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Health Literacy (Part 3): Why and What

September 17, 2013

Health is instrumental in the realization of human capabilities. It is fundamental to functional capacity, life satisfaction, and longevity. It can be measured in such terms as day-to-day sensory and mental function, mobility and independence, disability-adjusted life-years, resistance to disease and stress, mental and emotional health, aerobic fitness, and so forth.

Definitions of “perfect” health are contentious and probably not very useful, given the broad spectrum of maladies ranging from “the sniffles” to DOA (dead on arrival). Everyone experiences illness or injury at some time in his or her life, and for most, the incidents are infrequent, minor, and temporary. Others inherit or develop more serious, possibly disabling conditions, which might also be chronic. Some people experience catastrophic accidents and life-threatening events with extensive long-term consequences, such as severely limited physical or mental capacities. In addition, most people grow old (Dorian Gray, Benjamin Button, Dracula, and zombies the notable exceptions), and suffer varying degrees of health loss along the way. Thus, health is a measure not only of survival and longevity, but also of the quality of one’s experience while alive.

Health risks abound. They are both seen and imperceptible, quick and gradual, internal and external, pleasant and painful, inflicted and self-inflicted. They are in the sun, the air, the weather, the earth, our buildings, our transportation, our food, our water, and our lifestyles. The number and variety of risks is so vast, health almost seems implausible.

In addition to the natural disasters (earthquake, fire, flood, drought, locusts), humans have invented an endless array of hazards, including war, famine, climate change, pollution, crowding, poverty, noise, stress, diet, obesity, superstition, and TV. If smoke from inefficient cooking stoves doesn’t get you, a traffic accident, physical inactivity, or too much sugar, fat and salt probably will.

In addition to an individual’s characteristics and behaviors, many factors combine to affect health, including the full set of social and physical conditions in which people live and work—socioeconomic, demographic, environmental, and cultural—along with the health system itself. Where we live, the state of the environment, genetics, our income and education level, and our relationships with friends and family all have significant impacts on health. Individuals are unlikely to be able to directly control many of the determinants of health, but health literacy clarifies where, when and how a person can play an effective role in achieving, restoring or maintaining good health.

So health literacy matters. To some extent, everyone is responsible for his or her own health, and most will be responsible for the health of others, typically family members. You might be the primary health-literate person in your family, and your role will be to steward everyone’s health. Your partner might share this role with you, and at times other co-managers will include the professionals in your health system, for instance, doctors, nurses, pharmacists and various clinicians and community health practitioners.

A basic level of health literacy is essential, if for no other reason than to avoid endemic perils. Fundamental knowledge of sanitation, poisons, first aid, and how infectious diseases are spread are examples. You must know the rudiments of caregiving, and how to prevent sickness in the first instance. You must also know how to navigate the medical system and make decisions as required. If you or members of your family require medical intervention, you should know what is being done, why, likely outcomes, and costs. In sum, your health literacy will help equip you to effectively co-manage different health challenges over a lifetime, including end-of-life decisions.

Health literacy is not merely knowledge. Health literacy requires a person to be in possession of a set of tools, and the skills to use those tools effectively. Health literacy assumes that intelligence is behind those skills, and therefore ranks knowledge highly. Critical thinking is essential. However, behavior ultimately determines the use of tools, so cognitive and behavioral science must be central elements of health literacy.

For example, you have an appointment in the morning and you have calculated the time required to get ready and make the journey. You also know you might oversleep, so you set your alarm. In this, you have not only intelligently applied your cognitive and analytical abilities, but you have done so skillfully in the use of a mechanical reminder to get up and get dressed. If the appointment is for a regular visit to your primary care provider for a check-up, this is health literacy in action.

If you are using a system (or an app) to remind yourself to take medications, this too is skillfully applied health literacy. Similarly, a person who knows that smoking, drinking and overeating are health risks, can also recognize powerful obstacles to compliance with best medical practice, because they know their own habits are difficult to break. Skillful and effective application of knowledge about health risks will usually involve a variety of aids, reminders, friends, family support and so forth. Knowing about such aids, and how and when you need to enlist them is another example of health literacy. Behavior change is a big part of the agenda.

Decision aids are increasingly being developed and promulgated in patient-centered health care. Patients are engaged in dialogue and decision making about such things as tests, medical procedures, and medications. Meaningful engagement requires that patients be capable of understanding and evaluating options, risks, and outcomes. Eventually, costs will also be part of the mix, adding another layer of complexity to an already daunting decision matrix.

The curriculum for health literacy is specific to the place and to the individual/family. What someone needs to know about health, not only for themself, but also for their family, reflects such factors as: race; genetic and family history; age; gender; life course (childhood, adolescence, professional life, retirement); current health status; diet; activity levels; existing knowledge (including misinformation); health goals; and learning style. Thus, one’s health literacy is dynamic and progressive, focusing, for example, on maternal health, childhood disease, aging, or palliative care as appropriate.

Here are a few examples of health literacy subject matter:

  • Parents must teach youngsters that although motorized vehicles are hazardous (1.2 million deaths a year worldwide, another 20 million people disabled), physical inactivity is equally dangerous.
  • In a country that tends to punish illness and poverty, Americans should know that higher income is linked to better health, and that low education levels are linked to reduced income and poor health (often in a mutually reinforcing two-step).
  • Chronic disability (rather than premature death) now accounts for nearly 50% of all health loss in the U.S.
  • A majority of people should know the most important risk factors for health loss, and which diseases and ailments are preventable.
  • Dietary risks are the leading cause of disease burden in the U.S., contributing to more health loss in 2010 than smoking, drinking, and drugs combined. Pop quiz: What are the 14 components of dietary risk?
  • Everyone should recognize that sleep is as critical to health as diet and physical activity.
  • Most people want to get old, but health loss often accompanies aging. In the U.S. there are some 29 million family caregivers for those 75+ years of age.
  • In 2009, the U.S. health system wasted an estimated $190 billion on excess administration costs. If you need professional medical care, there will be paperwork and significant cost.

More on how to become health literate in the next installment in this series. In the meantime…

What  are the 3−5 basic things that everyone should know about health and safety?  We want to hear from YOU. (please leave a comment)

— Michael Lytton, AJPM Blog Editor

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