One of the important developments in health literacy research is the shift toward approaching health literacy as an interaction. This can sound a bit challenging, but fear not!
In this episode, you’ll learn about one remarkable person, and one powerful, nearly century-old concept, that can help you understand health literacy as an interaction.
EPISODE TRANSCRIPT
Hi. This is 10 Minutes to Better Patient Communication from Health Communication Partners. I’m Dr. Anne Marie Liebel. If you’ve been thinking about health literacy lately, you are not alone! This is a field on the move. You might know this past summer, the US The Department of Health and Human Services is seeking input into an updated definition of Health Literacy for Healthy People 2030. The Secretary’s Advisory Committee on National Health Promotion and Disease Prevention even proposed a working definition of health literacy to kick things off.
In this episode, I’m going to introduce you to a person and a concept that might be helpful to you if you care about health literacy research or practice.
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 for years.
Notably, in 2016, a group of leading health literacy researchers and scholars issued a group statement as a Discussion Paper from the National Academy of Medicine, titled “Considerations for a new definition of health literacy.”
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 instead invite us to think of “health literacy as an interaction.” Not as a decontextualized skill. Not as an information exchange. But as an interaction. And I am here for this! It’s where I want to park it for a bit.
This idea of health literacy as an interaction has caught on in some places. I have seen it firsthand, talking to health professionals over the past few years. Because you’re recognizing that improving health outcomes involves understanding your patients’ or clients’ 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.
But if health literacy is an interaction, maybe we should start with: what’s interacting with what?
So, I’m going to introduce you to someone who can help.
Louise Rosenblatt died 14 years ago and she was 100 when she died. She was a researcher in reading and writing for almost the whole 20th century and into the 21st. Maybe you’ve heard of her, but if you haven’t, and you look her up on Google you’ll get more than 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.
It’s difficult to overstate Rosenblatt’s impact on modern studies of reading, writing, speaking, and listening. One of her main contributions was her Transactional theory . It’s sometimes referred to as transactional theory of reading, but Rosenblatt and many others applied it to reading, writing, listening, speaking, and even viewing. In the show notes I have links to these early writings 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 as it applies 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]
Now, we are always reading something, right? She puts it as a “particular configuration of marks on a page,” but it also applies to images on a screen, even conversations. We’re also somewhere when reading it. As she puts it, “at a particular time in a particular context”. As readers, we consider these contextual factors, sometimes unconsciously, as we read and make sense of what we’re reading.
Text and context are huge parts of meaning-making and I’m not getting into them in this episode. I am going to try to dig little into the first part Rosenblatt mentions: the person, you, the reader.
We’re always ourselves or as Rosenblatt puts it, “a particular reader” as we’re reading. This may seem obvious, but stay with me here. It might be helpful to draw a kind of picture: imagine yourself, maybe standing in line somewhere, and scrolling on your phone through social media or the news.
We can’t 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, expectations, fears, experiences, friends, foes—they’re all with us, when we read. These shape how we understand, interpret, and make sense of what we’re reading.
Rosenblatt explains that our knowledge and experience is a kind of capital:
…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 imagine a different scenario. Think of your favorite song. Do you remember about how old you were when you first heard it? Do you remember how it made you feel those first, oh, dozen or hundred first times you heard it?
Has your response to it changed at all, over time? It may sound different to you now, then when you first encountered it. It might evoke different thoughts or emotions. Of course, that ‘text’ hasn’t changed; you have. You are hearing it differently, interpreting it differently. Your understanding and appreciation of it has changed because you have changed. What you bring to the transaction has changed.
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, writing:
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]
What does this have to do with health literacy? Well, 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, writing:
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. This persons’ physical and emotional state shapes how he reads the bottle. He is reading for a particular purpose, looking for specific information rather than reading every word.
Here’s another example I’ve written about before: it is not hard to imagine how receiving 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 factors. Again I’m not getting into text and context here but I might in a future episode.
So what you can do?
As you might imagine, over Rosenblatt’s long career, her transactional theory was taken up many different ways in theory and in practice. What I’ll invite you to focus on in your practice or research are your patients’ or clients’ assumptions and thoughts, expectations, fears and experiences, remembering that these shape how they hear and make sense of what they’re hearing.
Again, Rosenblatt wrote:
…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]
Try it for yourself. Considering health literacy as an interaction might shift what you’re focusing on! 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, view, and understand.
So, I invite you to think about health literacy as an interaction. One that involves you and your patients or clients, as well as any texts you share. This has been 10 Minutes to Better Patient Communication from Health Communication Partners.