Center for Health Literacy Promotion - Action research for effective use of health info & services
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Shanghai Declaration on Health Promotion: Strengthen Health Literacy
Update Health Literacy Research for the Third Era of Modern Healthcare
What does mothers' health literacy have to do with disparities?
Affordable Care Act Review by the Numbers
Short answer to Why promote parents’ health literacy?: DOHaD + SDoH = HL


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Center for Health Literacy Promotion Blog

Promoting Health Literacy: Consider Access Needs

Accessibility: A Universal Precaution
My dad states his age as older-than-dirt.  He's lost all hearing and has a bad back. He gets around with a walker. It's impossible for him to call the doctor to report an issue or schedule an appointment. He cannot drive or use public transportation. A routine office visit—getting dressed, out of the house, into the car, out of the car, into the office and onto the exam table, and then the whole process in reverse  — each step is an exhausting physical challenge and an assault on his pride. It's also exhausting and trying for Mom, his primary caregiver, driver and emotional compass.  A check-up takes most of a day. Nothing is simple.

Recently, Dad slipped off the edge of the bed and twisted his knee trying to get up. That led to four 911 calls: one to get him up (and discover he could not stand), and three "citizen assists"  to get him to the doctor's office, from there to the hospital, and after a night in the hospital, to get him home and into bed.  Thank you, my fellow tax payers.
He's not alone.
About 70 million of us Americans have such access needs that affect hearing, vision, or mobility and impair capacity to obtain heath information and services.  People with access needs contend with marked health disparities that may originate from the most fundamental  level —like inability to schedule an appointment, open a pill bottle, or read the fine print dosing instruction. Disparities also come from health professionals and researchers acting on assumption and stereotyping instead of data.
Access: first pre-requisite to health literacy
Access, the capacity to obtain…. information and services, is the first prerequisite to health literacy. And yet, several reviews report accessibility is not a topic of health literacy research and scholarly discussion.  Further, access needs is a missing demographic variable in most national databases.

Case in point: the 2003 National Assessment of Adult Literacy population sample included 30% with access needs; among them nearly half (48%) were deemed to have below basic health literacy. This is likely an underestimation since NAAL excluded those "who could not be interviewed due to cognitive or mental disabilities" and did not report demographics of those with access needs. A worldwide review of interventions to improve health literacy reports that research has, for the most part, followed NAAL's example and intentionally excluded people with mental or physical disabilities, along with other disadvantaged or "hard-to-reach" groups. Lumping together and then excluding "the disabled" from research causes disparities to persist; it's ethically questionable and alienating.  Reacting to a nurse who obviously assumed that his access needs indicated a cognitive deficit, Dad retorted, " I've got a little back problem. I can read."
Integrate accessibility into research, practice, policy
Health literacy standards should include accessibility and universal design approaches that make healthcare environments and information products usable to the greatest extent possible by everyone, regardless of their age, ability, or status in life.  Health literacy research should include accessibility, directly involve people with access needs, and report access-related demographics. To make the research process itself accessible to those with access needs, reports, like other health information,  should be available in multiple formats: standard, large print, Braile, text only electronic format, audiotape, sign language. 

Experts suggest we make greater use of access-enabling assistive technology to communicate with people with disabilities. The technologies show how universal design and commitment to accessibility help us all; email,  voice recognition, captioning, GPS — all were originally designed for those with access needs.
References & further reading
Perlow E. (2010). Accessibility: Global Gateway to Health Literacy. Health Promotion Practice 11 (1); 123-131.

Hollar DW & Rowland J. (2015). Promoting Health Literacy for People with Disabilities and Clinicians Through a Teamwork Model. Journal of Family Strengths 15 (2): article 5. Available at

D'Eath M, Barry MM, & Sixsmith J.(2012)tera Rapid Evidence Review of Interventions for Improving Health Literacy. Stockholm: European Center for Disease Prevention and Control.


A New Improved Definition for Health Literacy: Rx to end confusion?

