II. Communication, Culture, Health, and Mental Health Care:
Perspectives on literacy & health literacy, continued

There are different ways of conceptualizing health literacy.

Nutbeam (2000) described health literacy as comprising three levels: Level 1 is functional health literacy, which is based on factual knowledge of health risks or ways to use the health system; Level 2 is an interactive health literacy, which involves the use of personal skills such as a capacity to make decisions based on health knowledge, motivation, and self-confidence in acting on health knowledge; and Level 3 is critical health literacy, which is individual and community capacity to influence the social and political environment to improve the underlying social and economic determinants of health.

The Health Literacy Component (HLC) of the 2003 National Assessment of Adult Literacy (NAAL) offers a three-component model of health literacy that defines areas of health literacy as clinical, prevention and navigation of healthcare systems (U.S. DHHS, 2003).

• The clinical type addresses interactions between the patient and the healthcare provider, diagnosis and treatment of illness, and medication, requiring skill and ability to: 1) complete a patient information form for an office visit, 2) understand instructions for taking/administering medication; 3) understand activities needed for self-management of acute or chronic illness; 4) follow provider recommendations for diagnostic testing; and 5) provide accurate information for a medical history, in verbal or written format.

• The prevention type is associated with maintenance and improvement of health, prevention of disease and early intervention in emerging health conditions, and engaging in healthy behaviors and self-care. Such activities necessitate the ability to: 1) identify signs and symptoms of a health problem that requires intervention by a healthcare provider; 2) follow guidelines for preventive health services; and make modifications to decrease risks of developing serious illness.

• The navigation type is related to understanding how a healthcare system works, including knowledge and awareness of individual patient rights and responsibilities, familiarity with vocabulary, concepts and processes necessary to use the healthcare system. The ability to navigate a healthcare system requires: 1) knowledge of health insurance plan benefits (covered and uncovered services); 2) capacity to determine eligibility for public health insurance assistance; and 3) ability to provide informed consent for a health care service.

Another model of health literacy is adapted from models of literacy (see National Adult Literacy Survey [NALS], International Adult Literacy Survey [IALS], and ETS Literacy, at http://www.ets.org). This model defines categories of literacy skills as follows: prose literacy (how well someone understands and uses information, e.g., in newspapers, manuals, flyers, and brochures); document literacy (how well someone uses information in forms, schedules, charts, graphs, and tables); and quantitative literacy (how well someone uses numbers found in forms, flyers, articles, and other printed material, including the ability to perform mathematical calculations).

According to this model, health literacy is how well one follows instructions, for example, on how to take medication, use information on product labels, read an article about nutrition, fill out a patient history form, and read a summary of medical test results, clearly building on prose, document, and quantitative literacy skills.

Rima Rudd, of the Harvard School of Public Health’s National Center for the Study of Adult Learning and Literacy, developed a Powerpoint presentation that specifically describes different skills in health literacy.

A copy of this presentation is available at http://www.metro.org/SIGs/pdfs/chi_rudd_4_30_02.ppt.

Wendy Jones, of the National Center for Cultural Competence, refers to Dr. Rudd’s work in training on linguistic competence. Ms. Jones added content describing the bullet points of Dr. Rudd’s work in further detail. This excerpt is available for download here.