State of health literacy in higher education (M.H.S.A & M.H.A programs) in the U.S

Only 12% of the American adults are considered proficiently health literate. Limited health literacy is known to be associated with avoidance of seeking access to healthcare and poor adherence of healthcare instructions. While majority of the research of has been focused on the health literacy level of patients, nurses, and the physicians, few studies have focused on hospital CEOs. While hospital CEOs come with diverse educational backgrounds, Master of Health Services Administration (M.H.S.A) and Master of Health Administration (M.H.A) are known as programs that "groom" future leaders in healthcare. This is why this paper examines if M.H.S.A and M.H.A programs put much emphasis on health literacy. Descriptive analysis was done to examine top 5 ranked M.H.S.A and M.H.A programs’ vision, mission statements, and competency models and whether there was any mention of the word ‘health literacy.’ The result shows that none of the selected programs’ vision, mission statements, and competency models mentioned anything in regards to ‘health literacy.’ If programs fail to stress the importance of health literacy, future hospital CEOs will lack the knowledge regarding the importance of health literacy.


Introduction
According to the Centers for Disease Control and Prevention, health literacy refers to the social and cognitive capability that can assist the ability of an individual to understand, gain access to, and use health information to sustain and even enhance the level of health of that certain individual (CDC 2016). At a glance, proficient level of health literacy allows people to provide health information to physicians, understand how the healthcare system works, and engage in managing chronic-disease and self-care (HHS 2000).
On the other hand, limited health literacy is known to be associated with limited access, poor adherence and understanding of healthcare, and racial, ethnic, and other disparities as well (Lie et al. 2012). In other words, low Kim D, Standish M MedEdPublish https://doi.org/10.15694/mep.2019.000031.1 Page | 2 level of health literacy can result in negative health outcomes for the patients who step into the hospital. Unfortunately, the data indicates that the majority of the American population does not possess the proficient level of health literacy. Only 12% of the American adults are considered as proficiently health literate and 35% of the same population, which accounts for 77 million people, have either basic or below basic level of health literacy (HHS 2003).
Due to these staggering numbers, many researchers have come out with different methods that physicians can use in order for them to examine patients' level of health literacy. Studies resulted in methods such as: teach-back method, the Newest Vital Sign (NVS), Single Item Literacy Screener (SILS), photonovela, oral and printed communication (Osborne et al. 2007, Morris et al 2006, Nimmon 2007, Weiss 2007, Pfizer 2007. These methods, however, are specifically geared towards what physicians can do in order for them to assess patients' health literacy levels. Not many, if any, research has been done in regards to the Chief Executive Officers (CEO)' levels of health literacy.
Hospital CEO is the one that makes many of the important decisions as the faces of a hospital (Khaliq et al 2007). The impact that the CEO can have on a hospital cannot be emphasized enough. Hospital CEOs must be adept at dealing diverse issues with varied knowledge base (Leibert & Leaming 2010). They also need to be the resident expert in finance, personnel administration, purchasing, administration, public relations, and government affairs as well as a number of other key hospital functions (Leibert & Leaming 2010). Diverse hospital CEOs have diverse educational background, such as Bachelor's degree, MBA, PhD, and MD (Khaliq & Walston, 2012

