Advancing Health Literacy

A Framework for Understanding and Action

Christina Zarcadoolas, Andrew Pleasant, David S. Greer

• Publisher: Jossey-Bass
• Year: 2012
• Print ISBN:
  9780787984335
• eBook ISBN:
  9781118429747
• Edition: 1
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

Advancing Health Literacy addresses the crisis in health literacy in the United States and around the world. This book thoroughly examines the critical role of literacy in public health and outlines a practical, effective model that bridges the gap between health education, health promotion, and health communication. Step by step, the authors outline the theory and practice of health literacy from a public health perspective. This comprehensive resource includes the history of health literacy, theoretical foundations of health and language literacy, the role of the media, a series of case studies on important topics including prenatal care, anthrax, HIV/AIDS, genomics, and diabetes. The book concludes with a series of practical guidelines for the development and assessment of health communications materials. Also included are essential techniques needed to help people make informed decisions, advocate for themselves and their community, mitigate risk, and live healthier lives.

Chapter 1

Health Literacy

Why Is It a Public Health Issue?

More than half the adults in the United States find it difficult, if not impossible, to understand their health plan coverage, read instructions for taking medications and drug interactions, or understand and act on public health warnings. These tasks are a function of health literacy, which we can begin defining as a person’s ability to find, understand, and act on health information. While we will expand and elaborate on this definition throughout this book and present a new framework for understanding health literacy, this chapter establishes the fundamentals of why health literacy is a major public health issue that can and should be addressed by health professionals in many fields. (A number of important government and academic initiatives are now focused on health literacy: Ad Hoc Committee on Health Literacy, 1999; U.S. Department of Health and Human Services, 2000; Schwartzberg, VanGeest, & Wang, 2005; Partnership for Clear Health Communication, 2003; Nielsen-Bohlman, Panzer, & Kindig, 2004.)

Low health literacy contributes to a number of difficulties:

• Improper use of medications
• Inappropriate use or no use of health services
• Poor self-management of chronic conditions
• Inadequate response in emergency situations
• Poor health outcomes
• Lack of self-efficacy and self-esteem
• Financial drain on individuals and society
• Social inequity

The following are three examples of the dire consequences of the inability to successfully educate people about better health prevention and disease management in the United States:

• Type 2 diabetes. Diabetes is the seventh leading cause of death in the United States, directly affecting 6.2 percent of the population (17 million people). The disease disproportionately affects minority populations. Non-Latino blacks, Latino Americans, American Indians, and Alaska Natives all have a higher prevalence of diabetes than non-Latino whites. American Indians and Alaska Natives have the highest prevalence of diabetes (15.1 percent) of any racial/ethnic group studied (National Diabetes Information Clearinghouse, 2002). Type 2 diabetes is largely a lifestyle illness.

• HIV/AIDS. The rate of HIV infection has hovered at over 40,000 new cases per year since 1998. The rate of decline has slowed significantly, from 13 percent in 1997 to 3 percent in 1999. Minority groups disproportionately represent the highest rates of new infections. Blacks represent 12 percent of the general population yet make up 54 percent of new infections. Women between the ages of 13 and 24, especially women of color, make up 47 percent of HIV cases. There has been a resurgence of cases in young men who have sex with men, a group that previously showed dramatic declines in infection rates associated with intense education (Centers for Disease Control and Prevention, 2001).

• Maternal and newborn health. Roughly 4 million infants are born in the United States each year. Among developed countries, the United States is ranked 25th in infant mortality (National Center for Health Statistics, 2001) and 21st in maternal mortality (World Health Organization, United Nations Population Fund, United Nations Children’s Fund, & World Bank, 1999). While the infant mortality rate dropped more than 22 percent in the United States between 1991 and 2000 (6.9 percent of live births), black infants are more than twice as likely to die as white infants, and Hispanic women are three to four times as likely to die in childbirth in the United States (Division of Reproductive Health, n.d.). Preterm births occur in 9.7 percent of all U.S. births, yet the rate for blacks is double that of whites and the rate is 25 percent higher for Hispanics than for whites (Reagan & Salsberry, 2004). The proportion of all babies born with low birth weight in the United States between 1991 and 2000 increased 7 percent (March of Dimes, 2003). Financial cost is also embedded in these statistics. The average cost of caring for the tiniest newborns now exceeds $200,000, according to researchers (Preidt, 2005).

The role of women’s health literacy is important in these sobering statistics. For example, while it is believed that up to 70 percent of birth defects of the brain and spinal cord may be prevented if women take 4 milligrams (4,000 micrograms) of folic acid daily prior to and during early weeks of pregnancy, in 2002 only 31 percent of nonpregnant women surveyed said that they were taking a daily multivitamin containing folic acid. And those least likely to be consuming folic acid included women ages 18 to 24, women who had not attended college, and women with annual household incomes under $25,000 (March of Dimes, 2003).

The greater prevalence of chronic disease, technological and scientific revolutions, and globalization, including both the quicker spread of communicable diseases and the threats of bioterrorism, all set the stage for substantive changes in what public health means and how to attain it for the largest number of citizens (Institute of Medicine, 2003). The terrorist attacks on the United States of September 11, 2001, demonstrated both weaknesses and strengths in the public health system (Institute of Medicine, 2003). Much criticism points beyond infrastructure problems and toward communication problems—for example, federal, state, and local officials’ inadequacies in communicating with one another and the general public (Connolly, 2001). The Institute of Medicine (2003) summed up this critical need: “Therefore, the committee recommends that all partners within the public health system place special emphasis on communication as a critical core competency of public health practice. Government public health agencies at all levels should use existing and emerging tools (including information technologies) for effective management of public health information and for internal and external communication. To be effective, such communication must be culturally appropriate and suitable to the literacy levels of the individuals in the communities they serve” (p. 125).

