the health literacy framework. while these potential intervention points include interactions such as those of individuals and the education systems that they are engaged with, their health systems, and societal factors as they relate to health literacy, these points are not components of a causal model. the three potential intervention points are culture and society, the health system, and the education system. health outcomes and costs are the products of the health literacy developed during diversity of exposure to these three potential intervention points. referring to shared ideas, meanings, and values that influence an individual's beliefs and attitudes, cultural and societal influences are a significant intervention point for health literacy development. as interactions with healthcare systems often first occur at the family level, deeply rooted beliefs and values can shape the significance of the experience. included components that reflect the development of health literacy both culturally and societally are native language, socioeconomic status, gender, race, and ethnicity, as well as mass media exposure. these are pathways to understanding american life paralleling conquests for a health-literate america. the health system is an intervention point in the health literacy framework. for the purposes of this framework, health literacy refers to an individual's interaction with people performing health-related activities in settings such as hospitals, clinics, physician's offices, home health care, public health agencies, and insurers. in the united states, the education system consists of k–12 curricula. in addition to this standard educational setting, adult education programs are also environments in which individuals can develop traditional literacy skills founded in comprehension and real-world application of knowledge via reading and writing. tools for educational development provided by these systems impact an individual's capacity to obtain specific knowledge regarding health. reflecting components of traditional literacy such as cultural and conceptual knowledge, oral literacy (listening and speaking,) print literacy (reading and writing,) and numeracy, education systems are also potential intervention points for health literacy development. development of a health literacy program a successful health literacy program will have many goals that all work together to improve health literacy. many people assume these goals should communicate health information to the general public; however, in order to be successful, the goals should not only communicate with people but also take into account social and environmental factors that influence lifestyle choices. a good example of this is the movement to end smoking. when a health literacy program is put into place where only the negative side effects of smoking are told to the general public it is doomed to fail. however, when there is a larger program put in – one that includes strategies outlining how to quit smoking, raises tobacco prices, reduces access to tobacco by minors, and reflects the social unacceptability of smoking – it will be much more effective. the u.s. department of health and human services suggests a national action plan to implement a comprehensive health literacy program. they include seven goals: develop and disseminate health and safety information that is accurate, accessible, and actionable promote changes in the health care system that improve health information, communication, informed decision making, and access to health services incorporate accurate, standards-based, and developmentally appropriate health and science information and curricula in child care and education through the university level support and expand local efforts to provide adult education, english language instruction, and culturally and linguistically appropriate health information services in the community build partnerships, develop guidance, and change policies increase basic research and the development, implementation, and evaluation of practices and interventions to improve health literacy increase the dissemination and use of evidence-based health literacy practices and interventions these goals should be taken into account when implementing a health literacy program. there are also goals for the outcomes of a health literacy program. health-related goals: promoting and protect health and prevent disease understand, interpret, and analyze health information apply health information over a variety of life events and situations navigate the healthcare system actively participate in encounters with healthcare professionals and workers understand and give consent understand and advocate for rights in the creation of a program aimed to improve health literacy, it is also important to ensure that all parties involved in health contexts are on the same page. to do this, programs may choose to include the training of case managers, health advocates, and even doctors and nurses. due to the common overestimations of health literacy levels of patients, the education of health literacy topics and training in the identification of low health literacy in patients may be able to create significant positive change in the understanding of health messages. the health belief model has been used in the training of health professionals in order to share insight on the knowledge that it has been shown to most likely change health perceptions and behaviors of their patients. the use of the health belief model can provide basis for which patient health literacy may grow. the training of health workers may be seen as a "work around intervention" but is still a viable option and opportunity for mediating the negative outcomes of low health literacy. effective health literacy programs are created with cultural competency, and individuals working within health institutions can support individuals with low health literacy by being culturally competent themselves. in working to improve the health literacy of individuals, a multitude of approaches may be taken. systematic reviews of studied interventions reveal that one works to improve health literacy in one patient may not work for another patient. in fact, some interventions were found to worse health literacy in individuals. nonetheless, studies have illuminated general approaches that help individuals understand health messages. a review of 26 studies concluded that "intensive mixed-strategy interventions focusing on self-management" and "theory basis, pilot testing, emphasis on skill building, and delivery by a health professional" do aid in increasing levels of health literacy among patients. another study revealed that programs aimed at targeting more than one behavior through increased health literacy are no less successful than programs with a single focus. the importance of dignity and respect is emphasized when creating programs for increasing health literacy of vulnerable individuals. in intervention programs created for homeless individuals in specific, it has been found that "successful intervention programs use aggressive outreach to bring comprehensive social and health services to sites where homeless people congregate and allow clients to set the limits and pace of engagement". a social justice model is recommended for homeless individuals which is based on shared support of the community and their health literacy needs by those who provide services for this underserved group as well as the professionals who create and implement health literacy interventions. role of libraries in health literacy libraries have increasingly recognized that they can play a role in health literacy since the 2000s, influenced by the medical library association. library initiatives have included running education programs, fostering partnerships with health organizations, and using outreach efforts. pan american health organization contributed greatly through their libraries network. various medical library associations have made an effort to introduce health literacy programs by attempting to define the concept to include the librarian's role as including a set of abilities needed to recognize a health information need, identify likely information sources and use them to retrieve relevant information, and assess the quality of the information and its applicability to a specific health situation. the network of the national library of medicine (nnlm) twice yearly hosts the #citenlm wikipedia edit-a-thon initiative to "improve the credibility and content of medical and health-related articles on wikipedia by adding citations and information from national library of medicine (nlm) sources." alternative approaches a study published in the american journal of obstetrics and gynecology in 2018 suggested an alternative method of addressing health literacy. this alternative method is the use of "culturally-related/accepted" music and singing amongst low-literacy populations. in the example of this study, the music was shown to increase health literacy with regards to maternal health, and more specifically, antenatal care.