Julie asked Mark and me if we had any final thoughts after an active
week of discussions. I do have a few, and Julie's response to Andres is
a good place to start and end my final thoughts. 

First, there is always the possibility the NAAL data can be manipulated
to support different agendas, but this study is not unique in that
sense. All data can be manipulated unless the people who care about
their accurate representation speak up and offer clear explanations of
their significance and limitations. I appreciate Julie pointing out the
tremendous amount of attention that has come to this issue in the last
few years as a result of promoting even the limited data we had from
1992. Now we have the results from a study using a nationally
representative sample that has produced results that can be defended in
terms of their reliability and validity. That is a big step forward,
despite the many aspects of health literacy we could not capture in a
single study. 

Julie asked what we learned from the NAAL. We confirmed literacy and
health literacy skills are related. We confirmed the findings from the
smaller studies with more specialized and/or non-random samples. Age,
race/ethnicity, education, insurance status, and use of health
information all are associated with health literacy skills. We learned
we will likely have a difference of opinion with the education community
about what constitutes functional health literacy because we don't want
the zero line to be drawn between below basic and basic. We also learned
from the process of collecting materials for the NAAL, there are some
health materials that are so difficult in terms of their content and
presentation, almost no one could reliably use them. Proficient in NAAL
terms may not even be good enough when actual conditions of health
decision making are factored in, if only 12% can deal with the most
difficult material in a non-critical situation.    

Those who know me personally know I tend to speak frankly when critical
matters are at stake. I am going to do so now. I have sensed perhaps an
undercurrent of disappointment in some of the posts this week because
the NAAL didn't deliver one big, easy to understand set of findings. I
want to caution against undermining ourselves because we don't have all
the answers yet. I have a beloved colleague who recently retired from
her 40-year government position in public health, many of those years
spent advocating for health literacy improvement. She always reminds me
we are on the long road, and we have taken only one of many major steps
we need to find the answers and build the case. The conclusion that the
NAAL didn't answer every question we have should be a stimulus to keep
investing in the unanswered questions and expanding our knowledge, not
repeat individual v. system canards.  

The gains of the last few years are real. Julie points out several of
them. Others are a report from the most important and credible
scientific research and policy organization - the Institute of Medicine
- saying we have a real public health problem, and we need a
multi-disciplinary approach to address it. They have also said it is one
of the top 20 priorities for health system improvement. We have fresh
funding from NIH to support research, and remember in a zero budget
increase environment, this is a huge accomplishment.     

I think one of the real accomplishments of the discussion this week is
to document agreement in this very diverse and far flung community that
the problem and the solutions are about individuals AND systems and that
no single approach will do. Everyone has a contribution to make, and
these contributions will be additive and complementary. My hope is this
week's discussion lays to rest some of the individual v. system debates,
and has created a common understanding of the scope and nature of the
health literacy problem. I have appreciated the chance to participate
and want to thank everyone who has contributed. It has been my pleasure.


Cynthia   


-----Original Message-----
From: healthliteracy-bounces at nifl.gov
[mailto:healthliteracy-bounces at nifl.gov] On Behalf Of Julie McKinney
Sent: Thursday, September 20, 2007 7:55 PM
To: healthliteracy at nifl.gov
Subject: [HealthLiteracy 1267] Re: NAAL-health literacy and leadership

Andres,

I agree that we should keep pushing the definition of health literacy to
apply to institutions, systems and communities and not just individuals.
We have discussed the "blame" issue, and I think we all agree that we do
need to work hard to counteract blaming patients for communication
failures, and to hold systems, health care agencies, and communities
more accountable. 

But I do not think that a focus on NAAL and these results will have a
negative impact on our efforts. Quite the reverse, in fact. In the past
decade, the results of the last literacy survey seems to have have had a
tremendous effect on support for health literacy efforts, and funding
for new initiatives.  When the results of the 1993 NALS came out, (which
only included literacy skills and did not even attempt to assess health
literacy) the figure of 90 million Americans with marginal to poor
literacy skills was cited in numerous medical and health reports and
galvanized support for many new health literacy initiatives. 

