Ten years after the end of the Gulf War, questions continue to be raised about the health of U.S. service personnel who fought in that war. A primary concern is whether Gulf War veterans are receiving effective treatments for their health problems. Section 105 of the Veterans Program Enhancement Act of 1998 mandates that the Department of Veterans Affairs (VA) ask the Institute of Medicine (IOM) to convene a committee that would identify a method for assessing treatment effectiveness and describe already-validated treatments for Gulf War veterans' health problems, including the problem of medically unexplained symptoms. The specific charge to the committee is to (1) identify and describe approaches for assessing treatment effectiveness; (2) identify illnesses and conditions among veterans of the Gulf War, using data obtained from the VA and the Department of Defense (DoD) Gulf War Registries, as well as information in published articles; and (3) for these identified conditions and illnesses, identify validated models of treatment (to the extent that such treatments exist), or identify new approaches, theories, or research on the management of patients with these conditions if validated treatment models are not available.

Health literacy is the degree to which individuals can obtain, process, and understand the basic health information and services they need to make appropriate health decisions. Nearly half of all American adults - 90 million people - have inadequate health literacy to navigate the health care system. Implications of Health Literacy for Public Health is the summary of a workshop convened by the Institute of Medicine Roundtable on Health Literacy in November 2013 that focused on the implications of health literacy for the mission and essential services of public health. The workshop featured the presentation of a commissioned paper on health literacy activities under way in public health organizations. Other presentations examined the implications of health literacy for the mission and essential services of public health, for example, community health and safety, disease prevention, disaster management, or health communication. This report includes the commissioned paper and summaries of the workshop presentations.

There is great enthusiasm over the use of emerging interactive health information technologies-often referred to as eHealth-and the potential these technologies have to improve the quality, capacity, and efficiency of the health care system. However, many doctors, advocacy groups, policy makers and consumers are concerned that electronic health systems might help individuals and communities with greater resources while leaving behind those with limited access to technology. In order to address this problem, the Institute of Medicine's Roundtable on Health Literacy held a workshop to explore the current status of communication technology, the challenges for its use in populations with low health literacy, and the strategies for increasing the benefit of these technologies for populations with low health literacy. The summary of the workshop, "Health Literacy, eHealth, and Communication: Putting the Consumer First," includes participants' comments on these issues. Table of Contents Front Matter 1 Introduction 2 Overview of Issues 3 Outcomes and Challenges of eHealth Approaches: Panel 1 4 Outcomes and Challenges of eHealth Approaches: Panel 2 5 Emerging Tools and Strategies 6 Concluding Discussion References Appendix A: Glossary of Terms Appendix B: Workshop Agenda Appendix C: Workshop Speaker Biosketches

The Roundtable on Health Literacy brings together leaders from academia, industry, government, foundations, and associations and representatives of patient and consumer interests who work to improve health literacy. To achieve its mission, the roundtable discusses challenges facing health literacy practice and research and identifies approaches to promote health literacy through mechanisms and partnerships in both the public and private sectors. To explore the aspects of health literacy that impact the ability of patients to understand and follow discharge instructions and to learn from examples of how discharge instructions can be written to improve patient understanding of-and hence compliance with-discharge instructions, the Roundtable on Health Literacy held a public workshop. The workshop featured presentations and discussions that examined the implications of health literacy for discharge instructions for both ambulatory and inpatient facilities. Facilitating Patient Understanding of Discharge Instructions summarizes the presentations and discussions of the workshop. This report gives an overview of the impact of discharge instructions on outcomes, and discusses the specifics of inpatient discharge summaries and outpatient after-visit summaries. The report also contains case studies illustrating different approaches to improving discharge instructions. Table of Contents Front Matter 1 Introduction 2 Overview of Issues Involved in Creating Better Discharge Instructions 3 Inpatient Discharge Summaries 4 Outpatient After-Visit Summaries 5 Approaches to Developing Improved Discharge Instructions 6 Reflections on the Workshop References Appendix A: Workshop Agenda Appendix B: Biographical Sketches of Workshop Speakers

