Remembering Andrew Pleasant’s career and contributions

2.1.Andrew pre-health literacy

Andrew was the youngest of three brothers raised in Dolores, Colorado, where his parents, Larry and Marilyn, owned and published the local newspaper. Growing up in the newsroom, Andrew learned very early to observe and document people’s lives through stories and photographs, a skill that would define his life and career.

Andrew delighted in sharing the stories of his work as a journalist, though even telling tales of photographing the Super Bowl or following a soon-to-be President on the campaign trail did not bring a smile to his face as vividly as when he would recount “Andy Pleasant’s” first byline – around age five. He reported a sports story from his grade school.

Among other professions, Andrew worked as an archeologist and photojournalist before he found his way to academia and health literacy.

Andrew had an innate curiosity about people and communities that was reflected in his work. His constant and thoughtful questions to understand people’s stories illustrated his keen interest in the human condition. He remained focused on the factors that propelled individual behaviors and choices. One of Andrew’s guiding principles, repeated in many public presentations, was: “people (not ever “patients”!) are the experts in their own lives”. The impact of Andrew’s early experiences on the health literacy professional he became cannot be overstated.

As a health literacy professional, Andrew was active from a local to an international level as a community researcher, university faculty member, and community organization leader. Across diverse settings, Andrew wrote and shared his thoughts formally and informally to generate conversation about topics that aligned with his primary foci such as: health literacy (a term he came to despise as he found it divisive and imprecise); community health; women’s health; the environment; and measurement and metrics. He was generous with his energy and would freely brainstorm, co-write, edit, or otherwise support his peers to develop and share work he perceived to be important.

Because he remained curious and engaged in the disclipline, few realized Andrew quietly and unexpectedly retired to take care of his mother, Marilyn, at home throughout the pandemic until her death in 2021. Andrew continued to participate in meetings on topics interesting and important to him, mentored other scientists and thinkers, and continued to collect data.

2.2.Andrew’s health literacy contributions

In almost 25 years in the field of health literacy and health communications, Andrew published 75 papers, nine chapters, and one book. His most cited works focused on understanding and advancing a model for health literacy, developed in collaboration with Christina Zarcadoolas Ph.D. and David Greer M.D. in the early 2000’s. The New England Journal of Medicine wrote their book, “Advancing Health Literacy: A Framework for Understanding and Action”, was “required reading” for health communication professionals [1].

Aligned with his work on defining (and re-defining) health literacy, Andrew focused on how to assess and evaluate health literacy and labored to build a consensus regarding health literacy measurement [2–5]. He suggested measurement efforts were imprecise and not easy to compare because of disparate health literacy definitions, which were often confused with and confounded by general literacy. Andrew also hoped health literacy measurement would evolve from its initial focus on individual knowledge deficits.

To address these concerns, Andrew participated in the Centre for Literacy of Quebec’s Calgary Institute on Health Literacy Curricula, where the consensus paper, ‘The Calgary Charter on Health Literacy: Rationale and Core Principles for the Development of Health Literacy Curricula’, was developed [6]. The Calgary Charter serves as a guide for the development of health literacy curricula. It also advanced a new definition for health literacy, delineated a set of core principles, and fostered a set of five theory-based, self-report questions to assess individual health literacy [7].

When scanning Andrew’s CV, one consistent theme is his consistent focus on research that connected to people’s experiential and pragmatic concerns regarding: serious health conditions; chronic disease management; integrative health; and community level interventions [8–12]. A practical application involved leading tours through the aisles of the grocery store to improve shopping behaviors; evidence of how, despite his lofty achievements, Andrew was never far from how health literacy affects people’s lives [13].

The reflections below from Christina Zarcadoolas, Frederico Peres, and Catina O’Leary further discuss Andrew Pleasant’s research, personality, demeanor, and influence.

3.1.Meeting Andrew

So, a very tall fellow in his 30s walks into a bar – well actually my graduate class at the Environmental Studies Center at Brown University – in 1997. Mid semester I come to learn through no straight talk from him, that he spent years as a photojournalist working across a wide swath of the Western and Southern United States, covered presidential campaigns, and the war in Bosnia–Herzegovina.

I was intrigued and had to fight off the imposter syndrome in me. Just why was I teaching qualitative research to this fellow? In contrast, I had not driven around wearing a hard hat and bullet proof vest taking in events and every utterance. But over ensuing months and years, Andrew and I took deep dives into people’s lived experience, perceptions, and understandings across a vast range of topics – from the legacy of brownfields, mercury pollution, and environmental justice. I could not have known then – and am still trying to come to terms with – how many handprints Andrew would leave in my life and work.

