Putting the Mouth Back in the Body is Health Literacy Work

This blog post was originally posted on the Horowitz Center for Health Literacy website on May 6, 2019

Written by Dr. Alice Horowitz, Research Associate Professor, Horowitz Center for Health Literacy

Photo of Dr. Alice HorowitzTake both of your hands and place each one on a cheek so your hands encompass both jaws. While keeping them that same distance apart, bring them in front of your face. If you had an infection of that magnitude and size developing on your leg, you’d go screaming to the doctor. But when the same-sized infection manifests in your mouth, it’s suddenly invisible.

All too often, your mouth is the forgotten part of your body. Consequently, oral health and oral health literacy are not in the public health space or consciousness. I would argue that among all the topics covered in health literacy, oral health needs a boost in health literacy more than anything else; oral health is part of general health.

I’m currently working on a study focusing on pregnant women’s oral health. There is some evidence that if a pregnant woman has gum disease, it may result in a pre-term low birth weight for her child. There’s stronger evidence that when an infant develops tooth decay, the bacteria that caused it is most likely from mom. If we ensure an expecting mother’s mouth is healthy before she delivers, it’s much less likely she will transfer the decay causing bacteria to her baby.

That’s why we need primary caregivers – physicians, nurses, physician assistants – to help educate expectant women to go to the dentist. They need to understand that it is safe, necessary and paid for by Medicaid. In addition, we need to educate with hands-on demonstrations to increase awareness among expecting mothers about how to clean their infants’ mouths. Whenever I do demonstrations on infants, I attempt to practice clear communication techniques and use the teach-back method to make sure the mothers understand what I’ve instructed them. I ask them to demonstrate on their infants and present back to me. This is a technique that we urge all primary care physicians practice to ensure their patients understand. Making sure that they fully understand helps insure the child remains cavity free.

Many physicians and other health care providers aren’t trained on oral health for many reasons. They don’t receive comprehensive training during their pre-doctoral education nor are they tested on it at

the boards. This lack of education and training separates oral health from general health. We need their help because mothers are more likely to take their infants to primary care providers than to dental providers during the child’s first two years of life.


A health educator, Dr. Horowitz formerly was a senior scientist, National Institute of Dental and Craniofacial Health (NIDCR), National Institutes of Health (NIH).  Dr. Horowitz has extensive work in dental caries prevention and early detection. She also has developed numerous surveys on the subject. Dr. Horowitz was instrumental in initiating the need to address health literacy in dentistry and was one of the authors of the first NIH Program Announcement addressing health literacy. She also organized the NIDCR’s workshop on oral health literacy and co-authored the findings. She served as the NIH lead for the Healthy People 2010 Oral Health Chapter and worked on Healthy People and Healthy People 2020. Dr. Horowitz was a primary architect of the Maryland State Oral Cancer Prevention and Early Detection coalition. She initiated both state and national research on what health care providers and the public know and do about oral cancer prevention and early detection. She served on the recent Institute of Medicine’s panel, Advancing Oral Health in America. She has published over 125 scientific papers and book chapters.

Health Literacy Contributes to Achieving Health and Well-being Healthy People 2030 Goals

This blog post was originally posted on the Horowitz Center for Health Literacy website on April 26, 2019

Written by Dr. Dushanka Kleinman, Associate Dean for Research and Principal Associate Dean, School of Public Health

Photo of Dr. Dushanka Kleinman

Since 1979, the Nation has used the Healthy People framework to identify key issues and targets that will improve and promote health, as well as document successes and challenges to progress. Healthy People is a public-private process that happens every decade so we can reflect on, revise, and set health goals and objectives for the Nation. The objectives provide a roadmap to drive actions. Accurate and timely data and evidence-based programs and policies are additional tools that support public and private contributions and facilitate collective impact.

