Health literacy is critical to effective communication between individuals and their health care providers. However there is little consistency in conceptualization and measure of health literacy. The objective of this review is to examine existing health literacy models and measures to assess their application to limited English proficient population in the context of information and communication technology. Communication platforms change with the development of new technology and existing health literacy models and measures are insufficient to capture the complex interaction that occurred in these communication platforms. A new health literacy model composed of four domains: sources, context, process, and outcome were introduced.
KEYWORDS: limited English proficiency; health literacy; Asian Americans
Health literacy is fundamental to communication between individuals and their health care providers. With advances in information and communication technologies, the way in which health information is created and conveyed directly affects communication. A broader understanding is needed about when and where adults take action to locate, process, and act on health information. Reframing the concept of health literacy to better reflect the full array of literacy skills necessary to function in the current technological environment is particularly important for the growing number of residents in the US who speak little English.
Health literacy, as understood in the US, assumes that English is the primary language used by the individual and the health care system. As a result, language barriers increase difficulties with health literacy. Individuals with limited English proficiency (LEP) may be at greater risk for health problems because of their limited capacity to access, interpret, and use health information presented in English. Drawing on a review of the current literature on health literacy, with a sub-focus on LEP Asian Americans who may particularly have more specific problems in health literacy, this article proposes a new model to address the sources, processes, and outcomes of health literacy for LEP populations in the context of health information technology.
SOURCES OF HEALTH LITERACY AND HEALTH OUTCOMES
Health literacy is defined as 'the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions' (Institute of Medicine of the National Academies, 2004). It is typically recognized that health literacy is generative. Instead of remaining relatively stable over time, health literacy is dynamic, and the associated capacities evolve over the lifespan and are likely to be influenced by health-related, socioeconomic, psychosocial, and cultural factors (Baker, 2006; Derose & Baker, 2000; Zarcadoolas, Pleasant, & Greer, 2005). Core elements of health literacy that allow individuals to function in the health care system have moved beyond reading and numeracy to include a constellation of skills, such as critical thinking, problem solving, decision making, information seeking, and communication (Mancuso, 2009). The Institute of Medicine describes health literacy as the result of multiple, complex social and individual factors (Institute of Medicine of the National Academies, 2004). Individual factors may include education, culture, language, and communication skills. Social factors may consist of educational systems, health systems and the media.
Low health literacy impairs an individual's capacity to function in the contemporary health care environment, and particularly in the patient- physician encounter (Schillinger et al., 2003). Disparities in access to health information, services and technology due to low health literacy can result in less usage of preventive services, less knowledge of chronic disease management, higher rates of hospitalization, and poor self-rated health condition (Berkman et al., 2004). Low health literacy is common in the US, and little improvement in adult health literacy has been observed over time (Berkman et al., 2004; Kutner, Greenberg, Jin, & Paulsen, 2006; Rudd, 2007). In 2004, white adults had the highest rates of health literacy (Berkman et al., 2004), while an estimated 90 million Americans had limited health literacy (Institute of Medicine of the National Academies, 2004). The elderly, ethnic minorities, and persons with low levels of education tend to have low rates of health literacy (Kutner et al., 2006). For example, thirty-one percent of Asian Americans and Pacific Islanders have limited health literacy (Andrulis & Brach, 2007).
LIMITED ENGLISH PROFICIENCY AND LOW HEALTH LITERACY
In the US, adults whose primary language is not English have lower health literacy levels than speakers of English as their native or first language (Institute of Medicine of the National Academies, 2004; Rudd, 2007). An inability to speak and understand English contributes to poor health communication and consequently to health disparities (Farmer, Papachristou, Gotz, Yu, & Tong, 2010; Jacobs, Karavolos, Rathouz, Ferris, & Powell, 2005; Karliner, Jacobs, Chen, & Mutha, 2007). The number of people in the US who speak a language other than English at home has grown steadily in the past three decades. It is currently estimated that about 55 million Americans speak another language at home and in this group, about 44% (approximately 24 million) speak English less than 'very well' and require assistance in some situations (U.S. Census Bureau, 2010). Notably, among US residents who speak a language other than English, those speakers of Asian and Pacific languages have the highest rates of LEP (U.S. Census Bureau, 2010).
Although LEP individuals consistently demonstrate low health literacy levels, it is unclear which aspects of English competency (reading, writing, listening, or speaking) are associated with these results. Developing literacy skills in a second language requires a certain level of proficiency in the first language, and some skills require more time to acquire than others (Batalova & Fix, 2010). For individuals who acquire English as a second language, writing proficiency takes longer to develop than oral proficiency (Hakuta, Butler, & Witt, 2000). For Asian Americans, the primary context for acquiring health information is the face-to-face encounter since use of health information technology is low in this population (Ngo-Metzger, Hayes, Yunan, Cygan, & Garfield, 2010). Depending on contextual factors, language barriers may be more significant than limited health literacy in obstructing interactive patient- physician communication (Sudore et al., 2009).