It would happen like this. In class we would be talking about a reading – say Fadiman’s ‘The Spirit Catches You and You Fall Down’ [14]. The book recounts a heartbreaking, elucidating story of Lia, a seriously ill Cambodian girl living in Mercer CA, and a health care system that was hobbled by profound cultural myopia. And then, somehow, weeks or months later, in his characteristically self-effacing way, Andrew would mention that he met Fadiman during his journalistic sojourns out west a few years back.

Off to the races.

There were a number of grad students in those years who had lots of lived experiences and vastly different interests – an invasive species scientist, a demographer from the local department of health, and Andrew working to integrate interests in ethnography, communications, and equity. In typical Brown fashion, all were confidently testing the margins of accepted wisdom.

3.2.Co-authoring a health literacy book

Fast forward about two years, in 2002, I received a grant from the National Library of Medicine (NLM) to write a book that would contribute to the field of health literacy. I set out to bring thinking from a number of disciplines to reframe how we saw patients and the public. Both Andrew and David Greer M.D., former head of Brown’s Medical School, joined me to write, each of us having a “Let’s see where this takes us” attitude.

We were eager to start talking about the things we loved and were so curious about. Our interests included: historically how have experts in science and medicine perceived the public? What shifts are taking place in how the public perceives experts? What individual, cultural, social and political forces are at play in the public’s perceptions and engagement with health experts and information?

We knew that we could not rely on just our own thinking, so we were always reading, talking to others who were burrowing in similar holes, and all the time wondering if readers would dismiss it (and us) because what we were saying was a bit too inconvenient.

We would gather in the old Environmental Studies living room, situated conveniently across from Brown’s Medical School buildings. The room featured worn-out couches, glass fronted book cases with slightly yellowing zoology texts, original 1970’s Earth Day reports, mingled along with current lead poisoning data maps for Providence and student theses. Someone brought coffee and we would go at it. First the mundane, but then soon, invariably the conversation would change. Andrew had just been reading Freire or Hymes. Honest, provocative questions – why is the field so focused on reading? What about this theory? And always, questioning, if we write this will anyone relate, believe us?

It was not all sublime and heady. We were often in a maze. We were outsiders in the field of health literacy, which was at the time was mostly the purview of physicians talking about what their patients did not understand. Would these folks want to read about discourse theory, media literacy, or class oppression? It was the revered David Greer who brought his wise “small town doctoring” to what ailed us. We had to honestly interrogate our thinking and writing. When one of us would spin out of control, taking theory a bit too far, it was David’s mantra to bring us back to reality. “Think horses, not zebras”, he said.

For readers trained as physicians, you likely recognize the metaphor used in differential diagnosis training. The eager (and nervous) med student is reviewing a patient’s condition and called on to offer up a diagnosis. Books and egos sometimes prompt students to reach for the exotic instead of the likely condition. In turn, the proctor often prompts: “Think horses, not zebras”. Code to deal with what’s right in front of you.

I think we each believed that the process of writing the health literacy book, focusing on melding what we knew from our respective fields and world views, brought us together completely and powerfully. With Andrew’s passing, but honestly many years ago, I realized that working on that book in the old wood paneled living room with Andrew and David was one of the best experiences of my life.

More than anyone I have met in the field of public health, Andrew knew the great responsibility of passion and work. That you can reach people and change lives. He was always working to do better, which meant to be better, learn better, and teach better. He also had the strength of character and sense of responsibility that kept him focused on the heart of the discipline – and its diverse dimensions, such as field research, travel endless committees, meetings, and reports.

After Brown, Andrew went to Cornell to study communications with strong mentor Bruce Lewenstein Ph.D., followed by a faculty position at Rutgers University. Simultaneously Andrew was already entering the global health stage at the World Health Organization, PEW, Aldo Leopold, the South African Agency for Science and Technology Advancement (SAASTA), the Oswaldo Cruz Foundation (Fiocruz), and the Federal University of Rio de Janeiro (UFRJ). More about Andrew’s international initiatives is provided immediately below.

4.1.Meeting Andrew

In 2006, while visiting the Icahn School of Medicine at Mount Sinai (MSSM) in New York City as a fellow researcher, I was fortunate to be introduced to Christina Zarcadoolas Ph.D., a senior faculty at MSSM Department of Community and Preventive Medicine. Dr, Zarcadoolas recently had published a reference book on health literacy – a field of study new to me and to most of public health researchers in Brazil, my home country. My colleague and friend Luz Claudio, also a faculty member in the same department and director of my fellowship program, introduced me to Dr. Zarcadoolas after recognizing many connections between my studies on environmental risk perception and communication and Chris’ work on an ecological model of health literacy and public understanding.

