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Empirical research on the extended dimensions of health literacy

In document Health Literacy: (Page 102-111)

Chapter 3 Health Literacy

3.5 Empirical research on the extended dimensions of health literacy


Finally, the integrative model does not address the [mis]-match between empowerment and literacy. Schulz and Nakamoto (2012a) hold that empowerment is the subjective experience that motivates action, while health literacy includes the abilities and skills to use the empowering motivation. They would not agree that high levels of health literacy expertise will lead to empowerment. Health literacy, in their conceptualisation, refers to the individual’s capabilities to make health-related decisions and the capability to participate in the decision making; empowerment gives the consumers responsibility for the decisions. With the diverse perspectives and models that have developed health literacy is conceptually problematic.


knowledge, health empowerment, health judgment, and filtering out those studies focussed solely on functional health literacy. Google and Google Scholar were also searched for additional articles meeting the criteria.

Eligible studies: were written in English; involved health literacy empirical research; included the terms interactive or critical health literacy; and/or mentioned domains other than functional competences; and provided findings relevant to an extended conceptualisation of health literacy. Research studies were not included if they used measures that could be deemed to be measuring the extended conceptualisation of health literacy but were described by other terms.

For example, Ownby et al. (2014) used a health knowledge scale, S. G. Smith et al.

(2013) used a patient activation measure (PAM), and Mbuagbaw, Momnougui, Thabane, and Ongolo-Zogo (2014) used a health competence measurement tool (HCMT). Studies that were validating existing scales but not measuring relationships or associated elements were not included. One study was included that qualitatively evaluated health literacy dimensions and, indirectly, its association with related outcomes (Sykes et al., 2013).

This review found fifteen studies that met the criteria, with only three in the US (refer Table 3.4). The green shaded cells highlight the populations studied – 8 of the 15 studies sampled ill or at-risk (e.g., low socio-economic status) individuals.

Six of the studies used qualitative methods. The far-right column (orange-shaded cells) summarises the findings. The majority of these studies found support for a positive relationship between the extended dimensions and social practices aspects of health literacy and individuals’ engagement and involvement in their health management and decision making.


Author; Year;

Country Sample population Research method Respondents Findings


Ishikawa, Takeuchi

& Yano; 2008;


Diabetes patients


Self-report health literacy scale: functional (5 items), communicative (5 items), critical (4 items)

138 outpatients with Type 2 diabetes

Communicative and critical health literacy correlated with self-efficacy scores

2 Adkins & Corus;

2009; US

Low literate consumers Healthcare providers


interviews, observations, &

field notes

23 participants:

low literate consumers (n=10);

free-health clinic staff (n=5);

pharmacists (n=8)

Health literacy is socially constructed between consumers & healthcare providers.

3 S. K. Smith et al.;

2009; Australia General population


In-depth interviews, TOFHL


Framework analysis

73 participants:

lower education (n=41); University alumni (n=32)


skills and strategies in involvement; role of significant others; interaction with health professionals; & function of health information

4 Jordan et al.; 2010;


Adult patients (over 18 yrs of age)

General population


Face-to-face & phone interviews

Grounded theory analysis

48 participants:

chronic disease (n=20); general population (n=14);

emergency department patients (n=14).

Seven key abilities:

knowing when to seek health information;

knowing where to seek health information;

verbal communication skills; assertiveness;

literacy skills; capacity to process and retain information; & application skills.

Table 3.4 Empirical studies reporting dimensions and relationships regarding extended health literacy


Author; Year;

Country Sample population Research method Respondents Findings


Rubin, Parmer, Freimuth, Kaley, &

Okundaye; 2011;


Adults (mean age 70.7 yrs)

Telephone conversation S-TOFLA, healthcare satisfaction, & self-efficacy

334 low SES adults in health literacy trial.

Measures interactive health literacy based on oral interaction. Oral-based health literacy affected health outcomes.


Camerini, Schulz,

& Nakamoto;

2012; Europe

Fibromyalgia (FMS) patients


Critical health literacy 10 multiple choice questions related to FMS, adapted empowerment scale, & self-report of self-management.

Structural equation modelling

209 patients

Dimension of empowerment had large effect on health outcomes.

Some effects of knowledge/health literacy and empowerment on health outcomes.

7 Diviani et al.;

2012; Europe

Parents of adolescents (14-16yr) regarding MMR vaccination decision


Functional health literacy (3 questions), objective &

perceived knowledge (9 T/F statements), empowerment (12 items across 4

dimensions), & information search behaviour (2


Structural equation modelling

Proposal, no results reported

Proposed extended health empowerment model.


Author; Year;

Country Sample population Research method Respondents Findings


Edwards, Wood, Davies, &

Edwards, 2012;


Adult patients (aged 22-76) with a long term health condition

Qualitative & longitudinal.

Three interviews over 9 months

Analysis using framework approach

18 participants with long term condition, recruited from patient education programme

Five steps in a pathway model:

building health knowledge, developing health literacy skills & practices, displaying health literacy actions, the production of informed options, & making an informed decision.

Outcomes include: increased knowledge, active involvement in decision-making.

