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Center for Health Literacy Promotion Blog

“Functional Health Literacy” is not Functional

The term functional literacy traditionally refers to basic literacy skills, the 3Rs: reading, ‘riting, and ‘rithmatic. These autonomous skills for gaining knowledge were said to be functional, implying that they enabled a person to function in society. The idea was, if you can read and use numbers, you can learn what you need to know and do to function in any context.
That was true in 1852 when MA passed the first compulsory school laws. It was still true in 1918 when all American children were required to attend elementary school. 
At that time, the Sisters of Providence were arriving in Seattle on mule back from the Oregon Territory to establish the city’s first hospitals. The Sisters rode a circuit of the logging camps selling the first health insurance policies.  For $10 a year a logger was promised  full care in case of any injury or illness. The care consisted primarily of bandaging and amputations with handholding and whiskey for pain. The 3Rs were sufficient to understand the policy and to obtain the full benefits of care.
Times have changed, but thinking lags.
The term functional health literacy came into the healthcare discourse in 1993.  Starting with the traditional understanding of functional literacy, functional health literacy, came to be understood as basic literacy skills applied in a clinical setting, in other words, a patient’s ability to read and use numbers to understand medical, healthcare, and insurance related information. This conceptualization relies on the assumption that basic reading and ‘rithmatic skills still enable a person to function in society, and specifically in healthcare settings that were unimaginable even 50 years ago.
As the thinking goes, a patient who can read will be able to function in the healthcare arena. Reading will enable a person to recognize a medical problem, understand the difference and appropriate uses of primary and tertiary care, find an appropriate provider or collection of specialists, make appointments, manage transportation and child care, articulate symptoms, understand the diagnosis and treatment options, follow the medication regimen, change behaviors to prevent repeating or exacerbating the problem, file insurance claims and get reimbursed for costs that are unknown until the bill arrives.   All this in a complex, high tech, fragmented, rapidly changing environment with its own language and culture. 
Functioning in the health arena takes more than reading.
Modern literacy scholars say that the meaning of literacy is constantly changing to reflect society, so that what it means to be literate is context-specific. It’s different at different times and places for different ages and genders and cultures. Operationalizing health literacy simply as ability to read medical terms and documents surely oversimplifies the literacy tasks involved in managing personal and family health and healthcare. Time to update the way we think and talking about health literacy, and how it enables a person to function in the health arena.
Lucia, E.(1978). Seattle’s Sisters of Providence: The Story of Providence Medical Center~Seattle’s First Hospital. Providence Medical Center, Seattle.
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