Health literacy (HL) thought leaders on the National Academy of Medicine’s Health Literacy Round Table are calling for a new standard definition of HL. Because there are too many definitions in play and researchers have a tough literacy task just to choose one.  And because various experts have come up with too many piggy-back terms that connect specific content to the “central concept”. And since we can’t measure things like “basic information” and “appropriate decisions”. 
New definition to include providers’ literacy, context, progress, action
The new definition would first and foremost acknowledge that HL is multidimensional, that is, two sided— including “both sides of the exchange”: literacy skills of individuals’  (patient or family members and “information providers”) on one side, and system demands and complexities on the other.  The broadened perspective recognizes that healthcare professionals and other info-providers in insurance, pharmaceuticals and IT, like patients, have literacy skills.  Those skills may or may not enable Those-Who-Know to understand what patients are saying or to communicate effectively. 

Further, the proposed broadened view acknowledges the role of context — “the demands and complexities” of healthcare delivery and financing systems make it difficult for everyone to participate in and obtain the full benefit of healthcare, health promotion,  health protection, and “health coverage” (I think that means insurance). 
The new perspective embraces the notion of progress—well, shakes hands, at least.  HL is described as a process or a pathway, implying that improvement is possible —although the document never uses those terms, referring instead to process and change.  Nonetheless, this is a big step away from old evidence suggesting that adults rarely change their level of functional literacy, and the surprisingly wide acceptance of the inference that HL is a fixed individual trait. 

Further,  HL “operates” in various settings — healthcare, insurance and pharmaceutical organizations are mentioned. And it operates in various media,  not just print.
Finally, the new definition will link decision and action. (Applause!). Another big step from “appropriate decisions” usually interpreted as compliance, to “informed action”, which may be against medical advice and still not indicate a cognitive deficit.

The Perspective, as the document is called, is indeed a welcome and overdue broadening of the dominant view of HL as seen from US academic medical centers. However, essential issues remain. Perhaps unresolved debates explain why a new definition is not proposed, only described by its components.
Health Literacy is multi-dimensional.  Social dimension still missing
HL is not simply two sided. Literacy skills may be one dimension that exists on  “both sides of the exchange”, but literacy itself is multidimensional.  The missing dimension in health literacy as defined in the US, and still in the new perspective, is the social dimension.

Literacy is a social construct. Its meaning and measure are constantly evolving to reflect society.  Literacy is different for different jobs, communities, goals, as well as for different genders, ages, cultures, times and places. In the same way, the meaning of health is also multidimensional, socially defined and evolving.  Most healthcare decisions are made and acted on  —or not—  in homes and communities in everyday life, not by appointment in offices and hospitals. 
At the intersection of health and literacy, it is not surprising to find a diversity of overlapping, sometimes conflicting, always evolving definitions and measures.  Experts did not come up with a bunch of new terms to tie their favorite content to a clear central concept of HL — rather they recognized that the theory of multiple literacies for multiple contexts (financial literacy, computer literacy, Spanish literacy) applies to HL, too. So we have maternal HL, mental HL, oral HL, teen HL, LBGT-HL, health insurance literacy, and many disease literacies.
Alternative: new improved research approaches
Try as we might to make health literacy precise and clinical with biomarkers and specific corrective actions that produce predictable results demonstrated in randomized controlled trials, HL remains a social practice that is complicated, dynamic and messy.  To understand and influence HL, the challenge is not to distill its meaning down to something easy to research, but to figure out how to research something messy.
Pleasant, A., R. E. Rudd, C. O’Leary, M. K. Paasche-Orlow, M. P. Allen, W. Alvarado-Little, L. Myers, K. Parson, and S. Rosen. 2016. Considerations for a new definition of health literacy. Discussion Paper, National Academy of Medicine, Washington, DC. Health-Literacy.pdf.
Cook-Grumperz J (Ed). The Social Construction of Literacy, Second Edition Cambridge University Press

Excerpt free online:

Interactive Health Literacy: under researched, unclear concept, measurement challenge

Previously in this space we’ve said health literacy for disease preventionand health promotion is distinguished from health literacy for disease treatment. The latter is typically operationalized as functional literacy (reading and math) in a clinical setting. In contrast, to improve risk behaviors and conditions that affect their health, individuals, families and groups use interactive and critical health literacy skills.  These skill sets are applied mostly at home and in the community. We’ve looked at critical health literacy. Today we look at interactive health literacy, IHL for short.  As we might expect, research is limited and controversy abounds.
Not much is known about IHL
PubMed lists just 13 articles on “interactive health literacy”,  two of them review articles. I found no listings on “interactive health literacy” AND “parent” or “mother”. Most IHL studies have been reported from outside the US.

