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Health Literacy and Cultural Competence in Integrative Preventive Health and Medicine 

Health Literacy and Cultural Competence in Integrative Preventive Health and Medicine
Health Literacy and Cultural Competence in Integrative Preventive Health and Medicine
Integrative Preventive Medicine

Andrew Pleasant

and Jennifer Cabe



As the United States and the world continue to experience unsustainable growth in the rates of chronic disease and rising healthcare costs, most urgently needed are upstream solutions—far before the point of people needing and seeking medical treatment. The reality is that in the United States, we do not have a healthcare system, we have a sick care system.

In the United States, what is clearly required to address this untenable situation is a shift in the underlying premises of the health and medical philosophies and resulting infrastructure. This chapter proposes that an evidence-based solution lies in a convergence between an integrative approach to health and medicine and health literacy. That convergence inherently embraces cultural competency and leads health systems, healthcare professionals, and the people they serve—often referred to as “patients”—to work together as a newly integrated whole that is greater than the sum of the parts. By renewing and recombining various parts of the current sick care system into an integrative team, this approach can prevent and reverse chronic disease and lower the cost of care.

Recent efforts in the field of health literacy reflect this trend, which we later exemplify through the work of Canyon Ranch Institute, toward integrating health literacy into all policies and practices—and, as we explain, inherently moving toward an integrative approach to health as a result. Examples of this trend include the National Academy of Sciences, Engineering, and Medicine’s Roundtable on Health Literacy in the United States embracing and supporting the “two-sided” nature of health literacy for the past several years. Originally cast by some as a deficit in the public that health professionals had to endure and address, health literacy is now widely seen as an issue of supply and demand so that healthcare systems have a responsibility to lower health literacy barriers as well. (See

Other examples of this trend include the Calgary Charter on Health Literacy’s definition of health literacy that explicitly embraces the two-sided nature of health literacy.1 Later work, such as the conceptual basis for the European Health Literacy Survey effort (see reflect this ongoing trend around the world. The approach of the Ophelia Project—optimizing health literacy and access to health information and services—conceived and promoted by Richard H. Osborne largely in Southeast Asia and Australia, also approaches health literacy as a multidimensional concept. The Ophelia Project uses an integrated approach as the basis for both measurement and community-based interventions (see Finally, across the United States since the advent of the Patient Protection and Affordable Care Act of 2010, a large and growing number of health literacy organizations, such as Health Literacy Missouri or Wisconsin Health Literacy, are actively working to lower health literacy barriers to finding, understanding, evaluating, communicating about, and selecting (using) health insurance policies. That has produced a dramatic gain in the number of individuals in the United States with health insurance—often a necessary first step toward bringing people into actively seeking to address their health issues. All of this work—ongoing around the world—is developing and proving ways to redesign, reform, and refinance healthcare by merging health literacy with a robust conception of health while addressing a range of social, political, and environmental determinants of health, including culture, in order to lower barriers to healthcare, prevent chronic disease, improve health, and lower costs.

In the ongoing efforts of Canyon Ranch Institute, a 501c(3) nonprofit public charity based in Tucson, Arizona, we have worked to develop, refine, and prove the viability, effectiveness, and efficiency of this approach. In this chapter, we provide an overview of how to operationalize that approach and detail some of the many outcomes of the effort, which has produced healthier people, happier and more productive health care professionals, improved health system performance, and better relationships between health systems and the communities they serve.

Health Literacy

We start with a brief explanation of health literacy. Initially, a concept that focused on the public’s lack of success at understanding and navigating complex health knowledge and health systems, the idea of health literacy has since expanded to include the challenges created by health systems and healthcare professionals. In the approach taken at Canyon Ranch Institute, we employ health literacy as an evidenced-based path to behavior change for the public, health professionals, and health systems.1,2,3

Health literacy is how people can—or how they can be helped and supported to—find, understand, evaluate, communicate, and then use information to make an informed decision about their health and health behaviors.1,4 This is a move beyond the history of health communication, health promotion, and health education that all too often stopped at the goal of helping people understand information. That limited approach does nothing to help people to bridge the gap between what they know and what they actually do in practice. The approach we detail in this chapter has documented success at supporting people to make and maintain healthy behavior changes.

