Title: Working With Ideas in Health Literacy
Authors:
John M. Weiner, Dr.P.H.
Director, Idea Database Construction and Maintenance,
Center for Study of Scientific Ideas,
West Lafayette, IN 47906.
[email protected]
Sharon A. Weiner, Ed.D.,
Professor, Library Sciences
Booker Chair in Information Literacy
Purdue University Libraries
West Lafayette, IN 47906
[email protected]
Keywords: health literacy, idea analysis, interventional research design,
descriptive research design, text analytic approach, quantitative,
qualitative
Abstract
Sixty-five hundred articles were entered into PubMed during the period 2000-2015 dealing with
the subject of health literacy. The analytic method, Idea Analysis, identified, extracted, and
organized the ideas presented by the authors in their sentences. Over 700,000 ideas were
identified. An idea map involving terms linked with the central term – health -- showed a fairly
complete array of terms in the methods dimension suggesting that the research design favored by
author-specialists was the descriptive one. The addition of the term – literacy – to health
changed the idea map minimally confirming that the idea – health literacy – was the primary one
in describing the subject. Given the essential role of this central idea, maps were constructed
showing the implications of adding the terms – intervention or survey. The idea maps for the
quadratic ideas – health, literacy, intervention & related term vs. health, literacy, survey &
related term – demonstrate the differences in information associated with each. These maps
show the emphasis placed on different research designs by the author-specialists. The
intervention research design is used to describe existing variables and relationships as well as to
determine the effects of treatments in inducing changes in the conceptual structure. The
description design (illustrated by adding the term – survey to the central idea) is used to
determine the variables and relationships representing a phenomenon. The design is most useful
in determining new methods although present use has extended its applicability. In terms of idea
structures, health literacy represents a successful blend of quantitative and qualitative
approaches.
Working With Ideas in Health Literacy
Introduction
Ideas are important building blocks leading to conceptual structures describing existing
knowledge and examining potentially, new research strategies. Linguists have long emphasized
the importance of informative terms in learning and using information regarding a subject. (Lee
1996) In 1979 (Weiner 1979) introduced an approach which captured ideas presented in text.
This approach was based on the structure of the simple sentence. That consisted of a subject,
verb, and object. The combination of subject and object presented a thought or idea and was
inviolate irrespective of the change of verb.
Term pairs can and do exist in larger, more involved sentences. Their existence suggested larger
combinations of terms in forming more complex ideas. The operational definition of an idea
holds with respect to the simple and complex sentence. It is the combination of two or more
informative terms, presented by the author-specialist, within the domain of a sentence. This
focus on the contents of a sentence was considered important in maintaining contextual
relevance of the combination. While hyperlinking is popular, numerous examples can be seen
where the combinations of terms do not convey the author’s intended meaning.
Software could identify and separate sentences, as well as identify the informative terms within
the sentence, accurately and completely. The informative terms within each sentence were
combined to form pairs (ideas). Those were stored in a database file where they could be
organized and retrieved on demand. The Excel file format was selected because of its
widespread use.
This approach, Idea Analysis, has been studied in a variety of chronic diseases. (Weiner 2005)
Current databases include:
1.
2.
3.
4.
5.
http://researchdisaster.com
http://researchdogdisease.com
http://researchdentistry.com
http://researchhealthdisparities.com
http://researchhealthliteracy.com
Experience with these suggests that the idea database structure is significant in dealing with the
thousands to millions of ideas used by author-specialists in describing a subject. This process
will be illustrated using ideas from health literacy.
Health Ideas in Health Literacy
The 6,524 documents dealing with health literacy were entered into PubMed during the period
2000-2015. These were retrieved and analyzed. A total of 735,599 ideas were identified and
organized in excel files. The ideas dealing with the central term – health – were identified and
organized as a separate excel file. There were 67,340 ideas containing health linked with a
related term. These ideas were analyzed and the frequency of the linked terms was determined.
Table 1 shows the higher frequency terms linked with – health. Assuming that the subject
specialists emphasize ideas that are relevant in the subject, the more frequent inclusion of an idea
in sentences suggests that the idea is important. This argument is strengthened by the fact that
the idea is voiced by specialists throughout the world. (Weiner 2014) As might be expected, the
idea – health & literacy – is the most frequently cited in sentences. The “&” sign is used to
denote a link between the words. Larger combinations of terms are shown with commas
separating the central idea terms.
