From the desk of Andrew Pleasant, Ph.D.
Health literacy has always been present, but it is only during the past two decades that research and practice are beginning to formalize and increase the effectiveness of health literacy. At Canyon Ranch Institute we weave health literacy into our partnerships and programs with the goal of helping individuals, communities, and nations make informed decisions about health and increase the health and well-being of all people.
While the origins of the field of health literacy are truly international, growth of the field in the United States was propelled by the findings of the National Adult Literacy Survey (NALS) in 1993 and the National Assessment of Adult Literacy (NAAL) in 2003. While the 1993 NALS did not include a measure of health literacy, the findings did impact perceptions of the literacy skills present, and lacking, in American adults. That generated substantial interest into the implications of low literacy. The 2003 NAAL included a measure of health literacy, and those results have further generated interest in the connections between literacy and health in the United States.
The NAAL reported that 88 percent of Americans (nearly 9 out of 10) are below the proficient level in health literacy. Hundreds of studies indicate that the proficient level in health literacy is where Americans need to be in order to successfully navigate the complex health system in this country.
Over the years of development through continued practice and research, health literacy has been variously defined by different people and organizations. Early approaches focused on health literacy as a way for health professionals to get patients to do what they wanted. Thus definitions focused on “appropriate decisions” as outcomes of addressing health literacy.¹ Early conceptions of health literacy also focused on the concept as being something that only patients or the public lacked, assuming that health professionals were fully equipped with health literacy skills.
One hallmark in that history is the Surgeon General’s Workshop on Improving Health Literacy that took place in 2006. The movement toward holding this workshop was initiated by Canyon Ranch Institute President Richard H. Carmona M.D., M.P.H., FACS, while he served as 17th U.S. Surgeon General (2002-2006). The Surgeon General’s Workshop on Improving Health Literacy was among the first meetings at the national level to recognize the importance of health literacy and provide a venue for people who are working to advance health literacy to start to forge a new consensus on health literacy.
Today, there is a strong move toward defining and practicing health literacy as a complete theory of health behavior change, not just a skill that some people may or may not have. For example, the Calgary Charter on Health Literacy defines health literacy as follows:
- Health literacy allows the public and personnel working in all health-related contexts to find, understand, evaluate, communicate, and use information.
This definition inherently contains a logic model that all people, programs, and institutions can follow as they try to make informed decisions about health. That logic model begins with finding information – then moves through understanding, evaluating, and communicating – and concludes with using information (i.e. behavior change).
At Canyon Ranch Institute, we weave a robust approach to health literacy into all our integrative health programs to improve the health of individuals and populations and into our approaches to health system reform.
Andrew Pleasant, Ph.D.
Health Literacy and Research Director, Canyon Ranch Institute
Selected Health Literacy Publications and Presentations by Canyon Ranch Institute Team Members
Health Literacy as a Tool to Improve the Public Understanding of Alzheimer’s Disease. Annals of Long-Term Care. 18(1), 34-40. Kobylarz, F.A., Pomidor, A., Pleasant, A. (January 2010)
This article highlights the importance of health literacy for older adults who are often entrenched in the medical care system the most, yet comprehend medical information the least. The goal of the article is to familiarize readers with the concept of health literacy, demonstrate how health literacy can serve as a tool to improve the public’s understanding of Alzheimer’s disease (the seventh leading cause of death in the United States), and suggest generally applicable strategies for clinicians working with older adults in the United States. Despite all the barriers that patients and their clinicians face in regard to Alzheimer’s disease in particular, it is essential to increase the health literacy skills of older adults and their caregivers in order to help them make informed health decisions. Health literacy issues offer clear evidence that the health system must accommodate change. View article
Poster: CRI Life Enhancement Program at Urban Health Plan (November 2009)
CRI was selected to present a poster at the 137th Annual Meeting and Exposition of the American Public Health Association. The poster described the program and outcomes for the first class of people who participated in the CRI Life Enhancement Program at Urban Health Plan in the South Bronx, New York. Preliminary evaluation data highlighted early trends, including increased health literacy and positive changes in blood pressure, body-mass index, weight, and depression scores. Rainy Warf, M.P.H., CHES, CRI program manager for planning and evaluation, answered questions from conference attendees who expressed interest in learning more about this new approach to advancing health literacy through an integrative health model. Read the CRI LEP at UHP poster
Calgary Charter on Health Literacy. Authors in alphabetical order, Coleman, C., Kurtz-Rossi, S., McKinney, J., Pleasant, A., Rootman, I., Shohet, L. (October 2009)
The Calgary Charter on Health Literacy is a product of an international collaboration between multiple authors that is endorsed by a growing number of individuals and organizations. The Charter proposes a definition and understanding of health literacy and a set of core principles to support the development of curricula and evaluation tools that improve health literacy for diverse audiences and purposes. It specifically avoids labeling any groups and assumes that health literacy touches individuals and health systems, and while expressed differently in different contexts, is always based on the same underlying skills and abilities.