Relationship of Health Literacy and Cultural Competence

Before health literacy emerged as an area of interest, practice, and expertise, cultural competency had addressed the abilities of individuals to successfully navigate the varying and often difficult terrain when different cultural perspectives encounter each other. While some practitioners are continuing to maintain a distinction between health literacy and cultural competence, we suggest that is the less productive path.

If there is a golden rule to both health literacy and cultural competency, it is to directly engage with people as early and often as possible. The two approaches are deeply linked in an underpinning priority to the importance of individuals, their capacities, their perspectives, their beliefs, their knowledge, their practices, and their worldviews.

The early focus within health literacy on limitations to people’s skills and the idea of “plain language” as the solution may have been unsettling to practitioners of cultural competence as they felt individuals were being undervalued. Alternatively, the many (but far from all) of the early proponents of health literacy who came from medical and health professions may have felt the critical perspective of cultural competency as unacceptable and unnecessary within their healthcare practices.

Culture is most profoundly expressed through language and other modes of human communication. Health literacy is most focused on the uses of language and other modes of communication as well. The two fields should not only be in sync, they should be indistinguishable. The best practices of health literacy should always align with the best practices of cultural competency and vice versa. Nothing else will succeed in helping people to improve their health and helping health systems and healthcare professionals to help people accomplish that widely shared and highly valued goal of freedom from unnecessary disability and early death that are brought on by the myriad of preventable factors.

From that perspective, we address health literacy and cultural competency as a singular entity. We most often use the phrase “health literacy,” but readers should know that we do not distinguish between a health literate and a cultural competent approach. They are one and the same.

Integrative Preventive Health and Medicine

The third area of our focus is integrative approaches to health and medicine and how those can enhance prevention. First, to clarify, we assert that the distinction between health and medicine is still warranted. In the United States, our current healthcare system is largely focused on medicine—care for people after they fall ill. Health is a larger area of activity including health and medical professionals as well as people in their everyday lives. We would hope that distinction would one day be less severe as health and medical professionals adopt the best practices of health literacy (including, as discussed, cultural competency) and shift their focus to prevention versus solely treatment—especially in the context of chronic disease. That day is yet to arrive.

The approach to integrative health and medicine we employ at Canyon Ranch Institute is a focus on mind, body, spirit, and emotion. Often we encounter efforts that only list mind, body, and spirit in this equation. We suggest the importance of emotions in relation to behavior change is so critically important that it is a significant error to omit emotions from the definition and practice of integrative health and medicine.

Further, an approach to integrative health and medicine that firmly and robustly embraces the four components of mind, body, spirit, and emotion also produces a perfect partnership with health literacy and cultural competency. This is not a coincidence but is by design. Sadly, in the time that Americans spend with a healthcare professional they are most regularly treated as either a body carrying a problem or, if they are experiencing mental or behavioral health issues, they are treated as a mind carrying a problem. In both approaches they are distinctly not treated as a whole, complex person.

This is an outcome the design and incentives of the financial model underpinning our current sick systems as well as the current approach to training healthcare professionals to staff those systems. For example, if the stakeholders across a health system desire to shift their focus to prevention, they will find little reimbursement from payers (private and government insurance companies). That means the savings their efforts may create will not benefit their financial well-being, but instead will benefit the financial well-being of the insurance companies who experience the savings from the successful prevention of disease. That is, to be sure, not always the case, as examples of alternative possibilities are increasing in number; but the status quo majority remains entrenched in an approach that does not encourage either an integrative approach to health and medicine or a focus on prevention, or an equitable distribution of savings accrued by preventing chronic disease. The world does not have to operate in this mode.