Health literacy objectives were introduced in third (2010) and fourth decades (2020) of the Healthy People objectives. As stated in Healthy People 2010, “Closing the gap in health literacy is an issue of fundamental fairness and equity and is essential to reduce health disparities.” In early 2020, a new set of national health promotion and disease prevention objectives – Healthy People 2030 – will be released for the decade to come.

To provide the context and rationale for this initiative’s approach, the Healthy People 2030 Framework provides a vision, mission, foundational principles, overarching goals, and a plan of action.  The Framework also “communicate(s) the principles that underlie decisions about Healthy People 2030.” Health literacy is included in the Foundational Principles and Overarching Goals of this Framework: attaining health literacy is placed in the midst of achieving health equity and eliminating health disparities.

health literacy issue brief prepared for the 2030 process  makes the case for the critical role health literacy plays in improving population health and reducing health disparities. The brief provides the context for expanding the responsibility for health literacy beyond individuals, to include “organizations and professionals who create and deliver health information and services.” The brief’s authors suggest taking a “system’s approach” and aligning society’s actions for health literacy with the complex factors that affect people’s ability to find, understand, and use health information at all levels: individual, community and society.

From this new perspective, “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.” This alignment is pivotal to eliminating health disparities and achieving health equity.

If we want a realistic chance to realize the Healthy People 2030 vision of “A society in which all people can achieve their full potential for health and well-being across the lifespan,” then we must commit ourselves to concrete steps that improve health literacy and contribute to health equity.


Dr. Dushanka V. Kleinman is the Associate Dean for Research and Professor, Department of Epidemiology and Biostatistics in the University of Maryland School of Public Health. She is a senior science leader at the University of Maryland College Park and in these roles works closely with faculty at the School, University and across the University System campuses to contribute to identifying and supporting proposals for emerging research and research training opportunities. Her recent research interests include prevention of oral health disparities, health literacy, and strategies to integrate oral and general health as well as primary care with public health and social services. 

Health Equity Depends on Clear Communication

This blog post was originally posted on the Horowitz Center for Health Literacy website on April 19, 2019

Written by Dr. Sandra Quinn, Senior Associate Director of Maryland Center for Health Equity

Photo of Dr. Sandra Quinn

Health literacy and health equity have critical intersection points. On a general level, health literacy is an individual’s ability to find accurate and credible health information and services and act on them. When individuals are reluctant to seek information or ask questions, we see cracks in health literacy building blocks. When individuals are part of a population that is already disadvantaged, they tend to have even greater struggles with health literacy. That’s why health literacy and health equity are so inextricably linked. One doesn’t exist without the other. To obtain both, individuals must be able to access, understand, and use acquired knowledge and support to interact with practitioners to advocate for their health.

As a professor and chair of the Family Science department and senior associate director of the Maryland Center for Health Equity, I’ve learned a lot about health literacy while conducting research in the community. One aspect is the language we use. Being cognizant of my language with colleagues and in the community goes a long way in communicating effectively with different audiences. Being audience-centered promotes a key tenet of health literacy: clear communication. Part of clear communication is visual as well as spoken. Many of us are not trained to produce excellent visuals, but they help get a complicated message across.

Health literacy can be easily woven in the fields that I work in, most specifically family science. One research area I’ve participated in is the adult acceptance of vaccines. At a time in which misinformation is everywhere, clear communication is key when conducting research or field work. Luckily, we have our very own Center for Health Literacy that can offer the guidance and support to aid us in our work. Dr. Baur and Dr. Horowitz are able to help us modify certain research questions to make them more understandable.

Moving forward, we need to cultivate a culture of encouraging patients to ask questions and advocate for their health. To do this, facilities and centers need to proactively engage health literacy experts to go through their practices with a fine tooth comb. Are they truly understandable to a large array of audiences? Taking this first step in ensuring larger institutions are health literate will solidify the foundation for health equity for generations to come.


