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Article Excerpt
Improving consumers' health literacy addresses many of the rising problems in healthcare. We empirically support a reconceptualization of health literacy as a social and cultural practice through which adults leverage a range of skills as well as social networks to meet their needs. Pierre Bourdieu's "theory of practice" guides this reconceptualization and facilitates articulation of the array of strategies used in the complex healthcare marketplace. We focus on the low literate consumers' alternative forms of capital and the providers' recognition and support. The findings, from an emergent research design consisting of depth interviews with low literate consumers and healthcare providers, suggest a critical, reflective approach that enhances health literacy, empowers consumers to become partners in their own healthcare programs, and improves health outcomes.
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Low health literacy is one of the most pressing problems in public healthcare. Particularly, the lack of functional literacy in the health arena creates inefficient utilization of services, driving up healthcare costs (Kusuma et al. 2008). Consumers are overwhelmed by healthcare-related communications written well above their reading abilities (Davis et al. 1993). More than one-third of the U.S. population experience difficulties completing healthcare-related tasks such as utilizing charts, interpreting an over-the-counter (OTC) drug label, or following prescription instructions (Sondik 2007). Low and marginal literacy is related to the misunderstanding of prescription medication labels which, in turn, contributes to the more than $177.4 billion in annual costs attributed to medication noncompliance (Ernst and Grizzle 2001). In addition, low health literacy levels translate into limited access to health information, suboptimal preventive care, and ineffective decision making about treatments (Shore 2001). Low health literacy harms consumers, perpetuates the existence of preventable diseases, creates large disparities in healthcare services, and drives up healthcare costs (IOM 2004).
In this study, we develop and empirically support a sociocultural conceptualization of health literacy. Findings from our interpretive study illuminate the range of skills and social networks that consumers leverage to fulfill their needs in a healthcare marketplace. We further flesh out strategies that empower consumers to take responsibility of their healthcare decisions. We begin by delineating the relationship between traditional and health literacies.
PERSPECTIVES ON HEALTH LITERACY
Current Definitions and Measures of Health Literacy
A widely accepted definition of health literacy is the "degree to which individuals have the capacity to obtain, process, and understand basic health information and services to make appropriate health decisions" (Ratzan and Parker 2000). In accord with this definition, most often health literacy is measured using the Test of Functional Health Literacy in Adults (TOFHLA; e.g., Baker, Parker, and Clark 1998) and the Rapid Estimate of Adult Literacy in Medicine (REALM; e.g., Davis et al. 1993). TOFHLA consists of sixty-seven numeracy and reading comprehension questions, assessing one's health literacy level as inadequate, marginal, or adequate (IOM 2004). The REALM requires individuals to read and pronounce various medical terms and conditions in a three- to five-minute timeframe. Mispronunciations are counted as incorrect and the number of correct pronunciations forms the basis of this assessment (IOM 2004). Both these scales receive frequent criticism for being limited to reading comprehension rather than purposefully using health information (DHHS 2007).
More recent health literacy measures use skill assessments that overlap with tasks that measured generalized adult literacy in the 1992 National Adult Literacy Survey (NALS) (Kirsch et al. 1993). The 2003 National Assessment of Adult Literacy (NAAL; IOM 2004) included health content items that measure ability to purposefully use information related to healthcare. The items were designed to fit the general literacy assessments such as prose literacy (i.e., skills to search and comprehend organized texts), document literacy (i.e., skills to search and comprehend noncontinuous texts in various formats), and quantitative literacy (i.e., skills to perform numeric computations of numbers embedded in printed materials) scales. The results indicated approximately 36% of the U.S. adult population to be at a basic or lower level of health literacy and a mere 12% to possess the skills required to read lengthy and complex texts like those presented in most health-related communications (Kutner et al. 2006).
These conceptualizations and assessments of adult literacy skills typify an approach equating literacy to a neutral set of cognitive processing skills, dubbed as the functional perspective of literacy (Fingeret 1992). According to this dominant viewpoint, health literacy is consistent across contexts and it encompasses a set of narrowly defined cognitive skills necessary for obtaining and processing health information (Baker 2006; Parker 2000). Low health literacy is estimated to be a more prevalent problem in the United States compared with generalized low literacy as health-related materials are more complex than the materials encountered in everyday life (IOM 2004; Kutner et al. 2006; Sondik 2007).
A New Conceptualization of Health Literacy
Although the functional approach provides insight to the scope of health literacy, it may oversimplify the consumers' practices in the healthcare arena (IOM 2004). We propose a more complex and multifaceted view of health literacy as a social and cultural practice comprised of the totality of communicative practices in which individuals purposefully engage rather than a predefined set of reading and writing skills (Nutbeam 2000). This view is grounded in recent ethnographic studies demonstrating the existence of multiple "literacies" and contextual literacy practices (Street 2001). Literacy practices involve active construction and negotiation of meaning from the text in a unique social situation. Thus, literacy competence cannot be understood in terms of absolute levels of skill (Lonsdale and McCurry 2004). As a social practice, literacy shapes and is shaped by larger power structures (Cook-Gumperz 1986; Freire 1970). Many adult education programs adopt a sociocultural view, which is empowering in its acknowledgement of learners' indigenous knowledge (Wickens and Sandlin 2007).
Similar approaches to literacy exist in consumer studies. For instance, Viswanathan and Gau (2005) take a functional perspective where consumer literacy is a collection of competencies needed to function effectively in the marketplace. Similarly, Jae and DelVecchio (2004) suggest low literate consumers make poorer product choices because they depend on peripheral cues in advertising and packaging. Viswanathan, Rosa, and Harris (2005) investigate decision-making strategies of functionally illiterate consumers and the coping strategies they utilize. However, Adkins and Ozanne (2005) present consumer literacy as a social practice that arises in the marketplace as low literate consumers engage in coping and identity management skills to both protect and assert their self-worth to those who are literate. Our approach is an extension of this viewpoint, adapted in milieu of health literacy.
Recent work on health literacy adopts this broader perspective of literacy as a social practice. Newer conceptualizations of health literacy not only include reading and writing skills but also the ability to leverage personal and social resources to improve health in any health-related context (Zarcadoolas, Pleasant, and Greer 2005). Thus, the study of health literacy has evolved from asking if consumers can understand texts to considering the entire healthcare transaction including the issues of power between the patient and the medical provider.
In this sociocultural view, we define health literacy as the ability to derive meaning from different forms of communication by using a variety of skills to accomplish health-related objectives. Health literacy involves a range of practices in the social realm (e.g., language competencies and identity management skills); it is, therefore, a public act rather than an individual act of decoding forms. Power relations play an important role. For example, a low health literate who struggles to master the formal language of health professionals falls short of the standards in this setting, perhaps experiencing contempt and disempowerment as a result.
Ongoing Debates in Healthcare
Our study provides insight to inform some points of debate in healthcare. First, our research addresses the assumption of low traditional literacy as an innate deficiency from which the consumer suffers. Research shows consumers with higher levels of income and education often exhibit higher capabilities and motivations for active participation in their own health decisions (Kutner et al. 2006). Accordingly, a substantial amount of research concludes low literate individuals are incapable of taking on the tasks associated with healthcare (e.g., Shore 2001). These disempowered depictions of low literates propagate stereotypes and biases toward the undereducated (Sandlin 2001) and perpetuate disparities and gross inequities in healthcare services (Roter et al. 1998). Alternatively, moving beyond the perspective of low health literacy as a consumer deficit, some research depicts low literates as capable players who utilize social support for effective...
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