View and Sign on to the Charter
Knowledge, Attitudes, and Informational Behaviors of College Students in Regard to the Human Papillomavirus. Journal of American College Health. 58(2), 141-149. Sandfort, J., Pleasant, A. (September/October 2009)
This article reports on a survey of students at a large, public university in the Northeast United States that investigated their knowledge of the human papillomavirus (HPV) and how it is transmitted, the connection to cervical cancer risk, any stigma attached to HPV, their own sexual behaviors, HPV vaccination status, and sources of information about HPV. The majority of participants in the study did not accurately understand the prevalence and nature of HPV and generally underestimated their own risk of acquiring a sexually transmitted infection. The study highlighted several areas to target in efforts to improve health literacy, reduce inequities in health, and improve overall health status. The study concludes that “Information about HPV can be somewhat confusing. Considering that research is still producing new knowledge about HPV, public education about this virus and the ongoing scientific process is key. However, the lack of complete scientific understanding about HPV should not be seen as a deterrent for efforts to increase health literacy and knowledge about this highly prevalent sexually transmitted infection. A lack of understanding can lead to increased stigma about the virus, either as a result of a fear of the unknown or as fear of the misunderstood. Health literacy is a key tool that can increase empowerment about sexual health and is vital to increasing the public’s ability to prevent the further spread of HPV.” View article
The Potential and Challenges of Health Literacy, Institute of Medicine Roundtable on Health Literacy Workshop (September 2009)
CRI Executive Director Jennifer Cabe, M.A., delivered the closing summary at the Institute of Medicine (IOM) Workshop titled “Integrating Health Literacy in Prevention Programs.” The Workshop was hosted by the IOM Roundtable on Health Literacy, and addressed the need to integrate health literacy into primary and secondary prevention strategies. Invited speakers as well as members of the public attended the IOM Workshop and discussed questions and reviewed new evidence-based strategies and programs. The IOM Roundtable on Health Literacy has been very active in raising awareness of health literacy issues.
View the PowerPoint presentation
View the IOM Website for the Workshop
What We Know About...Health Literacy. Centers for Disease Control and Prevention (July 2009)
CRI Health Literacy and Communication Director Andrew Pleasant, Ph.D., was featured in the Centers for Disease Control and Prevention publication, "What We Know About" that focuses on health literacy. Dr. Pleasant was quoted on the current state of health literacy in the U.S. population and provided consultation on the document's overall content. Read More
Health literacy measurement: A brief review and proposal, Institute of Medicine Roundtable on Health Literacy Workshop. (February 2009)
In this presentation to the Institute of Medicine Roundtable on Health Literacy, CRI Health Literacy and Communication Director Andrew Pleasant, Ph.D. explored existing screeners of health literacy – as there currently is not a comprehensive measure of health literacy – and suggested an overall approach and methodological principles to serve as the basis for the development of a comprehensive measure of health literacy.