Dr. Quinn is Professor and Chair of the Department of Family Science, Director of the doctoral program in Maternal and Child Health, and Senior Associate Director of the Maryland Center for Health Equity, School of Public Health, University of Maryland. From 2011-2017, she was Principal Investigator (with S. Thomas) for the Center of Excellence in Race, Ethnicity and Health Disparities Research, and the PI on a study, Uncovering and Addressing Cultural Beliefs behind Vaccine Racial Disparities.  She is currently PI (w. D. Broniatowski, George Washington University) on a NIGMS grant, Supplementing Survey-Based Analyses of Group Vaccination Narratives and Behaviors Using Social Media.

Health Equity, Health Literacy and the Ethical Imperative to Coalesce

This blog post was originally posted on the Horowitz Center for Health Literacy website on April 15, 2019

Written by Dr. Stephen B. Thomas, Director, Maryland Center for Health Equity

Photo of Dr. Stephen Thomas

Imagine you had the opportunity to build a new health care facility from the ground up?  Would you build your grandfather’s hospital or your great grandmother’s clinic? That’s what can happen if things are left to “business as usual.”  The Maryland Center for Health Equity decided to do something “Fearless,” something disruptive … we decided to enter into a collaborative partnership with Catholic Charities, Archdiocese of Washington DC and Doctors Community Hospital to redesign health care delivery.

A little over two years later, the Susan D. Mona Center for Health and Wellness is the result of our Fearless Idea. The Mona Center provides primary care, dental care, and legal services to the Prince George’s County Temple Hills community.

The project is a work in progress. The future learning farm, teaching kitchen, physical activity studio and mental health service rooms need financial support to complete construction. What was once a dilapidated building boarded up on a trash strewn corner is a beacon light of hope for a community on the rebound. The Mona Center anchors new businesses, giving the neighborhood a new heartbeat of safety and compassion.

Disruptive change of this magnitude does not come by accident or serendipity. People of faith, empathy, science and love for humanity came together to bring the Mona Center to life. They applied servant leadership, infused with the spirit of social entrepreneurs. The Mona Family donated the building to Catholic Charities and reached out to Doctors Community Hospital and the University of Maryland School of Public Health, specifically the Center for Health Equity.

Mona Center Fall Health Fair

Dr. Thomas at the Mona Center Fall Health Fair

Think back to the last time you were in a hospital … the smell… the cacophony of sounds, the confusing signs and maybe out of the corner of your eye… you see human suffering.  It need not be this way. To create something fearlessly different, I called on the Center for Health Literacy. Drs. Cynthia Baur and Alice Horowitz came to the Temple Hills site and interviewed clients, asking them how they would like things phrased and what kind of signage is best. This work supports the goal of the Mona Center as a health literate organization!

If you create materials using plain language principles, but the institution in which you’re operating is not fair to the people you’re trying to serve, it doesn’t matter if they can read your materials. You have a system that’s still inequitable, still has barriers preventing people from accessing services. Ultimately, we’re stronger together. The more we do when we have health equity and health literacy together, the stronger we will be as a field and as a discipline.

The bottom line is health equity is about fairness. Does everyone have equitable access to services or knowledge about services? It’s about leveling the playing field across race, age, gender, sexual orientation, ability and more. And it begins with how you build relationships, trust, and a healthy community.

In 2002, the Public Health Leadership Society, a highly regarded group of senior public health officials and others, published the often cited Principles of the Ethical Practice of Public Health (PHLS, 2002). This code delineates twelve principles to guide the ethical practice of public health. Two principles stand out as useful for addressing health disparities:

  • Principle 1: Public health should address principally the fundamental causes of disease and requirements for health, aiming to prevent adverse health outcomes.

  • Principle 4: Public health should advocate and work for the empowerment of disenfranchised community members, aiming to ensure that the basic resources and conditions necessary for health are accessible to all.

These two ethical principals can help guide our mission to coalesce health equity and health literacy in the service of something greater than our unique disciplines. Indeed, we are not only stronger together, but the synergy we create has the potential to transform health care in Maryland.  The Susan D. Mona Center is one example of health literacy and health equity being tied at the hip. Although they have different origin stories, the two fields cannot creatively disrupt the status quo without the other.