HEALTH LITERACY IN THE CONTEXT OF INFORMATION AND COMMUNICATION TECHNOLOGY
Health literacy has been investigated in the context of education, public health, and health promotion. Less is known about the association between health literacy and the capacity for LEP individuals to engage in the health care environment of the 'information age' (Ferguson, 1995). New technologies can promote health communication by facilitating the exchange of information, promoting self-management and supporting continuity of care (Greenhalgh, Hinder, Stramer, Bratan, & Russell, 2010; Ngo-Metzger et al., 2010), while new media provide platforms for communication beyond in-person visits. New technologies have also changed the ways in which people obtain and disseminate health information. Therefore, researchers have begun to consider the ability to use current health information technologies as an aspect of health literacy (Berkman, Davis, & McCormack, 2011).
In the US, almost 70% of the population has access to the Internet and uses it to keep track of personal information, make appointments, and communicate with providers (Cantor et al., 2009). New strategies have been developed to promote preventive care, such as web-based decision aids for colorectal cancer screening (Holubar et al., 2009; Makoul et al., 2009; Miller et al., 2011) and self-management tools for diabetes (Glasgow et al., 2011; Ralston et al., 2009) and asthma (Cruz-Correia et al., 2007; Joseph et al., 2007). With the increasing emphasis on individual responsibility for acquiring and using information to manage health, many researchers have raised concerns that disadvantaged populations may be 'leftbehind' by the digital divide (Rudd, 2007; U.S. Department of Commerce, 2000). Individuals with lower levels of education are less likely to use new communication technologies (Kim et al., 2009), and those with limited health literacy may be unable to use them.
With over 65% of the World Wide Web's content written in English, LEP populations are less likely than fluent English speakers to find health information that they can understand (Global Reach, 2005; Norman & Skinner, 2006). Although Whites and Asians in the US use media at similar rates, Asian Americans prefer print materials (Nguyen, Barg, Armstrong, Holmes, & Hornik, 2008) and a large proportion of LEP individuals rely on translated sources for health information (Kirchhoff, Turner, Axelrod, & Saavedra, 2011). As a result, many LEP Asian Americans, particularly subgroups with lower socioeconomic status, may not receive the potential benefits of health information technology (Ngo-Metzger et al., 2010).
The current concept of health literacy may not be adequate in the context of the Internet or other electronic environments (Norman & Skinner, 2006). Little research has addressed how individuals with limited health literacy interact with contemporary health information and communication systems.
EXISTING HEALTH LITERACY MODELS
Health literacy is an evolving concept. Although it is generally agreed that low health literacy contributes to poor health outcomes, the mechanism that links health literacy and health outcomes is not well understood (Baker, Williams, Parker, Gazmararian, & Nurss, 1999; Dewalt & Pignone, 2005). Some health literacy models focus on the individual's ability to interact with the health care system, while others attempt to describe potential causal pathways between health literacy and health outcomes.
Zarcadoolas et al. (2005) proposed an expanded model that includes scientific, cultural, and 'civic' (roughly, governmental and social) domains in addition to fundamental literacy. They used the 2001 anthrax threat in the US as a case study to illustrate how each domain functions to assist the individual in obtaining information. From a very different perspective, Baker (2006) argued that a set of resources (e.g., reading fluency and prior knowledge) is required to facilitate health literacy. These resources affect the individual's ability to engage in oral communication about health and to understand written health information. The complexity and difficulty of the printed and spoken messages that an individual encounters while interacting with the health care system shapes the formation of new knowledge, beliefs, attitudes, and behaviors in that individual, with a consequent effect on health outcomes (Baker, 2006).
Paasche-Orlow and Wolf (2007) proposed another model based on medical and public health literature. They explain the causal pathway linking literacy to health outcomes by including both health care system factors and individual factors. In their view, health literacy is a single, stable entity that must be examined at three distinct points along the health care experience, including access to health care, medical encounters, and self-care activities.
Nutbeam (2008) proposed two different approaches to health literacy, namely health literacy as a 'risk' or as an 'asset'. In the first approach, health literacy is a risk factor that needs to be identified and managed. This approach has led to the development of screening tools to assess individual health literacy levels. Such tools can help health care providers become more sensitive in communicating with their patients. According to the second approach, health literacy is an asset that is constructed as an outcome of health education and communication. A wide range of skills can be developed as the basis of functional literacy (i.e., the ability to read and write), so that individuals are empowered not only to manage but also to promote and maintain good health through their own efforts.
