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Origins and development of health literacy

In document Health Literacy: (Page 67-72)

Chapter 3 Health Literacy

3.2 Origins and development of health literacy

Health literacy is increasingly considered essential in everyday living - “health literacy is one of the most critical capabilities in modern society” (Kickbusch, 2009, p. 132). Not only is health literacy an important element in illness prevention and health maintenance, but it is of relevance in multiple contexts of health, education, economics, and healthcare policy (An & Muturi, 2011; Begoray, Gillis, & Rowlands, 2012). If health literacy, as a social determinant of health, can


improve individuals’ health outcomes then decision makers, as well as individuals, will be keen to support and engage with health literacy interventions that take advantage of its considerable potential. Not only is health literacy a compelling initiative for health and wellbeing on moral grounds but also timely given the unsustainable costs predicted to face the healthcare sector (refer Chapter 2).

Health literacy has been appearing in health literature since the 1970s. The term health literacy was initially used to describe and explain an individual’s ability to apply literacy skills to health related materials; the investigation of health literacy, or more correctly health illiteracy, emerged primarily to help reduce health disparities. From this perspective, low rates of health literacy have been linked to a raft of health outcomes both individual and societal. This research linking health literacy to health outcomes has been predominantly US based with several reviews supporting consistent conclusions about the impact of health literacy on health outcomes, healthcare services, and health knowledge (Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, AMA 1999; DeWalt et al., 2004; Institute of Medicine, 2004; Rootman & Ronson, 2005). However, in an updated systematic review of health literacy and health outcomes commissioned by the United States’ Agency for Healthcare Research and Quality (AHRQ), the researchers found insufficient strength of evidence of links between many health outcomes that had in the past typically been associated with low health literacy, such as adherence, self-efficacy, healthy lifestyle, chronic disease prevalence, asthma, and diabetes control (Berkman et al., 2011).18

In contrast to the abundance of US-based research, there have been few UK studies linking health literacy with health outcomes (Jochelson, 2008). Despite research in the field being considered “in its infancy” (Sørensen & Brand, 2013, p.

640) in Europe, recent attention by European researchers has gathered considerable momentum culminating with the European Health Literacy Study (HLS-EU Consortium, 2012; Sørensen et al., 2012). This study surveyed 8000 EU individuals over 15 years of age across eight European countries. It used a

18 This review synthesised the data qualitatively from numerous studies and graded the overall body of literature according to the strength of evidence - high, moderate or low -

“…after considering the domains of risk of bias, consistency, directness, and precision”

(Berkman et al., 2011, p. ES-4).


measure of health literacy (47 items) based on self-reported health literacy incorporating measures of “interactions between individual competences and situational complexities or demands” (HLS-EU Consortium, 2012, p. 1). The conceptual model and definition that formed the basis for this research (Sørensen et al., 2012) are discussed later in this chapter. Importantly, policy initiatives regarding health literacy are now apparent at a national level in Europe. The European Commission’s Health Strategy 2008-2013 makes explicit mention of health literacy as a priority area for action and the European health policy framework - Health 2020 - recently adopted by EU member states, includes health literacy as a key dimension (European Commission, 2007; Kickbusch et al., 2013).

Closer to New Zealand, there is a robust and growing level of attention to health literacy in Australia at both an academic level (Batterham, Buchbinder, Beauchamp, Dodson, Elsworth, & Osborne, 2014; Jordan et al., 2013; Jordan, Buchbinder, & Osborne, 2010; Osborne, Batterham, Elsworth, Hawkins, &

Buchbinder, 2013) and at a national policy level. The Australian Commission on Safety and Quality in Health Care seeks to coordinate the activity around health literacy, particularly stressing the importance of environmental factors (namely, the infrastructure policies and processes of the health system) and the centrality of the individual consumer (ACSQHC, 2012, 2013). More recently, the Australian Research Council in collaboration with universities is undertaking a large-scale health literacy research and intervention project across eight health and community care organisations in Australia, known as the Optimising Health Literacy (Ophelia) process (Batterham, Buchbinder, Beauchamp, Dodson, Elsworth, & Osborne, 2014). From the perspective of health literacy as a multi-dimensional concept, this on-going research has identified the participants’ health literacy needs, including customised intervention options.