As we will discuss next, health literacy refers to more than reading and writing. It refers as well to the powerful skills that make it possible for people to talk about, know, and organize health information.

Definitions of Key Terms

Often the terms health communication, health promotion, and health education are used interchangeably. Because the discussion throughout this book uses all of these terms, we will use the following definitions, based on the 1998 WHO Health Promotion Glossary, greatly influenced by the Ottawa Charter for Health Promotion and the Jakarta Declaration of 1997 (Nutbeam, 1998).

Health promotion is the “process of enabling people to increase control over and to improve their health” (World Health Organization, 1998, p. 11). The mission of public health is actualized through health promotion and disease prevention. Health promotion relies on health education and health communication, as well as systems and policies that advance the public’s health status.

Health education is the full range of activities that involve communicating health information to people. It attempts to address the gap between what we know about health and what people actually practice (Glanz & Rudd, 1990; Griffiths, 1972). Health education can take place anywhere: in the home or community, schools and health care settings, work sites, and the consumer marketplace (Glanz & Rudd, 1990).

Health communication is the use of human and mass or multimedia and other communication skills and technologies to educate or inform an individual or public about a health issue and to keep that issue on the public agenda. Study after study has concluded that most consumers want more and better health information. A key objective is to construct linguistically, culturally appropriate, and innovative communications using the public health system and to have better patient-provider encounters.

Social marketing is the merging of traditional marketing and advertising strategies to persuade people to act in specific ways on social issues such as health and the environment (Andreason, 1995; McKenzie-Mohr & Smith, 1999). Social marketing focuses on designing and evaluating messages and campaigns through careful audience analysis, segmentation, identification of target audiences (market segmentation), understanding those audiences, and ultimately tailoring communications for a desired effect. Instead of starting with what an audience does not know and needs to know, the social marketer begins with knowing what people do and do not do, and why. The goal is behavior change.

Consumer decision making involves the active cognitive and emotional roles individuals play in attending to, evaluating, and acting on health information. Ever more frequently, health consumers are required to become more active coparticipants in their health and health care. Some examples are making medical treatment decisions, choosing health plans, or making decisions about lifestyle changes.

Health literacy is the wide range of skills and competencies that people develop to seek out, comprehend, evaluate, and use health information and concepts to make informed choices, reduce health risks, and increase quality of life. (We elaborate on this definition in Chapter 3.)

Medical Information

If the quantity of health information were the litmus test for a health-literate population, there would not be a health problem in the United States. Information about health in the United States is ubiquitous. As a society, we are awash with health messages—most too complicated, many often misleading. We receive health information from many sources: doctors, family and friends, television, newspapers, magazines, and the internet. Direct-to-consumer marketing by the pharmaceutical industry as well as online purchase of medications has created a climate in which the consumer is more and more able to ask for and receive commercially marketed products (David & Greer, 2001; Kaphingst, Rudd, DeJong, & Daltroy, 2004a).

Complexity of Health Information and Materials

Health education and promotion are critical for reaching and empowering the public in general and vulnerable people in particular. And yet much health education and promotion material in print and on the internet is written at the tenth-grade reading level or higher, far out of the reach of the average patient or consumer (Doak, Doak, & Root, 1996; Williams et al., 1995; Zarcadoolas, Ahern, & Blanco, 1997). The most easily identifiable complexity comes in the sentences and words we use. For example, the following health information texts are at the 12th- to 15th-grade level:

Navigating the Health Care System: Medicaid

The law cited below [not included here] requires that all conditions of eligibility must be verified at each redetermination of eligibility unless the verification is pending from a third party and the recipient has cooperated in obtaining the verification. Since you have not provided the necessary verification or you have failed to cooperate in obtaining verification from a third party, your cash and/or medical assistance must be stopped.

This is very hard to read for several reasons:

• High-level vocabulary (cited, eligibility, redetermination, and verification, for example)
• Long and complex sentences
• Passive versus active sentences (“the recipient has cooperated in obtaining . . .”)

Unfortunately, it is rare that only the vocabulary or sentences are complex. The following example is from a fact sheet on colorectal cancer from the American Cancer Society (2006) titled “What Are the Risk Factors for Colorectal Cancer?” Here, two important ingredients add to the complexity: the reader needs to know some basics about risk and risk factors and also needs to have skill in numeracy to understand personal risk.

A risk factor is anything that increases your chance of getting a disease such as cancer. Different cancers have different risk factors. For example, unprotected exposure to strong sunlight ...

Table of contents

• Cover
• Contents
• Title
• Copyright
• List of Tables, Figures, and Exhibits
• Preface
• Acknowledgments
• The Authors
• Chapter 1: Health Literacy
• Chapter 2: Advancing Health Literacy
• Chapter 3: Defining Health Literacy
• Chapter 4: Literacy at Work
• Chapter 5: The Traditional Mass Media
• Chapter 6: Health Literacy and the Internet
• Chapter 7: Baby Basics
• Chapter 8: Anthrax
• Chapter 9: Genomics and Health Literacy
• Chapter 10: Highlighting the Role of Civic Literacy
• Chapter 11: Highlighting the Role of Cultural Literacy, Part 1
• Chapter 12: Highlighting the Role of Cultural Literacy, Part 2
• Chapter 13: Program Evaluation
• Chapter 14: Guidelines for Advancing Health Literacy
• Reference
• NameIndex
• SubjectIndex