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Interactive Health Literacy: under researched, unclear concept, measurement challenge


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Interactive Health Literacy: under researched, unclear concept, measurement challenge

Previously in this space we’ve said health literacy for disease prevention and health promotion is distinguished from health literacy for disease treatment. The latter is typically operationalized as functional literacy (reading and math) in a clinical setting. In contrast, to improve risk behaviors and conditions that affect their health, individuals, families and groups use interactive and critical health literacy skills.  These skill sets are applied mostly at home and in the community. We’ve looked at critical health literacy. Today we look at interactive health literacy, IHL for short.  As we might expect, research is limited and controversy abounds.
Not much is known about IHL
PubMed lists just 13 articles on “interactive health literacy”,  two of them review articles. I found no listings on “interactive health literacy” AND “parent” or “mother”. Most IHL studies have been reported from outside the US.

Canadians Manafo and Wong looked at IHL promotion programs for older adults with chronic disease. They differentiated IHL from functional health literacy by the aim of the intervention (skill development to increase capacity to find information and make personal meaning from it vs. information giving to increase knowledge). They found five studies on IHL for seniors, 1 from Canada, 4 from eastern U.S.  All relate to training elders to search for health information online. My understanding of Nutbeam’s model of IHL is that it refers to interpersonal interaction and communication, not interactive (vs. static) information.   The reviewed studies are limited by small samples, no comparison groups, non-experimental design, non-comparable measures and outcomes.

The second review, from England, is a concept analysis of critical health literacy. Sykes and colleagues describe critical health literacy as a set of characteristics including effective interaction between service providers and users. Key attributes include social and communication skills, and interpersonal skills.  So critical health literacy is seen as “arising from …ability to interact effectively”, that is to navigate services, and to advocate and articulate confidently when communicating with a health professional —IHL.  This view looks at the faces of health literacy described by Nutbeam as a hierarchy of skill levels that develop linearly. However,not all scholars agree; and it seems difficult to separate interactive from critical health literacy.
Measures of IHL
Two studies, one from Japan and one from the Netherlands, used the Functional Communicative Critical Health Literacy scale which measures frequency of perceived difficulty with tasks indicative of the three levels. These authors describe IHL as the skills that can be used to participate actively in everyday situations, extract health information and derive meaning from different forms of health communication and apply it to changing circumstances,  while critical health literacy  refers to ability to exert control over health. Among Japanese patients with diabetes, interactive and critical health literacy, but not functional health literacy, were associated with self-efficacy, the most important factor in behavior change.  The Dutch authors conclude that IHL was associated with ability to organize care, interact with healthcare providers and perform selfcare.

Again, in these studies interactive/communicative and critical health literacy skill levels overlap and are difficult to differentiate. Indeed, in psychometric testing, communicative (interactive) and critical health literacy were closely related and findings were reported in two categories: functional vs. communicative and critical health literacy.

Rubin et al describe the Measure of Interactive Health Literacy,  a 10-minute telephone-administered “performance measure of an individual’s proclivity to engage in information seeking from health information sources” For more info, see:
Skill levels or categories? All are needed to protect and promote health
Another school of thought — the one I’m in — sees categories of health literacy skills rather than levels.  Individuals or groups combine skills from Nutbeam’s three categories in different ways for different tasks and situations.  Strength in one skill or skill set can make up for weakness in another.  And a family or community  member can contribute skills that an individual lacks. That’s how health literacy becomes a community asset.

Through interaction, information that is understood cognitively, is processed socially and personalized to the particular context and circumstance.  Interactive health literacy skills combine with functional literacy (reading and math) and critical health literacy skills to empower individuals and communities to use information for health and gain control over its determinants.
Reference & further reading
Manafo E & Wong S (2012).  Health literacy programs for older adults: a systematic literature review. Health Education Research 27 (6); 947-960. doi:10.1093/her/cys067 
Sykes S, Wills J, Rowlands G, & Popple K. (2013). Understanding critical health literacy: a concept analysis. BMC Public Health 13:150 doi:10.1186/1471-2458-13-150
Rubin DL, Parmer, J, Friemuth V, et al. (2011). Associations Between Older Adults Spoken Interactive Health Literacy and Selected Care and Health Communication Outcomes. Journal of Health Communication 16sup3, 191-204. doi:  10.1080/10810730.2011.604380
Ishikawa H, Takeaki T, &Yano E. (2008). Measuring functional, communicative, and critical health literacy among diabetic patients. Diabetes Care 31 (5),874-879.

Van Der Heide I, Heihmans M, Schutt AJ, et al. (2015). Functional, interactive, and critical health literacy: Varying relationships with control over care and number of GP visits. Patient Education and Counseling 98 (8), 998-1004.  doi: 10.1026/j.pec2015.04.006
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