View the PowerPoint presentation
View the IOM Website for the Workshop
View the Measures of Health Literacy: Workshop Summary
A second look at the health literacy of American Adults & the National Assessment of Adult Literacy. Focus on Basics. 9(B) 46-53. Pleasant, A. (September 2008)
In the United States, the field of health literacy has been steadily emerging since the early 1990s from two original streams of research and practice. On the one hand, health care professionals began investigating literacy effects on health and the provision of health care. On the other hand, adult basic education and literacy professionals began incorporating health into curricula and community empowerment efforts. A third approach has more recently emerged that incorporates a public health approach as a means to bridge the gap and create new opportunities to advance health literacy. However, many people and organizations in those two original streams remain somewhat isolated from each other. The field of health literacy has come a long way in a short time, but advances are still needed to reach a complete understanding and use of health literacy. For example, the field needs to advance from treating health literacy as an individual issue of fundamentals, at times referred to as basic literacy, which consists of reading, writing, speaking, and numeracy skills in a health context and move toward treating health literacy as an important, yet complex, social determinant of health. View article
A tale of two health literacies: public health and clinical approaches to health literacy. Health Promotion International, 23: 152 – 159. Pleasant, A., Kuruvilla S. (June 2008)
Public health concerns underlie a considerable portion of the global burden of disease, increasing the utility and need for promoting and assessing the knowledge about public health issues. A public health literacy knowledge scale was developed and tested in China, Mexico, Ghana, and India. A somewhat unexpected finding, which was that experts ‘scored’ less on the scale than the general public, led to consideration of differences between clinical and public health approaches to health literacy and their implications. These differences in perspective, for instance consideration of single case effects versus impacts at the societal level, pose significant challenges to developing and assessing health literacy. We suggest that a comprehensive approach to health literacy will include both clinical and public health approaches. View full article
Advancing health literacy: A framework for understanding and practice. Jossey-Bass. Zarcadoolas, C., Pleasant, A., Greer, D. (2006)
The culmination of a multi-year project among Andrew Pleasant, Ph.D., and colleagues Christina Zarcadoolas, Ph.D., and David Greer, M.D., this book includes a historical overview of health promotion, a theoretical explication of the domains of health literacy, a series of case studies further explicating the functioning of those domains of health literacy, and a set of guidelines for better communication of health information. Buy the book
Bridging the gap: Bringing research to health literacy practice. National Institute for Literacy Health and Literacy Special Collection. Pleasant, A., Kurtz-Rossi, S. (2005)
This article was produced by Andrew Pleasant, Ph.D. in collaboration with Sabrina Kurtz-Rossi, M.Ed. of World Education as a bridging device for practitioners of adult basic education attempting to incorporate the latest health literacy research into their classroom activities. The article includes an introduction to the processes of qualitative and quantitative research as well as an annotated bibliography of key health literacy research. The bibliography was based on a literature review of over 400 peer-reviewed articles on health literacy. View article
Understanding health literacy: an expanded model. Health Promotion International. 20:195-203. Zarcadoolas, C., Pleasant, A., Greer, D. (June 2005)
Through discourse and thematic content analysis of media content supplemented by qualitative interviews with key figures, the anthrax threat in the United States serves as a case study for an explication of the fundamental, civic, cultural, and scientific domains of health literacy. View abstract
Unweaving the web: An exploratory study of low-literate adults’ navigation skills on the World Wide Web. Journal of Health Communication, 7(4), 309-324. Zarcadoolas, C., Blanco, M., Boyer, J.F., Pleasant, A. (2002).
This article reports on one of the earliest examples of research, employing qualitative and quantitative research methods, into the access and use of information available via the internet by low-literate, low-income urban residents. View abstract
Selected Health Literacy Publications
The Health Literacy of America's Adults: Results from the 2003 National Assessment of Adult Literacy (NAAL)
The U.S. Department of Education's National Center for Education Statistics conducted an analysis of adult health literacy as part of their 2003 National Assessment of Adult Literacy (NAAL), investigating the variations in how Americans access and understand health information and linking those variations to demographics. Briefly, the report found strong links between the levels of health literacy and race/ethnicity, first language spoken (English vs. other languages), level of education, age (65 and older vs. under 65), income, level and type of insurance coverage (private vs. Medicare/Medicaid or none), and main source of health information (written sources vs. broadcast media).
Kutner M, Greenberg E, Jin Y, and Paulsen C. (2006). The Health Literacy of America's Adults: Results From the 2003 National Assessment of Adult Literacy (NCES 2006–483). U.S. Department of Education. Washington, DC: National Center for Education Statistics. View publication
Literacy Issues in the Medical and Public Health Literature
Rima Rudd, Sci.D., and colleagues have conducted extensive review of health literacy research in the medical and public health literature, including a bibliography of identified 241 articles published between 1990 and 1999. The studies they collected focused on such topics as the links between literacy and health, functional literacy and institutional settings, research tools for assessing health literacy, and guidelines for practice.
Rudd R, Moeykens BA, and TC Colton. “Health and Literacy: A Review of Medical and Public Health Literature.” In: Comings J, Garners B, and C Smith (eds.). Annual Review of Adult Learning and Literacy. New York: Jossey-Bass, 1999. View publication
Rudd RE, Colton T, and Schacht R. (2000). An Overview of Medical and Public Health Literature Addressing Literacy Issues: An Annotated Bibliography. Harvard Graduate School of Education. Cambridge, MA: National Center for the Study of Adult Learning and Literacy. View publication
¹ Institute of Medicine. A Prescription to End Confusion. 2004. Available at: http://www.iom.edu/?id=19750
