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Health Literacy for the Third Era

The third era of healthcare
It started in the 1980s. Epidemiologists —they study how disease is distributed and controlled— 
realized that events and experiences we have in the womb —before we are even born—influence 
our health in middle age.  Discovery of the “Developmental Origins of Health and Disease (DOHAD) 
is what they mean by landmark research; it marks a turn that requires a new way of defining 
and measuring health, and a second transformation of healthcare services.
Halfon and colleagues trace the evolution of healthcare from the first era —1900-1950— 
when medical and health systems focused on germ theory and acute care of infectious disease. 
Around 1950,  gene theory and social research led to bio-behavioral theories that said disease 
results from the interaction of genetic make-up and adult health behaviors.  So the second 
era of healthcare refocused thinking and resources on chronic disease. Health promotion 
tried in vain to change adults’ risky behaviors.  Later researchers recognized that gene 
networks interact with each other and the environment in complex and dynamic ways that 
influence how our bodies and minds are engineered and re-engineered to function in our 
environments. This is when we started talking about the social determinants of health. 
Developing Health
By 2000, the synthesis of biological, behavioural and social sciences led to the slowly emerging
third era of healthcare where your doctor will focus less on chronic disease diagnosis and treatment 
and more on lifecourse health development.  The goal of Medicine will be to optimize your health
trajectory — the way your health plays out across your lifecourse, from preconception through infancy, 
childhood and on to old age.
Redefining Health
Thought leaders now are talking about health as a capacity—an ability or power to understand, experience 
of do something.  Health is used to achieve one’s potential and accomplish one’s goals.
Clarifying the Health-Literacy Link
The evolved concept of health is strikingly similar to current descriptions of literacy as an ability used
to achieve ones potential and accomplish one’s goals, to function in some social context. In other 
words, you’re healthy and literate when you function — interact successfully— with your environment. 
We could say further, you are health literate when you interact with your environment in ways that 
optimize your health.
Context Matters. Embrace Complexity
Transition to the third era of health care requires refocusing heath literacy research and practice on 
the environment in which health and disease develop, that is, on the context in which people make 
meaning from  information and use it for health and healthcare decision making and action. The  
goal of health literacy promotion for the third-era is to optimize a person’s or a community’s health 
trajectory. That means we need to be promoting maternal health literacy earlier —preconception. 
Repositioning Maternal-child Heath
Further, the rapidly increasing understanding of DOHAD —the developmental origins of health and 
disease— positions maternal-child health at the foundation of personal and public health and at the
center of an evolved third-era healthcare system. It makes maternal health literacy the foundation
That’s why I am working on ways to use data to understand the contexts in which maternal-infant
health and maternal health literacy develop.  Successful efforts to untangle the web of interactions 
that influence the health trajectories of a mother and her child may answer the health literacy 
promoter’s essential question: Where to begin?  Stay tuned.

Halfon N, Larson K, Lu M, Tullis E & Russ S. (2014). Lifecourse Health Development: Past, Present 
and Future. Maternal Child Health Journal 18:344-365.
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