How Health Literacy, Cultural Competency, and Integrative Health and Medicine Lead to Prevention

The merger of health literacy and cultural competency when combined with a mind, body, spirit, and emotion approach to integrative health and medicine inherently demands of health systems and professionals that they address the people seeking their support and assistance from a whole-person approach. If health and medical professionals and institutions engage with people early and often; if they pay attention to not only a current health issue but to an entire life—what comes forward is a universal precautions approach to health literacy and respect for culture. This is the moment when healthcare professionals start to inherently and easily approach health and medicine from an integrative perspective and shift their focus from treating a disease to collaborating with a person to achieve better health and greater overall fulfillment in life.

This shift was summed up very nicely by Winston Wong, MD, our colleague on the National Academy of Sciences (NAS) Roundtable on Health Literacy and Medical Director, Community Benefit and Director, Disparities Improvement and Quality Initiatives at Kaiser Permanente, when he suggested during a recent NAS meeting that what medical care providers should ask patients, especially when they see them for such a little time each year, is “What does a good day mean to you?”

The discussion that led to that observation and suggested question had focused on expanding the relationship between medical care providers and the people they serve to move beyond what hurts—to how to help people live a better life. The possible result is an empowered person who is also more satisfied with the relationship they have with their health and medical professional—that professional becomes not just a “provider,” but is a true health partner with the person seeking to lie a healthier, happier life.5

The Canyon Ranch Institute Approach to Partnership

At Canyon Ranch Institute, our approach to partnership is a model that embraces the integrative health approach, health literacy, and cultural competency as one. In this approach, the whole is greater than the sum of the parts, and no part of the equation can be delinked from the others. The Canyon Ranch Institute PRIMES model is based on our experience that the most effective way to address the currently broken sick care system is to engage in multisectorial partnerships that include all of the people and institutions that have a stake in the outcomes of health and healthcare in the United States and globally.

PRIMES stands for Partner, Require Radical Equity, Insist on Infrastructure, Make it Known, Evaluate, and Sustain.

At Canyon Ranch Institute, we have three levels of engagement—Partner, Join, and Connect. What other organizations might call lead, we call Partner, and it is in our partnerships that we develop, hone, and evolve our programs and methodologies that advance health literacy to ensure that all people can become educated, inspired, and empowered to prevent disease and embrace a life of wellness. We discuss the Partner level of engagement more in this chapter. The “Join” and “Connect” levels are those in which we join with other like-minded people and organizations in coalitions, roundtables, convenings, associations, and the like, and also in which we simply introduce people to others who may be able and willing to answer questions and provide other supportive resources.

The “P” in PRIMES is Partner. At the Partner level, we follow a clearly delineated process to discuss and document shared understandings about our mutual missions and goals, so that we can have a pathway to as efficiently as possible make integrative health and health literacy the tools that we apply in our partnerships and programs to help people and systems advance health and well-being in novel and measurable ways. We have experienced that this up-front commitment to ethical and partnership development by all parties contributes to a long-term view of the relationships. These partnerships connect all of our work, across multiple programs, geographic regions, healthcare systems, cultures, languages, and more.

Next, the “R” in PRIMES stands for Radical Equity. The idea of radical equity across sectors and systems is a concept that we have not been able to find thus far in other organizations or systems. Our unique insistence at Canyon Ranch Institute on the idea that all sectors of society can help improve the social determinants of health and the overall health and well-being of individuals, families, and communities has led us to bring together low-income people who need access to healthy living opportunities; large corporate entities, healthcare professionals and the systems they work within; public, private, and charter schools; colleges and universities; government entities; a wide range of faith-based organizations across the broad spectrum of spirituality and religion that inform much of American life and culture; sports and athletic teams and organizations; restaurants, grocery stores, food banks, and other food-service organizations; nonprofit entities; media companies; and a wide range of other sectors of society that are important to people and their health. We bring all of these sectors together to communicate about their best practices with one another, specifically in the context of a program that we have all decided to explore and implement together focused on the integrative health model and advancing health literacy. This concept of radical equity applies to all of the partners in any Canyon Ranch Institute endeavor, and is inherent to our ability to ensure the integrative approach. That approach relies on the resources and strengths that certain people, organizations, and industries can bring to bear to help improve individual and community health.

