On this date, 14 years ago, Louise Rosenblatt died. She was 100 years old.
Louise Rosenblatt was a researcher in reading and writing for nearly the entire 20th century (!!) and into the 21st.
Maybe you’ve heard of her. If you haven’t, a Google search for her will yield about 3 billion results. So I’ll introduce you to one of her most important contributions, and then connect it to health literacy, in a way I hope will be helpful to you.
Before I turn to Dr. Rosenblatt, a bit of health literacy catching up.
New directions for health literacy
You know by now that there are many definitions of the term health literacy. You may also be aware that leaders in the field have been advocating for a wholesale redefinition.
In 2015, Rima Rudd, in “The evolving concept of Health Literacy: New directions for Health Literacy Studies,” explained that, over the years, the health literacy field had outgrown the current definitions: “Analysts began to note that the narrow definition of health literacy (defined and measured as individual skills and capacity) stymied attempts to redress [health] disparities.”
In 2016, a group of leading health literacy researchers and scholars issued a group statement as a Discussion Paper from the NAM, titled “Considerations for a new definition of health literacy.” In it, they take a brief look back at health literacy as a field, with the wisdom of hindsight:
“In the initial excitement of identifying a new variable for health analyses, researchers developed tools for measuring the health literacy skills and deficits of individuals without factoring in measures of the texts and talks and contexts within which these exchanges take place.”
They summarize that “When health literacy is conceptualized only as an attribute or ability of an individual, both research and practice will be stymied.”
They invite us to think of “health literacy as an interaction.”
Not as a decontextualized skill. Not as an information exchange (like exchanging phone numbers or pocket snacks). But as an interaction. And here’s where I want to park it for a bit.
This idea of health literacy as an interaction has caught on in some places. Talking to medical professionals over the past few years, I have witnessed this firsthand. Providers recognize that improving health outcomes involves understanding their patients’ thinking, knowledge, resources, goals, and contexts–and communicating with these in mind.
Seeing health literacy as an interaction opens the door to some new possibilities for research and practice.
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If health literacy is an interaction, what’s interacting with what?
To answer that, I’ll use a phrase that’s popular in some literacy and literature research:
People, texts, and contexts.
(The NAM Discussion paper above used a somewhat similar phrase, “texts and talk and contexts.”)
When we talk, listen, read, watch, or write something, we are interacting with that text, as well as with our environment (and sometimes with other people).
When we read, for instance, we are always reading something. One way of thinking about this is saying that we interact with texts.
This is still quite vague, so I’m going to turn to Dr. Rosenblatt for help. Then I’ll go to some examples.
I was in grad school at the time Dr. Rosenblatt died. A few weeks later, at Penn’s annual Ethnography Forum, stories of her life and contributions were pouring out, told by people who interacted with her throughout her long, prolific, revolutionary career. It’s difficult to overstate Rosenblatt’s impact on modern studies of reading, writing, speaking, and listening.
One of Rosenblatt’s main contributions was her Transactional theory of reading and writing.
Here I’ll share a couple quotes from one small section of this expansive theory, to give a sense of what it means to think about reading as an interaction–or, as Rosenblatt preferred, a transaction.
Then I’ll connect it back to health literacy. (The links are to one of Rosenblatt’s early writings about Transactional theory, if you would like to read more about it.)
Rosenblatt more or less gives us a no-nonsense, one-sentence definition of her Transactional approach to reading:
Every reading act is an event, a transaction involving a particular reader and a particular configuration of marks on a page, and occurring at a particular time in a particular context. [p.6]
We are always reading something (a “particular configuration of marks on a page,” or images on a screen, and more). We’re also somewhere when reading it (“at a particular time in a particular context”). We consider these contextual factors, sometimes unconsciously, as we read and make sense of what we’re reading. This is our part of the ‘transaction’ with the text.
And we’re always ourselves (“a particular reader”) as we’re reading. This may seem obvious, but stay with me here.
We cannot help but read (and hear and understand) from our own position. We read through the lenses of our own lives.
When we interact (or transact) with a text, we don’t ‘just read’ it. We bring our own assumptions and thoughts, fears and experiences, friends and foes with us, when we read. Rosenblatt explains that our knowledge and experience is “all each of us has to start from”:
…our funded assumptions, attitudes, and expectations about the world–and about language–this inner capital is all that each of us has to start from in speaking, listening, writing, and reading. [p.5]
Let’s make this concrete with an example.
Think of your favorite book, song, play, poem, or piece of visual art.
Has your response to it changed at all, over time? It may look different to you now, than when you first encountered it. It may evoke different thoughts or emotions. Of course, that ‘text’ hasn’t changed, you have. You are seeing it differently, hearing it differently, viewing it differently. Your understanding and appreciation of it has changed because you have changed. What you bring to the transaction has changed.
Similarly, different people can read the same ‘text’ and come away with different interpretations of it. You know this if you and your friends have ever argued over the meaning or significance of something in a movie or show. You saw the same thing, but interpreted it differently.
OK, we have our past collected knowledge and experiences with us when we interact or transact with a text. We also have our present assumptions, thoughts, emotions, and physical sensations. Rosenblatt describes this as “the physical and emotional state of the individual” and includes it in the transaction:
In the linguistic event, any process will be affected also by the physical and emotional state of the individual, e.g., by fatigue or stress. Attention may be controlled or wandering, intense or superficial. [p.6]
Why is this important to remember?
Every day, people encounter and interpret information related to their health and healthcare. They interact (or transact) with it.
Rosenblatt gives us a vivid, if extreme, example of how the transactional theory might apply to health literacy:
An extreme example is the man who has accidentally swallowed a poisonous liquid and who is rapidly reading the label on the bottle to learn the antidote. [p. 7]
Yes, it’s an extreme example, but effective. Here’s another example I’ve written about before: it is not hard to imagine how a diagnosis of cancer – or any bad news – can influence how someone reads a pamphlet, form, or website. Or how they hear the words of the provider (spoken words also can count as a ‘text.’)
The sense we make of what we read and hear turns out to be very connected to who we are, how we’re feeling, why we’re reading what we’re reading, and many more contextual factors.
What you can do
Try it for yourself. If you consider health literacy as an interaction, what might you want to pay attention to in the following scenarios? (These are all real health literacy interactions I have witnessed, or been told about by those involved):
- An ER pediatrician deciding how to articulate bad news to parents so they can make care decisions
- An adult child searching online for alternative therapies for his dad’s prostate cancer
- A medical educator socializing her students into the academic language of medicine
- A woman jogging on a treadmill in a gym watching TV ads for pharmaceuticals
- A patient advocate negotiating a bill on behalf of a clinic patient
We don’t communicate in a vacuum. Where we are, when, why, who we’re with, what we have—all of this makes a difference to the way we read, write, listen, speak, and understand.
I invite you to think about health literacy as an interaction. One that involves you and your patients, as well as the texts you share. In the coming months I’ll continue to explore this idea. Have questions? Want to know more? Contact me!