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Massively Multifactoral Health Literacy Needs Intervention Cocktail, Not Better Reading

Like health and literacy, health literacy is massively multifactoral*.  Its meaning and requirements
for an individual depend  on complex interactions of gender, age, culture, socioeconomic status,
education, occupation, health status, medical condition(s), knowledge and beliefs, language, experience
with professionals and institutions… the list goes on. Reflecting on the 2011 Health Literacy Annual
Research Conference –HARC held in Chicago, that is, for me, the take-home message that is making
itself ever more apparent in health literacy research. 

The idea is more easily acknowledged than applied.  Many researchers agree that health literacy is
content specific and context specific. There is discussion of diabetes health literacy, mental health
literacy, dental health literacy, oral health literacy, breast cancer literacy and of course, maternal
health literacy. There is acknowledgement that healthcare systems and professionals introduce factors
that influence patients’ health literacy.  There is a nod to the idea that people use their health literacy
at home and at work in everyday decisions that affect health, not just in clinical consults about major
disease, so it is a public health issue as well as a healthcare issue.

But the idea that health literacy is massively multifactoral is not widely accepted, in part because it
makes research messy and imprecise.  As a field, we are still stuck on measuring patients’ health
literacy by giving them reading tests, once.  This matters hugely. Because what we measure determines
what we find out about what works and what is worth doing and who should do it. 

The continued use of one-time reading tests implies that reading is the only factor in health literacy,
and that reading ability and health literacy are static – something you have or you don’t. It implies
that patients are autonomous and passive rather than part of a social web.  It assumes that health
literacy is purely cognitive – that reading ability leads to “an appropriate health decision” which
produces health promoting actions and seamless health services delivery.  This view is not supported
by the evidence.  It ignores large bodies of research from other fields. Further, although the practical
purpose of health literacy is described as making health decisions, research has not tied reading skill
with decision-making, except where an appropriate decision is equated with compliance.

What we find out by giving patients reading tests is that some (in most samples 15-30%) are poor readers
and testing engenders embarrassment and alienation. What we find out about what works is that
simplifying information and improving the way it is communicated make reading and understanding easier
for skilled and unskilled readers alike, and that is worth doing. 

However, to address a massively multifactoral problem, we need an intervention cocktail*.  We know
that clear, actionable information is part of it, but the active ingredients that enable a person to take
charge of their health and healthcare are yet to be identified. They are not to be found with reading

*Credit for these fine phrases goes to David Kessler, former commissioner of the US Food and Drug
Administration under presidents George H. Bush and Bill Clinton, and author of The End of Overeating.
He is referring to obesity.
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