Background
The Theory of Expert Leadership suggests that, in addition to a manager's basic leadership capabilities, expert leaders should also possess core knowledge of their business, and technical expertise that has been developed through industry experience (Goodall, 2012). While a relatively new theory for leadership, this theory aligns with a similar approach to hospital and health system leadership in which individuals with clinical backgrounds are viewed as providing additional value to top management roles (Angood, 2011). In 2011, a cross-sectional study reported on whether hospitals led by physicians had higher hospital performance, finding that there was a strong association between the top 100 U.S. hospitals rankings, and CEOs possessing a clinical background (Goodall, 2011). While this study did not dig deeper into why this might be the case, Angood (2011) went further to discuss why clinical knowledge in these roles may be beneficial to hospital and health system performance, suggesting that a physician's knowledge of clinical care models and patient care can play an important role in connecting the gap between medicine and management. This same article suggests that the medical expertise of physician-leaders also helps connect upper level management to the clinical workforce in a way that portrays a "common language" among both parties (Angood, 2011). This is all said keeping in mind that not all physicians are prepared to be leaders. The Accreditation Council for Graduate Medical Education does not include leadership as a core competency for which physician residents should be assessed on (The Milestones Guidebook, 2016). While a physician's health literacy seems to be advantageous to hospital and health system performance at the C-Suite level, there are still concerns about knowledge development in leadership and healthcare management, two skills commonly assessed across graduate students preparing for careers in health administration and healthcare management (CAHME Self Study Handbook, 2017).
While leadership is emphasized as one of the core competency groups in the profession of healthcare management, health literacy is not included as one of the four broad areas that graduate students should be assessed in as a requirement of accreditation by the Commission on the Accreditation of Healthcare Management Education (CAHME Self-Study Handbook, 2017). The lack of leadership and clinical competencies in each of these graduate training guidelines suggests that there is a gap between the competencies required of medical and healthcare administration graduate programs, contributing to the absence of a "common language" between each of these fields. More so, this gap in professions reveals a lack of formal training in at least one of these competencies when individuals are selected for leadership roles in hospitals and health systems.
In a synthesis of competency models currently being used by CAHME-accredited programs, health literacy did not emerge as a common competency across the identified models (Standish, 2018). In an effort to more closely review competency models in health administration programs for the health literacy competency, this study aims to take a closer look at the competency models across top ranking Master of Health Service Administration (M.H.S.A) and Master of Health Administration (M.H.A) programs to see if this competency is being assessed across graduate students. If clinical competence is becoming increasingly indicative of leadership performance, assessing the health literacy of students in graduate healthcare management education programs will be vital to the success of the profession.

Discussion
With only 12% of the American adults being considered as proficiently health literate ad 35% of that very population, which accounts for 77 million people, having either basic or below basic level of health literacy (HHS 2003), the importance of health literacy cannot be emphasized enough. This is the case because limited health literacy is known to be associated with limited healthcare access, poor adherence and understanding of healthcare, and racial, ethnic, and other disparities as well (Lie et al. 2012). While a lot of research has been conducted in regard to the patients' level of health literacy, not many, if any, research have been conducted in regard to the CEO's level of health literacy. Many of the CEOs have diverse educational backgrounds, but M.H.S.A and M.H.A programs are generally regarded as programs that educate students to become healthcare leaders and CEOs, making this study an important step towards putting emphasis on health literacy in student learning. After extensive descriptive analysis through vision, mission statement, and competency models of each of the 5 programs, it was found that none of these programs had any mention of the word 'health literacy.' The biggest strength of this paper is the fact that this type of study has never been conducted before. None of the existing literatures have looked to examine whether vision, mission statements, and competency models of M.H.S.A and M.H.A. programs actually include the word 'health literacy.' The importance of this study is that it provides segue into next, potential research studies where entire 70 M.H.S.A and M.H.A programs will be examined to see if any of the programs include or put much emphasis on heath literacy. Statistical analysis such as Natural Language Processing (NLP) can also be used to examine how well or poorly these programs' vision, mission statements, and competency models incorporate health literacy. Limitations of this study include the smaller sample of programs that were reviewed. Future studies should look to further review the competency models of other programs, or the M.H.S.A and M.H.A programs themselves should look to their models to evaluate whether or not they are assessing health literacy.

Implication
This paper argues the importance of assessing health literacy in professional healthcare management and administration programs. While not all programs were assessed as a part of this work, this paper serves as a call to all programs to begin assessing and accounting for health literacy skills in their students.
Competence in health literacy at the healthcare management level is important for having a better understanding of clinician knowledge, patient care, and personal health. If organizations are pushing for health care literacy in their patients, perhaps it is equally important to encourage that hospital and health systems require health literacy in their leaders to ensure they are role models for the communities they serve.
Assessing health literacy in M.H.A and M.H.S.A programs could be one step towards bridging the language gap between healthcare managers and healthcare clinicians and making sure that hospitals and health systems are practicing what they preach as health literacy becomes an increasingly important skill for population health outcomes.

Take Home Messages
Only 12% of the American adults are considered as proficiently health literate and 35% of the same population, which accounts for 77 million people, have either basic or below basic level of health literacy. M.H.S.A and M.H.A programs, which are programs that "groom future healthcare leaders" do not put much emphasis on health literacy. Competence in health literacy at the healthcare management level is important for having a better understanding of clinician knowledge, patient care, and personal health. These programs need to do a better job of teaching and putting emphasis on health literacy, in order for future healthcare leaders to be more aware of health literacy and its importance.