Canadians Manafo and Wong looked at IHL promotion programs for older adults with chronic disease. They differentiated IHL from functional health literacy by the aim of the intervention (skill development to increase capacity to find information and make personal meaning from it vs. information giving to increase knowledge). They found five studies on IHL for seniors, 1 from Canada, 4 from eastern U.S.  All relate to training elders to search for health information online. My understanding of Nutbeam’s model of IHL is that it refers to interpersonal interaction and communication, not interactive (vs. static) information.   The reviewed studies are limited by small samples, no comparison groups, non-experimental design, non-comparable measures and outcomes.

The second review, from England, is a concept analysis of critical health literacy. Sykes and colleagues describe critical health literacy as a set of characteristics including effective interaction between service providers and users. Key attributes include social and communication skills, and interpersonal skills.  So critical health literacy is seen as “arising from …ability to interact effectively”, that is to navigate services, and to advocate and articulate confidently when communicating with a health professional —IHL.  This view looks at the faces of health literacy described by Nutbeam as a hierarchy of skill levels that develop linearly. However,not all scholars agree; and it seems difficult to separate interactive from critical health literacy.
Measures of IHL
Two studies, one from Japan and one from the Netherlands, used the Functional Communicative Critical Health Literacy scale which measures frequency of perceived difficulty with tasks indicative of the three levels. These authors describe IHL as the skills that can be used to participate actively in everyday situations, extract health information and derive meaning from different forms of health communication and apply it to changing circumstances,  while critical health literacy  refersto ability to exert control over health. Among Japanese patients with diabetes, interactive and critical health literacy, but not functional health literacy, were associated with self-efficacy, the most important factor in behavior change.  The Dutch authors conclude that IHL was associated with ability to organize care, interact with healthcare providers and perform selfcare.

Again, in these studies interactive/communicative and critical health literacy skill levels overlap and are difficult to differentiate. Indeed, in psychometric testing, communicative (interactive) and critical health literacy were closely related and findings were reported in two categories: functional vs. communicative and critical health literacy.

Rubin et al describe the Measure of Interactive Health Literacy,  a 10-minute telephone-administered “performance measure of an individual’s proclivity to engage in information seeking from health information sources” For more info, see:
Skill levels or categories? All are needed to protect and promote health
Another school of thought — the one I’m in — sees categories of health literacy skills rather than levels.  Individuals or groups combine skills from Nutbeam’s three categories in different ways for different tasks and situations.  Strength in one skill or skill set can make up for weakness in another.  And a family or community  member can contribute skills that an individual lacks. That’s how health literacy becomes a community asset.

Through interaction, information that is understood cognitively, is processed socially and personalized to the particular context and circumstance.  Interactive health literacy skills combine with functional literacy (reading and math) and critical health literacy skills to empower individuals and communities to use information for health and gain control over its determinants.
Reference & further reading
Manafo E & Wong S (2012).  Health literacy programs for older adults: a systematic literature review. Health Education Research 27 (6); 947-960. doi:10.1093/her/cys067 
Sykes S, Wills J, Rowlands G, & Popple K. (2013). Understanding critical health literacy: a concept analysis. BMC Public Health 13:150 doi:10.1186/1471-2458-13-150
Rubin DL, Parmer, J, Friemuth V, et al. (2011). Associations Between Older Adults Spoken Interactive Health Literacy and Selected Care and Health Communication Outcomes. Journal of Health Communication 16sup3, 191-204. doi:  10.1080/10810730.2011.604380
Ishikawa H, Takeaki T, &Yano E. (2008). Measuring functional, communicative, and critical health literacy among diabetic patients. Diabetes Care 31 (5),874-879.

