“We’re burned by, ‘Tell ‘em what they need to know, and hope they heard.’ It’s the cultural legacy…”
A surgeon told me this when we were talking about health literacy. His candor startled me. He went on to make the point that he was convinced he (and his colleagues) could be doing better.
Despite the conceptual developments of the last decade around health literacy as a complex process, individualized approaches toward health literacy remain dominant in research. Health literacy, in professional and public discourse, still gets talked about as something individuals have, or don’t have, in adequate amounts.
Increasingly, however, health literacy is being considered as a process. Among researchers who consider health literacy as a process, many pay attention to different interactions that have bearing on individuals’ health literacy activities. Interactions like the one between this surgeon and his patients.
Why care about health literacy as an interaction?
Looking at health literacy as an interaction allows us more options for working with it. Options we don’t have if we see health literacy as only some trait that individuals have (or don’t have) in adequate amounts.
Researchers I’ve talked with express frustration with their limited options. For example, one ED physician in Academic Medicine shared with me her exasperation at including health literacy in her research. She felt current definitions just didn’t offer the tools to deal with all that she was finding in her research on patients’ use of the ED.
Seeing health literacy as an interaction opens the door to some new possibilities for research–and for everyday practice.
The surgeon’s statement at the opening describes a one-way process: tell ‘em and hope they heard.
When health literacy is seen as an interaction, that means there’s a two-way process here. And abundant opportunities to have an impact!
What’s interacting with what?
As some literacy, literature, and education folks like to say:
Interactions happen between and among people, texts, and contexts.
I wrote about one kind of interaction before: the interaction between us and the texts we read.
So this time, I’m going to write about social interactions. People interacting with people, as part of health literacy.
It’s not hard to imagine person-to-person conversations as a social interaction. You may know there’s a whole research history of analysis of the meanings, values and effects of the conversations between providers and patients.
I thought I’d focus instead on the health literacy interactions between and among patients and people outside the clinical context. Like friends, family, colleagues and social networks (in person and digital).
And then I’ll show you why this matters in everyday practice in the clinical context, and what you can do.
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Friends, Family, and health literacy
It is not surprising that interactions with people in the health care system can present various challenges for patients. One study describes the experiences of two patients:
“Elisabeth…revealed how, because of her level of English, she was unable to assert herself to get a dentist’s appointment over the phone.”
“Navid, who had to attend the outpatient department of his hospital, explained how in the ‘big’ hospital there was no time for people to explain things to him in detail.”
It is equally unsurprising that social networks matter. There’s increasing agreement that family and larger social groups are part of what makes up health literacy.
When confronted with complex health-related experiences, patients—even those with literacy difficulties–draw on a friends and family to understand their situation, and to navigate the health care system.
The same study found that:
Health literacy is shared knowledge and understanding, it resides in the family, the neighbourhood and the social network of a patient. An individual’s health literacy could thus be seen as the sum of what she knows and is able to do on her own and what she is able to achieve with the support from friends, family and other significant people in her environment.”
The same is true when it comes to health literacy in digital environments. One study about patient portals, health literacy, and adults with diabetes found: “Participants reported family members facilitated access and usage of HIT, taught them usage skills, and acted as online delegates.”
Teachers and classmates count as significant people in one’s environment, too. A 2014 study on ESL-based health literacy interventions “underscores the powerful and active role that adult ESL teachers can play in the development of new health literacy skills in immigrant communities.”
Adult students in ESL classes were invited to role-play interactions with doctors, family, and friends about type 2 diabetes risk. They also shared with classmates their personal views about risk, and identified sources of reliable health information in their lives.
The researchers found that “the social practices of preventive health knowledge sharing and diffusion – which occurred initially in the classroom – often can extend to contexts outside of school, in the home and community.”
It’s possible none of these research findings come as a surprise to you. At some level, it’s as if we know that we learn in interactions with other people. So what does this mean for your everyday interactions with patients of all literacy levels?
What you can do
- Find out who your patient talks to most frequently, and/or who in this persons’ life they turn to when they need help with a complex language task (known as literacy sponsors). And encourage their involvement!
- Make sure there is something your patient can take home and share with others. Continue to do your best to provide information in multiple modes.
The pressure is off you to ‘do it all’ in your time with the patient. This is because some learning will happen as your patient interacts with the material you share, and also with his or her various social groups. The learning continues when patients leave you, and that’s a good thing.
You may be getting the sense that this is not going to lead you to a one-way, one-size-fits-all routine (like ‘tell ‘em what they need to know, and hope they heard’).
But don’t worry. It is not endlessly varied, either.
Think about the trends or patterns you’ve noticed in how patients engage in interactions with you. Thinking in terms of these trends or clusters, you may find you can develop an approach that works for each of those different clusters or groups. If you’d like support in this, please let me know.