The Many Health Literacies: Advancing Research or Fragmentation?

Abstract

Health literacy is the degree to which individuals can obtain, process, understand, and communicate about health-related information needed to make informed health decisions and is an important factor in patient health outcomes and resulting health care costs. Because of its importance across many areas of health, specific attention has been given to studying and measuring health literacy in recent years; however, the field lacks consensus on how health literacy should be defined and measured. As a result, numerous definitions and measures of health literacy exist. This fragmentation and inconsistency creates a barrier to conceptualizing, measuring, and understanding health literacy across health domains and fields. A directed literature search reveals a substantial body of work on health literacy; however, findings from studies often emphasize health literacy within specific health domains, populations, contexts, and languages, which makes the comparison of findings across studies difficult. While there is recognition that the measurement of health literacy should be improved, it is important to take into consideration what can be gained from a general health literacy focus and how this could be applied across domains.

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The Many Health Literacies: Advancing Research
or Fragmentation?
Michael Mackert, Sara Champlin, Zhaohui Su & Marie Guadagno
To cite this article: Michael Mackert, Sara Champlin, Zhaohui Su & Marie Guadagno (2015) The
Many Health Literacies: Advancing Research or Fragmentation?, Health Communication, 30:12,
1161-1165, DOI: 10.1080/10410236.2015.1037422
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Health Communication, 30: 1161–1165, 2015
Copyright © Taylor & Francis Group, LLC
ISSN: 1041-0236 print / 1532-7027 online
DOI: 10.1080/10410236.2015.1037422
COLLOQUIUM
The Many Health Literacies: Advancing Research or Fragmentation?
Michael Mackert
Stan Richards School of Advertising and Public Relations and Center for Health Communication
University of Texas at Austin and
School of Public Health
University of Texas Health Science Center at Houston
Sara Champlin, Zhaohui Su, and Marie Guadagno
Stan Richards School of Advertising and Public Relations
University of Texas at Austin
Health literacy is the degree to which individuals can obtain, process, understand, and com-
municate about health-related information needed to make informed health decisions and is
an important factor in patient health outcomes and resulting health care costs. Because of its
importance across many areas of health, specific attention has been given to studying and
measuring health literacy in recent years; however, the field lacks consensus on how health
literacy should be defined and measured. As a result, numerous definitions and measures of
health literacy exist. This fragmentation and inconsistency creates a barrier to conceptualiz-
ing, measuring, and understanding health literacy across health domains and fields. A directed
literature search reveals a substantial body of work on health literacy; however, findings from
studies often emphasize health literacy within specific health domains, populations, contexts,
and languages, which makes the comparison of findings across studies difficult. While there is
recognition that the measurement of health literacy should be improved, it is important to take
into consideration what can be gained from a general health literacy focus and how this could
be applied across domains.
Health literacy—the degree to which individuals can obtain,
process, understand, and communicate about health-related
information needed to make informed health decisions
(Berkman, Davis, & McCormack, 2010)—is a significant
driver of both individual health outcomes and broad health
care system costs. Even as annual research conferences and
special issues of academic journals focus on health literacy,
the field continues to grapple with what health literacy really
“is” (Berkman et al., 2010).
Given the recognized importance of health literacy as a
determinant of outcomes and driver of unnecessary costs, it
is unsurprising that health literacy has drawn such increased
Correspondence should be addressed to Michael Mackert, PhD, Stan
Richards School of Advertising and Public Relations, The University of
Tex as a t Au sti n, 1 U ni ve rs it y Sta ti on A 12 00, A us ti n, TX 78 71 2. E- ma il:
mackert@utexas.edu
scholarly attention. With greater research attention, though,
come new challenges and potential issues for the field. For
example, in a recent review Berkman and colleagues (2010)
identified 13 different definitions of health literacy, sug-
gesting lack of consensus on the basic construct of health
literacy. Additionally, as researchers interested in particular
health issues or populations study health literacy, there may
also be a temptation to focus on health literacy in specific
contexts at the expense of more general health literacy. This
is a serious concern, as it could limit the ability of researchers
studying one disease or population to translate findings about
the role of health literacy in other diseases.
The purpose of this article is to highlight one poten-
tial concern that comes with the increased research on
health literacy: that of fragmentation. The remainder of
this article covers relevant areas in the academic study
of general health literacy, such as different definitions of

