Health Literacy (Part 2): The What of It
This is the second installment on the topic of health literacy. The previous post discussed the importance of health literacy, especially in the context of an increasingly complex healthcare system that assigns much decision-making responsibility to patients. Studies indicate that large segments of the population have health literacy deficits, and that such deficits typically have negative health consequences. Health literacy is also seen—especially in the United States—as a way to control runaway healthcare costs.
Health literacy is a term best thought of in quotation marks as there is not yet a consensus definition or set of measures, although much work is underway in both of these areas. Health literacy research and programs accelerated in the 1990s broadly along two paths: one oriented to clinical care and the interaction between patient and provider, and the other to public health and education of populations, often in developing countries. (See the AJPM article Public Health Literacy Defined.)
Health literacy is analogous to numeracy and computer literacy, the definitions of which offer some useful terminology and conceptual hooks.
- Numeracy is the ability to reason and apply numerical concepts . . .to possess basic knowledge . . .numeracy skills consist of number sense, operation sense, measurement, probability and statistics . . .a numerically literate person can manage and respond to the mathematical demands of life.
- Computer literacy is the knowledge and ability to use computers and related technology efficiently, with a range of skills from . . .implies the ability to self-teach.
These definitions, like reading and writing literacy, connote knowledge, a range of skills, and purposeful application of those skills, often to manage and respond to challenges. Continual learning is essential. When speech is combined with reading and writing in language, the purpose is communication, but the caution is not to confuse health communication with health literacy. Enjoying a holiday in a foreign country involves not only communication, but numeracy, navigation skills (possibly in combination with computer literacy), research skills, critical thinking, patience, and much more.
Health literacy might be understood to be everything you will need on a long strange trip. The trip lasts from cradle to grave and along the way, you’ll meet people who dress funny (lab coats) and speak different languages (medicalese and legalese). You’ll be poked and prodded by odd looking machines and given mysterious potions and pills. There will be things you can’t read or understand (prescriptions, bills, lab results). You’ll do things that are risky and eat stuff that will make you ill (sometimes chronically), but just about everybody is doing the same, and everyone’s got their own opinion. It could get very expensive. Did I mention this trip would be strange?
In this conceptualization, health literacy is a set of skills needed by individuals to (1) meet their responsibilities in co-managing their health on an ongoing basis, and (2) effectively interact on a periodic basis with their co-management partners in the health system. The skill set implies both capacity and application; an individual must have the capacity to find, validate and understand health-related information, and must then be able to apply that information in the co-management of her or his health.
The skills encompass several domains, including print, numeracy skills, communication (including listening, speaking, and negotiating), information seeking, and critical evaluation. There is a range of skill levels, which are also context sensitive. It has been suggested that what might be needed are core competencies; what does a 4th-grader, an 11th-grader, a young adult, a senior need to know? Could competencies be developed for different populations? And so forth.
Functional health literacy will help people to use the health system and take care of themselves, but not necessarily to comprehend dense insurance documents or become fluent in medical terminology. They will not be required to be knowledgeable in medical specialties, pharmaceuticals, surgery or obstetrics, and although reading important periodicals such as the American Journal of Preventive Medicine will be extraordinarily beneficial, it will not be essential.
Health literacy, like medical knowledge, is not static. (Remember when doctors advertised cigarettes?) Diseases, medical science, drugs, and technology evolve over time. The individual’s life course and challenges also shift. For example, health literacy skills for a high-income adolescent in Hawaii will be very different from those of a fixed-income senior in Detroit. One is thinking about sexually transmitted disease (the teen) and the other is dealing with diabetes and mobility issues.
Meanwhile, the scope of an individuals’ responsibility within a co-management and engaged “consumer” framework is still foggy. A recent New York Times story describes an informed patient who disagrees with her doctor, who in turn disagrees with her, and in the dustup, evidence-based medicine takes a couple of punches. This story illustrates the significance of information, especially whose information it is and how disagreements about its accuracy and relevancy are resolved. Is a joint decision possible, or is the doctor always the final authority—the decider?
The interaction between the patient and the specific health organization is therefore a critical aspect of health literacy as it hinges on both the capacity of the patient and the commitment and communication skills of all health professionals who are in contact with the individual. Organizations are just now starting to be assessed in terms of health literacy, using lists of such attributes as,
- Has leadership that makes health literacy integral the organization’s mission, structure and operations.
- Provides easy access to health information and services and navigation assistance.
- Uses health literacy strategies in interpersonal communications and confirms understanding at all points of contact.
(See the IOM Roundtable on Health Literacy’s Ten Attributes of Health Literate Health Care Organizations.)
In the next installment on this topic I will examine what people suggest are the essential skills needed, across the life course, to successfully navigate and engage with health systems, and what people need to know and understand to take care of their health. Stay tuned…
—Michael Lytton, AJPM Blog Editor