Seeking effective intervention to improve health literacy in parents, in 2009 leading US health literacy authors recognized the need to expand medical academia’s focus beyond reading difficulties. Clearly, intervention to improve health literacy requires a broadened perspective. Because when the problem is perceived as reading difficulties, intervention can only aim to make information easier to read (been there, done that, for decades now), or increase parents’ reading ability (still no pill for that).
Drawing on research from education, cognitive science and psychology, Michael Wolf, Terry Davis, Rima Rudd and colleagues proposed a research agenda to address what they call parents’ “health learning capacity”. In the seven years since its introduction this added conceptual layer, along with repeated calls for the field to move beyond documenting patients’ and parents’ low literacy, have not changed the direction of research.
Thought leaders described health learning capacity, as “the constellation of cognitive and psychosocial skills from which families must draw to effectively promote, protect and mange health”. In particular, learning capacity includes self-efficacy, listening and speaking, motivation and questioning. This sounds a lot like the World Health Organization’s 1998 definition which Renkert and Nutbeam (2001) adapted to describe maternal health literacy as “the cognitive and social skills which determine the motivation and ability of mothers (parents) to gain access to, understand, and use information in ways that promote and maintain their health and that of their children”.
This health promotion perspective on health literacy was roundly rejected by health literacy researchers in US academic medical centers as too broad, messy and unmeasurable; it “diffuses thinking on the matter”. This may be why the authors presented “health learning capacity” as a new concept related to reading ability in a medical setting, rather than suggest adoption of the established broader health promotion definition.
“Health learning capacity” recognizes reading skill (functional literacy) is insufficient to promote, protect and manage personal and child health. Proponents call for interventions to improve parents’ psychosocial skills (social and communication skills), which Nutbeam called interactive skills. Still, proponents reject the few reported interventions as too broad and continue seeking a single reproducible strategy to remedy the “true cause” of health literacy’s effects on clinical outcomes. But a massively multifactorial capacity like health literacy has no one true cause, and no one true remedy. Rather, to promote parents’ health literacy we need to find the right combination of factors that address a particular family’s complex and dynamic “real life”, not just their ability to communicate with doctors. Further, the randomized controlled trial is still considered the “true path” to the discovering the “true cause”. However, the RCT aims to isolate the effects of a single factor. Where the true cause is a dynamic combination of personal, social and environmental factors, an RTC is likely to prove that no single factor works.
Proponents hoped that the idea of health learning capacity would refocus research on how parents actually obtain process and understand information. Findings would better guide continued simplification of information and services. But reducing barriers for people with low literacy does not improve their health literacy, it only reduces the need for health literacy.
The still missing research question is how parents use information for health. What enables a parent to transform their understanding and decisions into desired actions and outcomes? Part of the answer is what WHO and Nutbeam describe as critical health literacy, the critical thinking used along with functional and social skills to ask questions, set goals, make plans, marshall resources, assess progress toward health and quality of life. The range of health literacy skills: are used together and all are required to protect, promote and manage health. The health learning capacity concept expands thinking from purely functional literacy skills (reading,math) to include interactive (psychosocial) skills, but leaves out the empowering critical skills.
Long term, the proposed research agenda calls for education reforms to train more health literate future generations. This suggestion is at once troubling and easy. Its troubling because it assumes adults’ reading and other cognitive abilities are not modifiable in a clinical setting, which means health literacy cannot be improved — so the only course is to reduce literacy demands in the system, and hope the children grow up to be more skilled. This underestimates and disempowers patients and parents. It implies what is needed for the healthcare system to work is a smarter patient.
The goal of better health education in the schools is easy. All that is needed is the political will. The work is done. Health literacy standards and curricula are already defined. They have been and remain de-funded.
Health literacy as a field is moving away from describing the problem of low health literacy, toward removing barriers to understanding health information and services. Intervention to improve parents’ health literacy and child health outcomes is still hamstrung by focus on parents’ cognitive deficits and the perception that improvement is not possible.
Wolf MS, Wilson EAH, Rapp DN, Waite KR, Bocchini MV, Davis, TC, & Rudd, RE. (2009). Literacy and Learning in Health Care. Pediatrics124 S3; s275-281.
Further reading on maternal health literacy improvement
Health Literacy and Depression in the Context of Home VisitationSmith, S. A., & Moore, E. J. (2012). Maternal and Child Health Journal 16, 1500-1508.
The Parents as Teachers Health Literacy Demonstration Project: Integrating an Empowerment Model of Health Literacy Promotion into Home-Based Parent Education.Carroll LN, Smith SA & Thomson NR. (2015) Health Promot Pract. 2015 Mar;16(2):282-90. doi: 10.1177/1524839914538968. Epub 2014 Jun 23 www.ncbi.nlm.nih.gov/pubmed/24957219
Maternal Health Literacy Progression Among Rural Perinatal Women Mobley S, Thomas S, Sutherland D, Hudgins, J, Ange B & Johnson M. (2014). Maternal Child Health Journal 18: 1881-1892.
Comparing Child and Family Outcomes Between Two Home Visitation Programs
Haynes G, Neuman D, Hook C, Haynes D, Steeley J, Kelly M,Gatterdam A, Neilson C, Paine M. (2015). Family and Consumer Sciences Research Journal 43 (3):209-228.