An expanded model of health literacy

A long and yet unfinished history of look intoing how single capablenesss and societal procedures explain or predict wellness indicates that hapless instruction, low literacy, hapless wellness and early decease are strongly linked around the universe. However, the complexness of those relationships is non to the full understood. In this article, we propose an expanded theoretical account of wellness literacy characterized by four spheres: cardinal literacy ( reading, composing, speech production and numeracy ) , scientific discipline literacy, civic literacy and cultural literacy. To research the public-service corporation of this theoretical account, we examine selected pieces of the public discourse about terrorist act and biological terrorism that dominated the mass media during the splenic fever menace in the United States during 2001. We conclude that this theoretical account of wellness literacy is utile to analyse wellness communicating, to help in building more apprehensible and appropriate wellness communicating, and finally can take to the development of a new step to measure wellness literacy accomplishments in persons.

Key words

biological terrorism


wellness literacy

public wellness

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There is a long and yet unfinished history of look intoing how single capablenesss and societal procedures explain or predict wellness. As demonstrated in major policy studies such as Healthy People 2010, hapless instruction, low literacy, hapless wellness and early decease are strongly linked in the United States and around the universe ( Grosse and Auffrey, 1989 ; Hohn, 1997 ; US Department of Health and Human Services, 2000 ; Schillinger et al. , 2002 ) . These are peculiarly of import countries of probe, particularly in visible radiation of the tendency evident since the beginning of the twentieth century that most major progresss in wellness are due to the application of new cognition and engineerings, such as immunisations and preventative medical specialty ( World Bank, 2002 ) .

In this article, we explore an expanded theoretical account of wellness literacy showing its efficaciousness through the illustrations of public communicating sing the splenic fever menace in the United States during the autumn of 2001. Moments such as the splenic fever onslaughts are when the populace actively seeks information, making existent chances to better wellness literacy. The populace ‘s concern, evident deficiency of trust in authorities and official information and a suggested nexus between hazard perceptual experience and complexness of information, lead us in this article to look into the wellness literacy demands of splenic fever messages. Proposing an expanded theoretical account of wellness literacy, we discuss the splenic fever menace non as a communicating challenge but as a series of chances to better wellness literacy.

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The term wellness literacy has been used to intend many things ( Hohn, 1997 ; Rudd, 2002 ) . The term, and field of survey, developed through a convergence of patient comprehension and conformity surveies by and large conducted by doctors ( Roter, 1984 ; Davis et al. , 1990 ; Williams et al. , 1995 ; Parker et al. , 1995 ; Williams et al. , 1998 ; Gazmarian et al. , 1999 ; Schillinger et al. , 2002 ) and wellness instruction and grownup literacy specializers looking at the mismatch between print stuffs and patient reading abilities ( Doak et al. , 1996 ; Root and Stableford, 1999 ; Zarcadoolas et al. , in imperativeness ) .

Over the last 10 old ages, a theoretical account of wellness literacy that by and large focuses on an person ‘s ability to interact with wellness attention suppliers has made progresss in mensurating and analysing the relationship between wellness literacy and wellness in the United States ( Parker et al. , 1995 ; Williams et al. , 1995 ; Baker et al. , 1997 ; Williams et al. , 1998 ; Davis et al. , 1998 ; Gazmarian et al. , 1999 ; Schillinger et al. , 2002 ) . That research plan has developed wellness literacy trials bring forthing statistically important yet little correlativities with factors such as the likeliness of possessing wellness information. Such grounds showing that many people who are low literate can non understand and move on wellness information has lead to a ‘clear linguistic communication ‘ motion concentrating on the analysis and simplification of linguistic communication.

The relationship between the complexness of wellness stuff and the literacy degrees of persons is an of import but non sufficient apprehension of wellness literacy. Reading degree entirely ( particularly sing the trouble of measuring true reading degree ) does non explicate the complex human accomplishments involved in going a wellness literate citizen. Aspects of wellness literacy beyond reading accomplishments, such as the power of spoken and online communicating, the impacts of understanding scientific discipline and the media, and the documented importance of cultural apprehensions lead us to further research our apprehension of how people make significance of wellness information ( Curran, 2002 ) .

