Literacy and health: expanding and deepening the intersectional analysis

• In Event: Public health

Proposal

Topic Relevance:

Health and education are closely linked and many in the international development space are now advocating for more strategic and aligned policy and planning between the two fields (The Learning Generation, 2016). Health literacy has become a high priority because sustainable behavioral and societal change is difficult without strategic and specialized education efforts to increase health literacy. Current health literacy assessments, however, do not always account for the interactional and critical aspects of learning (Berkman et al., 2011; Guzys et al., 2015), and few of these instruments take into account how communities define and assess for themselves what it means to be “literate” in their personal, community, and environmental health (Stewart et al., 2008; Parker, 2009). Community perspectives play a major role in improving and enhancing responsive assessments, and a serious commitment to engaging these perspectives is an important prerequisite for designing responsive assessments that promote continuous and collaborative learning (Gadsden et al., 2006; Johnston, 2005; Laing & Kamhi, 2003; Moll, 2010; Paris & Alim, 2017). Expanding common notions of health literacy through more sociocultural and critical analyses could provide helpful insights into how to address the gaps and limitations of common approaches to health literacy. The hope is that this inquiry will help us better understand how and why people engage (or disengage) with their personal, community, and environmental health, so that we can design more responsive and sustainable policy and programming.

Building on Existing work

Although health literacy has long been seen as basic writing and reading skill needed in healthcare settings, emerging health literacy frameworks draw from sociocultural and critical literacy epistemologies. Nutbeam (2000) draws from Freebody and Luke’s (1990) emphasis on thinking about literacy not just as a measurement or achievement but as what it enables us to do. He introduces critical health literacy which involves the skills needed to engage with information in empowering an conscientious ways. Gillis et al. (2012) draw from cite Barton et al (2000) to emphasize how all uses of literacy are socially situated and contextually dependent. Both Zarcadoolas et al. (2003) and Freedman et al. (2009) highlight civic literacies as an important piece of critical health literacy, and push for citizen-led mobilization around social inequities and for democratic participatory decision-making in health policy and planning. These are major strides forward in terms of expanding the narrow definitions of health literacy upon which the field was built. Yet despite this progress, many conceptualizations of health literacy continue to view it as a static product, rather than an iterative and malleable process (Sorensen et al., 2012). This is one area in which a Multiliteracies analysis could be helpful. Multiliteracies scholarship seeks to expand notions of text and context, and push literacy studies to acknowledge and address the multiplicity of cultures, languages, geopolitical forces, and modes of text that today’s increasingly globalized populations come into contact with every day (New London Group,1996).

Situated in terms of linguistic, national, or geo-political contexts

Western individualistic and cognitivist notions of health have been pervasive in health literacy discourse. Stewart et al. (2008) note that “Health promotion within a western construct” emphasizes helping individuals make independent health choices disconnected from the “interdependencies that exist among immediate and more distant environments”. Broder et al. (2017) argue that “this individual-based, action-focused perspective ‘appears to limit the problem of health literacy to the capacity and competence of the individual’” and “reflects a culture of individualisation in late modernity and ‘the risk society’ (p.20). They stress that “individual-level health literacy perspectives” may do very little to promote equitable and sustainable health outcomes. When health literacy conceptualizations give too much weight to cognitivism, behaviourism, and individualism, they sometimes fail to take into account the needs and vulnerabilities influenced by social or environmental materiality.

Some health literacy scholars already acknowledge that literacy is non-linear, that it is contextual, and is collaborative. Both Nutbeam (2000) and Levin-Zamir (2012) remind us that health literacy has its roots and in community based advocacy initiatives, and not in formalized top-down initiatives based on decontextualized standards and conceptions of health literacy. Nutbeam (2000), Nielsen-Bohlman et al. (2004), and Papen (2009) also remind us that functional health literacy is not a prerequisite to critical health literacy, and that even those with the lowest “functional” literacy (reading and writing skills) have can be successful at mobilizing resources and capital for community health. These are promising points of entry for more rigorous interrogation of what literacy means in these spaces and how to ensure that communities are supported in attaining equitable outcomes. A critical engagement with the multiliteracies framework would be particularly beneficial in this regard.

Implications, Originality, and Importance

Health literacy scholars have already expressed dissatisfaction with current, limited notions of what constitutes text within the discipline. Rudd et al. (2012) note the detrimental effects of a narrow focus on reading skills of patients in early health literacy studies and shows excitement at the new possibilities accompanying studies looking into the role of speaking, listening, and oral literacy skills in health literacy. Levin-Zamir and Wills (2012) highlight their colleagues use of the term “media health literacy” to focus on the importance of developing a critical eye towards health related information presented through multimedia platforms. These are examples of health literacy scholars questioning the role of written text as the primary mode through which people engage with literacy.

Currently, there are a plethora of underutilized resources in health promotion efforts especially for the most marginalized populations, and this is sometimes attributed to low health literacy levels (Levin-Zamir 2012). Yet if “literacy” within “health literacy” spaces were to take take a page from the multiliteracies framework and take on a more expansive and holistic conceptualization, one that recognizes the funds of knowledge (Moll et al. 2006) that these communities carry with them, as well as the various modes and mediums in which these literacies take form, then interruptions to this vicious cycle may be possible. Hopefully this can help us design more responsive and relevant health literacy policy and programming.

Author

• OreOluwa Badaki, University of Pennsylvania