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Health Literacy Outcomes and Public Health

Posted on by Cynthia Baur

How do we know that focusing on health literacy makes a difference?  The passing of Len Doak, co-author of the classic text Teaching Patients with Low Literacy Skills, places this question in a personal context. The question is also relevant for health research, evaluation and policy. Policymakers, managers, project funders, and professional and administrative staff want to know if paying attention to health literacy makes a difference.

Len and Ceci Doak and Jane Root wrote the book on health literacy practice in clinical settings. They were tireless advocates and made a difference by explaining health literacy and engaging others in the work.  The large number of people drawn into health literacy because of their book and gracious mentorship is one type of difference.

But, decisionmakers typically want evidence of a different kind. They want measurable outcomes aligned with organizational or policy requirements to know if a change or intervention is worthwhile.  Quality, cost and access are typical healthcare outcomes of interest. The two systematic reviews of evidence along with many single studies suggest that limited health literacy decreases healthcare quality and access and increases costs.

Defining outcomes for health literacy practice in public health is equally important. If we aim to reduce illness and death on a large scale, how can attention to health literacy help us get better public health outcomes? 

For example, many different organizations provide health information to the public. Sometimes they use highly visible mass media campaigns directed at millions of people; other times they may use a web site and targeted promotion to a very specific audience.

The outcomes for mass media campaigns might include reach (did we reach the audiences we intended to reach?), recall (does the audience recall seeing our messages and do they recall specific messages?), and attitude change (did our messages change their attitudes?). Web site metrics might include most popular features, time spent on pages and number of downloads of site products.  How might these outcomes help us learn about health literacy?   

As we think about the many types of public health work that could benefit from health literacy insights, we should also think about the outcomes we want. Please share your ideas about outcomes you already address and outcomes you’d like to address from a health literacy perspective.

Posted on by Cynthia Baur

4 comments on “Health Literacy Outcomes and Public Health”

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    Thanks for highlighting the importance of measuring outcomes of health literacy which I firmly believe is just as important to the Healthcare info provider as it is to the donors/decision makers.
    I am of the opinion that the solution lies in embracing more informal methods of communication aimed at promoting 2-way responses. Obviously, a one-on-one approach is impractical on a wide scale even in America let alone in developing countries like Nigeria, but effective use of IT such as websites, social media and of course mobile tech not only offers a unique kind of feedback, but even has the capacity to predict trends. The major health issues in developing countries are of preventable causes because people are grossly ignorant, and health myths prevail in addition to the insufficient facilities. This Nigerian based NGO Health And Life Africa Healthy-living Initiative (HALA)  focuses on discussing health issues in a user-friendly style and believes health awareness is a cost effective tool to ameliorate thes challenges.

    BUT STILL, the truth is that the help of website metrics for instance, can only go as far as providing clues; unfortunately, they cannot prove behavioural modification as a direct consequence. Nor can you exactly “claim” every landing on a webpage because of the mechanics of internet surfing.

    But we can turn to the marketing & communication ideology of the corporate business world that understands it as both “increased product awareness” and “interactive marketing communication”- and yes, they each have more specific indices for measurement. If profit making ventures realize the invaluable uniqueness of these, then I humbly submit that we in the healthcare communication industry need to take a cue from them and make “more accurate” impact assessment/outcome measurements by futuristic economic values in addition to the immediate invaluable responses of an expanding & engaged health community.

    You are right to say decision-makers want evidence before investing in better communication as there’s a cost. Joseph Kimble’s Writing for Dollars gives plenty of evidence that plain language saves money. But most managers in organizations need convincing that the writing style in their organization needs improving.

    The evidence is that most organizations still write badly. Despite the US Government passing the Plain Writing Act in 2010, our recent audit of government websites and news releases found documents poorly written. There’s a summary of the findings at:

    Nick Wright – Designer of the StyleWriter copy-editing software.

    Focusing on outcome assessment is definitely important to the health literacy field. Thanks for addressing the topic in response to the death of Len Doak. I’d like to see answers to the questions you raise. I’d also like to see impact questions raised and answers.

    The types of metrics you suggest are necessary but not sufficient if we want to know if the targeted professional, patient or health consumer actually puts the information into practice. We need to turn our emphasis to demonstrating impact of the practices we recommend on the desired short, medium and long-term outcomes. Such demonstrations apply not only to consumers but to health professionals.

    Two examples of beginning to do such demonstrations are underway here at the University of Maryland-College Park. The first focuses of improving the skills of health professionals; the second on consumers.

    A colleague and I, in partnership with the Maryland Department of Health and Mental Hygiene Office of Minority Health, are finishing a cultural competency and health literacy competency-based teaching guide for instructors of health professional students and practicing professionals. This effort is in response to state legislation focused on reducing health disparities.

    While we have found teaching resources which we matched to desired competencies, we have found almost no evidence that those resources lead to changes in the learners. Our national and state reviewers have recommended this gap be filled. To do so will require a research study to provide the evidence of fidelity between the teaching, the resources, the competencies, the actual application of the competencies and the ultimate outcome of patients and health consumers.

    In a two-year, multi-state study of rural, low-income mothers, with funding from the USDA Rural Health and Safety Grant program, we are testing core health messages designed to resonate with these mothers. We began with an empowerment frame as we gathered their input before designing and testing messages that met their desired content, voice, length, etc. We’re learned which messages they attend to and why and their preferred channel of communication. What we need to do next is to launch a longitudinal study that will measure if they actually act on the information and ultimately if the actions produce the desired outcomes.

    Do others see the need for such outcome assessment? And who is actually doing such measurement?

    One short-term outcome we address at Phoenix Children’s Hospital is evaluation of understanding of home care instructions. (This is discussed in Chapter 9 of the Doak, Doak, & Root book, and in all the literature on teach back.) If the family does not understand home care instructions, does not know how to identify problems or how to respond, it is less likely the longer-term health outcome measures would improve. Having them teach this information back to us is not as much a test of their knowledge, but a way to check if we individualized our teaching to make it clear to the learner.

    The next step, primarily in the follow-up outpatient setting, is to see if they were able to apply that information to practice, and if not, why not.

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