Van Der Heide I, Heihmans M, Schutt AJ, et al. (2015). Functional, interactive, and critical health literacy: Varying relationships with control over care and number of GP visits. Patient Education and Counseling 98 (8), 998-1004.  doi: 10.1026/j.pec2015.04.006

Research Review - Health Literacy for Prevention: Improvement Requires Intense Intervention

SNAPW: Improve these behaviors to prevent chronic disease
Smoking, Nutrition, Alcohol, Physical activity, Weight
To find out which providers can improve health literacy for prevention,  Australian researchers completed a systematic review of quantitative studies (What works?) and narrative synthesis of qualitative work (Why? How?). The review covers research published 1985 to 2009, much of which was done by US researchers. The authors focused on “members of the primary care team” —providers working in general and family practice, community health, home nursing, private or public allied health, health education, or information— and evaluated  their effectiveness in promoting positive change in health literacy and SNAPW behaviors. 

The researchers ran into some issues that I’ve come up against in an ongoing scoping review  to discover what is known about the impact of mothers’ health literacy on maternal-child health. Health literacy and related concepts are poorly indexed, so it is necessary to search on lots of terms. The Aussies wrestled 4691 papers down to 94. We started with 2600+ and are still wrestling. There are many varied outcome measures. There are 50+ instruments to measure functional heath literacy (reading & math) and none to measure interactive or critical health literacy.  Nonetheless, this research report is on my must-read list.
Take Home Messages
1.    Health literacy can be improved; 71% of reviewed studies demonstrated improvement in health literacy.  (A round of applause for the researchers who published what did not work.)    Some interventions improved health literacy (measured as knowledge, skill, attitude, self-efficacy, states of change, motivation, or patient activation) without affecting behaviors. This result supports other findings that knowledge and skill do not necessary translate to health promoting action; people make informed choices to not act on what they know.   On the other hand, some interventions resulted in improved behavior (smoking) without affecting health literacy; that supports previous findings that specific knowledge may not be a prerequisite for behavior change. One RCT* found that brief counseling by a physician led to increased patient action, but only those who were referred to group programs demonstrated improvement in diet and weight.  I suspect that improvement in one health literacy indicator is insufficient to support behavior change, which likely requires some combination of knowledge and skills and motivations and self-efficacy and social support.

2.    Non-physician providers are effective health literacy promoters. Nine of 10 interventions provided by nurses, dietitians, health educators (92%) or multidisciplinary teams (91%) improved health literacy. Compare that to three of nine (33%) interventions provided by physicians.

3.    Intensity of the intervention seems to be the difference. One study found the average length of visit with a primary care physician was 8 minutes shorter than the time it takes to deliver smoking cessation counseling. Indeed, time was the barrier to improving health literacy most frequently mentioned mentioned by providers, followed by attitudes and beliefs. Most physician-delivered interventions were brief, one-time encounters. In comparison, interventions delivered by non-medical service providers ranged from 6 hours to 2 years. Limited time in clinical settings may preclude the trusting relationship required to support behavior change.     
Conclusion: Moderate to high intensity interventions are needed to address SNAPW behaviors.  Production demands in primary care settings (see 30 patients a day) limit physicians to brief interventions that can increase knowledge and motivate patient action but rarely result in improved behaviors.

Call to Action
Clinicians:  to improve health literacy for prevention of chronic disease, collaborate with-, refer to- and promote participation in intensive programs led by other health professionals and paraprofessionals.

Health educators, home visitors, community health workers, dietitians, public health nurses, social workers, case managers, parent educators, program directors: collaborate with clinicians to integrate health literacy promotion into your usual activities, organize referral relationships, bridge home and healthcare.
*RCT: Randomized Controlled Trial
Dennis S, Williams, A, Taggart J, et al. (2012). Which providers can bridge the health literacy gap in lifestyle risk factor modification education: a systematic review and narrative synthesis. BMC Family Practice. 13:44. 91 citations.  Open Access. Free at


The Future of Health Literacy is in Public Health Refocus on disease prevention and health promotion