Bioterrorism, drug-resistant disease, transmission of disease by global travel . . . there's no shortage of challenges facing America's public health officials. Men and women preparing to enter the field require state-of-the-art training to meet these increasing threats to the public health. But are the programs they rely on provide the high caliber professional training they require? Who Will Keep the Public Healthy? provides an overview of the past, present, and future of public health education, assessing its readiness to provide the training and education needed to prepare men and women to face 21st century challenges. Advocating an ecological approach to public health, the Institute of Medicine examines the role of public health schools and degree-granting programs, medical schools, nursing schools, and government agencies, as well as other institutions that foster public health education and leadership. Specific recommendations address the content of public health education, qualifications for faculty, availability of supervised practice, opportunities for cross-disciplinary research and education, cooperation with government agencies, and government funding for education. Eight areas of critical importance to public health education in the 21st century are examined in depth: informatics, genomics, communication, cultural competence, community-based participatory research, global health, policy and law, and public health ethics. The book also includes a discussion of the policy implications of its ecological framework. Table of Contents Front Matter Abstract Summary 1. Introduction 2. History and Current Status of Public Health Education in the United States 3. The Future of Public Health Education 4. Future Role of Schools of Public Health in Educating Public Health Professionals for the 21st Century 5. The Need for Public Health Education in Other Programs and Schools 6. Public Health Agencies: Their Roles in Educating Public Health Professionals Conclusion References Appendix A: School of Public Health Catalogue Abstraction Appendix B: School of Public Health Survey Instrument Appendix C: Organizational Input Appendix D: Education of Public Health Professionals in the 21st Century Appendix E: Occupational Classifications Appendix F: A Collection of Competency Sets Appendix G: Public Meeting Appendix H: Committee Biographies Index

Approximately 80 million adults in the United States have low health literacy - an individual's ability to obtain, process, and understand basic health information. Low health literacy creates difficulties in communicating with clinicians, poses barriers in managing chronic illness, lessens the likelihood of receiving preventive care, heightens the possibility of experiencing serious medication errors, increased risk of hospitalization, and results in poorer quality of life. It is important for health care organizations to develop strategies that can improve their health literacy, yet organizations often find it difficult to determine exactly what it means to be health literate. How Can Health Care Organizations Become More Health Literate?: Workshop defines a health literate health care organization as "an organization that makes it easier for people to navigate, understand, and use information and services to take care of their health." In November 2011, the IOM Roundtable on Health Literacy held a workshop to discuss the growing recognition that health literacy depends not only on individual skills and abilities but also on the demands and complexities of the health care system. How Can Health Care Organizations Become More Health Literate?: Workshop summarizes the workshop. Table of Contents Front Matter 1 Introduction 2 Attributes of a Health Literate Health Care Organization 3 Reaction Panel 1 4 Reaction Panel 2 5 Reaction Panel 3 6 Reaction Panel 4 7 Reflections on Lessons Learned Appendix A: The Other Side of the Coin: Attributes of a Health Literate Health Care Organization Appendix B: Agenda Appendix C: Speaker Biographical Sketches

Genomics is the study of the entire human genome. Genomics explores not only the actions of single genes, but also the interactions of multiple genes with each other and with the environment. As a result, genomics has great potential for improving the health of the public. However, realizing the benefits of genomics requires a systematic evaluation of its potential contributions and an understanding of the information necessary to facilitate the translation of research findings into public health strategies. In October 2004, the Institute of Medicine convened a workshop to discuss major scientific and policy issues related to genomics and public health, examine major supports for and challenges to the translation of genetic research into population health benefits, and suggest approaches for the integration of genomic information into strategies for promoting health and preventing disease. Implications of Genomics for Public Health summarizes the discussions and presentations from this workshop. Table of Contents Front Matter 1 Introduction 2 Workshop Presentations 3 Priorities Appendix A: Glossary Appendix B: Biosketches Appendix C: Workshop Agenda