Research workers concentrating on the public apprehension and battle with scientific discipline are besides interested in the relationships between attitudes toward scientific discipline, heed to science, cognition, and behaviour. For case, several similar large-scale public studies have been conducted in several states, including semiannual attempts by the US National Science Foundation and several Eurobarometers ( National Science Foundation, 2003 ; European Commission, 2003 ) . However, the complex nature of the scientific discipline and society relationship frequently consequences in findings that negate hypotheses of a positive linear relationship between apprehension, attitudes and behaviours ( Pardo and Calvo, 2002 ) . Research workers are go oning to develop theoretical accounts of scientific discipline literacy-including spheres such as cultural literacy, civic literacy and practical literacy-as good as farther researching the complex relationships between scientific discipline and the populace ( Laugksch, 2000 ; von Grote and Dierkes, 2000 ; Pleasant et al. , 2003 ) .

Other valuable positions are found in the last 30 old ages of research in the Fieldss of sociolinguistics and discourse analysis ( Labov, 1972 ; Hymes, 1974 ; Stubbs, 1983 ; Labov, 1994 ) , literacy and reading ( Olson, 1980 ; Orasanu, 1986 ; Britton and Graesser, 1996 ; Olson and Torrance, 2001 ) , the relationship between written and spoken proficiencies ( Kroll and Vann, 1981 ; Scribner and Cole, 1981 ) , the construction and map of narrations in comprehension ( Propp, 1968 ; van Dijk, 2001 ) and cultural determiners of significance ( Gumperz, 1982 ; Achard and Kemmer, 2003 ) . Overall, the field of wellness literacy is merely get downing to do usage of the cognition generated in other academic spheres that can lend to a really rich apprehension of literacy. We draw on this broad organic structure of cognition to suggest a theoretical account of wellness literacy.

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In our position, a wellness literate individual is able to utilize wellness constructs and information generatively-applying information to fresh state of affairss. A wellness literate individual is able to take part in the on-going public and private duologues about wellness, medical specialty, scientific cognition and cultural beliefs. Health literacy evolves over one ‘s life and, like most complex human competences, is impacted by wellness position every bit good as demographic, sociopolitical, psychosocial and cultural factors. Therefore, the benefits of wellness literacy impact the full scope of life ‘s activities-home, work, society and civilization. In this position, we are to the full aligned with broader ethical and policy statements such as the Ottawa Charter of Health Promotion place that ‘health is a resource for life, non the object of life ‘ ( World Health Organization, 1986 ) .

Therefore, we define wellness literacy as the broad scope of accomplishments, and competences that people develop to seek out, comprehend, evaluate and utilize wellness information and constructs to do informed picks, cut down wellness hazards and increase quality of life.

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Our definition of wellness literacy leads straight to a multi-dimensional theoretical account for understanding and bettering the populace ‘s wellness literacy. The theoretical account we propose in this article is characterized by four cardinal domains-fundamental literacy, scientific discipline literacy, civic literacy and cultural literacy.

Cardinal literacy refers to the accomplishments and schemes involved in reading, speech production, composing and construing Numberss ( numeracy ) .

Science literacy refers to degrees of competency with scientific discipline and engineering, including some consciousness of the procedure of scientific discipline. We specifically include:

cognition of cardinal scientific constructs,

ability to grok proficient complexness,

an apprehension of engineering and

an apprehension of scientific uncertainness and that rapid alteration in the recognized scientific discipline is possible.

Civic literacy refers to abilities that enable citizens to go cognizant of public issues and to go involved in the decision-making procedure. Categories in this sphere of wellness literacy include:

media literacy accomplishments,

cognition of civic and governmental procedures and

an consciousness that single wellness determinations can impact public wellness.

Cultural literacy refers to the ability to acknowledge and utilize corporate beliefs, imposts, world-view and societal individuality in order to construe and move on wellness information. This sphere includes a acknowledgment and accomplishment on the communicator ‘s portion to border wellness information to suit powerful cultural apprehensions of wellness information, scientific discipline and single and corporate action ( Kreps and Kunimoto, 1994 ) .

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During late September and early October of 2001, monolithic public attending was focused on the apparition of biological terrorist act in the United States. Public discourse about terrorist act and biological terrorism dominated the content in the traditional mass media, multiplied on the World Wide Web, and topped the docket around dinner tabular arraies and H2O ice chests. The US Postal Service mailed a post card to every family in the state while federal and local wellness sections rapidly dusted-off, revamped and expanded exigency programs for possible Acts of the Apostless of biological terrorism in the hereafter. In short, the state was seeking to quickly react to a new menace ; fighting to construct new apprehensions of a all of a sudden changed universe.