Health literacy is not just for patients
Mothers, and the rest of us, use heath literacy across three domains: disease treatment, disease prevention and health promotion [1]. We should address those domains in opposite order. If we put health literacy for enhancing health first, we would have less need to struggle with disease and treatment.
Most health literacy research has taken place in US academic medical centers. The focus has been exclusively on disease treatment. In Australia, they differentiate this narrow conceptualization as medical literacy.  In these lines of inquiry, health literacy is operationalized as low reading skill in a clinical setting. It is identified by brief reading tests using medical terms. Since the problem is perceived as limited reading skill in patients, the solution is to reduce the literacy demands of medical and insurance information and improve its delivery.  The goal is to enable patients to better manage disease and improve treatment outcomes.
Quality information is essential for accessible, quality healthcare. But the clinical approach cannot achieve the national vision of a health literate society [2]. That requires ramping up the public health model of health literacy.  
Health literacy to prevent risk from escalating to need
From a public health standpoint, health literacy is seen as a personal and community asset that can be developed [3]. The asset enables and empowers individuals, families, communities to use information and services to protect and promote health. This is health literacy in everyday life.
11 reasons to refocus on health literacy in everyday life
1.    Americans spend about 1 hour per year in a clinical setting [4]. Health is lost or gained, protected, promoted and managed in the other 8759 hours at home and in the community.

2.    Low literacy is one among many interrelated personal, systemic, social and environmental factors in patients’ “failure” to engage and comply with medical care and preventive practices.

3.    Poor outcomes are not fully explained by low literacy. Medical care can be hazardous to health.  In 1999 the Institute of Medicine shocked the nation with its report that medical errors alone accounted for about 100,000 deaths per year [6]. In 2015, estimates are up to 400,000 deaths annually due to preventable medical errors— that is 1000+ deaths— plus 10,000 serious complications cases— resulting from preventable medical errors every day [7]

4.    About 10-15% of early deaths could be avoided by more accessible or otherwise better medical care. The low potential is not so surprising since we spend 95% [4] of our $3 Trillion national health investment — 16% of the GDP [5] — on medical treatments. 

5.    In contrast, about 40% of early deaths are caused by behaviors [4]. This figure takes on greater significance in light of recent reports of declining life expectancy among middle-aged Americans. 

6.    About 30% of early deaths are due to genetic predisposition [4], which takes us back to behaviors, which can determine whether a gene is expressed.

7.    Another 15% of deaths are attributed to social conditions [4].

8.    The remaining 5% are due to environmental exposures [4].

9.    The potential payoff from improving health literacy for disease treatment is up to 15%. Compare that to a potential 40 to 90% payoff from improving health literacy for disease prevention and health promotion.

10.  The Affordable Care Act is shifting resources to prevention and health promotion. 

11.  Increased understanding of DOHaD — Developmental Origins of Health and Disease— led the United Nations General Assembly to recommend all nations work to promote health literacy [in the public health asset model] as a global strategy to address the burdens of non-communicable disease [8].
It is time for Public Health to step up
Public Health has, especially in the US, with some encouraging exceptions, approached health literacy in the medical model with research questions related to the risks of low literacy (reading, math skills) to potential patients and healthcare systems. Can the public understand when and how to call 911? disaster preparedness guidance? emergency communications? health insurance options? Leading public health scholars have argued that health literacy is behavior change and health literacy improvement can be measured by changes in a person’s or a community’s actions, practices and behaviors [3] indicating increasing autonomy and capacity to produce the identified consequences of improved health literacy: positive changes in risk behaviors, selfcare, and health services utilization [1,9].  At least five published studies now demonstrate the feasibility of directly improving health literacy through usual health promotion activities: health education, skills development, and direct information assistance. Groups like Just Health Action are promoting community health literacy. 
We have strong theory, available measures, and early evidence.  We have a federal mandate, and an international call to action. We need leadership and resources to build the science around the public health model of health literacy as a personal and community asset to be developed.  Because the highest and best use of health literacy is to prevent health risk from escalating to medical need.
References & further reading
1. Sorenson, K., Van den Broucke, S., Fullam, J., Doyle, G., Pelikan, J., et. al. (2012) Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health 12:80.

2.  Nielsen-Bohlman, et al. (1999) Health Literacy: Prescription to End Confusion, Institute of  Medicine. Free online:

3. Nutbeam, D. (2008) The evolving concept of health literacy. Social Science & Medicine 67, 2072-2078.

4.  McGinnis JM, Williams-Russo P, & Knickman JR. (2002). The Case For More Active Policy Attention To Health  Promotion, Health Affairs, 21, no.2:78-93. Full text online:     

6.  Institute of Medicine (1999). To Err is Human: Building a Safer Health System. Free online:

7. McCann, E. (2014). Deaths by Medical Mistakes Hit Records. HealthcareITNews. Free online:

8. United Nations Economic and Social Council. (2010). Health literacy and the millennium development goals:  United Nations Economic and Social Council regional meeting background paper. Journal of Health Communication15, 211-222.