Organizational Change to Improve Health Literacy is the summary of a workshop convened in April 2013 by the Institute of Medicine Board on Population Health and Public Health Practice Roundtable on Health Literacy. As a follow up to the 2012 discussion paper Ten Attributes of a Health Literate Health Care Organization, participants met to examine what is known about implementation of the attributes of a health literate health care organization and to create a network of health literacy implementers who can share information about health literacy innovations and problem solving. This report discusses implementation approaches and shares tools that could be used in implementing specific literacy strategies. Although health literacy is commonly defined as an individual trait, there is a growing appreciation that health literacy does not depend on the skills of individuals alone. Health literacy is the product of the interaction between individuals' capacities and the health literacy-related demands and complexities of the health care system. System changes are needed to better align health care demands with the public's skills and abilities. Organizational Change to Improve Health Literacy focuses on changes that could be made to achieve this goal. Table of Contents Front Matter 1 Introduction 2 Panel 1: Implementing Attributes of a Health Literate Organization 3 Panel 2: Implementing Attributes of a Health Literate Organization 4 Panel 3: Implementing Attributes of a Health Literate Organization 5 Concluding Panel Appendix A: Workshop Agenda Appendix B: Speaker Biosketches

The roots of health literacy can be traced back to the national literacy movement in India under Gandhi and to aid groups working in Africa to promote education and health. The term health literacy was first used in 1974 and described as "health education meeting minimal standards for all school grade levels". From that first use the definition of health literacy evolved during the next 30 years with official definitions promulgated by government agencies and large programs. Despite differences among these definitions, they all hold in common the idea that health literacy involves the need for people to understand information that helps them maintain good health. Although the United States produces a majority of the research on health literacy, Europe has strong multinational programs as well as research efforts, and health literacy experts in developing countries have created successful programs implemented on a community level. Given these distinct strengths of efforts worldwide, there are many opportunities for collaboration. International collaboration can harness the United States' research power, Europe's multilingual and multinational experience, and developing nations' community-based programs to create robust programs and research that reach people-not based on language or nationality but on need and value. A workshop on international health literacy efforts that feature presentations and discussion about health literacy interventions from various countries as well as other topics related to international health literacy was held as the basis for this report. Health Literacy: Improving Health, Health Systems, and Health Policy Around the World summarizes the findings and discussions at the workshop. Table of Contents Front Matter 1 Introduction 2 Welcome 3 Health Literacy Perspectives 4 Health Literacy Policy and Programs 5 Innovations in Health Literacy 6 Concluding Panel Appendix A: Commissioned Paper: Health Literacy Around the World: Part 1: Health Literacy Efforts Outside of the United States Appendix B: Speaker Biosketches

Health literacy-the ability for individuals to obtain, process, and understand basic health information and services to facilitate appropriate health decisions-is increasingly recognized as an important facet of health care and health outcomes. Although research on health literacy has grown tremendously in the past decade, there is no widely agreed-upon framework for health literacy as a determinant of health outcomes. Most instruments focus on assessing an individual's health literacy, yet the scope of health literacy reaches far beyond an individual's skills and abilities. Health literacy occurs in the context of the health care system, and therefore measures of health literacy must also assess the demands and complexities of the health care systems with which patients interact. For example, measures are needed to determine how well the system has been organized so that it can be navigated by individuals with different levels of health literacy and how well health organizations are doing at making health information understandable and actionable. To examine what is known about measures of health literacy, the Institute of Medicine convened a workshop. The workshop, summarized in this volume, reviews the current status of measures of health literacy, including those used in the health care setting; discusses possible surrogate measures that might be used to assess health literacy; and explores ways in which health literacy measures can be used to assess patient-centered approaches to care. Table of Contents Front Matter 1 Introduction 2 An Overview of Measures of Health Literacy 3 Approaches to Assessing Health Literacy 4 Population-Based Approaches to Assessing Health Literacy 5 Measuring Health System Responses to Health Literacy 6 Measuring Health Literacy: What? So What? Now What? References Appendix A: Workshop Agenda Appendix B: Workshop Speaker Biosketches Appendix C: CAHPS(r) Clinician and Group Survey: Health Literacy Item Set

Until fairly recently, genetic information was used primarily in the diagnosis of relatively rare genetic diseases, such as cystic fibrosis and Huntington's Disease, but a transformation in the use of genetic and genomic information is underway. While many predictions have been made that genomics will transform medicine, to date few of these promising discoveries have resulted in actual applications in medicine and health. The Institute of Medicine's Roundtable on Translating Genomic-Based Research for Health, established in 2007, held its first workshop to address the following questions: 1. Are there different pathways by which new scientific findings move from the research setting into health care? 2. If so, what are the implications of those different pathways for genomics? 3. What can we learn from the translation of other new technologies as we seek to understand the translation of genome science into health care? Information obtained from the workshop was then used to further discussion and exploration of the answers to these questions. This book summarizes speaker presentations and discussions. Any conclusions reported should not be construed as reflecting a group consensus; rather they are the statements and opinions of presenters and participants.

