Overview The Nebraska Association of Local Health Directors (NALHD) is Nebraska's SACCHO. NALHD amplifies the impact of local health departments (LHDs) at the state and local level through leveraging resources, pursuing organizational excellence, facilitating peer learning, and building collaborative systems. NALHD supports LHDs by building partnerships, systems, and infrastructures that enhance their capacity to promote and protect the health of Nebraskans. Currently, 16 of Nebraska's 20 local health departments are represented in NALHD, covering over 80% of the counties in the state. LHD sizes range from 20,000 to greater than 200,000, with the vast majority of counties designated as rural, frontier, or outlying micropolitan. The total jurisdiction size of NALHD is 200,000-299,999. Nebraska LHDs identified health literacy as a public health issue. Health Literacy is the collection of skills needed to communicate about health care. Both health care providers and consumers need Health Literacy Skills. These skills help providers to clearly inform consumers about health-related choices, and help consumers to make sense of and participate in these choices. In response, NALHD created the Outreach Partnership to Improve Health Literacy (OPIHL) to provide health literacy training, resources, and technical assistance to LHDs and their partners, statewide. OPIHL was initially funded through HRSA's Rural Health Care Services Outreach Grant program. The goal of OPIHL was to build health literacy skills and capacities of those working in the Public Health System, including health care providers, and reduce the literacy burden placed upon community members who seek services within that system. Starting in 2013, OPIHL engaged 15 LHDs, covering 75 of Nebraska's 93 counties, in comprehensive, organizational health literacy skill and capacity building. First, OPIHL defined the health literacy education and training needs of Nebraska's rural LHDs. Next, OPIHL developed and implemented a comprehensive health literacy education and training program, including specific health literacy strategies to meet the needs of LHD personnel. OPIHL's unique and responsive training program included the following elements: Health Literacy Writers Workshop participants create and evaluate written materials that are easy for patients and community members to understand and use facilitators incorporate didactic instructions on health literacy strategies with ample time for participants to collaboratively apply health literate best practices to their own materials includes a Health Literacy Train-the-Trainer component Health Literacy Communication Workshop participants learn and practice strategies for communicating with patients and clients, orally, in heath literate ways facilitators incorporate scenerios and role plays to engage participants and provide an opportunity to apply Teach Back and other health literate best practices includes a Health Literacy Train-the-Trainer component Collabinars participants build upon and apply health literate best practices introduced in the Workshops participants connect with geographically separated colleagues and engage in real-time, collaborative feedback of written materials using a webinar platform Health Literacy Organizational "Check-up" and Action Plan provides LHDs an organizational-level framework addressing knowledge, strategies, and tools to assess their organizational health literacy status formulates meaningful action plans to sustain LHD's health literacy training and internal health literacy endeavors helps LHDs begin to effectively meet and document PHAB Accreditation requirements in Domains 3, 7 and 8. The OPIHL goals were achieved through the Workshops, Collabinars, and Health Literacy "Check-up" and Action Plans. When the OPIHL project began, only two LHDs serving eight counties described themselves as having health literacy expertise. During the first 3 years of this work, over 130 LHD staff participated in at least one OPIHL training, with over 30 from 11 LHDs participating in 2 or more trainings. Now, multiple staff members at 15 LHDs, covering over 80% of the state, are trained and have access to LHD-specific resources for 1.) replicating training with community partners, 2.) applying health literacy best practices in their work, 3.) formalizing health literacy practice in their (and their partners') organizations. See http://www.nalhd.org/resources-HL.html. Several factors led to the success of this practice, including collaboration between LHDs, OPIHL project leadership, coordination by NALHD, and leveraging community partnerships to expand the reach of health literate practice. The public health impact of this practice is the development of an organizational culture that tailors health communications and interventions in ways that mitigate the negative impact of health literacy to improve health outcomes across communities. OPIHL assists Nebraska LHDs in aligning the 3 Public Health Core Functions and 10 Essential Services with health literacy best practices to improve population health.