9. Sykes, S., Wills, J., Rowlands, G. &  Popple, K. (2013). Understanding critical health literacy:  A concept  analysis. Biomed Central Public Health:13:150.  Open Access:  http:www.biomedcentral.com1471-2458/13/150

Pope demonstrates importance of context in health communication and policy

Zika, the mosquito-borne virus that seems to cause microcephaly (abnormally small head with severe brain damage) has dominated the news this month. In my blog I argued that several governments’ advice to women to avoid pregnancy ignored reality on the ground in countries where access to contraception is limited, abortion is a crime,  and women are disempowered. This week the Pope indicated that Zika presents a special circumstance in which Catholics could use contraceptives to avoid pregnancy.  Heath ministers, take heed. 

Zika prevention advice extends to men

Men, wear your rubbers. Even if you have no symptoms

If you have travelled to one of 25 countries where Zika virus is spreading rapidly, or if you are planning to attend the Summer Olympic Games in Rio, stock up on condoms.  Get any brand, style, size or type of condom,  plus cool posters, key chains and reminders at
Consider visiting the Great Northwest instead of Rio
Public health warnings related to mosquito bites and birth defects intensified this week. Leading national and international health organizations now advise men possibly bit by mosquitos carrying the virus to use condoms.  At least three cases of sexual transmission have been confirmed. CDC says, so far, there is no evidence of transmission from an infected woman to a sexual partner. Zika virus has not spread to the US; but experts expect local transmission in southern states. The day-biting skeeters that spread Zika like tropical climates. Local spread is already reported in US territories — Puerto Rico. Virgin Islands, American Samoa. Health officials say there is virtually no risk of Zika coming to Washington state or Canada.
Zika is barely noticeable in adults, devastating to developing babies
Mounting evidence links the Zika virus to microcephaly, usually defined as head size two standard deviations smaller than the mean for age, size and gender.  Last week Brazilian researchers found evidence that the virus attacks developing babies in the womb. It seems to target nerve cells causing brain damage and developmental disabilities.  Seattle Times health reporter Jonel Aleccia interviewed Dr William Dobyns of Seattle Children’s Hospital after he reviewed brain scans from Brazilian babies. He found an “extremely rare, recognizable pattern” of severe cerebral palsy, epilepsy and feeding problems.
From a health literacy standpoint,  “Use a condom” is understandable and actionable. Condoms are inexpensive, readily available, and require no prescription. In some countries, governments are giving away condoms.  Earlier, still standing, advice telling women to avoid pregnancy, is understandable but not actionable in Zika-infected countries where women have very limited access to birth control and abortion and little protection from sexual violence.
What to tell a woman who travelled to a Zika-infected area,
or  had sex with a partner returning from a Zika-infected country:  “See your doctor right away.”  CDC recommends that women with symptoms get a blood test, but at this point only a few advanced labs can do the test.  It is not known whether babies of women with no symptoms become infected. Knowledge is advancing rapidly. Advice will continue to change. Stay tuned.
For up to the minute reliable information:

Zika and Health Literacy. Advice ignores context

Don’t get pregnant until 2018.
That is the current public health message from El Salvador’s health minister. Colombian women are warned to postpone pregnancy for 6 to 8 months. Jamaica just released similar advice. The intent is to prevent mother-to-baby transmission of Zika.

The mosquito-borne virus known since 1947 as a rare mild disease limited to central Africa, is spreading rapidly across dozens of countries in Latin America and the Caribbean. No one knows why. The World Health Organization (WHO) warns Zika is likely to reach every country in the Americas, except Canada and Chili. There is no treatment or vaccine, largely because only about 20 percent of infected adults have any symptoms. They might have a headache, body aches, a fever and red eyes for a few days.

