Reflections on Dr. Rima Rudd's Significance to Health Literacy in the Shadow of Health Equity

Reflecting on Dr. Rima Rudd's distinguished career provides a fitting starting point for understanding what health literacy means today when equity concerns are central to understanding public health priorities. The 10 Essential Public Health Services model (Public Health Accreditation Board, 2020), our basic framework for understanding public health's scope and responsibilities, has been redefined to put health equity at the core. The effects of the coronavirus disease 2019 (COVID-19) pandemic, targeted violence against racial, ethnic, and other groups, and continuing disparities in housing, education, and employment, are among the many indications that we have not created equitable societies. Fresh attention to the digital divide highlights the lack of broadband and Wi-Fi services in many communities and their disconnect from vital information.

Dr. Rudd stands out as someone who has beckoned us time and again to look at inequities in all areas, and especially in literacy, numeracy, and information accessibility (Rudd, Kaphingst, et al., 2004; Simonds et al., 2011). Her scholarship is one of knowledge to action, in the spirit of Paulo Freire (Rudd & Comings, 1994), and her example calls us to consider the consequences if we don't pay enough attention to health literacy as we pursue equity goals (Flecha et al., 2011; Koh & Rudd, 2015; Rudd, 2007; Rudd, 2017; Rudd, Kirsch, et al., 2004).

The health literacy bond that Dr. Rudd and I share was forged 24 years ago in Healthy People 2010 and the first national health literacy objective. We articulated health literacy and information equity as matters of social justice. Two decades later, Healthy People 2030 (U.S. Department of Health and Human Services, n.d.) formally recognized health literacy as essential to the elimination of health disparities and the achievement of health equity.

I have heard Dr. Rudd argue many times for rigor, one of her favorite words, in our health literacy scholarship and teaching so that we fully understand the barriers people face when trying to find and use health information and services (Rudd, 2022). Her focus on adult literacy skills and the longstanding inequities in our educational and health care systems that undermine information accessibility is a unique contribution to public health disparities work (Rudd & Keller, 2013; Rudd, Kirsch, et al., 2004). She reminds us that as professionals, we are obligated to respect people's dignity, another of her favorite words, and as health professionals with a code of ethics, we should not shame people when they don't understand our jargon, unclear behavioral recommendations, or unnecessarily complicated insurance and health care delivery systems (Rudd, 2013).

I have known Dr. Rudd as a teacher, mentor, scholar, advocate, colleague, and friend, and she excels in all these roles. Of her professional roles, my first thoughts of her are as a teacher and mentor because of the impact she has had on educating people about health literacy. She is a sought after public intellectual and speaker who helped globalize the health literacy concept and demand for health literacy expertise. In the late 1990s, few countries outside the United States had their own health literacy experts, and Dr. Rudd was often the first person in many countries to bring lectures, guidance, and mentorship.

This role of teacher and mentor that Dr. Rudd occupies so naturally is unique for the health literacy field. Unlike other areas in public health, few faculty specialize in health literacy, teach dedicated health literacy courses, and invest in developing the next generation to the degree that Dr. Rudd has. Her former students who have entered the academy can now train and mentor others in health literacy as part of academic programs. The lack of enough trained faculty to educate students and build the future workforce is part of the field's unfinished work.

Like other sources of inequities, health literacy is about system level failures that interfere with people getting what they need from health information and services. Dr. Rudd was among the first to focus attention on how health systems operate and how health professionals communicate as root causes of “low health literacy.” Dr. Rudd's work on adult literacy and numeracy skills and her close attention to task difficulty when accessing health information and services underpins the organizational health literacy concept and methods (Rudd, 2013).

I have discussed Dr. Rudd's career without mentioning key words that pervade our current public discourse about health information: misinformation, conspiracy theories, and infodemic. These concepts became prominent during the COVID-19 pandemic. Dr. Rudd's dialogic process of deep understanding of an audience and continuous checking on and correcting for misunderstandings, comprehension, and unanswered questions provides an alternative to misinformation despair. Health literacy techniques, such as using everyday language, providing clear and explicit directions, and combining words, numbers, and images to explain an idea, go a long way toward enhancing information comprehension and usefulness. A rigorous application of health literacy techniques is a preventive measure against both infodemics and information inequities.

To honor Dr. Rudd's legacy and be true to communication and health literacy science, what can we do to align health literacy and health equity work? Because public health is a data-driven enterprise, health disparity and equity researchers who are building and mining data sets and developing new measures and data collection systems should bring health literacy researchers to the table and collaborate on testing and fielding health literacy measures. Until health literacy measures become a routine component of key public health datasets and equity analyses, health literacy issues will be less visible and easier to dismiss.

We can also make health literacy assessments part of existing program evaluations and include health literacy elements in new programs. Dr. Rudd's leadership in developing health literacy study circles and organizational health literacy assessment tools shows how organizations can take responsibility for their actions to make information and services accessible (DeWalt et al., 2011; Grabeel et al., 2022).

Perhaps the most direct step is to ensure that every public health and health professions student is educated to recognize health literacy barriers and apply basic techniques to remove those barriers. Dr. Rudd's own teaching brings health care and public health students together to learn clear communication techniques.

It is risky business to try to summarize a field, let alone summarize another person's life. Retirement tributes often highlight the retiree's many fine personal qualities, and Dr. Rudd has many. But I have intentionally called out her professional attributes and accomplishments for a reason. We forget how much women now in their 70s, 80s, and 90s have had to overcome to create rich professional lives, and we forget legal work to dismantle sex discrimination happened long into the careers of our senior stateswomen. We should pause in respect for what it took for Dr. Rudd, her peers, and those before her to forge a life of the mind, be working professionals, and build the careers they now step away from. It wasn't easy for them.

A different observer might have spun another tale of why health literacy matters so much in the age of health equity, but Dr. Rudd would still have been a main character. She was one of the health literacy field's founding voices. Let's congratulate Dr. Rima Rudd on being that original voice that helped launch a field and called us to action. Let's honor her by doing the work and fully integrating heath literacy into the struggle for equitable societies.