Table 1. Frequency of Ideas Involving the Central Term – Health.
Terms
Total Ideas
literacy
information
education
mental
assess
knowledge
research
intervention
adult
skill
service
public
access
population
community
clinic
Freq
67339
8899
2622
1806
1540
1291
1211
1079
1074
1051
994
989
960
943
909
789
781
Etc.
Figure 1 shows the higher frequency terms combined with health by the author-specialists. In
developing a conceptual structure representing the term – health – and related terms, dimensions
(sub-topics or components) were determined. Any subject can be conveniently divided into the
following dimensions:
1. Personal factors – variables describing the individuals studied.
2. Environmental factors -- variables describing the physical, social, psychological and
cultural environments in which the individuals live.
3. Subject/Disease factors – variables describing the clinical, laboratory, physical,
psychological, social, cultural characteristics describing the subject.
4. Treatment factors – variables describing the physical, pharmacological,
psychological, or education characteristics designed to change subject/disease factors
of interest.
5. Outcome factors – variables describing beneficial or adverse changes related to the
application of treatment factors.
6. Methods – variables describing the tools and procedures employed in realizing the
conditions described in the other dimensions.
Figure 1. Terms Linked with the Central Term – Health – 2000-2015.
Figure 2. Terms Linked with the Central Idea – health & literacy – 20002015.
The predominant dimension (see Figure 1) is the methods, suggesting that the study design most
frequently employed is the descriptive one. This design involves the capture of the status quo
either in terms of the measures and observations involved or in the array of relationships
observed. It might be characterized by the use of the survey in order to acquire and organize the
information depicting a phenomenon. The ideas suggest that the descriptive design might be
summarized by the following configuration of dimensions:
Description: Method  Personal / Environmental/ Subject
This arrangement of dimensions is contrary to the intervention design. That study design allows
for the two essential needs – description of the status quo and indications of change in the idea
structure associated with intervening factor(s). The arrangement depicting this design is --
Intervention: Personal + Environmental + Subject + Treatment  Outcome
Figure 2 shows the higher frequency ideas – health & literacy. Terms entered in Figure 1 and
unchanged are shown in black. Those repeated in Figure 2 are shown in red and new terms are
shown in blue. The methods dimension continues to dominate in terms of number of ideas.
Again, the impression conveyed is one associated with a descriptive design. In essence, the idea
structure remained essentially the same when the central term was health vs. the central idea –
health & literacy. The modification from simple pairs (health & related term) to triadic ideas
(health, literacy, & related term) had little influence on the idea map.
What is Intervention?
The term – intervention – describes the act of imposing a change or potential for change.
Interventions may be pharmacological, physical, educational, or psychological factors. The
existing idea structure is changed by the intervention so that beneficial or adverse results are
observed. The intervention study, in its most appropriate form, can be considered as a causeeffect situation. Even without causation, the intervention design offers insights into enhanced
description of the relationships making up the phenomenon studied plus improved understanding
of underlying mechanisms and possible change factors. This design is unique in introducing and
improving knowledge. It provides a formalized, reproducible approach to acquiring and using
information.
Intervention Ideas in Health Literacy
Figure 3 displays the higher frequency quadratic ideas representing the central triadic idea –
health, literacy, & intervention -- for the period 2000 – 2015. The terms in the dimensions
illustrate the features of the interventional design. There are a number of outcomes, an important
component of the design. The treatments and methods dimensions employed consist of different
potential change factors. These ideas, supplied by author-specialists studying health literacy,
emphasized the relevance of this design in studying this subject.
The relationship between the interventional design and the interpretation of cause-effect comes
from the alignment of dimensions. The dimensions would be organized as – personal,
environment and disease/subject factors – in defining the population studied. Treatment
factors would involve attempts to introduce change. Outcome factors would describe change in
status – adverse or beneficial. The findings of such an arrangement would be interpreted as –
treatment induces change in outcome in the population defined by personal, environmental
factors with disease/subject characteristics.
Figure 3. Terms Linked with the Central Triadic Idea – health, literacy, &
intervention – 2000-2015.