Here is the public health concern: in Brazil, since an outbreak of Zika started there last May, more than 3800 babies have been born with microcephaly, 30 times the expected rate, according to WHO. Microcephaly is a rare birth defect characterized by a very small head and incomplete brain development leading to death or lifelong disability. There is little scientific evidence, but the apparent association between Zika and microcephaly warrants public health warnings, and delaying pregnancy seems wise. However…

The advice to women to avoid pregnancy ignores the context in which they are expected to comply. In El Salvador and Colombia there is little access to contraception, especially for poor rural women. Abortion is illegal in all cases in El Salvador, where the teen pregnancy rate is among the highest in Latin America accounting for a third of all births.  Abortion is illegal in 99% of cases in Colombia. In Jamaica, abortion is legal in some cases with the approval of the father and two medical specialists. There is little or no sex education in the schools. Sexual violence is prevalent. So women lack the knowledge, services and power to heed the advice.
Good risk communication?
Colombia’s health minister explained that his message to women is a good way to communicate risk. The minister seems to forget that women do not become pregnant by themselves. No similar messages have been directed to men. For sure, women who hear the warning will fear pregnancy and birth defects more than they already do, but left to protect themselves, this amounts to a “Just say No” campaign. It leaves women vulnerable to blame for unplanned pregnancy and birth defects in their babies, and to charges of non-compliance that could be misinterpreted as evidence of low health literacy.

Don’t get bit
A better message, free of gender bias, understandable and actionable, is to avoid mosquito bites. CDC has issued Level 2 travel advisories  (for all, not just pregnant women) for the Caribbean, South and Central America, Puerto Rico, Cape Verde, Samoa and Mexico.  Travelers are advised to “practice enhanced precautions”. In this case,

•       see your doctor before and after travel to areas where Zika is active
•       Use insect repellant (safe and effective for pregnant women)
•       Wear clothing to cover as much of your body as possible
•       Sleep under a mosquito net
•       Keep doors and windows closed or screened
•       Avoid standing water 
Important Notes:
The offending mosquitos bite in the morning, not just late afternoon and evening like other skeeters. 
The infection lasts only a week or less. The danger is only to a current pregnancy.  There is no danger to future pregnancies.

US Centers for Disease Control and Prevention Information is being updated regularly

Parents’ “Health Learning Capacity” Are we moving beyond reading difficulties?

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

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.

Health Empowerment: the act-ive ingredient health literacy

Health literacy refers to a person’s ability to use information and services for health. (More definitions) 

Using information for health implies three steps: 
1) Understanding, that is, decoding the words
2) Making personal meaning, that is, reflecting on the question: What does this mean for me in my situation with my resources, my family, my beliefs, my values?
3) Acting, that is, making choices and turning those choices into desired actions and health outcomes.

These steps coincide with three steps in problem solving, 
which I’ve described previously as The Three-Step Dance

1) What do you want?  For example, a woman decodes information in Beginnings Pregnancy Guide. She understands smoking can harm an unborn baby.

2) What have you got?  She acknowledges that she has a pregnancy, and a smoking habit that she enjoys and that relieves stress. She has a husband who smokes and a mother-in-law who smoked through her pregnancy and has a son who turned out fine. She has a budget already stretched, a friend who’s been after her to quit, and a doctor who’s offered some aids.  Through self-reflection and discussion with family, friends, experts she makes personal meaning from the information.

3) What’s Next? She makes a choice (decision) not to act  or to take action — some small step that she is willing and able to do now to move toward her chosen outcome — a healthy baby, which she understands requires a smoke-free womb. 

It is the action (or inaction) that affects the outcome. 
The first two steps in using information for health, and in addressing a health problem, are “all in your head”, a purely cognitive exercise with no health effects. 

What’s empowerment got to do with it?
Take another look at Step 3 in using information for health:  making choices and turning those choices into desired actions and health outcomes.  This is the World Bank’s definition of empowerment.  And the “Three-Step Dance” is the process of empowerment described by David Emerald in his book The Power of TED* The Empowerment Dynamic.

Empowerment is the act-ive ingredient in health literacy.  Without it, it’s all in your head. 

“Knowing is not enough; we must apply. Willing is not enough; we must do.” ~Goethe    

Note the Goethe quote is typically featured in the front matter of reports from the Academy of Medicine (formerly the Institute of Medicine). It is often attributed to Bruce Lee, but  Goethe said it first)

Further Reading 
Alsop, R. & Heinsohn, N. (2005) Measuring Empowerment in Practice : Structuring Analysis and Framing Indicators. World Bank. Free online:

The Power of TED by David Emerald - YouTube
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