ERIC Identifier: ED478948
Publication Date: 2003-00-00
Author: Kerka, Sandra
Source: ERIC Clearinghouse on Adult
Career and Vocational Education Columbus OH.
Health Literacy beyond Basic Skills. ERIC Digest.
The relationship between health and literacy is often discussed in terms of
the health-related problems that may be associated with low literacy. However,
health literacy is an issue that spans education and age levels. This Digest
looks beyond adult basic education to address issues of health and literacy for
all adults and educational responses to them.
In contemporary society, a constellation of changes has complicated the
adult's challenge of being healthy: the health care system's shift from a
paternalist to a partnership model, with more individual responsibility for
prevention, informed decision making, and consent; complex choices about
insurance; the need for self-management of chronic conditions such as diabetes
and high blood pressure; and responsibility for both children's and elders'
health care. Adults at all literacy levels must cope with conflicting media
reports about environmental health hazards, diet and nutrition, the safety of
hormone replacement therapy, and the appropriate frequency of screening tests;
myths and misconceptions about communicable diseases such as smallpox, anthrax,
and SARS; pharmaceutical company advertising about new drugs; and the vast
amounts of health information available on the Internet.
Health literacy is defined as the capacity to obtain, interpret, understand,
and use information to promote and maintain health (Greenberg 2001; Shohet
2002). Health consumers must be able to evaluate information for credibility and
quality, analyze relative risks and benefits, calculate dosages, interpret test
results, and locate health information, tasks that may require visual, computer,
information, and computational literacy (Sullivan 2000). Nutbeam's model (1999)
depicts three levels of health literacy that encompass the skills and abilities
in these definitions: (1) functional health literacy--basic reading and writing
skills to understand and follow simple health messages; (2) interactive health
literacy--more advanced literacy, cognitive, and interpersonal skills to manage
health in partnership with professionals; and (3) critical health
literacy--ability to analyze information critically, increase awareness, and
participate in action to address barriers.
Research documenting links between levels of education and health outcomes
(Hammond 2002; Wilson 2001) suggests that people with higher educational
attainment may have a health advantage. However, health literacy is not
identical to general literacy (Davis et al. 2002). Health literacy issues that
go beyond basic skills include (1) health information communication; (2)
literacy and health as cultural and social practices; (3) the relationship among
health information, literacy, and behavior; and (4) the impact of the Internet
on the use of health information.
COMMUNICATION OF HEALTH INFORMATION
Numerous studies have
demonstrated that many written health materials such as pamphlets, self-care
instructions, and insurance forms require a high reading level (Davis et al.
2002). Greenberg (2001) cites a study showing that even college-educated
individuals have difficulty understanding information on the benefits and risks
of mammography. The medical literature has emphasized simplification, or plain
language, and the use of visual aids and pictographs for low-literacy patients,
although Greenberg suggests that all patients would benefit from
easy-to-understand directions. However, many writers caution against
overreliance on plain language. McConnell-Imbriotis' (2001) analysis of
literature for diabetes patients shows that simplification can impede learning
even for highly literate people if no context for unfamiliar concepts is
provided; brevity can lead to the use of narrow, ethnocentric examples and
oversimplification of critical information. Multiple factors beyond readability
and presentation may influence consumer use of health information, including
patients' demographic characteristics, health locus of control, and beliefs and
environmental factors (Koo, Krass, and Aslani 2003). Plain language is useful
but not the primary solution: written communication should supplement
physician-patient conversations (Shohet 2002). The problem is that physicians
often use language not readily understood by the general public. Even when
physicians think they are using "everyday" language, patients do not perceive it
as such (Davis et al. 2002). Freebody and Freiberg (1997) discuss the role that
expert knowledge and the protection of a professional elite play in the opacity
of health care communication. They urge recognition of both literacy and health
as sets of cultural practices, as well as understanding of the ways in which
communication patterns act to position people with respect to knowledge and
LITERACY AND HEALTH AS CULTURAL AND SOCIAL
Research on health and literacy often categorizes people
demographically (e.g., geographic location, income, ethnicity, age, literacy
level) and attaches health risk variables to these categories. According to
Freebody and Freiberg (1997) this limited discourse ignores the literacy
practices of diverse groups. Greenberg (2001) points out how basic definitions
of health literacy fail to recognize the role of cultural belief systems and
social norms. Health literacy in one language/culture may not transfer to
another (Wilson 2001). The cultural expectations of the U.S. health-care system
may clash with those of the patient; there may be tensions between the system's
emphasis on individual care and a cultural view of health as a collective
responsibility (Robinson and Gilmartin 2002). Miscommunication may occur because
of different meanings of words and phrases to express health problems by
speakers of other languages (ibid.). In Davis and Flannery's (2001) study,
Puerto Rican women found health information trustworthy when its sources were
compatible with cultural beliefs and values. Kakai et al. (2003) observed
different patterns of health information sources among Caucasian, Japanese, and
Pacific Islander cancer patients; ethnicity overrode educational level in
shaping their choices of health information. Key social relationships enabled
the health of lower-educated men to parallel that of men with higher education
(Antonucci et al. 2003), suggesting that social networks and practices could
moderate the effects of low literacy on health. These findings indicate that
health literacy depends on context, and individuals' cultural world views and
social practices must be taken into account in determining their level of health
HEALTH INFORMATION, LITERACY, AND BEHAVIOR
The effect of
context on health literacy is also seen in examining its relationship with
health behavior. People who are highly literate in other situations may have
difficulty dealing with health information when they are ill and coping with the
associated emotional trauma and stress (Freebody and Freiberg 1997; Wilson
2001). Highly literate individuals can become low-literate patients because of
cognitive or physical disabilities such as visual impairment. Age can be a
compounding factor. Older adults experience more chronic illness and must learn
more new medical information and procedures (Brown and Park 2002). When Brown
and Park compared older and younger adults' recall of new information on
familiar and unfamiliar diseases, both groups learned more about the unfamiliar,
suggesting that prior knowledge may hinder learning of new information on the
same topic. The older group consistently learned less regardless of familiarity.