Medications are an important component of health care, but each year their misuse results in over a million adverse drug events that lead to office and emergency room visits as well as hospitalizations and, in some cases, death. As a patient's most tangible source of information about what drug has been prescribed and how that drug is to be taken, the label on a container of prescription medication is a crucial line of defense against such medication safety problems, yet almost half of all patients misunderstand label instructions about how to take their medicines. Standardizing Medication Labels: Confusing Patients Less is the summary of a workshop, held in Washington, D.C. on October 12, 2007, that was organized to examine what is known about how medication container labeling affects patient safety and to discuss approaches to addressing identified problems. Table of Contents Front Matter 1 Introduction 2 Presentations 3 Federal Agency Reaction to Prescription Use Instruction Standardization 4 Reaction from the Pharmacy Field to Prescription Use Instruction Standardization 5 Other Stakeholder Reaction to Prescription Use Instruction Standardization: Physicians and Patients 6 Other Stakeholder Reaction to Prescription Use Instruction Standardization: Educators of Pharmacists and Physicians 7 What Would It Take to Move Toward Prescription Use Instruction Standardization? 8 Closing Remarks References Appendix A: Workshop Agenda Appendix B: Biosketches of the Workshop Speakers Appendix C: ACP White Paper

Over the past century, we have made great strides in reducing rates of disease and enhancing people's general health. Public health measures such as sanitation, improved hygiene, and vaccines; reduced hazards in the workplace; new drugs and clinical procedures; and, more recently, a growing understanding of the human genome have each played a role in extending the duration and raising the quality of human life. But research conducted over the past few decades shows us that this progress, much of which was based on investigating one causative factor at a time&#8212often, through a single discipline or by a narrow range of practitioners&#8212can only go so far. Genes, Behavior, and the Social Environment examines a number of well-described gene-environment interactions, reviews the state of the science in researching such interactions, and recommends priorities not only for research itself but also for its workforce, resource, and infrastructural needs. Table of Contents Front Matter Summary 1 Introduction 2 The Impact of Social and Cultural Environment on Health 3 Genetics and Health 4 Genetic, Environmental, and Personality Determinants of Health Risk Behaviors 5 Sex/Gender, Race/Ethnicity, and Health 6 Embedded Relationships Among Social, Behavioral, and Genetic Factors 7 Animal Models 8 Study Design and Analysis for Assessment of Interactions 9 Infrastructure 10 Ethical, Legal, and Social Implications 11 Conclusion Appendix A Methodology: Data Collection and Analysis Appendix B Recommendation from the National Academy of Sciences Report, Facilitating Interdisciplinary Research Appendix C Social Environmental and Genetic Influences on Obesity and Obesity-Promoting Behaviors Appendix D The Interaction of Social, Behavioral, and Genetic Factors in Sickle-Cell Disease Appendix E Modern Epidemiologic Approaches to Interaction: Applications to the Study of Genetic Interactions Appendix F Acronyms Appendix G Biographical Sketches Index

Public health efforts have resulted in tremendous improvements in the health of individuals and communities. The foundation for effective public health interventions rests, in large part, on a well-trained workforce. Unfortunately there is a major shortage of public health physicians who are prepared to face today's public health challenges. Training Physicians for Public Health Careers focuses on the critical roles that physicians play in maintaining and strengthening the public health system, identifies what these physicians need to know to engage in effective public health actions, explores the kinds of training programs that can be used to prepare physicians for public health roles, and examines how these training programs can be funded. Medical schools, schools of public health, health care and public health care professionals, medical students and students of public health will find this of special interest. Table of Contents Front Matter Summary 1 Fundamentals 2 Physicians in Public Health 3 Physician Training 4 Funding 5 Conclusion Appendix A: Recommendations from The Future of the Public's Health in the 21st Century Appendix B: Glossary and Acronyms Appendix C: Agendas of Open Session Committee Meetings Appendix D: Committee Biographies