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Health Literacy for All

October 16, 2013

Health Literacy: Part 5 of 5

Bill Keller, the eLiteracy graphicxecutive editor of the New York Times from 2003 to 2011, discusses health care in a recent Op-Ed column. He tells a wonderful story about innovations that are underway that promise to transform health care in America. Keller describes “accountable care organizations [that] have become the Silicon Valley of preventive care, laboratories of invention driven by the entrepreneurial energy of start-ups.” He cites “new medical SWAT teams—including not just doctors but health coaches, care coordinators, nurse practitioners—to intervene and encourage patients to live healthier lives. “

There is emerging brave talk about transforming health care from the market model of treating disease and selling medicine, to social policies of preventing illness and promoting well-being. Health literacy—the ability to make sound health decisions in the context of everyday life at home, in the community, at the workplace, in the marketplace, and the political arena—will be a key part of that transformation.

Health encompasses physical, mental, and social wellness, and is determined by individual behaviors, the environment, and by social, economic, political, and institutional factors or contexts, including the health system. Everyone exposed to 21st-century (especially urban) lifestyles is vulnerable to the behavioral and environmental risk factors that contribute to chronic disease, including unhealthy diet, physical inactivity, financial insecurity, poor housing, inadequate public transportation, workplace stress, limited green space, violence, pollution, and so forth. Obesity, high blood pressure, cardiovascular diseases, cancer, depression, diabetes and anxiety are just some of the examples of the metabolic, physiological, and psychological risk factors that form part of a holistic health literacy curriculum.

In this context, health literacy must equip all citizens with the means to adapt and cope in the face of environmental, economic, social, physical, and emotional challenges. This implies a shift in focus from the hospital to the home and from patient to population. It also asks if the focus on cognitive, rational choice behavior matches the reality of patients and consumers. (A recent study in the Netherlands reports that patient activation is a stronger predictor for seeking and using health information than functional health literacy). A possible approach to making such shifts is by conceptualizing health literacy as a catalyst of behavior change that produces positive health outcomes. This applies equally to those whose decisions and actions are making us ill, as to patients and consumers.

The transformative vision articulated by Bill Keller includes new health infrastructure such as gyms and community teaching kitchens, along with community-based healthy cooking classes, mental exercise programs and dance lessons. Citizens at home, in the community center or clinic, at school, in the workplace, and in the marketplace will be exposed to such health literacy fundamentals as the modifiable behavioral risk factors for noncommunicable diseases, and the ways to prevent and control them.

The argument that the medical perspective on factors influencing people’s health should be shifted toward a societal level is not new. In this journal in 2009 Freedman et al. called for public health literacy, stating that “[w]hereas health literacy has traditionally been operationalized as an individual-level construct, public health literacy takes into account the complex social, ecologic, and systemic forces affecting health and well-being.” This notion has been further developed and promoted in such documents as the 2006 European report, Navigating Health: The Role of Health Literacy, and the 2012 discussion paper, An Inter-Sectoral Approach for Improving Health Literacy for Canadians.

Linking these and other documents are the imperatives for a comprehensive approach and collective engagement. The language is explicit, calling for “a joint effort,” “multiple partners,” “all sectors,” and “all levels of society.” The broad reach of the emerging health literacy project encompasses governments, finance, agriculture, the health and education sectors, workplaces and businesses, community organizations, professionals, planners, policymakers, politicians, taxpayers, voters, families, and individuals.

And perhaps most significantly, such an inclusive mandate introduces the idea that those who are directly and indirectly, consciously and inadvertently, purposefully or accidentally responsible for the environmental, social, economic, political, and institutional factors that ultimately determine the state of our health, must eventually become health literate themselves, and thus the guardians of our well-being. It could happen.

— Michael Lytton, AJPM Blog Editor

Further Reading in AJPM:

Krist AH, Shenson D, Woolf SH, et al. Clinical and Community Delivery Systems for Preventive Care: An Integration Framework. Am J Prev Med 2013;45(4)508-16.

Fineberg HV. Public Health and Medicine: Where the Twain Shall Meet. Am J Prev Med 2011;41(4S3):S149-51.

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