Infrastructure is the “I” in PRIMES, and refers to the need for organizations engaged in advancing best practices in health, including and especially in integrative health and health literacy, to have stable infrastructure. That infrastructure, while often not the core business of such an organization, is essential to partnership development and sustainability. The legal, financial, governance, and logistical aspects of an organization make the mission-driven programmatic work possible.

Make it Known refers to the need for strategic communications planning, execution, and measurement to ensure accurate and consistent messaging about both integrative health and health literacy concepts and programs. This “M” is PRIMES is necessary for two main reasons. The first is that the integrative approach and health literacy are not already widely accepted aspects of society. The second reason is the extensive and unrelenting competition for attention by a wide range of topics unrelated to health, and certainly unrelated to integrative health and health literacy. By conveying accurate and reliable information across a range of dissemination platforms, including online and in person, partnerships and the organizations that nurture them are not only sharing the best practices of health literacy but also modeling those practices.

Evaluate—is the “E” in PRIMES and focuses on the utility and necessity of rigorously tracking progress and outcomes of a partnership. We approach evaluation as a subset of scientific research—thus evaluation should produce usable, valid, and reliable evidence. Among the many possible and desired outcomes of conducting rigorous evaluation of a partnership are to inform participants of the changes they have made or not made; provide valid and reliable evidence of success or failure; justify the program to funders and management; document need for additional resources—support future funding efforts/sustainability; indicate areas requiring program modification and improvement—continuous quality improvement; inform policy; and facilitate the sharing of best practices.

Sustainability is the “S” in PRIMES and refers to the desired result of the PRIMES model. Sustainability does not refer to sustaining a particular project, program, or annual event. Rather, it focuses on sustaining the integrity of the mission of the organization engaged in each of the previous aspects of the PRIMES model. Achieving sustainability is both the highest purpose and a crucial necessity for organizations such as Canyon Ranch Institute that are involved in making a positive difference in the lives of people globally, through partnerships that educate, inspire, and empower people to prevent disease and embrace a life of wellness.

The Canyon Ranch Institute Life Enhancement Program*

We now turn to the Canyon Ranch Institute Life Enhancement Program (CRI LEP), an example of how a true healthcare system might function by focusing on health literacy and an integrative approach to health and medicine with the goal of preventing and reversing chronic disease. The CRI LEP is developed and implemented in partnership with a community-based healthcare organization. Staff members—representing specialists with backgrounds in nutrition, physical activity, behavior change, sense of purpose, integrative health, stress management, and social support—join together to form an integrative Core Team to provide the CRI LEP to their patient population. They work together as a team so that CRI LEP participants experience the entire range of the integrative health model in a coordinated and effective fashion. Those staff members participate in a two-part training program that focuses on the best practices of health literacy and integrative health and medicine in practical ways that help people help themselves to better health.

The program itself comprises at least 40 hours of group sessions and a minimum of 4 hours of one-on-one consultations with healthcare professionals. The group sessions include presentations and discussions on all aspects of the integrative model—mind, body, spirit, and emotion—as well as sessions focused on nutrition, cooking, physical activity, behavioral health, spirituality, pharmacology, oral health, and a grocery-store tour. The one-on-one consultations allow participants to explore deeper connections with their own health in conversations with accredited healthcare professionals who were trained by Canyon Ranch Institute experts in the best practices of integrative health and health literacy. These one-on-one consultations include, at a minimum, at least four 1-hour conversations and hands-on activities focused on integrative health, nutrition, physical activity, and behavioral health.