The silent ‘promise ‘ long-established between public wellness functionaries and the populace they serve is to supply seasonably, accurate and trusty information to safeguard people ‘s wellness and wellbeing. Trying to forestall overreaction and widespread terror during the splenic fever menace, functionaries needed to give the populace and imperativeness concrete and apprehensible information and advice in reply to basic inquiries such as:

What was splenic fever?

Who was at hazard?

What were public wellness functionaries making?

What should the populace make?

Once the splenic fever menace hit the intelligence, poll takers began inquiring about splenic fever. A Gallup canvass taken between October 19 and 21, 2001 found that merely 13 % of Americans were ‘very confident ‘ in the authorities ‘s ability to forestall extra splenic fever exposures. Thirty-eight per centum said they were ‘not excessively ‘ or ‘not at all confident ‘ ( Gallup, 2001 ) . A Pew Research Center For The People and The Press canvass ( Pew Research Center for the People and the Press, 2001 ) conducted between October 10-14, 2001, found that ‘About seven- in-ten ( 69 % ) have some concern over new onslaughts, and better than half ( 52 % ) are at least slightly worried that they or their households could go victims of terrorist act ‘ ( Pew, 2001 ) .

A canvass conducted by The New York Times/CBS News between October 25 and 28, 2001 found that approximately 50 % of the state felt the authorities was non stating people everything they needed to cognize about splenic fever ( Berke and Elder, 2001 ) . A Gallup canvass conducted in November 26-27, 2001 found that persons with less formal instruction were more likely to be worried about exposure to anthrax. Forty-four per centum of Americans with a high school instruction or less were worried compared with 21 % of those with a college grade ( Jones, 2001 ) .

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To research the public-service corporation of our theoretical account and each of the spheres of wellness literacy-fundamental, civic, scientific discipline, and cultural-we bend to illustrations from the mass media and official authorities informational attempts during the splenic fever menace.

Cardinal literacy: reading, composing, speech production and numeracy

The Centers for Disease Control ( CDC ) were the primary beginnings of information from the US authorities during the splenic fever menace. At the clip, a nexus on the CDC place page labeled, ‘Terrorism and Public Health-info for spouses, professionals and the populace ‘ , led to a definition of splenic fever written at the college and post-college degree that is rather unaccessible due to complex vocabulary and embedded compound and complex sentences ( CDC, 2002 ) . The definition presented by the CDC did non fit the cardinal literacy of a bulk of the American population ( Figure 1 ) .


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Fig. 1:

CDC web site definition of splenic fever ( CDC, 2002 ) .

For illustration, the 3rd sentence of the CDC ‘s definition of splenic fever, ‘Human splenic fever has three major clinical signifiers: cutaneal, inspiration and gastrointenstinal ‘ contains a few easy to read words ( e.g. has, three, major, signifiers ) , but runs into an understanding barrier when presuming the reader comprehends the embedded construct of a ‘clinical signifier ‘ . Even readers with a high adequate degree of cardinal ( reading ) literacy to understand the words cutaneal, inspiration and gastrointestinal may non hold a degree of wellness literacy equal to understanding the construct of clinical signifier. Merely through rearward detective work could readers cobble together any thought of what ‘clinical signifier ‘ might intend.

With the exclusion of the words ‘anthrax ‘ and ‘death ‘ , most readers would non understand this definition. When a text is difficult to read, readers will by and large prevail, rearranging the text to do some significance, even if it is non the text ‘s intended significance. For illustration, a often used reading scheme of ‘skipping and thinking ‘ would probably take readers of the 4th sentence to the following reconstructed significance: If left untreated, splenic fever in all signifiers can take to septicemia and decease.

Is reconstructed as: Anthrax in all can take to decease.

While there were first-class, easy-to-read illustrations of media and authorities messages during the splenic fever menace, it is frequently more instructional to concentrate on topographic points where communicating was hard or less successful. This subdivision of the CDC web site was one of those instances. Within the sphere of cardinal literacy, the complex linguistic communication does non run into basic demands of most readers-it does non utilize shared, common linguistic communication and does non progress wellness literacy. This definition by the CDC could really make injury by misleading or turning citizens to other, possibly less dependable, beginnings of information.

Science literacy: the impact of uncertainness

Built-in to biological terrorism is a double potency for mass devastation ( decease and unwellness ) and mass break ( fright, terror and misgiving of official beginnings ) . Without uncertainness, there would be no break. In the instance of anthrax-tainted letters in the United States, break occurred on a larger graduated table than devastation.

