Health Literacy – Still Not Feeling It?

Literacy-1Blog post by Bernadette Keefe MD

Health Literacy – It’s still not catching on.

The Center for Disease Control and Prevention (CDC) defines health literacy as

“The degree to which an individual has the capacity to obtain, communicate, process and understand basic health information and services to make appropriate health decisions”.

As a believer in improved general literacy for citizens, I have assumed that health literacy, achieved through quality health information, having been easily accessed and well understood, would be akin to the process of general literacy. But just as education involves more than the conveyance of information, it is similar for achieving health literacy.

Although considerable efforts have been made regarding the formulation and dissemination of health and self-care information, we are seeing little effect on health outcomes. All parameters of health and wellness in the U.S. remain stubbornly poor, including the high incidence of obesity, type 2 diabetes, heart disease, cancer, mental health, and addiction. Healthcare systems and healthcare professionals continue to tout patient engagement strategies and the importance of health literacy, but as Michael Friedman states in his excellent piece on the topic:

But it could be argued that to have true health literacy, we cannot focus exclusively on information and logic. We must understand that for most of us, health decisions involve a substantial emotional component, in which our fear, sadness and other emotional states influence our decisions.

– Michael Friedman MD 

The following schema illustrates health literacy’s role as part of an outcomes model for health promotion.

Figure 1

From: Health literacy as a public health goal…– Oxford Journals

The Prepared Mind and Heart – Emotions

Indeed, receptivity to health messages is not simply a rational process. In many ways, we hear what we are ready to hear, and, ready to hear” has a host of components.  Some basic questions to consider about receptivity to health messaging might be: Is the individual rested, relaxed, empowered, and respected?  Does the individual have chronic pain, and inadequately addressed mental/emotional illness? So many variables, other than the raw messages, impact whether or not health messaging is actually received.

The Conducive vs  Non-conducive environment

Communicators have tweaked their messaging as well, incorporating little “nudges” to help us towards improved behaviors. Wellness programs and fast food restaurant calorie postings are just such interventions. However,

“….nudging sometimes simply isn’t effective. Some employers are finding that their wellness programs don’t work, bringing about diminished morale instead of health benefits (let alone corporate savings). Likewise, calorie labeling may raise awareness of health issues without reducing junk-food consumption.”

– Frank Pasquale  “Why ‘Nudges’ Hardly Help”

Without considering the context of individual lives, the environment in which people “swim”, these programs and their messages,”nudges”, can easily fall on deaf ears. If employees do not trust their employer, or have personal issues which may carry stigma such as obesity and mental health, or are already under undo stress, will they be eager to sign up for a wellness program? Posting caloric content on menu boards in fast food restaurants is industry norm but this move has not really changed the ordering in fast food restaurants.  Perhaps we need to look at whether these people have alternative food options and the money to afford them. Nudging without knowledge of context rarely leads to better outcomes.

The Cost Shift Strategy

The U.S. government and employers, overwhelmed by the burden of healthcare costs, have additional levers to “encourage” health literacy by way of incentivizing healthier behaviors. A popular method now is to cost shift more of healthcare to individuals, a policy meant to increase individuals’ “skin in the game”, hoping that the wallet can be motivational. However, when the wallet is nearly empty, and it’s a choice of food or engaging with a costly healthcare system, people are simply avoiding healthcare. The skin in the game strategy simply doesn’t translate as a “value message”.

The Expanded View – Solutions

Ultimately, it seems, achieving true widespread health literacy – “health literacy plus” – must be a team sport. Team members include: individuals and populations, a wide variety of professionals and communicators, and, enlightened governance in order to support and foster the endeavor. This health literacy plus involves understanding and caring for people’s emotions, removal of barriers to accessing health information, fostering conducive environments such that individuals are “ready” to hear and empowered to act, and sensitively and intelligently conveying the value proposition. Getting to this place is not a task for the faint hearted and is a marathon, not a “quick fix”.  As the graphic below demonstrates, there are a host of elements that must be incorporated under “The Health Literacy Umbrella”

Figure 2

Finally, to truly achieve better health outcomes we need to attend to the personal: the context of people’s lives, including their resources, and values, and imbue every intervention with respect. Please join us Tuesday May 31st at 8:30pm ET (for your local time click here) for our weekly #hcldr chat on the following topics:

  • T1 What is your definition of health literacy? How successful is your country in fostering it?
  • T2 How much does the health literacy of populations matter, and why?
  • T3 How would you prioritize and design a successful health literacy program?
  • T4 Social support of people seems to be important in getting to real health literacy. How should that be accomplished?


“Learn About Health Literacy”, Centers for Disease Control and Prevention,, accessed May 26 2016

“Health Literacy”, Penny Glassman et al, National Network of Libraries of Medicine,, accessed May 26 2016

“Why Nudges Hardly Help”, Frank Pasquale, The Atlantic, December 4 2015,, accessed May 26 2016

“Health Literacy: A Necessary Element for Achieving Health Equity”, Robert A Logan et al, July 24 2015,, accessed May 26 2016

“Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century”, Don Nutbeam, Oxford Journals,, accessed May 26 2016

“Health literacy interventions and outcomes: an updated systematic review”, Berkman MD, March 2011,, accessed May 26 2016

“Health Literacy Interventions and Outcomes: An Updated Systematic Review”, Nancy D Berkman, March 2011,, accessed May 26 2016

“Health Affairs and the Movement to Collaborate for Community Health”, Build Healthy Places Network, November 7 2014,, accessed May 26 2016

“Ignorance is not bliss when it comes to health literacy”, Colin Hung, HCLDR Blog, March 2 2014,, accessed May 26 2016


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