Each CRI LEP is rigorously evaluated toward constant quality improvement of the program and to document program outcomes, including behavior changes and physical and physiological health changes. This evaluation is—at most sites—conducted at baseline, post-program, 3-month post program, and 1-year post program. Some sites are adding a 2-year post program evaluation as well. The evaluation includes blood work (cholesterol panel, blood glucose, and C-reactive protein), exercise (sit-ups, push-ups, flexibility, and a treadmill test), physical measurements (waist, hips, height, and weight), and an extensive knowledge, attitudes, behaviors, and beliefs individual interview.6,7 (See

Health Literacy Best Practices

Uniquely, the CRI LEP is tailored to each partner site. To accomplish this tailoring, Canyon Ranch Institute staff members conduct extensive formative research in each community prior to the training of the partner’s Core Team and the launch of the CRI LEP. This formative research consists of individual in-depth interview conducted with community leaders and representatives from businesses and organizations that reflect the integrative model—mind, body, spirit, and emotion. Additionally, individuals who reflect the population who would participate in the CRI LEP are directly engaged in a series of focus group discussions. The findings of the formative research are used as a basis to tailor program materials, the training of the core team that will provide the program, and the content and framing of presentations within the program.

A particular aspect of this tailoring of the program to the cultural, environmental, social, and political realities of each community involves the use of narratives as an approach to demonstrating the viability of change in that environment. Narratives are perhaps the most powerful means for individuals to construct coherent accounts of their lives.8,9 Most often, the sense-making activity associated with health literacy takes the shape of a narrative.9,10 Narrative structure consists of an opening situation, a moment of transformation, and a closing situation wherein all change presented is depicted as a new and coherent reality. The moment of transformation is what makes narrative a strong element of a behavior change model.

The CRI LEP materials include a participant guide, which is given to each participant. In this book, there are—by design—a series of narratives about the lives of different individuals that run throughout the length of the volume, beginning in the second chapter and culminating in the final chapter. These narratives are drawn from the formative research. We gather stories of success and failure in each community, then use those details to craft narratives that involve individuals that reflect the population that we are targeting in each community. The narratives involve challenges to health that are common within the community and then—through the narrative structure—demonstrate how those challenges can be successfully addressed in the lives of individuals that reflect the lives of participants in the program. Thus, participants in the CRI LEP are directly exposed to a linguistic structure of positive change based on the lives of real individuals in each community. As a result, participants often reflect that they are reading about people just like them who are struggling with—and overcoming—the same challenges to living a healthier and happier life.

Training Health Professionals in Best Practices of Health Literacy

We also use the formative research as a basis for training of the healthcare professionals in each community who will actually deliver the CRI LEP to the participants in that community. In this training, we merge the realities of each community with the best practices of health literacy and the full model of integrative health and medicine that underpin the CRI LEP.

In particular, the health literacy best practices we focus on in the training include:

  • The approach to health literacy as a theory of behavior change rather than health literacy as simply focused on plain language and numeracy skills.1,4,7

  • The need to improve health literacy versus simply removing complexity, as integrative health and medicine are, indeed, complex and we need to assure that participants effectively embrace that complexity in their lives.

  • The need to adopt universal precautions versus highlighting the dominant yet incomplete and potentially damaging “deficit model” of health literacy. That is, we focus on the skills people already have and are using, and work to expand and improve those skills, rather than focus solely on what skills people do not have. This approach supports even people who have low or nonexistent health literacy to identify manageable goals and behavior changes they can make and sustain.

  • Transforming the skills and abilities of healthcare professionals from talking at or to people to talking with people. This transformation, which is truly a change in philosophy and behaviors and not merely additive to other thought processes and activities, reflects the underlying principle that while educating people has a value, the overarching goal is not only to help people increase their knowledge but also to decrease the gap between what they know and what they do.11

  • An effective approach to use of the teach-back technique. In particular, we focus on shifting the need to use the teach-back not to reflect the participant’s potential lack of understanding but to see the lack of usage of health information to make informed decisions about health to actually be caused by the healthcare professional. By making this switch, we tap into the healthcare professional’s desire to improve their own skills and we elicit the participation of the people who are experiencing the CRI LEP to help the healthcare professionals reach that goal.

