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Health Literacy Lessons from Adult Learning Research (Part 2)

Adult development, habits of thinking determine health literacy 
Adults make sense of the world through a cognitive lens, a way of thinking, that develops
in specific ways across the lifespan, John Comings, EdD told us at the 2011 health literacy
annual research conference. The levels of cognitive development align with levels or
categories of literacy skills and the way people use information.  

With instrumental thinking, the undeveloped cognitive lens, knowledge is certain and its
sources are authorities. This level uses basic literacy skills (reading and numeracy) to
understand information. At this level, “if it’s on the news or in print, it must be true”; and
“if it matters, the doctor would have told me”.  Adults with basic or below basic literacy skills
interpret words literally and may miss the context. For example, it is common to understand
information about “most children” but not relate it to their own child. 

With socializing thinking, the developing adult becomes
more open to knowledge being uncertain and relies on
peers, family and other social networks to make meaning
from information. This cognitive lens employs, in addition
to basic literacy skills, interactive skills (speaking, listening)
to personalize information. For example, by talking with a
home visitor, healthcare provider, or friend to interpret how
information about “most children” relates to a particular child.

With self-authorizing thinking, a fully developed adult sees knowledge as uncertain, draws from
all sources, and uses her own criteria for judging sources and determining right action. At this
level of development, an adult uses critical skills (reflection, synthesis, analysis) to apply
information in context for personal benefit. This is the realm of the “activated patient” and
the “responsible healthcare consumer”, who not only understands information, but makes
personal meaning from it and acts on it ways that promote health. 

Lessons: To promote health literacy, develop interactive and reflective skills
Understanding health/medical information is only the beginning of health literacy. While reading
(basic literacy) is helpful in a clinical setting and other health contexts, it is certainly insufficient
for an activated patient or a parent who manages personal and family health.  To translate
information to decisions requires interactive (social) skills. And to convert decisions to action
requires reflective (critical thinking) skills.

Teach by asking
The most effective tool for developing interactive and reflective skills is the reflective question
The change necessary to improve health literacy is not a change in the information or in those who
receive it; it is the change in those who would promote health literacy. And the critical change is
from telling people what to do, to asking them questions that enable them to think critically for

Doak, C. C., Doak, L. G. & Root, J. H. (1996). Teaching patients with low literacy skills (2nd ed.).
Philadelphia: PA: J. B. Lippincott Company.
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