We have seen more plain language information coming out of NIH and the
National Library of Medicine, we have seen JCAHO requirements addressing
health literacy, we have seen the American Medical Association
supporting the cause, and health literacy resources developed by the
U.S. Deptartment of Health and Human Services, among other things. I
think that the "90 million" figure was instrumental in achieving this
kind of progress. What do others think?

So my question now is: what have we learned from this new data that can
continue to support our efforts? 

Julie

Julie McKinney
Discussion List Moderator
World Education/NCSALL
jmckinney at worlded.org


>>> "Muro, Andres" <amuro5 at epcc.edu> 09/20/07 12:28 PM >>>

Ok, here I go with my rant, but I cannot take full responsibility for
it. Dr. Ian Bennett got me thinking about this with his posts. 

 

I think that the focus on the NAAL and on how we define literacy could
have a negative impact on what we hope to accomplish if we are not
careful. Health literacy is often defined as something like individuals
having the knowledge to be able to make informed decisions about health.
The NAAL tells us that many don't have this knowledge. So the task for
us becomes figuring out how to provide the lacking knowledge to
individuals. 

 

Presumably, if we provide this knowledge, individuals will do better on
the NAALS and also they will engage in healthier behaviors. I don't know
if anyone sees a problem with this sort of thinking, but I find it to be
individualistic and archaic thinking and contradictory to the idea that
health is a community responsibility. We don't think like this by
accident. We inherited this from 18 century British thinking pandering
to special interest. But, while the Brits have gotten over this
mentality, In America, this form of thinking has become very ingrained,
particularly since the 1980s. 

 

So, let's suppose that we increase an individual's health literacy
knowledge and the person knows that it is important to eat fruits,
veggies and grain and exercise every day, get dental checkups, etc. That
does not mean that the person will have the skill or ability to eat
healthier and exercise, get dental checkups, mammograms, etc. If the
person lives next to a smelting plan, near a polluted river in a
neighborhood were there is taco bell, pizza hut and lots of convenience
stores, the person will likely not go jogging every day and will not eat
hydroponic lettuce salad with watercress, dried cranberries and olive
oil. So, increasing an individual's knowledge does not guarantee
healthier behaviors and lifestyles. 

 

As long as we define health literacy as an individual skill and measure
it as such, we will be promoting this sort of thinking. I have been
making the argument that health literacy should be defined not just as a
person's knowledge, but at the community's ability to provide spaces for
people to participate in healthy lifestyles and to provide opportunity
for clear communication among all members. So, it is not just my
responsibility to cook healthy and go running. It is also the
community's responsibility to create inviting open spaces, to increase
access to healthy stores, to provide places where people can get
checkups, etc. 

 

Right wing groups are pretty good at developing agendas that create
spaces that they favor. So, for example, in my community, they have
managed to reduce healthy sex education in the public schools and
increase sex abstention education. At the same time, they have driven
away naked women bars to a certain distance from public schools and
forced most stores to keep condoms behind counters. 

 

So, if communities have the ability to do this, why not force businesses
to be required to only sell healthy foods near schools and force the
creating of clean healthy spaces. If the definition of health literacy
were modified as I propose, then HHS can come up with tools to measure
the health literacy of a community and promote community health
literacy. A way to measure this could be to develop health literacy
indicators and promote policies that require communities to demonstrate
this. 

 

For example, health literacy indicators could be a certain number of
stores that only serve a certain type of menu within x many miles from a
public school or the number of open spaces and health food stores that
are accessible in each neighborhood. So, for example, Mc Donald's serves
healthy stuff now. A community could say that near a school, Mc Donald's
can only sell certain foods. 

 

We need more definitions that lead towards this, more tools to measure
this and policies that lead to this, and less effort in trying to
measure an individual's knowledge. 

 

What do you all think?

 

Andres   

 

 

 


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