  • A simulated participant exercise in which the healthcare professionals interact with an individual trained to fulfill the role of a CRI LEP participant. The guide for the simulated participant is rewritten in each community to incorporate particular aspects of the determinants of health, surrounding natural and built environment, and local culture that is encountered during the formative research. In particular, during this exercise Core Team members are encouraged and trained to listen first, then speak; address the whole person’s life, not just a diagnosis of a health condition; use the teach-back technique in order to “chunk and check” information that is shared during the session, engage directly with the simulated participant to collaborate on the identification of viable small-step goals focusing on healthier behavior change.

Individual-Level Outcomes

The CRI LEP’s application of that robust approach to integrative health—mind, body, spirit, and emotions—combined with the best practices of health literacy has produced dramatic health outcomes for participants across a broad range of cultural settings and contexts to date. Put simply, people are healthier, happier, and leading fuller lives as a result of their participating in the program. Specifically, outcome data combined from seven disparate sites to date—in Arizona, Missouri, Ohio, New York, Georgia, and Massachusetts—show statistically significant healthy changes across numerous indicators reflecting the underlying approach to integrative health and medicine. For example, a brief look at outcomes for the over 900 participants to date at sites across the United States includes:

  • A self-reported gain, on average, of seven healthy days each month. If that sustains for a year, participants will gain 84 healthy days—nearly three months more of health per year.

  • For those with high blood pressure at baseline, a drop in blood pressure on average of 14.7/10.3.

  • An average increase of 66 minutes of exercise each week.

  • A drop in depression, using the PHQ-9 depression scale of 9.1 points for participants who were at risk for depression at baseline (PHQ-9 score of 15 or higher). That is roughly a 45% drop in depression.

  • A 111% increase in health literacy scores using our new measurement tool based on the Calgary Charter on Health Literacy.

  • A 78% increase in health knowledge regarding nutrition, stress management, physical activity, integrative health, and personal health.

  • This all occurs with a savings, in comparison to other interventions to achieve the same health gains using a Quality-Adjusted Life Year approach, of $188,395.77 on average.

Community-Level Outcomes

The impacts of the CRI LEP go far beyond changes in individual health status for participants and extend into the communities where the program is offered and into the careers of the healthcare professionals who offer the program. One of the earliest community-level impacts of the program came at the first site with a premier federally qualified community health center, Urban Health Plan, Inc., located in the South Bronx, New York. During the program start-up and training phase, it became clear there was a problem. The South Bronx, at the time, was essentially a food desert. You could talk to people about eating a balanced diet including vegetables—but there was not a fresh vegetable to be found for sale at any market or restaurant in the entire community. To address this huge problem, the CEO of Urban Health Plan essentially guaranteed sales with a small market located next to the clinic. As a result, that store started selling a small tableful of fresh vegetables. Fast-forward to today, now that small store only sells fresh fruits and vegetables, there is a new grocery store on the next block. That grocery store offers a robust produce section, with a wide range of fresh fruit and vegetables for sale at affordable prices, and there are now two farmer’s markets in the community, both offer cooking demonstrations that provide credits to shoppers for observing the demonstrations. Those credits can be used to purchase goods at the farmer’s markets. In addition, the farmer’s market doubles the value of all state- and federally sponsored food benefits.

At that same site, Urban Health Plan, the introduction of health literacy via the CRI LEP has led the organization to establish its own health literacy center—a unique feature for a federally qualified health center. This awareness and integration of health literacy principles and practices extends into a workforce development program for the community, and into having health educators as a part of pediatrics, OB/GYN, adult medicine, and school-based health programs.