Responsiveness and Innovation 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”.[i] It is a bi-directional phenomenon that requires skills on the part of consumers, providers, and health-related organizations and institutions. Limited health literacy affects people across the range of socio-demographic characteristics, including age, educational attainment, income level, and English language proficiency. Research associates limited health literacy with a growing list of negative health outcomes, including misdiagnosis, poor disease self-management, medication errors, longer hospital stay, lower use of preventive services, and increased risk of death[ii]. The most comprehensive study of health literacy in the U.S. found only 12% of adults “proficient”[iii]. Citing this, the Centers for Disease Control and Prevention (CDC) noted: When 90% of people have a "problem," then it's likely the problem isn't with the people but with the system or product they are trying to use…. it is vital for public health professionals to understand and address the gap between the health information and services they provide and people's skills to do something beneficial for their health...[iv] Nebraska LHDs identified health literacy as a public health issue for several reasons. Limited infrastructure in terms of staff, expertise, and geography, made it difficult to address health literacy concerns. Absent a formal adoption of health literacy practices and priorities at the organizational level, even well-intentioned LHDs with trained staff struggled to make progress in their overall health literacy capacity. When the OPIHL project began, only two LHDs serving eight counties described themselves as having health literacy expertise. Early on, some LHD personnel were not convinced of the need for increasing capacity to address health literacy. Finally, limited health literacy was not commonly understood to have an impact on health outcomes in Nebraska, nor were attitudes and behaviors relating to health literacy measured on a statewide scale. The OPIHL project serves 75 of the 93 counties in Nebraska; 61 are designated rural, frontier, or outlying micropolitan counties and include 737,000 rural Nebraska residents. The LHD staff at the 15 district LHDs in this area were the direct targets of the work of OPIHL as well as their community partners such as Federally Qualified Health Centers, primary care clinics, and cancer centers. To date, no comprehensive public health training program or approach has directly addressed health literacy in rural Nebraska. The OPIHL project is the first of its kind. The current practice is better because it builds capacity at an organizational level, improves accountability, includes mechanisms to replicate training, eliminates geographic barriers, and measures health literacy attitudes, behaviors, and practices. The OPIHL project has resulted in: Greater capacity. Health Literacy Workshops and the Health Literacy Check-up and Action Plan Formal directly assist in the capacity-building of local resources by outlining a process for adopting and integrating health literacy practices and priorities at an organizational level, resulting in growing, sustainable health literacy capacity with an emphasis on Quality Improvement Improved accountability. The Health Literacy Check-up and Action Plan provide a formal mechanism for organizations to demonstrate how they and their staff are accountable for implementing health literate practices. Replicability of training process. Through Workshops and the Train-the-Trainer program, LHDs have become local health literacy content experts, resulting in the replication of training with community partners and eligibility for sub-contracting. Dissolution of geographic barriers. Through the use of online “Collabinars,” geographically separated individuals and groups shared their knowledge with one another by collectively reviewing written materials for health literate best practices. Increased understanding of health literacy’s impact on health outcomes through Health Literacy Workshops that addressed pervasiveness of the problem as well as the impact on patient and population-based health outcomes. A statewide tool for collecting data regarding health literacy. OPIHL project staff worked with state partners to add health literacy items to the Behavioral Risk Factor Surveillance System (BRFSS). Starting 2015, Nebraska-specific BRFSS data on health literacy is available for describing and addressing the need for ongoing attention in this area. During the first 3 years of this work, multiple staff members at 15 LHDs, covering over 80% of the state, are trained and have access to LHD-specific resources for 1) replicating training with community partners 2) applying health literacy best practices in their work, 3) formalizing health literacy practice in their (and their partners’) organizations. See http://www.nalhd.org/resources-HL.html. At OPIHL’s inception, Nebraska LHDs were not focusing on health literacy as part of public health practice. LHDs knew that research showed that limited health literacy is an issue across communities nationwide, that it impacts health, and that evidence-based tools for addressing health literacy existed. The OPIHL approach was innovative in that it was the first statewide effort to formally implement health literacy strategies as part of public health practice. NALHD conceived the OPIHL project based upon several models and continues to incorporate (and add to) new evidence and models developing