The growth of interest in health literacy is also evidenced by the seemingly exponential expansion of research output. Over recent decades the body of health literacy literature and scholarship, produced across many disciplines, has grown prodigiously (Bankson, 2009). Sørensen et al. (2012, p. 2) cite 5,000 PubMed listed publications up to 2011 with most of these having been published since 2005.

Similar figures are cited by Sykes, Wills, Rowlands, and Popple (2013) who


recorded a ten-fold increase in articles on health literacy between 1997 and 2007.

Along with this proliferation in research output, numerous health literacy measurement tools have been developed. A recent comprehensive review identifies 51 such instruments, yet despite this proliferation most of these instruments measure limited dimensions of health literacy and lack adequate construct validity (Haun, Valerio, McCormack, Sørensen, & Paasche-Orlow, 2014).

Research associating health literacy with a range of outcomes has until recently focussed on functional health literacy. Investigations into health literacy and specific health conditions (for example, asthma, diabetes, hypertension, cancer screening) reveal that low functional health literacy is associated with poorer health regardless of the illness (DeWalt, Berkman, Sheridan, Lohr, & Pignone, 2004), increased rates of hospital admission, and generally increased use of healthcare services (Brown et al., 2011; DeWalt et al., 2004; Mancuso & Rincon, 2006; Powers, Trinh, & Bosworth, 2010; Wolf, Gazmararian, & Baker, 2005.) Other researchers found low literacy to be associated with low medication adherence and less engagement in preventive health activities (deBuono, 2004;

Miller, Brownlee, McCoy, & Pignone, 2007). In several studies patients with low health literacy demonstrated a lowered ability to act on health information lowering their ability to manage their condition(s) (Gazmararian, Williams, Peel,

& Baker, 2003; Heijmans, Waverijn, Rademakers, van der Vaart, & Rijken; 2015;

Jordan, Buchbinder, & Osborne, 2010; Mancuso, 2008; Paasche-Orlow et al., 2005).

Health literacy has also been linked to social and interactional consequences. For example, health literate people were shown to live longer and be more productive (Ratzan, 2001) and demand fewer health services (Sørensen et al., 2012). People with low health literacy have been found to generate higher health expenditures (e.g., Hardie, Kyanko, Busch, LoSasso, & Levin, 2011; Mancuso & Rincon, 2006) and they are less able to make effective use of healthcare resources (Eichler, Wieser, & Brugger, 2009; Howard, Gazmararian, & Parker, 2005; Ishikawa &

Yano, 2008). Low functional health literacy has also been linked to lower participation by patients in their health decision making (DeWalt, Boone, &


Pignone, 2007; McKinstry, 2000) and lowered preference for involvement in healthcare problem-solving (Goggins et al., 2014). Different levels of health literacy are associated with varying conceptualisations of involvement in the patient-practitioner relationship (Smith, Dixon, Trevena, Nutbeam, & McCaffery, 2009). However, while these studies measure health literacy using different tools and typically measure restricted conceptual dimensions of health literacy, understanding of the phenomenon will be limited and interventions could be misdirected.

Despite the abundance of health literacy research and policy measures, part of the challenge is a lack of agreement over the concept, with multiple definitions and limited operationalisation of the term (Berkman, Davis, & McCormack, 2010;

Chinn, 2011; Frisch, Camerini, Diviani, & Schluz, 2012; Sørensen et al., 2012).

Advances in theorising have been further hampered by the diverse health contexts in which very different individuals with very different goals exercise a range of knowledge, skills, and judgments, in all of which health literacy may be considered applicable (Pleasant, McKinney, & Rikard, 2011). Therefore, although initially defined as reading, writing, and numeracy skills in a health context, the construct of health literacy is being re-examined and re-constructed as a multi-dimensional construct, including broad notions of health understanding and consumer empowerment. In this evolution of the construct, Chinn (2011) considers that the term ‘literacy’ may even have been stretched to “an indefensible extent” (p. 60) and Tones (2002) that it is little more than “old wine in new bottles”

and that the other constructs themselves are often debated and open to misinterpretation.

The next section reviews definitions of health literacy and the conceptual frameworks that have been developed as the construct of health literacy has evolved.


In document Health Literacy: (Page 67-72)