The members of the Core Teams for the CRI LEP programs across the country have also grown internally and spread that growth across the healthcare system of which they are a part. For example, the integrative health Core Team member and leader of medical education for the hospital system he is part of recently called his experience as a CRI LEP core team member “the most meaningful experience” in his medical career. Time after time, we find that exposing professionals in medical systems to the CRI LEP—and giving them the ability to truly interact with participants outside of the medical model focused solely on disease diagnosis and treatment—reminds them of why they went into health and medicine in the first place and reignites their internal drive to excel. As a result, we continually hear from our partners how the presence of the CRI LEP has changed the way they interact with all of the people who come seeking care, not just the participants in the CRI LEP.

For example, one Core Team member recently told us,

“I think the excitement of it all in our connection and our conversations that we have with each other, it’s kind of bubbled up more my excitement and the passion for what I do with my work. And so I have more conversations. I try to fill it into more groups that I’m running, into more one-on-one conversations with patients that I’m working with. And even with my co-workers. Which then can sometimes shift and change the way we operate as a team and gets back into what the patients get.”

A participant in the CRI LEP also recognized how this program has shifted not only their own health status but also their perception of the healthcare organization that is offering the CRI LEP in their community, saying in a recent focus group, “And it’s like a new side to them. It’s like you walk in the front door and they’re like, ‘Oh, my gosh! I’m so glad you’re here!’ And it makes you want to come back.” This occurred in a community where the formative research conducted prior to the arrival of the CRI LEP revealed a significant amount of antipathy of the local hospital system, which was most frequently referred to as the place where people in the community went to die.

Those effects have continued to diffuse across not only the healthcare delivery organizations that offer the CRI LEP but also the lives and communities of participants. The focus of the CRI LEP is on reaching the people at the lower levels of health in a community. Improving their health is the surest way to improve the overall health of a community.

What has happened as a result is not only an improvement in community health but also an empowerment of individuals within the community to not only take control of their own lives but also begin work to empower others in their community to improve their own health and well-being. That move, on each participant’s own part, has often resulted in some significant transformations in their own lives—and as a result reaching everyone else in their lives. For example, numerous participants in the CRI LEP are now employed by the healthcare delivery organization where they experienced the program. This level of engagement ranges from being a patient greeter to a member of the board of directors.

A stellar example, which we will tell in greater detail elsewhere in the future, is the story of Reginald Franklin of Savannah, Georgia. “Reggie” was a member of the first group of participants in the CRI LEP in Savannah, which was a partnership with Curtis V. Cooper Primary Health Care, Inc.—a federally qualified health center. When Reggie started the program he was obese, depressed, and, during the baseline assessment for the CRI LEP, learned he had type 2 diabetes. By the end of the program, Reggie had lost over 20 pounds. Two years later, he has tripled that weight loss. He has started regular practice of yoga, runs nearly every day, and continues to work with the exercise specialists and nutritionists he met during the CRI LEP. Further, he is now a member of the Core Team offering the CRI LEP in Savannah working to support participants, and is now the vice chair of the board of directors of Curtis V. Cooper Primary Health Care, Inc. His new personal motto is “No U-Turns,” and Reggie is working every day to continue his own personal health journey and inspire the entire Savannah community through a video documentary of his transformation to health as well as documenting his story in newspaper articles and speaking engagements.

Finally, the CRI LEP has influenced both Canyon Ranch Institute and our partners to develop a suite of healthy lifestyle programs based on the best practices of integrative health and health literacy in order to prevent and reverse chronic disease. These include, but are not limited to, the CRI Theater for Health program, which uses interactive theater in a community to change health behaviors. The initial pilot of this program was held in a shantytown of Lima, Peru, through a partnership with Clorox. The outcomes of the effort include a reduction of e Coli and listeria in the cooking areas within the shantytown.12 Additionally, CRI has developed a CRI Healthy Table program (focused on healthy cooking), the CRI Healthy Community program (for parents and their children), the CRI Healthy Garden program (healthy gardening and stress management focus), and variations of the CRI LEP—the CRI LEP for Families, which focuses on young children and their caregivers, and the CRI LEP for Teens, which focuses on teens and their caregivers.


