End of an era? Health literacy as we know it first appeared in the US medical literature
in 1993 following publication of findings of the 1992 National Adult Literacy Survey (NALS).
Along with the International Adult Literacy Survey, the NALS made clear that limited
fundamental literacy skills (3Rs – reading, ‘riting and ‘rithmatic) is the norm in the US and
other industrialized nations. But we quickly dismissed and forgot widespread criticism that
George H. Bush’s campaign for adult literacy was largely a political explanation for a
deteriorating economy, like similar historical clamors over low literacy that have arisen with
each of the country’s economic downturns. We also forgot several official statements from
developers of the NALS that unconventional test interpretation schemes likely overstated low
Now, 17 years later, 1500 published articles show that materials about health and healthcare
are difficult and people struggle to use them. This is due to in part to low reading ability;
and in larger part to complex, anxiety-producing topics, complicated medication regimens,
high tech-low touch treatments, unequal access to information and care; and communication
that relies on jargon laden printed material. And perhaps, it is due in part to the natural
reluctance of the knowledge elite to give up power. I am thankful this period is coming to
The approach that has focused on patients’ low scores on medical-word recognition tests and
sought to quantify the negative impacts of patients’ cognitive deficit on healthcare quality and
costs cannot succeed. This is true for a litany of reasons; primarily because it holds patients
as unable to learn what they need to learn and do what they need to do to recover, maintain
and promote their health. While what we want is “activated patients” who take “response-ability”
for their personal, family, and community health, we have focused our attention, efforts and
dollars on demonstrating their inability to meet that expectation.
New challenge I am thankful the field is refocusing. Dr. Rima Rudd set the new challenge for
health care researchers in her keynote address to the 2011 Health Literacy Annual Research
Conference: figure out how to support individuals’ action for health.
This is no small tweak to the dominant approach to health literacy. It’s a proverbial shift in
the wind. It means rethinking the meaning and measure of health literacy, what is worth doing
and who should do it. It means supporting health-promoting action instead of documenting
cognitive deficits and non-compliance. It means reconsidering who produces health and where.
It means reflecting deeply on the American default to individualism and recognizing the social
nature of both health and literacy.
The Cutting Edge I am especially thankful for and to the home visitors and their supervisors
and program directors who have already accepted the challenge to support individuals’ actions
for health and promote health literacy. They are the cutting edge. In particular, I salute the
staff and leadership of these programs that I know are working everyday to promote health literacy
by building parents’ capacity to manage personal and family health and health care: Enterprise
Community Healthy Start, Augusta, GA; Early Head Start of Monterey County, Salinas, CA; Partnership
for Strengthening Families, Bozeman, MT; Garrett County Health Department, Oakland MD and Healthy
Families America programs across Maryland; Healthy Families Indiana MOM Project, Indianapolis, IN;
Healthy Families of Grant County, Marion, IN; Child Health Investment Partnership of Roanoke Valley,
VA; Welcome Home Baby and Hand to Hand - Aspiranet programs in San Pablo, CA; South Phoenix
Healthy Start, Tempe Az; Parents as Teachers-National; PAT parent educators in Popular Bluff,
Neelyville and Twin Rivers, MO.
Hourigan, M.M. (1994). Literacy as social exchange: Intersections of class, gender, and
culture. Albany, NY: State University of NY Press. National Academy of Sciences & National Research
Measuring literacy: Performance levels for adults. Committee on Performance Levels for Adult
Literacy, Robert M. Hauser, Christopher F. Edley Jr., Judith Anderson Koenig, and Stuart W. Elliott,
Editors, National Research Council. Retrieved on March 12, 2009 from