in the fast-evolving field of Health Literacy. At the onset, NALHD relied heavily on tools and strategies from the Agency for Healthcare Research and Quality (AHRQ) Universal Precautions Toolkit. This evidence-based resource was designed to help health organizations ensure that systems are in place to promote better understanding by all patients. This tool addresses each of four key change areas: Improve Spoken Communication, Improve Written Communication, Improve Self-Management and Empowerment, Improve Supportive Systems. OPIHL used this toolkit in the early stages of the project as a means of gathering relevant information and for planning and development of appropriate technical assistance to local health department. The tool and its cited resources continue to help OPIHL project staff develop observation protocols and surveys for the needs assessment and evaluation, as well as identify health literacy strategies that are more relevant to population-level communication, and developing teaching and practice tools (checklists). Shortly after the OPIHL project was funded, the IOM released its 10 Attributes of Health Literate Health Care Organizations. This framework provided a useful, if imperfect, lens for the overall OPIHL project. The Attributes also provided a guide for several LHDs that have developed quality improvement plans and performance management process related to health literacy. The OPIHL project’s use of the Attributes was featured in an IOM Roundtable on Health Literacy’s November 2013 Workshop on the Implications of Health Literacy in Public Health. All OPIHL-related training and technical assistance has featured and continues to feature evidence-based strategies, such as Plain Language and the Teach Back method, as well as evidence-based tools such as the Centers for Disease Control and Preventions’ Clear Communication Index and AHRQ’s new PEMAT (Patient Education Materials Assessment Tool). OPIHL uses the Plain Language Checklist and the CDC Clear Communications Index in the Writer’s Workshops to guide participants as they engage in peer review and editing exercises. The Communication Workshop uses a health literate best practice, Teach Back, in a simulation exercises to engage participants in a triad experience, which includes utilizing and observation checklist tool. Finally, The National Association of County and City Health Officials’ (NACCHO) Mobilizing for Action Through Planning and Partnerships (MAPP) process supported the OPIHL project’s work to assure that LHD health literacy efforts contributed to larger community priorities. MAPP is a community-driven strategic planning process for improving community health that is routinely used by NALHD-member LHDs. This framework helps communities apply strategic thinking to prioritize public health issues and identify resources to address them. Through the MAPP process, LHDs have established strong relationships with all stakeholders in the Local Public Health System that facilitates their efforts to engage providers and other community partners in health literacy activities and conversations. Health literacy is a contributor to health outcomes. Some studies have found it the strongest predictor of negative health outcomes—stronger than race, income, educational level, age, and other social determinants of health. Thus, all of the CDC’s Winnable Battles are addressed by health literacy. Endnotes [i] U.S. Dept of Education. Washington, DC: National Center for Education Statistics. U.S. Department of Health and Human Services. (2000). Healthy People 2010. Washington, DC: U.S. Govt. Printing Office.[ii] DeWalt, D., Berkman, N., Sheridan, S., Lohr, K., and Pignone, M. (2004). Literacy and health outcomes. Journal of General Internal Medicine, 19. 1228-1239.[iii] Kutner, M., Greenburg, E., Jin, Y., & Paulsen, C. (2006). The Health Literacy of America’s Adults: Results From the 2003 National Assessment of Adult Literacy (NCES 2006-483).[iv] CDC Features - Health Literacy Training for Health Professionals: Free Continuing Education." Centers for Disease Control and Prevention. Web. 04 Nov. 2011. <http://www.cdc.gov/features/onlinetraining/>.
LHD and Community Collaboration and Implementation Strategy The goal of the Nebraska Association of Local Health Directors’ (NALHD’s) Outreach Partnership to Improve Health Literacy (OPIHL) project is to build health literacy skills and capacities of those working in the Public Health System, including health care providers, with the objective of reducing the literacy burden placed upon community members who seek services within that system. The OPIHL project staff developed a comprehensive training program to build health literacy skills of LHD staff and resources available to them. The program addressed some of the unique challenges and needs of rural LHDs and the rural communities they serve. The 5 distinct elements of the OPIHL training program are designed to be complimentary, interconnected, and sustainable. The elements are: Health Literacy Writer’s Workshop, Health Literacy Communication Workshop, Health Literacy Train-the-Trainer, Collabinars, and the Health Literacy Check-up and Action Plan. Since its inception, the OPHIL project focused on engaging LHD personnel, as well as numerous stakeholder and community groups. The