SUMMARY Health literacy is a relatively new concept in health promotion. It is a composite term to describe a range of outcomes to health education and communication activities. From this perspective, health education is directed towards improving health literacy. This paper identifies the failings of past educational programs to address social and economic determinants of health, and traces the subsequent reduction in the role of health education in contemporary health promotion. These perceived failings may have led to significant underestimation of the potential role of health education in addressing the social determinants of health. A ‘health outcome model’ is presented. This model highlights health literacy as a key outcome from health education. Examination of the concept of health literacy identifies distinctions between functional health literacy, interactive health literacy and critical health literacy. Through this analysis, improving health literacy meant more than transmitting information, and developing skills to be able to read pamphlets and successfully make appointments. By improving people’s access to health information and their capacity to use it effectively, it is argued that improved health literacy is critical to empowerment. The implications for the content and method of contemporary health education and communication are then considered. Emphasis is given to more personal forms of communication, and community-based educational outreach, as well as the political content of health education, focussed on better equipping people to overcome structural barriers to health.

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Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century

Health literacy concerns the knowledge and competences of persons to meet the complex demands of health in modern society. Although its importance is increasingly recognised, there is no consensus about the definition of health literacy or about its conceptual dimensions, which limits the possibilities for measurement and comparison. The aim of the study is to review definitions and models on health literacy to develop an integrated definition and conceptual model capturing the most comprehensive evidence-based dimensions of health literacy. A systematic literature review was performed to identify definitions and conceptual frameworks of health literacy. A content analysis of the definitions and conceptual frameworks was carried out to identify the central dimensions of health literacy and develop an integrated model. The review resulted in 17 definitions of health literacy and 12 conceptual models. Based on the content analysis, an integrative conceptual model was developed containing 12 dimensions referring to the knowledge, motivation and competencies of accessing, understanding, appraising and applying health-related information within the healthcare, disease prevention and health promotion setting, respectively. Based upon this review, a model is proposed integrating medical and public health views of health literacy. The model can serve as a basis for developing health literacy enhancing interventions and provide a conceptual basis for the development and validation of measurement tools, capturing the different dimensions of health literacy within the healthcare, disease prevention and health promotion settings.

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Health literacy and public health : a systematic review and integration of definitions and models

OBJECTIVE: To review the relationship between literacy and health outcomes DATA SOURCES: We searched MEDLINE, Cumulative Index to Nursing and Allied Health (CINAHL), Educational Resources Information Center (ERIC), Public Affairs Information Service (PAIS), Industrial and Labor Relations Review (ILLR), PsychInfo, and Ageline from 1980 to 2003 STUDY SELECTION: We included observational studies that reported original data, measured literacy with any valid instrument, and measured one or more health outcomes Two abstractors reviewed each study for inclusion and resolved disagreements by discussion DATA EXTRACTION: One reviewer abstracted data from each article into an evidence table; the second reviewer checked each entry The whole study team reconciled disagreements about information in evidence tables Both data extractors independently completed an 11-item quality scale for each article; scores were averaged to give a final measure of article quality DATA SYNTHESIS: We reviewed 3,015 titles and abstracts and pulled 684 articles for full review; 73 articles met inclusion criteria and, of those, 44 addressed the questions of this report Patients with low literacy had poorer health outcomes, including knowledge, intermediate disease markers, measures of morbidity, general health status, and use of health resources Patients with low literacy were generally 15 to 3 times more likely to experience a given poor outcome The average quality of the articles was fair to good Most studies were cross-sectional in design; many failed to address adequately confounding and the use of multiple comparisons CONCLUSIONS: Low literacy is associated with several adverse health outcomes Future research, using more rigorous methods, will better define these relationships and guide developers of new interventions

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Literacy and health outcomes

ContextHealth literacy is a measure of patients' ability to read, comprehend,
and act on medical instructions. Poor health literacy is common among racial
and ethnic minorities, elderly persons, and patients with chronic conditions,
particularly in public-sector settings. Little is known about the extent to
which health literacy affects clinical health outcomes.ObjectivesTo examine the association between health literacy and diabetes outcomes
among patients with type 2 diabetes.Design, Setting, and ParticipantsCross-sectional observational study of 408 English- and Spanish-speaking
patients who were older than 30 years and had type 2 diabetes identified from
the clinical database of 2 primary care clinics of a university-affiliated
public hospital in San Francisco, Calif. Participants were enrolled and completed
questionnaires between June and December 2000. We assessed patients' health
literacy by using the short-form Test of Functional Health Literacy in Adults
(s-TOFHLA) in English or Spanish.Main Outcome MeasuresMost recent hemoglobin A1c (HbA1c) level. Patients
were classified as having tight glycemic control if their HbA1c
was in the lowest quartile and poor control if it was in the highest quartile.
We also measured the presence of self-reported diabetes complications.ResultsAfter adjusting for patients' sociodemographic characteristics, depressive
symptoms, social support, treatment regimen, and years with diabetes, for
each 1-point decrement in s-TOFHLA score, the HbA1c value increased
by 0.02 (P = .02). Patients with inadequate health
literacy were less likely than patients with adequate health literacy to achieve
tight glycemic control (HbA1c ≤7.2%; adjusted odds ratio [OR],
0.57; 95% confidence interval [CI], 0.32-1.00; P
= .05) and were more likely to have poor glycemic control (HbA1c ≥9.5%;
adjusted OR, 2.03; 95% CI, 1.11-3.73; P = .02) and
to report having retinopathy (adjusted OR, 2.33; 95% CI, 1.19-4.57; P = .01).ConclusionsAmong primary care patients with type 2 diabetes, inadequate health
literacy is independently associated with worse glycemic control and higher
rates of retinopathy. Inadequate health literacy may contribute to the disproportionate
burden of diabetes-related problems among disadvantaged populations. Efforts
should focus on developing and evaluating interventions to improve diabetes
outcomes among patients with inadequate health literacy.

https://jamanetwork.com/journals/jama/articlepdf/195143/JOC12049.pdf

Association of health literacy with diabetes outcomes.

Increasingly, consumers engage in health information seeking via the Internet. Taking a communication perspective, this review argues why public health professionals should be concerned about the topic, considers potential benefits, synthesizes quality concerns, identifies criteria for evaluating online health information and critiques the literature. More than 70 000 websites disseminate health information; in excess of 50 million people seek health information online, with likely consequences for the health care system. The Internet offers widespread access to health information, and the advantages of interactivity, information tailoring and anonymity. However, access is inequitable and use is hindered further by navigational challenges due to numerous design features (e.g. disorganization, technical language and lack of permanence). Increasingly, critics question the quality of online health information; limited research indicates that much is inaccurate. Meager information-evaluation skills add to consumers' vulnerability, and reinforce the need for quality standards and widespread criteria for evaluating health information. Extant literature can be characterized as speculative, comprised of basic 'how to' presentations, with little empirical research. Future research needs to address the Internet as part of the larger health communication system and take advantage of incorporating extant communication concepts. Not only should research focus on the 'net-gap' and information quality, it also should address the inherently communicative and transactional quality of Internet use. Both interpersonal and mass communication concepts open avenues for investigation and understanding the influence of the Internet on health beliefs and behaviors, health care, medical outcomes, and the health care system.

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Bresolin Lb

Papers

Health Literacy: Report of the Council on Scientific Affairs