Maryland is positioned to make groundbreaking impacts in the world of health equity and health literacy. In the 2017 legislative session, we secured Senate and Delegate support for the University of Maryland School of Public Health, Center for Health Equity Health in All Policies Act of 2017. Signed into law by Govenor Hogan, the Act requires representatives from all state agencies to come around one table and examine how their work affects population health.

If you work for the transportation or housing department, it’s easy to think that your policies don’t have an impact on human health, but science tells us they do. Maryland is in the forefront of new strategies for innovating health care delivery that is sensitive to the social determinants of health and promoting statewide campaigns for health literacy and health equity.

The Health in All Policies Act is an example of addressing issues beyond the individual level.  It’s important that we tackle health equity and health literacy issues at each level of our social ecology. Focusing on the individual level without addressing the institution is not enough. Creating institutions that lack empathy toward human suffering is unethical. I agree with Powers and Faden (2006), the moral foundation of public health and health policy is social justice. By explicitly linking, blending, and knitting health equity and health literacy together, we can tranform health care and bend the moral arc of history toward justice.



Racial and Ethnic Disparities as a Public Health Ethics Issue

Stephen B. Thomas (2019)

The Oxford Handbook of Public Health Ethics

Edited by Anna C. Mastroianni, Jeffrey P. Kahn, and Nancy E. Kass

PHLS (Public Health Leadership Society). 2002. Principles of the Ethical Practice of Public Health. https://www.apha.org/-/media/files/pdf/membergroups/ethics/ ethics_brochure.ashx.

Powers, M., and Faden, R. 2006. Social Justice: The Moral Foundations of Public Health and Health Policy (Oxford: Oxford University Press).


Dr. Wilson is an associate professor with the Maryland Institute for Applied Environmental Health (MIAEH) and Department of Epidemiology and Biostatistics, School of Public Health, University of Maryland-College Park. Dr. Wilson is an environmental health scientist with over ten years of experience working in community-university partnerships on environmental health and justice issues. He has expertise in exposure science and applied environmental health including community-based exposure assessment, environmental justice science, social epidemiology, environmental health disparities, built environment, air pollution monitoring, and community-based participatory research (CBPR). For the past two years, he has been building a program on community engagement, environmental justice, and health (CEEJH) to engage impacted communities, advocacy groups, and policymakers in Maryland and the Washington, DC region on environmental justice issues and environmental health disparities.

Health Literacy is the Heartbeat of Public Health

This blog post was originally posted on the Horowitz Center for Health Literacy website on April 8, 2019

Written by Dr. Boris Lushniak, Dean, University of Maryland School of Public Health

Photo of School of Public Health Dean Boris Lushniak

When the School of Public Health was established twelve years ago, the Horowitz Center for Health Literacy was created at the same time. We were inspired to establish the school and immediately realized the need for the Center to achieve our goals. They were born together, mirroring a clear relationship between health equity and health literacy in the real world. One doesn’t happen without the other.

Health equity is about achieving the highest levels of healthcare for all. Health literacy is how an individual makes decisions to achieve that high level. We can aspire and proclaim that we’re shooting for health equity in our community, but it’s not going to happen until we spend a lot of time working on health literacy.

At the School of Public Health, integrating health literacy into the curriculum is key to fueling our future leaders’ fight for health equity. One of the ways we do this is through “How to Be a Health Advocate: Health Literacy in Action,” an undergraduate class centered on health literacy. The course is the brainchild of the Horowitz Center’s Director, Dr. Cynthia Baur, and Heather Platter, a Rima Rudd Health Literacy Fellow. Throughout the semester, students learn how to advocate for their health and the community’s health through interactive discussion and projects.

This is the first time we’ve offered an undergraduate health literacy class, and we don’t plan on it being the last. I don’t see us teaching health literacy as one separate course. When we’re teaching health exposures and public health in action, we need to intertwine the health literacy component. Whether it’s a passing reference or a guest lecture, health literacy must be present in all facets of public health teaching. Students cannot turn it off as soon as they’re done with one course.