development of the training program incorporated feedback (including focus groups, interviews, needs assessment surveys, and training event evaluation surveys) from LHDs as well as community stakeholders. In 2012, 230 LHD staff participated in a baseline survey that assessed their perceptions related to health literacy. OPIHL project staff visited 19 sites where over 144 and LHD staff and directors took part in on-site trainings, focus groups, and interviews. The survey and site visit data underscore several rural populations that will particularly benefit as LHDs continue to gain health literacy-related capacity through OPIHL’s efforts. Among these groups are (1) the elderly (2) vulnerable children and their families, and (3) Limited English Proficient community members. These visits and data also revealed an interest in and need for skills related to health literate writing, including guidance on how to select or develop more health literate materials relevant to the populations listed above. Site visits revealed a desire for and need for robust opportunities for LHD staff to collaborate with others in Nebraska who could help build their health literate skills and who had experience with similar public health programs. The vast geographic distance between LHDs across the state of Nebraska emerged as a major barrier to the collaboration necessary to address the identified needs. LHDs understood health literacy as a tool for addressing some of the growing low-incidence language diversity in rural communities. OPIHL partners (including LHDs, faculty at the University of Nebraska Medical Center College of Medicine and Public Health, The Great Plains Public Health Training Center, the Nebraska Department of Health and Human Services Office of Health Disparities and Health Equity) supported the work of the project with expertise in research, evaluation, training, and Cultural and Linguistic Appropriate Services (CLAS). After reviewing survey results and outcomes of site visits, OPIHL staff developed the Health Literate Writers Workshop. In 2013-2014, a team of OPIHL staff traveled to LHDs, or in some cases partner facilities such as a local Community Colleges, to deliver Writers Workshops. Some of these workshops invited community members to review the written materials developed by the participants, in a usability testing exercise. Details, including the workshop outline and associated resources, are at nalhd.org. In January 2014, OPIHL began providing monthly web-based Collabinars that allow geographically separated rural health department personnel to implement health literacy writing practices in a supported, workshop environment. In 2015, OPIHL contracted with the Nebraska Cancer Control and Prevention Program to deliver Health Literate Communication Workshop to Cancer Center personnel, local health departments and other health care providers. To date, OPIHL has provided 10, day-long, in person Health Literate Writers Workshops across the state and 5 Health Literate Communication Workshops. These workshops included both local health care providers and LHD staff. This integration of public health and health care created an opportunity for learning and collaboration. In the fall of 2015, NALHD LHDs were offered an incentive to complete the OPIHL Health Literacy Check-up and Health Literacy Action plan. All member LHDs completed the Check-up and developed Action Plans. The Action Plan uses SMART goal-setting principles and encourages local health departments to incorporate their PHAB Accreditation goals. Funding In May 2012, NALHD received funding through HRSA’s Rural Health Care Services Outreach Grant Program. This grant provided the funding ($150,000 for each of the 3 grant years, for a total of $450,000) to launch the OPIHL project. These funds were budgeted to support association-level expertise and capacity building as well as to provide support for all 15 LHDs’ participation in all aspects of the comprehensive training. Start up costs: Personnel: Including NALHD full-time project director with significant health literacy expertise, Project Evaluator, and other administration ($100,000) Travel: Including site visits and LHD participation in state and national health literacy conference and training events ($18,000) Supplies: Including What to Do books provided to LHDs ($5000) Other: Including 15 LHD training stipends, printing, webinar platform and other subscriptions ($27,000)
Evaluation When the Outreach Partnership for Improving Health Literacy (OPIHL) project began, only two local health departments (LHDs) serving eight counties described itself as having health literacy expertise. Now, multiple staff members at 15 LHDs, covering over 80% of the state, have participated in training and technical assistance. Organizational practice and policy has been enhanced as a result of the evidence-based Writer’s Workshops. Furthermore, the health literacy skills of and resources available to public health professionals, statewide, was enhanced through the OPIHL project, thus improving the effectiveness of LHDs’ communications to their communities. In many communities, LHDs have moved from health literacy learner to health literacy trainer. Goals/Objectives/Results Goal 1: Define the health literacy education and training needs in Nebraska’s