SHORTCOMINGS OF THE EXISTING MODELS: COMMUNICATION PLATFORMS AS THE PROCESS
Many proposed health literacy models have attempted to describe the relationship between health literacy and health outcomes without addressing one important component - the 'communication platforms' or specific contexts in which health communications occur. Yet health literacy is both context- and setting-specific (Berkman et al., 2004; Nutbeam, 2008). The existence of a wide variety of communication platforms, especially in our current technology-driven environment, suggests new avenues of research into the strategic use and practice of health literacy skills, particularly among non-native speakers of English. Yet none of the existing models have been applied to LEP populations or to contemporary communication technologies.
Using health information to make meanings that lead to behavioral change requires specific skills such as the ability to engage in oral communication and to understand online communication (Curran, 2002). Health-related communication can occur in a wide range of contexts and situations, such as face-to-face encounters (requiring oral skills), textual media (requiring writing and reading skills), different languages (requiring access to an interpreter), and contemporary electronic and social media (often requiring additional skills such as typing). Existing health literacy models have not addressed this proliferation of contexts and media, which may have a tremendous impact on the health outcomes of individuals with limited health literacy. None of the current models describe the ways in which LEP individuals understand and act on the information obtained through these sources, so we have little knowledge of the factors that might facilitate or impede access and exchange, decision-making, and social support. Nor can the available models tell us anything about the effect of information and communication technologies in shaping individual health literacy levels. As a result, we need to investigate communication platforms in order to advance our understanding of the role of health literacy in health promotion.
HEALTH LITERACY MEASURES
Similarly, existing health literacy measures are insufficient for capturing the highly complex interactions that occur in these communication platforms. Among the available tools are the rapid estimate of adult literacy in medicine (REALM), a direct measure of reading and word recognition, and the test of health literacy in adults (TOFHLA), which assesses reading comprehension and numeracy skills (Parker, Baker, Williams, & Nurss, 1995). Both instruments also have shorter versions (Baker et al., 1999; Bass, Wilson, & Griffith, 2003). However, these tools are incomplete, because each measures only reading skill, which is taken to be representative of overall capacity (Baker, 2006). Yet the ability to read is only one of the skills needed to perform as a health literate individual. As a result, none of these tests can provide a comprehensive assessment of an individual's communicative capacities, which also include the cognitive and social skills necessary to make use of health systems (Greenberg, 2001; Hill, 2004).
Additional instruments have been developed, such as the wide range achievement test (WRAT; Hanson-Divers, 1997), the newest vital sign (NVS; Weiss et al., 2005), and the short assessment of health literacy for Spanishspeaking adults (SAHLSA; Lee, Bender, Ruiz, & Cho, 2006), but they have not been widely used because of a lack of rigor in their psychometric properties. Other tests include 'screening aids' developed to identify those with inadequate functional health literacy (Chew, Bradley, & Boyko, 2004; Davis, Kennen, Gazmararian, & Williams, 2005; Morris, MacLean, Chew, & Littenberg, 2006; Wallace, Rogers, Roskos, Holiday, & Weiss, 2006; Williams et al., 1995). A newer instrument, the health activities literacy scale (HALS; Educational Testing Services, 2011), includes 191 items that assess health-related competencies in five domains, including health promotion, health protection, disease prevention care and maintenance, and systems navigation (Rudd, 2007).
Preliminary evidence shows that assessing written English language skills may not be appropriate for measuring comprehension of health information in LEP Chinese Americans, and that the translated versions of REALM and S-TOFHLA are not valid measures of health literacy levels in LEP Korean Americans (Han, Kim, Kim, & Kim, 2011; McWhirter, Todd, & Hoffman-Goetz, 2011; Todd & Hoffman-Goetz, 2011). Further, few health literacy instruments are available in languages other than English, and those that have been published to date tend to be in Spanish or Hebrew, rather than in Asian languages.