9 Massey et al.;

2012; US

Adolescents (aged 13-17 yrs)


Focus groups & interviews Grounded theory analysis

12 focus groups, publicly insured, low-income adolescents (n=137), & 8 key-informant interviews with physicians

Five dimensions:

navigating the system, rights and responsibilities, preventive care,

information seeking; & patient–provider relationship.


Chinn &

McCarthy; 2013;


General population


3 factors, 14 item self-report scale AAHLS

Mixed administration methods

146 participants, mixed ethnicity

Functional - skills in using written health information;

Communicative - skills in communicating with healthcare providers;

Critical - skills in health information management and appraisal;

- assertion of individual autonomy with regard to health.


Author; Year;

Country Sample population Research method Respondents Findings

11 Jordan et al.; 2013;


Adult patients Emergency & chronic illness


HeLMS scale, 8 factors & 29 items

350 respondents:

emergency department attendees (n= 238);

individuals with a chronic condition (n=112)

Multidimensional understanding of health literacy including abilities and contextual factors.

12 Sykes et al.; 2013;


Database search since 1995

Policymakers &

practitioners with interest in health literacy.

Literature analysis and in-depth interviews

Theoretical & colloquial evolutionary concept analysis

8 practitioners 5 policy makers

Contextual variations in understanding.

Critical health literacy:

advanced personal skills; health

knowledge; information skills; effective interaction between service; providers and users; informed decision making; and empowerment including political action.

13 van der Heide et

al.; 2013; Europe General population


Face-to-face Survey (HLS-EU).

Competences of accessing (13 items); understanding (11 items); appraising (12 items);

applying (11 items).

925 Dutch adults

Domains of healthcare, disease prevention

& health promotion.

Perceived social status affected all health literacy competences.

Mixed results on age and health literacy.


Author; Year;

Country Sample population Research method Respondents Findings

14 Londono & Schulz;

2014; Europe Asthma patients

Quantitative Self-administered Health literacy questions, scenario-based judgment skill tool, asthma control test,

& self-management questions

80 patients (aged over 18) from medical offices

Diagnosed with asthma

Judgment skills were related to health information use.

Higher judgment skills meant patients:

visit doctor more often when they

experience problems; were more compliant with their control medicine; & made appointments more regularly with their physicians.


Heijmans, Waverijn, Rademakers, van der Vaart, &

Rijken; 2015;


Chronic disease patients

Quantitative Dutch Functional

Communicative & Critical Health Literacy Scale, Partners in Health scale, &

Perceived Efficacy in Patient-Doctor interactions

1,341 Dutch adults on national panel of adults with chronic illness or disability

Communicative and critical health literacy significant in self-management of chronic disease & confidence in medical



3.5.1 Implications for extended health literacy dimensions

As health literacy definitions evolve to encompass the interactions between individual capabilities and healthcare providers, the healthcare system, and society, the constructs of individual control, empowerment, decision-making are being brought into the ambit of health literacy (Chinn & McCarthy, 2013;

Sørensen et al., 2012). Consequently, recent quantitative health literacy measures have sought to develop a better linkage between the items being measured and these wider definitions of health literacy.

The pre-understandings of this thesis come from a broad array of literature. Health literacy is not a simple construct but a complex multi-dimensional phenomenon.

Table 3.5 summarises three key categories of health literacy dimensions that have provided critical pre-understandings for this thesis and research direction. Schulz and Nakamoto (2012b) emphasise that while individuals shift between these dimensions this does not necessarily imply a hierarchical or superior relationship between them. Moreover, Schulz and Nakamoto alert researchers to appreciating health literacy as more than knowledge elements by introducing aspects of empowerment and motivation. Thus, these researchers question the assumption that empowerment and health literacy go hand-in-hand, that individuals who are health literate are also (and always) empowered and motivated to act on their knowledge. This notion presents important pre-understandings; first, to consider health literacy as a construct independent, yet connected to empowerment, and second, that a multitude of factors can influence health literacy making it a dynamic and variable phenomenon.


Table 3.5Comparison of health literacy dimensions

Schulz & Nakamoto, 2012a,b Sørensen et al., 2012 (11 dimensions) Osborne et al., 2013 (9 domains) Declarative knowledge Able to perform basic reading literacy.

Able to derive meaning from information - comprehension.

Able to perform basic numerical and arithmetical tasks - numeracy.

Understanding health information well enough to know what to do.

Having sufficient information to manage my health.

Procedural knowledge Able to communicate on health matters - interaction.

Able to find health related information - information seeking.

Able to use process or act on health information and apply new information to changing circumstances.

Skill to navigate in society and in health systems to manage one’s health needs.

Feeling understood and supported by healthcare providers.

Ability to actively engage with healthcare providers.

Navigating the health system.

Ability to find good quality health information.

Judgment skills

-Integration of knowledge -Adaptation to changes in knowledge

Able to make sound health-related decisions and informed choices.

Able to take responsibility for one’s health.

Able to filter, interpret, and evaluate information.

Confidence (self-efficacy) to take action to improve personal and community health.

Appraisal of health information.

Actively managing my health.

Social support for health.


In document Health Literacy: (Page 102-111)