LHDs. Objective 1: Implement a health literacy needs assessment. In the beginning, OPIHL needed to know to what extent Nebraska’s LHDs were utilizing evidence-based health literate strategies and tools because there was not a good source of data surrounding this issue in Nebraska. OPIHL implemented a needs assessment. The components and protocols necessary for the needs assessment were selected and/or modified by the evaluators in consultation with the Project Director. Data collection techniques included online surveys to all staff from participating LHDs, interviews with LHD Directors and site visits (to observe the use of health literate practices/techniques and evidence of the 10 Attributes of Health Literate Health Care Organizations) using the Agency for Healthcare Research and Quality (AHRQ) developed Tool to Assess Your Practice questionnaire from the Health Literacy Universal Precautions Toolkit and a modified 360 degree assessment. The 360 degree assessment examined health literacy from multiple perspectives and drew from Suitability of Materials by Doak and Doak, an observation tool. The survey assessing baseline knowledge of health literate practices/techniques was administered at all 16 LHDs and 3 tribal health departments (THDs) initially involved in the grant. A total of 230 individuals completed the survey, including 13 (5%) responses from THDs and 188 (82%) responses from LHDs. When OPIHL began, only two LHDs serving eight counties described themselves as having health literacy expertise. Now, multiple staff members at 15 LHDs, covering over 80% of the state, have participated in training and technical assistance. The OPIHL evaluation survey administered at the end of the grant to LHD staff and directors (N= 79 respondents from all OPIHL-eligible LHDs) in 2015 revealed an increase in personal preparedness to help clients understand spoken and written instructions (95% and 79% of respondents, from the end of grant survey and baseline needs assessment respectively) and in organizational preparedness to help clients understand spoken and written instructions (91% and 70% of respondents, from the end of grant survey and baseline needs assessment respectively). Additionally, the end of the grant evaluation survey demonstrated an increase across the domains of: Health literate organizational support (such as organizations train staff on health literate practices and tools, employ at least one staff member as health literacy point persons, create an environment that enables clients to ask questions and interact with their health, etc.). Furthermore, 66% (49/74) of respondents indicated that their LHD had a policy in place that incorporates health literacy tools and techniques when delivering services (such as developing materials, working with clients in clinics or health education presentations, etc.). Health literate organizational practice (such as organizations distribute materials that are easily understood and act upon, offer clients help with filling out forms and giving directions even when they do not appear to need help, have staff/volunteers available to help clients or patients fill out forms or find their way). Over 2/3 (49/74) of respondents indicated they use the Health Literacy Advisor Software with nearly 1/3 (22/74) of respondents using Teach Back and Usability Testing (independently) when delivering services. Goal 2: Develop and implement a comprehensive, evidence-based health literacy education and training program, including specific health literacy strategies, to meet the needs of rural health department personnel. Objective 2: Provide at least 4 Writer’s Workshops across Nebraska that emphasize evidence-based health literacy strategies and tools needed to implement health literacy best practices. OPIHL provided 10, day-long, in-person Health Literacy Writers Workshops across the state. The evaluation team developed an online survey to evaluate these professional development trainings. These surveys were given to all training participants after each training and 6 week post-training, to assess the extent to which participants were implementing health literacy strategies. The evaluation team analyzed data by using frequencies and extracting themes from open-ended questions, with regular feedback to the project staff so that appropriate modifications could be made to trainings. Of the 209 individuals who attended, 151 (72%) were LHD staff, 6 (4%) were THD staff, 5 (4%) were Nebraska Department of Health and Human Services staff, and 45 (22%) were from partner organizations (such as hospitals, Federally Qualified Health Centers, Head Starts, and Cancer Centers). As a result of the workshop, the overwhelming majority (90-95%) of participants reported that they are better prepared to: Explain principles of writing easy to read materials Critique materials based upon easy to read principles Apply easy to read principles to modify written materials Know key components of usability testing Describe and support health literate writing processes Describe and support health literate standards appropriate to their workplace. Results from Health Literate Writers Workshops follow-up surveys confirmed that participants continued to find value in what they had learned during workshops and felt that their health literacy