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Health Literacy (Part 4): How We Know

September 25, 2013

On my fridge is a copy of a 1918 poster on malaria, issued by the US Public Health Service and provided free to “health officers and sanitarians…in numbers suitable to their needs.” On it, a finger points to a drawing of a huge mosquito, with two smaller drawings illustrating how to distinguish the malaria mosquito from others (they stand differently). The poster declares in bold letters, “You Yourself Can Prevent Malaria,” and in smaller type, “It Is Our Patriotic Duty to Keep Well.” Should you unpatriotically get malaria, further advice is offered; “Don’t take patent medicines, see your doctor, quinine will cure you.” Good to know, especially the last point about the medicinal properties of gin and tonic.mosquito

Such posters displayed in post offices and railroad stations were part of an early health literacy campaign. Disseminating useful information as part of health education was quite straightforward, once upon a time.

Today it might be thought easier to get the word out, but with all the information noise around us, it is actually much harder. Maybe some group will deny the existence of malaria, or protest the killing of one of God’s all-time favorite creatures, the adorable Anopheles gambiae. Anything now seems possible in a culture that makes achieving health literacy an extraordinary challenge. People are fearful of immunization, sex education is prohibited in schools, contraception and abortion are opposed on religious grounds, and evolution and climate change are denied.

Government policies, legislation, product marketing, manipulated science and vast quantities of misinformation and opinion have resulted in a health literacy landscape of mixed messages, confusion, contention, and vitriol. The overarching fact is that the country has yet to achieve universal health care, and the current fee-for-service reimbursement model, with its focus on volume over value, fails to align incentives with wellness, health literacy, and prevention over sickness.

For example, despite encouragement to provide patient education about sunscreen use and sun-protective behaviors, doctors do not routinely discuss the topic with their patient/consumers, even those with a history of skin cancer (see Akamine et al., 2008).  In addition, political decisions, such as the recent federal bill to drastically cut food stamps, suggest indifference, if not outright hostility, to the health and welfare of millions of Americans.

The average person might assume that they have a health and safety ally in the Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF), but there are some 300 million guns in private hands in the U.S., and it took 30 years for tobacco control to move from information campaigns to smoking bans. I can only hope that the patriots and libertarians will be thwarted in their dreams of wearing bandoliers of explosives in public places.

Or consider the Federal Trade Commission (FTC), established to enforce federal law that says when consumers see or hear advertisements, the ad—don’t laugh—“must be truthful, not misleading, and when appropriate, backed by scientific evidence.”  The FTC claims to look “especially closely at advertising claims that can affect consumers’ health or their pocketbooks—claims about food, over-the-counter drugs, dietary supplements, alcohol, and tobacco. . . .” OK, laugh, but just a short guffaw.

Achieving health literacy will be a daunting task for individuals and families, partly because the structures of society promote consumption patterns that we think of as normal, but which produce obesogenic environments. Unhealthy lifestyles present what Harvard Professor Ron Heifetz describes as adaptive problems, requiring changes in attitudes and perspectives. Changing lifestyle to eat healthily, get more exercise, and lower stress are adaptive solutions, taking medication or having surgery are medical/technical solutions.

How we know is the basis for competencies more generally, and is the foundation for the mental complexity that adaptive challenges call for. Health literacy will require us to pay attention to how we reach decisions, but we must also recognize that lifestyles are not merely the result of “independent preferences” (in the language of the standard economic model), because choices are usually influenced, even constrained, by environmental conditions, including social structures, cultural and political conditions.

To the extent that citizens who attempt to make significant lifestyle changes for health face almost insurmountable sociocultural barriers, experts argue that governments need to shift to cultures of health by creating the societal structures that make healthy living the default option. Innovations in technology and infrastructure, regulation, pricing, marketing and new social norms can be used in combination to create healthy choice environments. Governments will play essential roles in helping humans become healthier, perhaps by encouraging discussions that expand visions of well-being beyond consumption and competitive self-interest. Health literacy might even explore a greater diversity of paths and new metrics of prosperity. Stranger things have happened.

— Michael Lytton, AJPM Blog Editor

Further Reading in AJPM

Kalichman SC, Benotsch E, Suarez T, et al. Health Literacy and Health-Related Knowledge Among Persons Living with HIV/AIDS. Am J Prev Med 2000;18(4):325–31.

Wolf MS, Gazmararian JA, Baker DW. Health Literacy and Health Risk Behaviors Among Older Adults. Am J Prev Med 2007;32(1):19–24.

Osborn CY, Paasche-Orlow MK, Davis TC, Wolf MS. Health Literacy: An Overlooked Factor in Understanding HIV Health Disparities. Am J Prev Med 2007;33(5):374-8.

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