Our work never finishes when it comes to educating future public health leaders within our doors. Students, armed with their public health degrees, will make decisions later on that affect scores of individuals. To ensure health equity for all, we must always be educating and interweaving health literacy in these crucial conversations.

Health Literacy and Equity Principles Can Bring True Reform to US Healthcare

This blog post was originally posted on the Horowitz Center for Health Literacy website on April 1, 2019

Written by Dr. Cynthia Baur, Director of the Horowitz Center for Health Literacy

Photo of Cynthia Baur

Health literacy and health equity principles embody a health system many Americans would choose, if they could. A system based on health literacy and equity would be designed and implemented so that everyone can understand, use, and access (including afford) the information, products, and services they need for health and well-being.

The UMD Center for Health Literacy is sponsoring this blog to begin a public conversation about the contribution health literacy and equity principles can make to a truly inclusive and health and well-being-promoting system in the US. We have invited several UMD School of Public Health faculty to offer their perspectives, and we welcome comments and suggestions for future topics and bloggers.

According to Healthy People 2030, the nation’s health goals and objectives, 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. Health equity means that everyone has a fair and just opportunity to be healthier, which requires removing obstacles to health such as poverty, discrimination, and their consequences.

Arguably, the most significant US health literacy issue is the gap between the general perception that health care is excellent/good and affordable1 and the large volume of data and policy reports that shows otherwise. The US ranks poorly in health care costs, quality measures, and health outcomes against its own measures and in country comparisons.2  Health system errors have been documented when culture and language are not considered, as well as evidence-based protocols are not followed.3

Many reasons could explain this perception-data gap, including dense, jargon-filled policy documents understandable primarily by “insiders” and periodic public communication campaigns to generate fear and spread misinformation about health policy changes.4

If policymaking began with people’s health and well-being needs instead of the healthcare sector’s interests as the policy cornerstone, then a system based on health literacy and equity is an obvious starting point. More than a decade ago, the National Academies of Sciences, Engineering and Medicine named health literacy as one of two cross-cutting priorities to transform healthcare quality.

No shortcut to a healthy society exists when so many people are excluded from understanding and accessing necessary information, products, and services to pursue a healthy life. We hope this blog stimulates the long-overdue focus on health literacy and equity as the essential pieces of healthcare reform in the service of a healthy society.



1 Patients’ Perspectives on Health Care in the United States. Poll conducted September 8—November 9, 2015 by the Harvard T.H. Chan School of Public Health in partnership with the Robert Wood Johnson Foundation and NPR.

2 AHRQ National Healthcare Quality and Disparities ReportsHealthy People 2020; It’s Still The Prices, Stupid: Why The US Spends So Much On Health Care, And A Tribute To Uwe Reinhardt. Anderson GF, Hussey P, Petrosyan V. Jan. 2019 Health Affairs

3 The National Academies of Sciences, Engineering, and Medicine, Health and Medicine Division. Crossing the Quality Chasm: The IOM Health Care Quality Initiative. Accessed March 6, 2019. http://www.nationalacademies.org/hmd/Global/News%20Announcements/Crossing-the-Quality-Chasm-The-IOM-Health-Care-Quality-Initiative.aspx

4 Plain Writing Act of 2010; Why the “Death Panel” Myth Wouldn’t Die: Misinformation in the Health Care Reform Debate. Nyhan B. 2010. The Forum.


Dr. Cynthia Baur became the Director of the Horowitz Center for Health Literacy in January 2017. Prior to coming to UMD, Dr. Baur worked for 17 years in communication leadership roles with the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, and the U.S. Department of Health and Human Services (HHS) in Washington, D.C. Most recently, she served as the Senior Advisor for Health Literacy in the CDC Office of the Associate Director for Communication and CDC’s Senior Official for the Plain Writing Act implementation.