knowledge had grown. The Health Literate Writers Workshops met the goals of increasing the health literacy knowledge and skills of LHD staff and a Communications Strategies Workshop has been added to the menu of trainings that are being sustained. In response to feedback from Writers Workshop participants, OPIHL began providing web-based Collabinars that allow geographically separated, rural health department personnel to implement health literacy writing practices in a supported workshop environment. Participants wanted a venue that they could practice what they learned in the Writer’s Workshops on a more frequent basis. To date, 101 attended 12 Collabinars. Of the 101 attendees, 63 (62%) were from LHDs, 26 (26%) were from partner organizations such as hospital/clinics and Head Start, and 12 (12%) were from various offices within Nebraska’s DHHS. Nearly 80% of survey respondents (n=83) indicated that they are better prepared to apply health literate techniques. OPIHL’s Listserv and Collabinars provide a platform where LHD staff members are able to engage one another with questions and ideas for sustaining high-quality work despite the geographic barriers that exist. OPIHL provided 5, in-person Health Literacy Communication Workshops across the state. Of the 100 individuals who attended, 69 were LHD staff, 8 were cancer center staff, and 23 were from partner organizations (such as hospitals, Federally Qualified Health Centers, and non-profit organizations). The evaluation team developed an online survey to evaluate these professional development trainings. These surveys were given to all training participants after each training to assess prior knowledge and knowledge gained of health literacy and the extent to which participants showed intent to implement health literacy strategies. The evaluation team analyzed data by using frequencies and extracting themes from open-ended questions, with regular feedback to the project staff so that appropriate modifications could be made to trainings. Of the 48 participants who responded to the survey, nearly 60% of respondents indicated they had an average to below average knowledge of health literacy before they participated in the workshop. As a result of the workshop, the overwhelming majority (90-95%) of participants reported that they are better prepared to: Use evidence-based health literate tools and strategies (i.e. Teach Back) Avoid using jargon with patients and their families Describe and support health literate writing processes Describe and support health literate standards appropriate to their workplace. Overall, the comprehensive training program created as a result of the OPIHL project proved to be successful in reaching a diverse population and increasing the health literacy knowledge and skills of the target population. The Health Literacy Check-up and Action Plan was launched in the late spring of 2015. As of October 2015, 9 of 16 NALHD member LHDs have completed the Check-up and Action Plan. Action plans reflect a continuing commitment to health literacy professional development and to formalized practice.
Sustainability The Nebraska Association of Local Health Directors (NALHD), Outreach Partnership to Improve Health Literacy (OPIHL) project works with Local Health Departments (LHDs), to continue to tap into and build on health literacy expertise as a tool for maximizing LHDs’ impact across the state. Over the past 3 years, the OPIHL project has provided in-person and web-based health literacy training, resources, and technical assistance to rural LHDs and their partners. We learned and witnessed how statewide engagement supports the health literacy technical skills and capacities gained and makes those gains less vulnerable to staff turnover and/or competing priorities for staff members. We learned that collaborative connections keep LHD staff engaged in and excited about health literacy practice. These comments are reflective of comments from OPIHL training participants generally. “We now effectively use health literate best practices to engage community members in giving us feedback about our health education materials, which has improved what we’re trying to do as a health department.” Worksite Wellness Coordinator, Panhandle Public Health Department, Hemingford, NE. “Now, when writing a press release or preparing a brochure, I try to review the material as if I know nothing of the topic. Sharing with other [workshop] attendees helped me develop a great network!” Program Assistant, Four Corners Health Department, York, NE We learned that absent a formal adoption of health literacy practices and priorities at the organizational level, even well-intentioned LHDs with trained staff struggled to make progress in their overall health literacy capacity. Through the OPIHL project, NALHD and all of NALHD’s member LHDs are working towards formalizing Continuous Quality Improvement-informed strategies and have completed a first round of the Health Literacy Check-ups and Action Plans. These tools formalize health literacy training goals for LHDs (and eventually their partners) and identify LHDs ready to take the lead as their communities’ hub of health literacy expertise. The Health Literacy Check-up is an on-line tool (see http://www.nalhd.org/resources-HL-Champion.html) that local health