor to adverse health outcomes. Research has linked low or limited health literacy with such adverse outcomes as poorer self-management of chronic diseases, less healthful behaviors, higher rates of hospitalizations, and overall poorer health.

This PA invites applications to develop research on health literacy in general areas that include, but are not limited to, the following: 1) modeling and measuring the nature and scope of health literacy; 2) variation in health literacy over the life course or among native and nonnative speakers of English; 3) mediators and moderators of low health literacy; 4) the impact of low health literacy on health outcomes, diseases, behaviors, and treatments, including the contribution of health literacy to informed decision making, adherence to preventative or therapeutic regimens, utilization of health care services, risk avoidance strategies, and other consumer health care-related actions; 5) the identification of effective preventive and other interventions to improve health literacy among populations and to enable the health care and public health systems to communicate effectively across different health literacy levels; and 6) the development of effective methods and new technologies in health literacy research.

Applications should be relevant both to the objectives of the PA and to at least one of the participating institutes' general research interests. Prior to preparing an application, researchers are strongly encouraged both to review the general research interests of the participating institutes and to contact program staff of the relevant institutes to discuss the proposed research.

A wide variety of research approaches are encouraged under this PA: basic research that investigates or describes the nature of health literacy and the magnitude of health literacy problems, and applied research addressing issues pertinent to health literacy practices (e.g., systems-level interventions) and research in practice (e.g., active potential end users participate as supportive research partners). Applications also may develop theoretical models, refine research constructs, improve methods and measurements, and establish causal relationships (e.g., between low health literacy and lack of effective health promotion). Researchers also may address the effectiveness of interventions, or adapt and test existing programs (including those that are not research-based) to reduce low health literacy and its adverse consequences (e.g., interventions implemented by health care systems and systems outside of health care such as systems of public education).

The research must involve either 1) health literacy, or one of its many components, as a key outcome; 2) health literacy as a key explanatory variable for some other outcome; 3) methodological or technological improvement to strengthen research on health literacy; or 4) health literacy-focused preventions and interventions. Studies to develop or evaluate the readability or utility of specific materials that are intended for single uses or single audiences are not responsive to this PA unless these investigations are integral to testing a significant research hypothesis related to health literacy.

Projects may employ any one or combination of study designs, research approaches, and data collection techniques. Secondary analyses of existing data sets as well as meta-analytic studies are also suitable for this PA. Multilevel, multidisciplinary, and interdisciplinary research is also encouraged, especially studies that incorporate individual, family, community, and societal mediators of health literacy in childhood and adulthood, or state-of-the-art health communication theory and knowledge.

Researchers are encouraged to address ongoing investigations of prevention, healthy living, chronic disease management, patient-based health care, cultural competence, and health disparities to inform the research on health literacy. Research questions can focus on consumers, patients, clients, or other population groups; the strategies and tactics used by providers of medical and health information and communication to enable them to effectively reach literacy-challenged populations; or the influences of health literacy upon interactions between consumers, patients, clients, providers, and organizations or systems.

The Institute of Medicine's 2004 report Health Literacy: A Prescription to End Confusion reviews the current body of knowledge about health literacy, and identifies actions for the promotion of health literacy in society. Applicants are encouraged to consult this report as a general reference.

This PA will use the NIH R01 award mechanism. As an applicant, you will be solely responsible for planning, directing, and executing the proposed project. This PA uses just-in-time concepts. It also uses the modular budgeting format (see http:// grants.nih.gov/grants/funding/modular/modular.htm). Specifically, if you are submitting an application with direct costs in each year of $250,000 or less, use the modular budgeting format. This program does not require cost sharing as defined in the current NIH Grants Policy Statement at http://grants.nih.gov/ grants/policy/nihgps_2003/NIHGPS_Part2.htm.

Applications must be prepared using the PHS 398 research grant application instructions and forms (rev. 5/2001). Applications must have a Dun and Bradstreet Data Universal Numbering System (DUNS) number as the Universal Identifier when applying for federal grants or cooperative agreements. The DUNS number can be obtained by calling 1-866-705-5711 or through the website at http:// www.dunandbradstreet.com/. The DUNS number should be entered on line 11 of the face page of the PHS 398 form. The PHS 398 document is available at http://grants.nih.gov/grants/funding/phs398/ phs398.html in an interactive format. For further assistance, contact GrantsInfo by calling 301-435-0714 or e-mailing [e-mail].

Applications submitted in response to this PA will be accepted at the following receipt dates: 13 October 2004, 13 October 2005, and 13 October 2006.

Contact: For the complete listing of contacts, please consult the full PA, available online at http://grants1.nih.gov/grants/guide/pa-files/PAR-04-116.html. Reference: PA No. PAR-04-116