Two critical countries of uncertainness contributed to the potency for wide societal break. First, there was uncertainness about what action a bioterrorist would following take. Second, there were scientific uncertainnesss about splenic fever. Prior to this act of biological terrorism, there was an extended organic structure of scientific cognition about Bacillus anthracis, the cause of splenic fever, stretching back to the development of Koch ‘s posits ( Inglesby et al. , 1999 ) . Bioterrorism, nevertheless, ripped open the ‘black box ‘ of cognition about splenic fever in a really public manner ( Latour, 1987 ) . The Acts of the Apostless of biological terrorism created and brought into full public show scientific uncertainness related to the sum of spores that can do inspiration splenic fever ; the ability of splenic fever to cross-contaminate other pieces of mail, edifices and treating machinery ; and the likeliness of secondary aerosolization of splenic fever spores. Public wellness functionaries needed to turn to these countries of uncertainness to successfully reply the populace ‘s inquiries and dispel indefensible frights potentially taking to greater societal break.

Dr Anthony Fauci, manager of the National Institute of Allergy and Infectious Diseases of the National Institutes of Health, was subsequently described in US News and World Report as, the state ‘s go-to cat when it comes to explicating the new facts of life with biological terrorism ‘ . When asked by Katie Couric on NBC ‘s Today show what the response would be for postal workers if splenic fever spores were found in their installation, Fauci described the scientific procedure as it was being applied to finding the response to anthrax at assorted postal installations in apprehensible footings. He attempts to better the scientific discipline literacy of the viewing audiences. As you know, this is a work in advancement because it is still non certain, as we have non heard from the CDC, as to whether or non there are more of these letters in add-on to the Daschle missive. But allow ‘s merely presume, for illustration, that there is a missive that has some taint. The primary installation in Washington, D.C. , is the Brentwood installation that is clearly contaminated, so anyone who is in that installation and managing bulk mail demands to be treated. … There has already been certification that people have gotten inspiration splenic fever from secondary installations. So the premise is that if one is contaminated they might wholly be contaminated. Therefore, pre-emptively, people are being given antibiotics while their installation is being swept for the grounds of there being taint. If it is contaminated, so you continue the antibiotics. If it is n’t, so that is when you have heard about giving people 10 yearss merely to do certain they are covered. Then if the trials come back that in fact their peculiar installation is negative-there has been no contamination-then you can retreat. That is the general doctrine that has been put Forth.

Fauci addressed the construct that scientific and medical apprehensions are works in progress-a complex impression for a people used to comprehending scientific discipline as a beginning of distinguishable replies and cosmopolitan truths ( Nelkin, 1987 ; Gregory and Miller, 1998 ; Friedman et al. , 1999 ) . He besides attempted to explicate the eventualities of intervention for postal workers depending upon the grounds of exposure and the stance toward hazard that was taken. If the kind of communicating Fauci delivered was the norm instead than the exclusion, public wellness literacy could hold clearly benefited.

Civic literacy

The splenic fever menace besides demonstrates the function civic literacy dramas in alining personal wellness attention decision-making with public wellness ends. On October 15, 2001, NBC News ground tackle Tom Brokaw said, ‘In Cipro we trust ‘ while keeping up a phial of pills as he closed the eventide intelligence. The powerful antibiotic Cipro, more normally referred to as Cipro, is a recommended intervention for splenic fever. Brokaw was one of the comparatively little figure of Americans validly taking Cipro as a preventive for splenic fever. At that minute, there were four confirmed instances of splenic fever in the US ; one was an helper to Brokaw diagnosed with cutaneal, or tegument, splenic fever ( CDC, 2001 ) .

Brokaw ‘s drama on the slogan ‘In God we trust ‘ that appears on US currency more than typify his personal response to being a mark of biological terrorism. Brokaw tacitly allowed the full state to believe safety for all was found in the broad-spectrum antibiotic. ‘In Cipro we trust ‘ implies that taking Cipro was in the corporate good while, in fact, unnecessarily taking Cipro is an single act that could lend to a turning public wellness menace.

Unnecessary usage of antibiotics in response to the splenic fever panic would amplify an already turning public wellness concern-the development of antibiotic resistant diseases. In 1999, antibiotic opposition was already estimated to be $ 30 billion dollars yearly ( American College of Physicians-American Society of Internal Medicine, 2000 ) . Recently, both the AMA and the WHO encouraged doctors to distribute fewer antibiotics and to explicate the downside of antibiotic opposition to their patients. However, public sentiment polls during the splenic fever menace found that between 3 and 6 % of the American populace reported obtaining a prescription for an antibiotic in response to the menace of biological terrorism ( Blendon et al. , 2001 ) . As a per centum, that seems a comparatively modest reaction, but 3 % of the US population is over eight million people.

