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Health Literacy & The World of Diabetes Update

People have been asking about my presentation on health literacy at the World of Diabetes Update 2011, an annual event of the University of Washington’s Continuing Nursing Education office. Here is an abridged version.  More on health literacy as empowerment another day. 

For permission to use any of the slides or content, please email me.  

The artwork on this slide is one of a series of 16 Reflective Drawings associated with the Beginnings Parents Guide.  Each line drawing conveys a key message without words. As a mother colors in the drawing, she personalizes the message and reflects on how it applies in her life. The message here, is Read to your Child. Reading aloud to a child improves parental literacy and fosters the child’s emerging literacy.  The artist is Laurel Burch.  

I’ll give myself an A for this session if you leave with an interdisciplinary understanding of health literacy so that you can read the literature critically and decide for yourself what it means for people with diabetes and for your work.
We’ll look at reflection as a literacy skill, a health literacy skill, and as the foundation for empowering a person as an “activated patient”, a “responsible healthcare consumer” and as one who exerts increasing control of the determinants of their health.

We cannot talk about health literacy without first talking about literacy.  The meaning of literacy is constantly changing to reflect society.  In the traditional view, literacy refers to basic individual skills used to acquire knowledge; the “3 Rs”: reading, ‘riting, and ‘rithmatic. It is considered an expression of cognitive ability. Low literacy is considered a deficit and bears a stigma. This is the perspective of most health literacy research that you might read in the medical journals.  A more current view recognizes literacy as a social interaction so that what it means to be literate is defined by the context, and by the person’s age, race, gender and culture.   This leads to concept of multiple literacies, in which literacy is seen as practical and empowering.

Health literacy is most often defined in the autonomous view of literacy, which focuses on individual cognitive skills; so that in the medical literature, health literacy almost always refers to ability to read medical terms and healthcare documents.   The research focuses on low health literacy as a risk to patients and to the healthcare system, which clinicians    The definition is from the Institute of Medicine and is used by Healthy People 2020.

Nearly all research has measured health literacy by one of two tests –see the slide. The REALM has been whittled down to a 7-word, 7-second word recognition test. The FHL in TOFHLA stands for functional health literacy – meaning basic skills. The 3Rs are traditionally called “functional” literacy skills as they were assumed to enable a person to function in any context. Literacy scholars now recognize that it takes more than the 3Rs to function in modern society.   These tests are used only in research because patients like them about as much as they like needles.

This alternative definition comes from the World Health Organization. You would encounter it when reading the international public health literature.  In this more current view, health literacy involves a range of skills and goes beyond understanding info and making decisions to using information in context – acting on it in real life situations– to enhance health. In this view, health literacy is a personal and community asset that can be developed through health promotion activities. 

We can think of health literacy as one of multiple literacies. This concept says that literacy skills always are used for some practical purpose. A person has at one time many literacies at varying levels of proficiency. Each of your multiple literacies enables you to function in some social context.

Here is a conceptualization of information literacy as encompassing many more specific literacies. Uncle Sam wants you to embrace digital literacy. And here’s a handbook of sustainability literacy.


Health literacy enables people to use the healthcare system and manage personal, family and community health.

Now we can say, in short, diabetes health literacy means ability to manage diabetes.

And promoting diabetes health literacy means empowering patients to manage healthcare and self-care for diabetes.  Stay tuned for more on empowering “activated patients”. For more on empowerment now explore TED* The Empowerment Dynamic.

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