The success of the CRI LEP is grounded in many elements. Two primary elements are our approach to partnership and the best practices of health literacy being infused throughout the program. The partnerships we develop based on the PRIMES model become self-sustaining, award-winning, and create transformation among the partners. Health literacy is infused throughout the tailoring of the program and training of the Core Teams that provide the program in their community. The words, approaches, and tools used become an injection of health literacy, health, and well-being. The dosage and manner of application are tailored to each participant and community. That content and style, much like an immunization, seeks out and modifies or replaces the ideas and habits causing poor health. The CRI LEP content is embedded within participants’ hearts and minds. In turn, the participants go out and share what they have learned and changed in their lives with friends, family, and their entire community. Through that process of diffusion, the CRI LEP metastasizes, in a healthy manner, to far more people than directly participate in the program experience the positive health effects in their lives as well. This is how we can turn the world’s health around for the better.

As noted earlier, the CRI LEP is one of a growing number of examples of efforts to merge the best practices of health literacy into a universal precaution approach. This approach, as noted, inherently addresses a person’s entire life rather than just their symptoms and the diagnosis of the day. This approach explicitly addresses culture, knowledge, communication ability, self-efficacy, empowerment, and the entire range of social, political, and environmental determinants of an individual’s, a community’s, and the world’s health and well-being. We close by suggesting that the approach we have described is perhaps the most financially sustainable, cost-efficient, equitable, and effective manner to truly achieve health in all policies and health for all.

Suggested Reading Materials


1. Coleman C, Kurtz-Rossi S, McKinney J, Pleasant A, Rootman I, Shohet L. Calgary Charter on Health Literacy. 2009. Accessed July 13, 2010.

2. Zarcadoolas C, Pleasant A, Greer D. Advancing Health Literacy: A Framework for Understanding and Action. San Francisco, CA: Jossey Bass; 2006.Find this resource:

3. Zarcadoolas C, Pleasant A, Greer D. Understanding health literacy: An expanded model. Health Promot Int 2005;20:195–203.Find this resource:

4. Pleasant A, Cabe J, Patel K, Cosenza J, Carmona R. Health literacy research and practice: A needed paradigm shift. Health Commun 2015;30(12):1176–1180.Find this resource:

5. Roundtable on Health Literacy; Board on Population Health and Public Health Practice; Institute of Medicine; The National Academies of Sciences E, and Medicine. Health literacy: Past, present, and future: Workshop summary. Washington, DC: Roundtable on Health Literacy; Board on Population Health and Public Health Practice; Institute of Medicine; The National Academies of Sciences, Engineering, and Medicine; 2015.Find this resource:

6. Pleasant A, Kuruvilla S, Zarcadoolas C, Shanahan J, Lewenstein B. A Framework for Assessing Public Engagement with Health Research. Geneva, Switzerland: World Health Organization; 2003.Find this resource:

7. Pleasant A. Health literacy: an opportunity to improve individual, community, and global health. New Dir for Adult and Cont Educ. 2011;2011(130):43–53.Find this resource:

8. Labov W. Some further steps in narrative analysis. J Narrat Life Hist 1997;7:395–415.Find this resource:

9. Shanahan J, Pelstring L, McComas K. Using narratives to think about environmental attitude and behavior: an exploratory study. Soc Natur Resour 1999;12:405–419.Find this resource:

10. Fisher WR. Narration as a human communication paradigm: the case of public moral argument. Commun Monogr 1984;51(1):1–22.Find this resource:

11. Pang T, Sadana R, Hanney S, Bhutta Z, Hyder A, Simon J. Knowledge for better health—a conceptual framework and foundation for health research systems. B World Health Organ 2003;81:815–820.Find this resource:

12. Pleasant A, de Quadros A, Pereira-Leon M, Cabe J. A qualitative first look at the Arts for Behavior Change Program: Theater for Health. Arts Health 2015;7(1):54–64.Find this resource:


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