After anthrax-filled letters were sent to media forces and Senate bulk leader Tom Daschle ( D-SD ) , an chance to increase wellness literacy in relation to antibiotic opposition was missed. Low wellness literacy combined with hapless public wellness messages resulted in a refusal on the portion of some single citizens to mind public wellness messages. In that communicating environment, the undermentioned figure illustrates a way of weak communicating that did non progress the populace ‘s wellness literacy ( Figure 2 ) .


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Fig. 2:

A mini-case: Messages about Cipro non taking to the desired result.

Cultural literacy

Communication delivers information about the content of the message every bit good as about the relationship between the participants. This is peculiarly of import to see when pass oning between civilizations ( Kreps and Kunimoto, 1994 ) . Cultural differences-in the signifiers of workplace and racial differences-increased the possible for struggle and misinterpretations during the splenic fever menace. For illustration, while no postal installations were closed or single postal workers were tested instantly after the missive to Senator Daschle was received, workers at the Capitol edifices were tested, given Cipro, and the House of Representatives closed.

The message sent by taking direct action to close down installations where splenic fever spores were known to be present was a strong, proactive and positive message both in footings of content and relationship to persons who worked at those installations. However, workers at postal installations that remained unfastened knew that they handled mail delivered to installations that were closed. The postal workers interpreted the same message rather differently-especially in footings of the message about their relationship-and arrived at what was for them a rather logical decision that the governments did non care as much about their wellness.

In another illustration, the usage of rhinal swabs was ab initio considered a method to observe the disease, but during the class of the probe, CDC epidemiologists determined the swabs were chiefly utile in finding the spread of spores. However, the pattern became a symbol of positive action on an single versus the public wellness degree and was rapidly politicized. The wellness commissioner of Washington D.C. , Dr Ivan Walks, told The New York Times he received inquiries like, ‘The folks on the Hill got swabbed, now you ‘re non swobing us? ‘ and ‘White people got swabs, black people did n’t acquire swabs ‘ ( Lipton and Johnson, 2001 ) .

In the effort to understand, racial backgrounds were a much more touchable difference between the two populations of workers than any scientific uncertainness about splenic fever. A consequence was a threatened break of the societal contract as evidenced, in portion, by cases filed by the postal workers ‘ brotherhood avering unjust intervention by the authorities.

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We have used an expanded theoretical account of wellness literacy and the component spheres of cardinal literacy, scientific discipline literacy, civic literacy and cultural literacy to analyse selected communications during the splenic fever menace. We demonstrated that hard linguistic communication without definition and account, complex sentence construction and assumed cognitions are among the important issues that must be addressed in footings of cardinal literacy. In footings of scientific discipline literacy, we examined the successful and less successful efforts to explicate the scientific procedure and the branchings of that to the splenic fever menace. In footings of civic literacy, we demonstrated the function civic literacy accomplishments play in alining single determinations with the involvements of public wellness ends. In respect to cultural literacy, we show that cultural differences can take to different readings and reactions to the same message. We have demonstrated the public-service corporation of our expanded theoretical account of wellness literacy.

Much of the clip, a cardinal challenge to public wellness is deriving the attending of a distrait, decelerate to be motivated public. During the splenic fever menace, Americans were actively seeking information about splenic fever. That presented a great chance to present apprehensible linguistic communication about the splenic fever menace, to progress apprehension of scientific discipline and scientific uncertainness, to advance know aparting rating of beginnings and of information received, and to aline single determinations with the corporate good. The splenic fever menace presented a great chance to progress public wellness literacy.

Attempts to better wellness literacy should be high among the list of precedences as the state responds to the possibility of terrorist act and biological terrorism. An effectual policy would include turn toing the import and impact of a complex apprehension of the multiple spheres of wellness literacy. That apprehension will assist to make successful wellness communicating attempts, supply an analytical model from which to analyse wellness communicating as it is encountered, and finally lead to development of a fuller step of wellness literacy.

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This research was supported in portion by a publication grant from NIH/NLM No. 1G13 LM07484-01. We would besides wish to admit the media research activities of Polly Reynolds.

© The Writer 2005. Published by Oxford University Press. All rights reserved. For Permissions, please electronic mail: journals.permissions @

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