Our initial meeting at Mount Sinai had a profound impact on my career and life. Over the years, Chris became one of my dearest friends. I started to study many aspects of health literacy as a key concept in public health, and addressed how health literacy could be incorporated into Latin American health policies. And, during that same meeting, in 2006, Chris mentioned that Andrew Pleasant, a former student and a professor at Rutgers, would be a perfect source to discuss the integration of health literacy with the environmental health studies I was conducting in Brazil.

A few days later, Andrew and I were sitting at a steakhouse outside New York’s Penn Station, discussing environmental health and Latin America. I was surprised by his extensive knowledge of regional culture, including many visits to Brazil, Peru, and Argentina. During the dinner, I realized that Andrew knew more about Paulo Freire and his work than most Brazilian academics (an assumption that I confirmed over time).

I recall mentioning a project I coordinated between 2000–2004, in which I developed a fotonovela (photographic soap opera, a popular folk literature in many Latin American countries) to highlight risks associated with pesticide use in rural Brazil, using some “Theater of the Oppressed” techniques. I was about to explain what the Theater of the Oppressed was, when Andrew said: “Yep, I took a few workshops with Augusto Boal (the Brazilian dramaturg who created the Theater of the Oppressed), it is a great approach”.

That was Andrew.

4.2.Andrew’s international influence

Andrew’s applied understanding of Boal’s ideas later became the foundation of an innovative Peruvian initiative. The Arts for Behavioral Changes (ABC) Program, the Theater of the Oppressed was based on storytelling arts (theater, music, dance …), which promoted health literacy about healthy hygiene practices in Lima’s low-income communities. The Theater of the Oppressed was an integral component of the ABC program, which impacted healthier hygiene practices contextualized within Lima’s community settings.

Overall, Andrew had a deep and genuine interest in foreign cultures and people, and became an outstanding academic on the international stage, with contributions to research groups in India, Australia, South Africa, Peru, and Brazil. His contributions to advancing health literacy have been significant, helping to raise awareness about the importance of health literacy to improve health outcomes, reduce health disparities, and promote health, individually and collectively.

For 20 years Andrew worked energentically in different parts of the globe, providing advice to international organizations, such as the World Health Organization, and to associations, such as the International Union for Health Promotion and Education (IUHPE), the International Health Literacy Association (IHLA) and the Public Communication of Science and Technology Network (PCST). His initiatives strived to: develop health literacy policies and programs; conduct research on health literacy; yield positive impacts on health outcomes; develop strategies to evaluate health literacy in different settings, such as communities, healthcare facilities and organizations; and foster evidence-based practices to incorporate health literacy into public health policies and programs.

4.3.Brazilian hang gliding as a mantra

Through his career, I had the honor and pleasure to host Andrew several times in Rio de Janeiro. During Andrew’s first visit, he tried to convince me to do a hang glider flight with him, telling me a true carioca (people from Rio de Janeiro) had to try it at least once in a lifetime. I told him I was born in Niterói (a city next to Rio, crossing the Guanabara Bay), so his suggestion did not apply to me!

So, Andrew flew by himself (two or three times, I think). After one voyage, he nudged me a second time and said: “this is like doing research, you just need to walk a few steps and suddenly it is happening, your feet are off the floor, and you are flying”. The quotation could not be more representative of Andrew’s thinking on work and life: one step at a time, take a breath, move forward and it will happen.

Following Andrew’s mantra, we had memorable times working together in Brazil and in the United States. We implemented a training program for Brazilian public health officers involved with the National Environmental Surveillance Program, in which we combined health literacy and risk communication frameworks. Andrew also served as advisor to a number of research projects I coordinated that identifed opportunities to improve health literacy among rural workers exposed to pesticides in different parts of Brazil. We even enticed Chris Zarcadoolas to come to Brazil and visit some of the project’s sites. The latter was an unforgettable experience.

4.4.Connecting people

Perhaps Andrew’s past as a photojournalist prepared him to seek an optimal framing of countries, cultures, and people. Andrew always envisioned the best angle – the most appropriate places and people. In this way, he was able to articulate academic and popular knowledge, which contributed unprecedented approaches to improve health and science communication. He knew how to connect people, including co-workers from my own institution, the Oswaldo Cruz Foundation (Fiocruz). For example, in 2007 Andrew introduced me to Luisa Massarani, a leading internationally recognized researcher in science communication, who became a close friend and collaborator in different projects, such as creating a graduate course on scientific communication at Fiocruz.

Most of all, Andrew was one of the most generous people I have ever met. Through Andrew’s vast network of international collaborators, he tried to bring people together, particularly around projects that articulated science and communication, in academic and non-academic settings.