Description (Survey) Ideas in Health Literacy
Figure 4 displays the higher frequency ideas representing the quadratic ideas – health, literacy,
survey, & related terms -- for the period 2000 – 2015. The terms in the dimensions illustrate the
features of the descriptive design. The most prevalent dimension describes methods. The
outcome and treatment dimensions are small and contain more general rather than specific terms.
This design may be most relevant in determining new methods although reports employing this
design tend to emphasize conceptual structure in terms of themes, i.e., interpretations rather than
an emphasis on new procedures or tools.
Figure 4. Terms Linked with the Central Triadic Idea – health, literacy, &
survey – 2000-2015.
Comparison of Ideas
Figures 3 and 4 illustrate the differences in conceptual structures associated with ideas, provided
by author-specialists, intended to convey specific information. In health literacy, ideas dealing
with treatment may be presented in the treatment, methods and information dimensions. The
ideas considered in the outcome dimension should include those that represent the change
process. In Figure 3, the outcome terms describe this change. For example, the term –
empowerment – was linked with the central idea. That quadratic idea linked with some form of
education could represent a measure of change in outcome. As such, terms depicting the
affective state also can be captured and displayed. The personal, environment, and disease
dimensions describe characteristics of the group being treated.
Table 2. Comparison of Frequencies of Quadratic Ideas Representing
Intervention versus Survey Approaches – Terms Linked with Either – health,
literacy, & intervention vs. health, literacy, & survey.
Terms
education
design
research
skill
adherence
medication
clinic
Intervention Survey
83
43
53
30
43
15
42
13
35
18
33
15
30
16
:
:
assess
adult
demographic
knowledge
information
sample
disorder
belief
cancer
:
mental
community
treatment
social
quality
diabetes
access
Diff
Intervention
Intervention
Intervention
Intervention
Intervention
Intervention
Intervention
:
41
21
4
20
29
2
16
10
15
:
83
63
60
57
52
45
38
35
26
Survey
Survey
Survey
Survey
Survey
Survey
Survey
Survey
Survey
84
21
28
21
18
14
18
Same
Same
Same
Same
Same
Same
Same
:
75
31
22
26
17
20
15
What is Description?
The term – description – describes the capture and organization of measures/observations and
relationships in order to describe a phenomenon. The intent is to develop a conceptual structure
representing a complex, real situation. The approach encourages individual interpretation of
findings rather than the data-driven results stemming from the interventional (change) design.
The descriptive design is most frequently employed with qualitative variables.
Table 2 shows an excerpt of these comparisons. The ideas (health, literacy, intervention, &
related terms) favoring intervention tended to emphasize the treatment and outcome dimensions
(terms such as education, medication, or adherence). In contrast, the ideas (health, literacy,
survey, & related terms), favoring the description design, represent personal, method or
environmental dimensions (assess, demographic, or belief). The ideas reflecting relative equality
between the two designs tend to depict the personal or subject dimensions (e.g., community) and
characteristics studied (cancer or diabetes).
Dimensions in the Idea Structure
The descriptive study design is intended to depict present conditions and/or relationships without
indicating the benefits or adverse effects of changes in the idea structure. These studies do not
offer insights into future improvements.
In Figure 4, the dimensions would be organized first as – methods -- in defining the data
captured. The methods terms most clearly depict the descriptive focus. Treatment factors
would represent general rather than specific approaches designed to introduce change. Outcome
factors would tend to describe affective changes. The findings of such an arrangement would be
interpreted as – methods describes the population defined by personal, environmental factors
with disease/subject characteristics.
Discussion
The terms linked with health, literacy, and survey constitute a set of quadratic ideas that express
the author-specialists’ understanding and use of the descriptive research design. Table 3 shows
the disciplines of first authors in a random sample of the documents favoring the interventional
design vs. the survey one.
Survey ideas were associated with 50 percent of the authors from social science departments.
This suggests training and experience in descriptive studies. In contrast, forty-seven percent of
the authors using the interventional design were from medical departments. This difference in
experience and discipline suggests the emphasis on design choice.
Those trained in medicine favored the interventional design with dimensions describing study
individuals, the environment in which they live, and the measures/observations depicting
conditions affecting them with specific treatments to effect change in the outcome dimension
factors. Those authors favoring the descriptive design had social science backgrounds. In the
descriptive design, the methods involved in capturing information are focused on identifying the
factors and relationships making up the phenomenon of interest. Outcome is not a primary study
issue.
