Promoting Functional Health Literacy
Sandra Smith, MPH, PhD [email protected]
HARC 2009
Promoting Functional Health Literacy: A Conceptual Framework for Measurement & Intervention
This poster presents the conceptual foundation for a line of research to inform health literacy promotion practice. In
other words, to discover intervention strategies which enable people to use information and services in progressively more
effective ways to maintain or promote their health.
We cannot promote functional health literacy from where we are now (bottom row). Because there is nowhere to go
when functional health literacy is understood and measured as a fixed trait, and focus on low health literacy as a risk to
manage. Most research has conceptualized functional health literacy as basic technical skills that enable people to acquire
knowledge and comply with prescribed behavior (bottom row). Nutbeam introduced these higher levels of health literacy skills
that enable people to prevent and solve problems, participate in healthcare, and exercise some control over their health (left
column). He suggested health promotion activities that could build these skills as assets, along with the types of outcomes that
might demonstrate improvement (middle column).
But we’re still stuck with no room for improvement due to the narrow 20th century view of functional health literacy
as basic technical skills for basic functioning. The National Literacy Act of 1991, which generated initial interest in health literacy
research, intended to replace this narrow view with the broader idea of multiple functional literacies. In this concept, literacy
skills are always used for a practical purpose. Skills matter because they enable a person not only to understand information,
but to do things in real life. Health literacy skills (entire left column) enable people to use information and services in ways that
maintain or promote their health. In practical terms, health literacy enables people to use the healthcare system and take care
of themselves and others. In this way, health literacy is a personal and community asset that can be built through health
promotion efforts. Looking at health literacy as one of multiple functional literacies, we can connect the levels of literacy skills
(arrows, left column) so that we have room for improvement.
Staying with the idea of multiple functional literacies as an array of skills that enable people to function in society, we
can link the progressive levels of health literacy skills (left column) to progressive levels of health functioning (arrows to left
column). This makes improved health function the outcome of improved health literacy skills. So we can assess improvement
in health literacy skills by improvement in health functioning.
Health literacy promotion aims to increase ability to use information and services in ways that maintain or promote
health. We can describe the pathway to progress by characterizing increasingly effective ways-that-maintain-or-promotehealth. In other words, we can identify health attitudes, actions, behaviors and practices that demonstrate health literacy skills.
Then using Likert scales we can map progress from inadequate skill and functioning to optimal skill and functioning for groups
of individuals.
The Health Literacy Progression instrument Attached are two scales comprising the Health Literacy Progression for
parents of young children. The Healthcare Literacy Scale rates parents’ use of information and healthcare services. The Selfcare
Literacy Scale rates self management of health at home. Both scales are derived from the Life Skills Progression instrument
(Wollesen &Peifer, 2006) Measures are repeated over time (intake, every 6 months, closure). Comparison of sequential
measures shows progress and regression. Low scores show needs to address; high scores show strengths to build on.
A two-year field test (N=2532 parents) showed these tools are useful in practice. An intervention focused on
improving parents’ interactive and reflective skills produced statistically significant improvements in functional health literacy in
the first six months regardless of reading level.
Nutbeam, D. (2008).The evolving concept of health literacy. Social Science &Medicine, 67, 2072-2078.
Smith, SA. (2009). “Promoting Health Literacy: Concept, Measurement & Intervention” (PhD dissertation. Union Institute &
University, Cincinnati).
Wollesen, L. & Peifer, K. (2006). Life Skills Progression: An outcome and intervention planning instrument for use with families at
risk. Baltimore: Brookes.
Promoting Functional Health Literacy
Sandra Smith, MPH, PhD [email protected]
Sandra Smith, MPH PhD [email protected]
The LSP Healthcare Literacy Scale
©Brookes, 2006
The Healthcare Literacy Scale is one of two scales comprising the Health Literacy Progression. Both scales are
derived from the Life Skills Progression instrument. This scale rates parents’ use of information and healthcare
services. The shaded area represents the target range of adequate to optimal functioning in the healthcare system.
In this hypothetical case, the mother scored 2.9 on healthcare literacy (average of available scores), well below
target range. Her interest in information from healthcare providers is developing (item 10 Use of Information). She
has established a medical home for her child (item 20 Child Well Care) but not for herself (item 18 Parent Sick
Care). She is beginning to use health services, albeit inconsistently.
Promoting Functional Health Literacy
Sandra Smith, MPH, PhD [email protected]
Sandra Smith, MPH PhD [email protected]
The LSP Selfcare Literacy Scale
©Brookes, 2006
The Selfcare Literacy Scale is one of two scales comprising the Health Literacy Progression. Both scales are derived
from the Life Skills Progression instrument. This scale rates parents’ management of personal and child health at
home. The shaded area represents the target range of adequate to optimal functioning in the healthcare system.
In this hypothetical case, the parent scored 3.3 on selfcare literacy (average of available scores), below target
range. Item 4 Attitudes to Pregnancy is not scored since the pregnancy is ended, or the parent is a father. The
parent avoids unhealthy behaviors (items 24 Substance Use & 25 Tobacco). S/he is beginning to make use of
information to support child development (item 7) and to use community resources (item 11).