1162 MACKERT ET AL.
health literacy, measurement, and how health literacy has
been integrated into health communication theories. This
is followed by a discussion of examples of potential frag-
mentation, lessons to be learned from this fragmentation,
and thoughts on how to deal with this concern for the
field.
GENERAL HEALTH LITERACY
Berkman, Davis, and McCormack (2010)raisetheconcern
that the concept of “health literacy” is associated with a
wide variety of meanings and that there continues to be
much debate surrounding its conceptualization. This could
be a result of evolution that the concept has experienced
over time, where the initial definition of health literacy was
strongly tied to math and reading capabilities in a health
context. Health literacy has come to reflect many things,
ranging from these initial skills to cognition and social char-
acteristics of an individual and even the differentiation of
health literacy into smaller components such as function-
ality (focus on skills needed to “function” in a health care
context/setting) and numeracy (focus on quantitative infor-
mation in a health care context/setting). Moreover, there are
inherent questions as to what health literacy should be—
should health literacy be thought of as an individual skill
or a community/global-level ability? Also, does health lit-
eracy develop over time given specific experiences endured
by an individual, or does this capacity remain more or less
constant through adulthood? After their review of the litera-
ture, Berkman and colleagues (2010)concludethatthereis
no one correct definition of health literacy, but rather that the
definition utilized often depends on the purpose of the study.
Reflecting the varied definitions and conceptualizations
of health literacy, there are numerous established measures
of general health literacy, which capture this capacity using
different approaches. For example, the Rapid Estimate of
Adult Literacy in Medicine (REALM) implements a word
recognition test, where patients are asked to read health-
related words out loud and pronunciations are rated by a
researcher as correct or incorrect (Davis et al., 1993). While
also focused on patient reading ability, the Test of Functional
Health Literacy in Adults (TOFHLA) measures health liter-
acy through a reading comprehension test, where patients
select health-related words to complete sentences (Parker,
Baker, Williams, & Nurss, 1995). The Newest Vital Sign
(NVS) requires patients to look at a nutrition label and
answer orally administered questions about the information
on the label. This test combines reading and math abilities to
determine general health literacy ability (Weiss et al., 2005).
ArecentdevelopmentistheHealthLiteracyManagement
Scale (HeLMS), which assesses components of health lit-
eracy such as literacy skills, verbal communication, and
knowledge of where to access health information (Jordan
et al., 2013).
In addition to expanding and refining the general defi-
nition of health literacy, and measuring the construct more
effectively, there are ongoing efforts to determine how health
literacy theoretically relates to established health communi-
cation and behavior concepts and outcomes. Paasche-Orlow
and Wolf (2007), for example, provided a framework show-
ing the causal pathways between limited health literacy
and patients’ health outcomes. The relationship between
self-efficacy, included in that framework, and health lit-
eracy has been tested more directly in the context of
patients’ understanding of informed consent documentation
(Donovan-Kicken et al., 2012). The role of health literacy
in the Health Belief Model has also been conceptualized
(Mackert & Guadagno, 2013).
The end result of efforts to advance conceptualizations of
health literacy, its role in established theoretical frameworks,
and ongoing efforts to improve measurement is a growing
awareness and understanding of the impact health literacy
has on patient health outcomes and public health. As knowl-
edge of general health literacy progresses, though, another
strategy for progress being pursued is focusing on the role of
health literacy in specific contexts.
THE MANY HEALTH LITERACIES
To get a s e nse of r e sear c h t hat ha s f ocus e d on the r o l e of
health literacy in more narrow contexts, a directed literature
search of academic and medical databases was undertaken to
look for health literacy research in particular health domains
(e.g., various chronic conditions, assorted communicable
diseases), focusing on populations (e.g., by role or age), in
specific contexts (e.g., e-health), and languages. This litera-
ture search demonstrated the breadth of research on health
literacy.
Var i o u s s t ud i e s h a v e i n v e s t i g a te d t h e r o l e of h e a l t h l i t -
eracy as it relates to specific illnesses and conditions.
Examples include chronic conditions such as oral health
(Naghibi Sistani, Montazeri, Yazdani, & Murtomaa, 2013),
diabetes (Yamashita & Kart, 2011), and hypertension
(Joyner-Grantham et al., 2009; Kim et al., 2012). Research
has considered mental health literacy (Jorm, 2000;Jorm
et al., 1997; Loureiro et al., 2013), as well as mental health
literacy focused on specific conditions such as schizophrenia
(Furnham & Blythe, 2012)ordepression(Dunn,Goldney,
Grande, & Taylor, 2009). There have also been studies
looking at the role of health literacy as it relates to can-
cer, including cervical cancer (Helitzer, Hollis, Sanders,
&Roybal,2012)andcoloncancer(Pendlimari,Holubar,
Hassinger, & Cima, 2012). In addition to a focus on more
chronic conditions, the role of health literacy in infectious
diseases has also been studied; examples include influenza
(Jhummon-Mahadnac, Knott, & Marshall, 2012), respiratory
infectious diseases (Zhang et al., 2012), and HIV (Ownby
et al., 2013).