When Benson and Forman (2002) gave the Test of Functional Health Literacy to 93
affluent, well-educated older adults, 30% had poor comprehension of written
health information, especially informed-consent forms and numeracy-related
questions such as blood sugar numbers. They concluded that comprehension
problems may reflect age-related difficulty with the skills required for health
Other studies show that "high literacy levels are no guarantee that a person
will respond in a desired way to health education and communication activities"
(Nutbeam 1999, p. 52). Most of the college-educated people surveyed by Ludwig
and Turner (2002) overestimated industrial radiation risks and underestimated
medical radiation risks. In a survey of 400 adults (77% college educated), 55%
were unaware of the Dietary Guidelines for Americans and many misinterpreted and
misapplied these ambiguously written standards (Keenan, AbuSabha, and Robinson
2002). Factors besides health knowledge and health literacy affect the adoption
of health behavior: perception of risk, self-efficacy beliefs, physical
environment, and perceived costs and benefits (Gordon 2002).
HEALTH INFORMATION ON THE INTERNET
The Internet is another
context in which health literacy is critical. Internet users tend to have higher
literacy levels and better access to the vast amounts of health information
available online, and this information can empower consumers to participate
actively in their health care and challenge the decisions of health-care and
insurance providers. In addition, critical literacy is crucial because of
concerns about reliability and accuracy, access to information lay persons may
lack the background to interpret, and the potential dangers of self-diagnosis
and treatment. Internet users interviewed by Eysenbach and K"hler (2002)
recognized ways to assess the credibility of websites, but in an observational
study, none of them used these criteria to verify health information. A Harris
Poll (http://www.harrisinteractive.com/news/newsletters_healthcare.asp ) found
that 93% of Americans surveyed trusted online health information, 85% found it
easy to understand, and 82% judged it to have good quality. For both high- and
low-literate individuals, critical "cyberliteracy" is necessary for effective
and safe use of Internet-based health information. Projects such as
MedCIRCLE--the Collaborative for Internet Rating, Certification, Labeling, and
Evaluation of Health Information (www.medcircle.org) and the Health on the Net
Foundation (www.hon.ch/) can help educate consumers of online health
The research discussed here indicates that high levels of literacy in one
context do not automatically transfer to other contexts. Factors such as the
complex and changing health-care environment; the way health information is
communicated in print, online, and interpersonally; the effects of the
intersecting cultures and practices of the health profession, the individual,
and the dominant society; and the gap between knowledge/information and behavior
suggest a need to increase the health literacy skills of all adults as well as
the communication skills of the health profession. How can adult educators
Based on the work of the Massachusetts System for Adult Basic Education
Support, components of an effective health literacy system that involves many
levels of educational, health-care, and community service providers have been
identified (Wilson 2001): (1) an information dissemination system providing
materials that are readable, comprehensible, trustworthy, and culturally
sensitive; (2) a coordinated health literacy learning system; (3) a measurement
and assessment system; (4) a formal and informal health advice system, including
a hotline, handbook, and online support; and (5) a professional health provider
learning system. Recommendations for using effective adult learning principles
in health literacy development include the following (McConnell-Imbriotis 2001;
Shohet 2002; Wilson 2001):
* Link learning to adults' prior health consumer experiences. It should meet
the needs of broad cultural, economic, and social groups; encompass a variety of
learning styles; and be specifically targeted to client concerns and learning
* Provide literacy learning experiences that are contextual and experiential.
* Involve adults in planning their own health literacy learning by using
participatory approaches linked to individual and community empowerment.
Freebody and Freiberg (1997) characterize literacy as both critical,
purposeful, accurate management of print, visual, and other information and as
cultural savvy-reading the world. In order to help adults reach the functional,
interactive, and critical health literacy levels envisioned by Nutbeam (1999),
health literacy should move beyond a focus on basic skills toward individual and
communal efficacy for change.
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