Table 3. Comparison of Author Disciplines in Random Samples of
Documents Representing the Interventional or Descriptive Designs.
Intervention Design
Author
Freq
Computer
3
Dentist
3
Medicine
46
nurse
12
nutrition
2
Pharm
5
psychology
3
Social
25
Total
99
Description Design
Author
Freq
dental
5
medical
10
nurse
4
pyschology
6
social
25
Total
50
Examples of Complex Ideas in Authors’ Sentences
Producing triadic and quadratic ideas within authors’ sentences may be considered as a rare
event. However, analysis of single pairs in documents favoring intervention (2.1%) and those
favoring description (0.7%) suggested that complex ideas were the standard with 3 or more terms
presented in a sentence. Examples of sentences favoring description and intervention follow.
Ohl and colleagues (Ohl 2010) indicated that “rapid and accurate health literacy
screening tools could assist interventions to improve care in the HIV clinic setting”, but
that such screening had not been performed. The authors studied attendees to two HIV
clinics and administered the screening questions. They concluded that “HIV providers
often misjudge patients' health literacy. In the absence of rapid and accurate health
literacy screening tools, clinics caring for persons with HIV/AIDS should implement
clinic-wide interventions to improve health communication”.
To illustrate the possibilities, the informative terms within a sentence are highlighted in red.
Ideas formed from the terms shown in the Ohl document would be pairs, triads, higher formats:
health & literacy
health&screening
health &intervention
health & HIV
health & clinic
literacy & health
literacy & screening
etc.
health, literacy, & screening
etc.
health, literacy, screening, & intervention
etc.
health, literacy, screening, intervention, & HIV
etc.
health, literacy, screening, intervention, HIV, & clinic
etc.
A study was reported in 2011 (Macabasco-O'Connell 2011) that illustrates the
descriptive design approach. They used a web-based survey to assess the knowledge and
perceptions of health literacy among a random sample of nursing professionals. The
findings were subjected to a qualitative textual analysis designed to “define health
literacy using their own words”. They concluded that “nursing professionals'
knowledge of health literacy and their understanding on the role health literacy plays
on patient health outcomes was limited”. The distinction between descriptive and
interventional studies can be seen by considering their concluding sentence. The authors
suggested that “educating nurses on health literacy and improving patient
communication and understanding can improve health outcomes”.
The authors (Kim 2010) analyzed data from the “National Cancer Institute's 2005 Health
Information National Trends Survey”. The authors indicated “that factors that distinguished
cancer e-patients from other cancer information seekers were age, gender, education,
employment status, health insurance, and membership in online support groups”. However,
they concluded that there was “little evidence that e-patients were savvy health information
consumers who could make informed decisions on their own health”. They suggested that
there was a “need for a better design and delivery of health information literacy programs for
cancer e-patients”.
These examples of sentences containing complex ideas also illustrate the distinction between
descriptive and interventional designs. Ohl and colleagues concluded that “In the absence of
rapid and accurate health literacy screening tools, clinics caring for persons with HIV/AIDS
should implement clinic-wide interventions to improve health communication”. MacabascoO'Connell et al. suggested that “educating nurses on health literacy and improving patient
communication and understanding can improve health outcomes”. Kim suggested that there
was a “need for a better design and delivery of health information literacy programs for cancer epatients”. Statements of this type assume that appropriate interventions have been developed.
However, no references to these were provided and the mechanisms for accomplishing
improvements were unstated. The nature of descriptive studies prohibits declarations of
observed changes in the idea structures, associated with interventions, as those are beyond the
scope of the investigations.
The report by Pellowski (2016) describes an interventional study. These authors
indicated that the “mixed results of previous interventions for people with HIV and low
health literacy, warranted investigating possible targets for improved adherence”. They
proposed “to identify the correlates of optimal and suboptimal outcomes among
participants of a recent skills-based medication adherence intervention”. They
concluded that “higher levels of health literacy and lower levels of alcohol use were the
strongest predictors of achieving HIV viral load optimal outcomes”.
The distinctions between the two designs are indicated by the emphasis placed on change. The
interventional design employs data-driven change while the descriptive design emphasizes the
importance of opinion-driven interpretations.
The health literacy subject offers a unique opportunity to compare the two major research
designs in use. That suggests an effective merger of the qualitative and quantitative approaches
in developing new knowledge about decisions in health care.
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