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 INFORMATIONNumerous 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
medical care. LITERACY AND HEALTH AS CULTURAL AND SOCIAL PRACTICESResearch 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
literacy.
HEALTH INFORMATION, LITERACY, AND BEHAVIORThe 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
literacy.
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 INTERNETThe 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
information. Improving Health Literacy 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 respond? 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 goals. * 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. REFERENCESAntonucci, T. C. et al. "The Effect of Social
Relations with Children on the Education-Health Link in Men and Women Aged 40
and Over." SOCIAL SCIENCE & MEDICINE 56, no. 5 (March 2003): 949-960. Benson, J. G., and Forman, W. B. "Comprehension of Written Health Care Information in an Affluent Geriatric Retirement Community." GERONTOLOGY 48, no. 2 (March-April 2002): 93-97. Brown, S. C., and Park, D. C. "Roles of Age and Familiarity in Learning Health Information." EDUCATIONAL GERONTOLOGY 28, no. 8 (September 2002): 695-710. Davis, R. E., and Flannery, D. D. "Designing Health Information Delivery Systems for Puerto Rican Women." HEALTH EDUCATION & BEHAVIOR 28, no. 6 (December 2001): 680-695. Davis, T. C. et al. "Health Literacy and Cancer Communication." CA: A CANCER JOURNAL FOR CLINICIANS 52, no. 3 (May-June 2002): 134-149. http://caonline.amcancersoc.org/cgi/content/full/52/3/134 Eysenbach, G., and Koehler, C. "How Do Consumers Search for and Appraise Health Information on the World Wide Web?" BRITISH MEDICAL JOURNAL 324 (March 9, 2002): 573-577. http://bmj.com/cgi/content/full/324/7337/573 Freebody, P., and Freiberg, J. ADULT LITERACY AND HEALTH. Melbourne, Australia: National Languages and Literacy Institute, 1997. (ED 430 088) Gordon, J. C. "Beyond Knowledge: Guidelines for Effective Health Promotion Messages." JOURNAL OF EXTENSION 40, no. 6 (December 2002). http://www.joe.org/joe/2002december/a7.shtml Greenberg, D. "A Critical Look at Health Literacy." ADULT BASIC EDUCATION 11, no. 2 (Summer 2001): 67-79. Hammond, C. LEARNING TO BE HEALTHY. THE WIDER BENEFITS OF LEARNING PAPERS NO. 3. London: Centre for Research on the Wider Benefits of Learning, University of London, 2002. http://www.learningbenefits.net/index.htm Kakai, H. et al. "Ethnic Differences in Choices of Health Information by Cancer Patients Using Complementary and Alternative Medicine." SOCIAL SCIENCE & MEDICINE 56, no. 4 (February 2003): 851-862. Keenan, D. P.; AbuSabha, R.; and Robinson, N. G. "Consumers' Understanding of the Dietary Guidelines for Americans." HEALTH EDUCATION & BEHAVIOR 29, no. 1 (February 2002): 124-135. Koo, M. M.; Krass, I.; and Aslani, P. "Factors Influencing Consumer Use of Written Drug Information." ANNALS OF PHARMACOTHERAPY 37, no. 2 (February 2003): 259-267. Ludwig, R. L., and Turner, L. W. "Effective Patient Education in Medical Imaging: Public Perceptions of Radiation Exposure Risk." JOURNAL OF ALLIED HEALTH 31, no. 3 (Fall 2002): 159-164. McConnell-Imbriotis, A. "'Take This Brochure...': An Analysis of Current Educational Materials Given to Clients with Diabetes." AUSTRALIAN JOURNAL OF ADULT LEARNING 41, no. 3 (November 2001): 335-358. Nutbeam, D. "Literacies across the Lifespan: Health Literacy." LITERACY & NUMERACY STUDIES 9, no. 2 (1999): 47-55. Robinson, M., and Gilmartin, J. "Barriers to Communication between Health Practitioners and Service Users Who Are Not Fluent in English." NURSE EDUCATION TODAY 22, no. 6 (August 2002): 457-465. Shohet, L. "Health and Literacy: Perspectives in 2002." Adult Literacy and Numeracy Australian Research Consortium Online Forum, March 15-April 19, 2002. http://www.staff.vu.edu.au/alnarc/onlineforum/AL_pap_shohet.htm Sullivan, E. "Health Literacy." In CONSUMER HEALTH: AN ONLINE MANUAL. Houston, TX: National Network of Libraries of Medicine, South Central Region, 2000. http://nnlm.gov/scr/conhlth/hlthlit.htm Wilson, K. K. PROMOTING HEALTH LITERACY. Clemson, SC: Institute on Family and
Neighborhood Life, Clemson University, 2001. (ED 466 621)
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