Health literacy as an important social
determinant of health:
The need for an expanded understanding and
comprehensive measurement tools
Andrew Pleasant, Ph.D.
Rutgers University
Department of Human Ecology
Extension Dept. of Family and Community
Health Sciences
All content  2006 A. Pleasant
[email protected]
In collaboration with Christina Zarcadoolas, Mount Sinai School of Medicine &
David Greer, Dean Emeritus, Brown University School of Medicine
APHA • Washington D.C. • 2007
Who’s here?
Work in health literacy?
Alphabet soup of current measures
NAAL/ NALS/ IALS - National Assessment of Adult
Literacy and HLC (Health literacy component)
HALS - Health Activities Literacy Scale
REALM - Rapid estimate of adult literacy in
medicine now REALM Spanish, REALM Teens
(really!)
TOFHLA, S-TOFHLA, Adapted TOFHLA - Test of
Functional health literacy in adults
Newest Vital Sign
The single (or 3) item issue
And … WRAT - Wide range achievement test
And … SMOG, Fry, Flesch-Kincaid, etc.
Initial development samples
REALM - Black women with low levels
of education
TOFHLA - Hispanic and African
American, all with less education
NVS - Hispanic Women
Chew - White men with GED or higher
Wallace - White women with less than
high school and insured by
TennCare/Medicare
Troubled TOFHLA: A brief look (N=50)
Average refusal + exclusion = 40% (n=48)
No consistency in reporting (anything)
3 basic versions (in English), variation exists
18 of 50 articles used 36 point scale; 13 consistently
25 of 50 articles used 100 point scale; 13, 5, 3, 2
consistent in different ways
7 used different scale or didn’t report
Inconsistent treatment - linear or categorical
No random samples
Meta-analysis population significantly dif. than U.S.
Ceiling and floor effects
Validity - several biases identified in literature
So … What?
Influences direction of funding, interventions, and
policy decisions
Little or no viability for pre-post design
Ethics of health literacy measurement in clinical
settings
Where is public health?
Validation method = Circle the wagons
No underpinning theory of health literacy
No direct utility for informing or evaluating
interventions, curricula, accrediation, policy, or pay
for performance
A health literacy research wish list
Be based on theory/ framework
Be multi-dimensional (real world contexts)
Theory & measure should reflect, respond to,
or inform:
Research agenda (determinants, MDGs)
Intervention design
Policy needs
Design of medical school/health professional
curricula & evaluation of professionals (2
sidedness) – performance criteria
(DeVillis 1991; Streiner & Norman, 1995)
Wish list … 2
Treat health literacy as a latent construct
Multiple items that sample the conceptual
domains outlined by theory.
Respect the principle of compatibility
For the attitude-behavior-knowledge relationship
to hold true, these must be measured at
equivalent levels of action, target, context, and
(Ajzen, 2005; Ajzen & Fishbein, 2005)
time.
Commensurate/comparable across contexts
(culture, life course, population group,
research setting).
(DeVillis 1991; Streiner & Norman, 1995)
Theory building
Only a few existing frameworks, theories,
models …
Nutbeam, 2000
Zarcadoolas et al., 2006
Paasche-Orlow & Wolf (2007)*
Bernhardt et al., 2005 (AMA)
Schilling & Davis 2005 (AMA)
Nielson-Bohlman et al., 2004 (IOM)
Does that leave us here?
Nutbeam model (2000) - 3 levels
Functional – basic skills in reading and writing
to be able to function effectively in everyday
situations. Speaking? Numeracy? Etc.
Communicative – cognitive, literacy, and social
skills used to participate in everyday activities
including the ability to apply new information to
changing circumstances. What skills?
Critical – advanced cognitive and social skills
applied to critically analyze information and use
information to exert greater control over life’s
events and situations. Defined by outcomes.
Four domains of health literacy
(Zarcadoolas et al., 2003; 2005; 2006)
Causes of the causes …
Fundamental
Civic
Scientific
Culture
Putting it all together
Communicative Operational
Skill domains
A synthesis rather than
Fundamental
arguing for the primacy of one.
Reading,
Start at the beginning writing,
literacy.
speaking, and
numeracy
Focus on what people can do
skills
and what they don’t always do
well.
Generati ve
Skill levels - Nutbeam, 2000; Halliday, 1975;
skills Πapply
Green, 1988; Street, 1993
existing ski lls
Content domains - Zarcadoolas et al., 2006;
to new
Bernhardt et al., 2005; Schilling & Davis 2005;
situation
Nielson-Bohlman et al., 2004; and many more.
A
k
Operational
Fundamental
Reading,
writing,
speaking, and
numeracy
skills
Content domains
Scientific
Civic
Cultural
Communicative Operational
Critical
Literacy levels
Fundamental
Reading,
writing,
speaking, and
numeracy
skills
Content domains
Scientific
Civic
Cultural
Suggested approach … 1
Form a broad collaborative effort
Enhance content validity
Seek delphi (virtual) conference funding - I’ll take
the lead on grant writing if YOU agree to
participate.
Agree on definition
Improve conceptual framework
Form working groups aligned with framework and
methodology
Finalize concept explication
Generate item pool - much of this already exists.
Test and reduce # of items
Suggested approach … 2
First step … adapt & develop a core module
Suggest - Operational level across domains.
Framework also provides basis for core plus …
Topic specific measures. (E.g., HIV/AIDs, diabetes)
Maintaining comparability across topic specific
measures.
‘Swapping out’ modules to fit needs and interest
Adapting modules to different contexts/ cultures
without necessarily losing commensurability/
comparability
What we get ..
A unified approach to health literacy
A stronger field
An ability to map out (e.g. structural equation
modeling) the “causes of the causes”
An ability to make explicit the connections between
health literacy and health
AND .. Bonus prizes!!!
A basis for the design of curricula, of complex
interventions, and of pay for performance metrics.
The end … thanks!
Questions? – Any takers?
Andrew Pleasant
[email protected]
 2006 A. Pleasant