THE MANY HEALTH LITERACIES 1163
Another avenue for researchers to follow is focusing
on specific patient populations. This has led to studies
focused on specific individual roles, such as caregivers
(Hironaka, Paasche-Orlow, Young, Bauchner, & Geltman,
2009), mothers (Pati, Mohamad, Cnaan, Kavanagh, & Shea,
2010), and parents (Dunn-Navarra, Stockwell, Meyer, &
Larson, 2012;Otaletal.,2012). Others have considered life
stage, such as children (Sharif & Blank, 2010), adolescents
(Ghaddar, Valerio, Garcia, & Hansen, 2012), college stu-
dents (Harper, 2014), and seniors (Farrell, 2011;Kaldy,
2011). Potential gender issues in health literacy and health
have also been studied, as they relate to both men (Peerson
&Saunders,2009)andwomen(Shieh&Halstead,2009).
Numerous studies have focused on health literacy in lan-
guages other than English, often with a focus on translat-
ing English-language health literacy instruments, including
Chinese (Leung, Lou, Cheung, Chan, & Chi, 2012); German,
Italian, and French (Connor, Mantwill, & Schulz, 2013);
Portuguese (Apolinario et al., 2012); and Spanish in Puerto
Rico (Rivero-Méndez et al., 2010).
Athirdstreamofresearchhasfocusedondifferent
channels by which consumers might receive health infor-
mation. This work has considered media health literacy
(Levin-Zamir, Lemish, & Gofin, 2011)ande-healthlit-
eracy (Norman & Skinner, 2006). Moving beyond media
and advancing the idea that health literacy represents a
social practice of information exchange, Rubin and col-
leagues (Rubin, Parmer, Freimuth, Kaley, & Okundaye,
2011)proposedanassessmentofinteractivehealthliteracy.
Additionally, the role of health literacy in interpersonal inter-
actions has been studied, such as the impact of health literacy
on provider–patient communication (Schillinger, Bindman,
Wang , S tew art, & P i ette , 2004).
This proliferation of research has unsurprisingly and
appropriately spurred the creation of more specialized health
literacy assessments. Aside from language-specific transla-
tion of existing English-language instruments and devel-
opment of new instruments, assessments have been devel-
oped to assess domain-specific health literacy. This research
includes, but is not limited to, the Oral Health Literacy
Adults Questionnaire (OHL-AQ) to measure oral health lit-
eracy (Naghibi Sistani et al., 2013), the eHEALS scale
to assess e-health literacy (Norman & Skinner, 2006), the
Assessment of Colon Cancer Literacy (ACCL) instrument
(Pendlimari et al., 2012), the HBP-HLS to assess high blood
pressure health literacy (Kim et al., 2012), and HIV-related
health literacy (Ownby et al., 2013). These instruments, typ-
ically developed and validated against general health literacy
assessments, are useful tools as scholars focus on health
literacy in these specific contexts.
MOVING FORWARD
The proliferation of health literacy research outlined in the
previous section is a testament to the range of scholars
interested in the topic, as well as their creativity and interest
in advancing knowledge on a crucial health issue. Given that,
the point of this article is not to simply start a conversation
about a potential fragmentation of the field. Indeed, domain-
and population-specific investigation of health literacy can
contribute to a deeper understanding of health literacy and
its impact on patient outcomes. Continued effort to study the
role of health literacy in different contexts, and developing
improved instruments to be used in that research, is a crucial
element of advancing the field.
Even as scholars focus on the role of health literacy in the
context that interests them, however, it is useful to maintain a
broader recognition of the overall field of health literacy. The
most obvious concern here is health literacy measurement.
As noted earlier, there is a recognition that health liter-
acy measurement needs to improve (Pleasant, McKinney, &
Rikard, 2011). One way to answer that call is to develop
more nuanced measures of health literacy in specific health
domains, an approach that has yielded useful instruments
(Kim et al., 2012;NaghibiSistanietal.,2013; Norman &
Skinner, 2006;Ownbyetal.,2013;Pendlimarietal.,2012).
The use of these instruments in practice, though, raises a
potential concern. If scholars rely only on domain-specific
health literacy assessments (e.g., for high blood pressure),
the ability of those studying other chronic conditions and
other health issues may be limited. While those develop-
ing more focused health literacy assessments have relied on
general instruments to validate their measures, in the actual
practice of research there is a continued need to use gen-
eral literacy assessments. Without broad and consistent use
of general health literacy instruments, the ability of schol-
ars working in disparate contexts to learn lessons from other
research will be seriously hindered.
In addition to concerns about measurement, the other con-
cern about fragmentation lies in identifying meaningful dif-
ferences between contexts. As noted earlier, Berkman et al.
(2010)proposehealthliteracyisthedegreetowhichindi-
viduals can obtain, process, understand, and communicate
about health-related information needed to make informed
health decisions. Such a definition highlights the distinc-
tion between domain-specific health-related information and
domain-specific health literacy. How is health literacy fun-
damentally different for a patient with high blood pressure,
diabetes, cancer, depression, or any other illness? This is not
to say that there may not be differences across domains, con-
texts, or populations, but it is crucial that the development
of more focused health literacies build productively on the
more general construct of health literacy.
CONCLUSION
Increased attention on health literacy, from scholars and
practitioners alike, has significant potential to improve
patient outcomes and reduce health care system costs.
Researchers interested in particular contexts—diseases,

1164 MACKERT ET AL.
populations, or communication channel—must recognize the
potential for fragmentation, however. Improving the under-
standing of health literacy in one context is less helpful
if the research cannot more broadly inform knowledge in
other contexts. Designing studies to be as generalizable
as possible, such as through use of general health literacy
instruments that can enable cross-context comparisons, can
advance the field more broadly. It is crucial that scholars not
miss the “forest” of health literacy for the “trees” of their
specific interest area.
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