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Center for Health Literacy Promotion Blog

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
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