departments and/or community partners can use to annually assess their internal health literacy organizational practices in the areas of Performance Management, Policies and Procedures, and Community Partners. Once the Check-up is complete, the submitting organization is contacted by OPIHL staff who reviews the results of the Check-up and works with the organization to develop an Action Plan. The Action Plan uses SMART goals to help address areas for improvement. Based on the outcome of the Health Literacy Check-up and completion of the Action Plan, the organization may be awarded the Health Literacy Champion designation. This designation signifies that the organization has proficiency in health literacy and is ready to champion health literacy in their communities. Additionally, the Check-up and Action Planning tools can contribute to documentation related to PHAB Accreditation requirements in Domains 3, 7 and 8. We learned that, despite the overwhelming evidence of the prevalence of limited adult literacy and health literacy, making the case for health literacy is still vulnerable to those who doubt that it is an issue “here”. OPIHL’s work with LHDs and other partners (including various divisions of the Nebraska Department of Health and Human Services [DHHS]) has built the statewide understanding of health literacy’s role in health outcomes. Engaging state-level partners paved the way for local and state leaders to continue to learn more about the impact of health literacy specific to Nebraska and to start to measure it at the population level. OPIHL staff were key to efforts to include 3 health literacy questions in the Nebraska state Behavioral Risk Factor Surveillance System (BRFSS) in 2014 and 2015. The Nebraska-developed data collection items were adopted in neighboring Iowa and Missouri for use in 2015. Cost/Benefit OPIHL estimated its economic impact factor as part of the HRSA grant evaluation. This was estimated using the Rural Assistance Center’s Economic Impact Analysis Tool. For every $1.00 of rural specific spending, this project generated $0.58 of additional economic activity. This is a conservative estimate of the impact across the state because it does not reflect impact in non-rural areas where several of the project’s partners are located. Stakeholder commitment and Sustainability Plans Many of the LHDs are preparing to submit applications to achieve (or retain) PHAB Accreditation. Health literacy is related to specific PHAB Accreditation requirements, and therefore, LHDs are viewing their internal health literacy practices and competencies in a new light. The Nebraska Association of Local Health Directors (NALHD) continues to work to ensure that key elements of its OPIHL project will be sustained and expanded going forward, to address the ongoing demand for health literacy support and the lessons learned through OPIHL’s implementation since 2012. NALHD’s association staff now includes five individuals with significant health literacy expertise (including the Executive Director who was an invited presenter at the IOM Roundtable on Health Literacy’s November 2013 Workshop) who will continue to provide leadership and support to all NALHD members and who strive to apply health literacy principles to all of the association-level work. This established multi-level capacity will allow NALHD to continue to expertly facilitate core OPIHL activities, such as in-person trainings, Collabinars and other web-based training, Action Planning technical assistance, and to maintain and share health literacy resources of particular relevance to Nebraska’s LHDs. OPIHL, through partnerships with our APHA affiliate and other statewide organizations, continues to offer in-person and web-based health literacy trainings at least quarterly. To ensure the sustained workshop-style training opportunities (for current and new LHD staff and for partners from a variety of sectors), OPIHL is engaged with the Public Health Association of Nebraska (PHAN) to strategize on mutually beneficial ways that Health Literate Writers Workshops and Health Literate Communication Strategy Workshops might be incorporated as part of the annual PHAN conference through at least 2017. OPIHL’s Collabinars continue to provide an on-demand platform where LHD members from different sites, who otherwise have limited (if any) interaction with one another, are able to tackle health literacy questions and share ideas for sustaining high-quality work. Additionally, NALHD’s OPIHL project has expanded to include a partnership with the Nebraska Cancer Coalition and the Nebraska Comprehensive Cancer Control and Prevention Program to provide on site, health literacy training for rural cancer centers, including technical assistance regarding organizational assessment and action planning. Depending on their starting point, LHD staff members are involved in this work, either as fully sub-awarded technical assistance providers to their local cancer centers, as mentored technical assistance providers working with OPIHL staff to hone their training skills, or as new learners about health literacy best practices. This contract not only expands to reach of OPIHL’s health literacy trainings, it is contributing to new and deeper relationships between the LHDs and cancer centers across the state.