A NEW MODEL FOR HEALTH LITERACY
Most health literacy models do not address English competency level, while existing health literacy measures fail to assess English competency or use of communication platforms. Further, because health literacy studies tend to focus on speakers of Spanish instead of Asian languages, we cannot to expect to find broadly relevant and effective solutions to improve the health literacy of the entire LEP population. Developing a model to guide future research in a systematic way is thus imperative. Based on an extensive literature review, we propose a new health literacy model compromising four components: source, context, process, and outcomes (Figure 1). This model represents a causal relationship between health literacy and health outcomes for LEP populations within the context of communication platforms. Antecedents of health literacy include health status (Britigan, Murnan, & Rojas-Guyler, 2009; Lee et al., 2006; Lee, Tsai, Tsai, & Kuo, 2010), health knowledge, education level (Marks, Schectman, Groninger, & Plews-Ogan, 2011; Wolf, 2007), socioeconomic status, and level of acculturation (Guerra, Dominguez, & Shea, 2005; Thomson & Hoffman-Goetz, 2011). Along with language (McWhirter et al., 2011; Todd & Hoffman- Goetz, 2011), these factors influence core health literacy, which is essential for individuals to function in the health care system. Five domains represent the core health literacy skills necessary to interact with the health care system, including speaking, reading, writing, listening, and numeracy (Rosenfeld et al., 2011; White, Osborn, Gebretsadik, Kripalani, & Rothman, 2011). Although these skills are not necessarily correlated (for example, an individual may have good numeracy skills but poor speaking skills), when they are positioned in a specific health context, they contribute to the communicative capacities of an individual to seek, find, understand, and use health information to address a specific health problem or achieve a specific health goal (Golbeck, Paschal, Jones, & Hsiao, 2010). They are integral to health literacy and are also the building blocks for other skills (e.g., computer use) that further enhance interactions between an individual and the health care system.
As noted in Figure 1, health literacy operates within the context of specific platforms where individuals exercise their communication skills. Social media, interpersonal encounters, and written forms are examples of communication platforms that exist at the individual level (including families) as well as at the system level (including health care settings) and allow both one-way and two-way communication (Britigan et al., 2009; Sarkar, Schillinger, Lopez, & Sudore, 2011) Written forms include printed materials received from health professionals or agencies, such as brochures, letters, laboratory reports, and pamphlets. Interpersonal communications include interactions between individuals and networks of friends, family members, interpreters, or providers. Social media include communications that occur via such channels as smartphone applications, telemedicine, social networking sites, and Web-based applications.
Embedded in this model is the hypothesis that an individual's ability to use various communication platforms depends not only on the core domains of health literacy but also on the characteristics of individual platforms. Some communication platforms may even have the potential to enhance individual health literacy.
As new technologies are introduced, communication platforms change. Depending on the platform chosen, the five domains of health literacy can be invoked separately or in combination. For example, listening and speaking skills will be used significantly more than other skills in the interpersonal communication platform, while reading skills will dominate for written forms. In addition, different platforms can be used simultaneously to achieve a given health goal. Limited skills in certain domains may hinder utilization of a specific communication platform, whereas a high overall level of health literacy will enhance an individual's ability to use all platforms. Individuals will make decisions after processing the information gathered through various platforms, and then engage in health-related activities to address specific health issues (Ngo-Metzger et al., 2010). In this model, health literacy is dynamic and receptive, and it can change according to changes in skills and communication platforms.
IMPLICATIONS FOR RESEARCH AND PRACTICE
The proposed model provides a better fit to LEP populations than previous models because it includes core literacy skills and enables health care providers to assess health literacy levels while taking into account the antecedents of health literacy (e.g., acculturation) that are unique to LEP individuals. In assessing health literacy levels, health care providers must consider the full spectrum of relevant skills. Instead of screening out those with limited health literacy, the new focus of health literacy assessment should be on identifying individual strengths and weaknesses in each of the core skills. Health professionals can then leverage their patients' existing health literacy skills to promote engagement in care delivery. In addition, health professionals can expand their patients' communication capacities by designing interventions that enhance the skills that they need. Developing core health literacy skills is a non-linear and timedependent process. The overall goal is to enable consumers of health care to become functionally health literate within an environment of everchanging communication platforms.
Our proposed model elucidates the mechanisms of health literacy and the causal pathway that links health literacy, health behaviors, and health outcomes. This model provides a comprehensive approach to studying health literacy by introducing the constructs of source, context, process, and outcome. Interactions between health literacy and communication platforms offer important insights into the processes by which an individual seeks, accesses, and uses health information. This is particularly important for measuring the potential role of health literacy as a determinant of the health disparities experienced by many LEP individuals. In addition, the model allows examination of the potential roles of information and communication technologies in moderating the effect of health literacy on health decisions. An understanding of how literacy skills evolve not only enables us to better use information today, but will also guide our development of health literacy concepts and shape future research into this dynamic field.
I acknowledge the assistance of a medical editor, Raymond Harris, PhD, in drafting the final version of this manuscript.
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Received 15 July 2011 Accepted 25 September 2011
Division of General Internal Medicine, School of Medicine, University of Washington, Seattle, WA, USA…