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Center for Health Literacy Promotion Blog

In response to The Arc of Health Literacy, a Viewpoint published in JAMA online August 8, 2015.

From the Opinion:
Over the past 2 decades the lens of health literacy has widened greatly. In addition to focusing on the needs of individual patients, the field now brings the promise of greater commitment and shared responsibility from clinicians, institutions, and care systems.

With the highest respect for Drs Koh & Rudd,  I propose the lens is not widened enough to achieve national health goals.

Historically, heath literacy has not focused on the needs of patients so much as on their deficient reading skills and limited medical vocabulary and the risks and costs those deficits present to clinicians, institutions and systems.  The health literacy lens has widened,  but not enough to capture the full picture. The frame now includes clinicians and their contexts — institutions and system. This is important and necessary. But the picture still excludes patients' contexts - their lives beyond the clinical encounter; for the average American that's all but about one hour per year spent in a healthcare setting.  If health literacy  is to achieve its promises of  healthcare quality and health equity, the health literacy lens must widen enough to include the social determinants of health.

When the lens is turned inward so that we only see individuals as patients, it looks as if the problem is a combination of their low literacy and healthcare's demands and complexities. It looks like health literacy skills are only used or needed in clinical settings, (and secondarily in epidemics or disasters).  It looks like the solution is better information — more explanation of the jargon, clearer instructions, more readable medication labels.  It looks like taking the right medication at the right time, managing diabetes, and following discharge instructions are "routine tasks".  It looks like the problem is in patients and the solution is in clinicians, institutions, and systems.

The authors mention that national health goals mandate efforts beyond the walls of patient institutions to reach people in the community.  But the lens has not widened far enough to see health literacy in everyday life at home and in the community where health information is interpreted and used or disregarded. The focus is still too narrow to see what besides reading ability and quality of information  determine how and how well individuals manage the "routine tasks" and episodic challenges of keeping healthy and caring for others. The lens is still too clinically focused to see what besides improving information and its delivery might be worth doing and who besides clinicians might do it. 

Wild applause to all in health literacy for widening the lens to recognize that systemic problems in healthcare do not belong entirely to the patient.  Now let's open the lens further to see individuals as more than patients in exam rooms so we can keep bending the arc of health literacy toward population health and health equity.

Read the "Arc of Health Literacy" free online from JAMA.
Better information is certainly important and necessary, and also insufficient to enable patients to benefit from healthcare services.
Greater commitment and shared responsibility on the part of clinicians and institutions also is welcome and necessary. But we are still missing an essential element for achieving the national vision of a health literate society. The authors suggest that healthcare systems form  partnerships to reach people of all ages and backgrounds in the community as well as in the clinic setting.
The arc of health literacy now needs to move beyond its focus on improving information to improving capacity to use information and services for health.
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