In 2016, during the International Union for Health Promotion and Education (IUHPE) Conference in Curitiba, Brazil, Andrew introduced me to some key actors in the field of global health literacy who were attending the meeting. He left the impression with them that I was a key figure in the country and someone to be considered for regional projects.

Soon afterwards, I was invited to attend the Global Working Group on Health Literacy (IUHPE GWG-HL) meeting and, since then, I have been collaborating with the latter group, expanding my own international network, and opening new opportunities for joint academic projects and institutional partnerships. All this was due to Andrew’s generosity and ability to see the best in people.

Although Andrew and I collaborated continuously for about 15 years, we only had the time to publish one paper together, sadly one of his last published articles. ‘Scoping Health Literacy in Latin America’ was written by a group of researchers from Latin America, the U.S. and Europe, with whom Andrew had been working [15]. During the process of writing, I was able to witness Andrew’s sharp insights, challenging the other authors to take a more critical perspective with a constructive demeanor that prompted further engagement.

That too was Andrew.

On another paper about maternal and child health promotion in Africa, Andrew’s insights and insightful comments contributed to reframing the manuscript. He successfully challenged the authors to shift from “selling” health literacy as a universal solution to all humankind problems to highlighting strategies for competencies and skills development, allowing a specific population group to benefit from health promotion initiatives. Some other unpublished material (such as an Op-Ed paper on how Brazil, India and the United States failed to prevent Covid-19 mortality, as well as a survey aiming to take a quick snapshot of health literacy around the world) evidenced some of Andrew’s last thoughts and contributions.

5.1.Meeting Andrew

I met Andrew much later than Chris or Fred, in 2014, when Andrew was Senior Director for Health Literacy and Research at Canyon Ranch Institute (CRI) in Tucson, Arizona. Of course, I knew Andrew’s work, but we did not meet until the Health Literacy Media (HLM) Board selected him to receive the organization’s highest honor, the Ceci and Len Doak Award.

When the HLM Board selects an annual recipient, it’s my responsibility to share the great news with the honoree and confirm their willingness to accept the award. Typically, this task is relatively easy and, frankly, a lot of fun.

Yet, when Andrew was selected it was more complex. Andrew, as I learned was typical, was traveling internationally, buried in a slew of papers, and completely unreachable. After multiple attempts to connect, I finally was able to schedule a 10-min window to speak with him on a Sunday afternoon. The mutual, initial awkwardness was palpable. Andrew was busy, slightly annoyed at having to take time from his Sunday to speak to me, and had no clue what a random person of a somewhat competing, Missouri-based health literacy organization could possibly want to discuss so urgently!

Once I was able to get out my reason for calling and share the news, Andrew graciously agreed to accept the award in Missouri (after expressing a bit of shock) and showed a humbleness and humility that I came to know as central to his personality. Although he was a prolific writer, published extensively, and was considered an international health literacy leader and visionary, Andrew still thought of himself as “just a tall guy from Colorado”.

5.2.Our collaborations

Over the years, we developed a close personal relationship and worked collaboratively in many contexts while he was at CRI and moving forward, as he later joined HLM. For about a decade, I did not write a word about health literacy that was shared publicly without his perspective. We sat together on the National Academies of Sciences, Engineering, and Medicine Roundtable on Health Literacy for several years.

At the Roundtable, Andrew encouraged peers to think more deeply about foundational concepts in the field, such as “what does health literacy even mean,” “how do we move from sick care to health care?” “where’s the community voice?” and “why can’t we talk about people, not patients?” He participated actively in the development of important Roundtable discussion and perspective pieces, such as the frequently cited “Considerations for a new definition of health literacy” and “Strategies to enhance numeracy skills" [16,17].

Andrew joined HLM in 2017 as Senior Director for Health Literacy Evaluation. At HLM, Andrew led the establishment of HLM’s Clearly Communicating Clinical Trials (C³T) program that supports communication of clinical trial information in plain, clear language to participants before, during, and after trial participation. The development of this innovative program fostered the most significant growth in HLM’s history and directly impacted HLM’s sustainability.

The Clinical Trials program required the development of a robust audience testing program that continues to support hundreds of 1:1 interviews and focus group sessions with community members who are living with an array of health conditions. The interviews and focus groups provide a constant reminder of the obligation to focus on what is most important to people with direct, lived experiences.

Andrew reminded us frequently that we need to ask people early and often if we are getting it right and, when we are not, ask them how to do better. It was a labor of love for Andrew to communicate complex health and scientific information to people most in need of understanding information within the context of their lives. Accompanying his deep relationships and many written contributions to the field, Andrew’s legacy is his passion to appreciate, listen, and learn.