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  • Keyword Essay:Health Literacy
  • Jessica Nalani Lee and Amy C. Hickman

The term "health literacy" (HL) evokes conflicting definitions that reflect varying disciplinary standpoints of community literacy, clinical, and public health disciplines. This disharmony becomes problematic when designing HL assessments meant to inform clinical practice. The Community Literacy Journal (CLJ) defines "literacy" as "the realm where attention is paid not just to content or to knowledge but to the symbolic means by which it is represented and used" ("Focus and Scope"). From a community literacy standpoint, then, we understand any definition of HL to begin with the variety of means by which HL is defined and its use in healthcare contexts. Understanding how HL functions as a definition enables a greater appreciation for how it necessarily reflects disciplinary epistemologies and worldviews.

The purpose of our keyword essay is to explicate how HL is variously defined by scholars and practitioners in clinical, public health, and community literacy. All three disciplines interrogate how healthcare recipients interact with the content generated from using the healthcare system and how these recipients build knowledge about health and disease, but key differences exist. For example, HL assessments in clinical settings tend toward a skills-based functional literacy in order to identify healthcare recipients with low HL, whereas public health disciplines engage HL as a method to prevent disease, while community literacy disciplines address the complex and socially situated nature of HL. Community literacy disciplines tend to position their work as a critique of more functional approaches to literacy shaped by institutional goals and practices. Clinical, public health, and community literacy disciplines define HL differently, yet may not fully account for insights gained across disciplinary boundaries. In this keyword essay, we address that gap in understanding through a review of commonly used definitions of HL. We then present a framework for bringing these different understandings of HL into synthesis.

Our backgrounds in writing studies, public health, and nursing lend insight into the divide between clinical HL assessments and community literacy understandings of literacy. We seek to explore the ways in which community literacy scholarship might be taken up by public health and clinical healthcare practitioners to reflect current and more complex applications of the concept of literacy. In addition, community literacy scholars will find this discussion useful in designing HL policy and programs. As Michael Mackert and Meg Poag note in CLJ, research on literacy programs' efforts to improve HL among adult literacy students with low literacy levels "highlights an opportunity to increase collaboration among literacy programs and medical [End Page 73] education programs to help students of all types—adult basic education, doctors, nurses, and pharmacists—learn together" (70).

In what follows, we first consider accepted definitions of HL that shape how it is assessed in clinical settings. We then consider definitions of HL specific to public health perspectives. We ground our definitional analysis by examining three commonly used types of HL assessment in clinical practice: T.C. Davis et al.'s Rapid Estimate of Adult Literacy in Medicine (REALM), Ruth M. Parker et al.'s Test of Functional Health Literacy in Adults (TOFHLA), and Barry Weiss et al.'s Newest Vital Sign (NVS). In our analysis, we note the gaps between clinical, public health, and community literacy understandings of HL and share a framework that can be used to ensure that HL assessment in clinical and community contexts reflects current and robust definitions of community literacy.

Health Literacy Defined through Clinical Perspectives

HL, as a concept, has gained prominence in public health forums and policy discussions regarding the nature of health disparities and rising healthcare costs (Mackert and Poag; DeWalt et al.; Weiss and Palmer). It is generally understood that low literacy and poor health are correlated (Nielsen-Bohlman et al.). This keyword essay explores how a clear understanding of how HL functions to affect these variations in healthcare outcomes and expenses remains elusive in part due to the slow uptake of more situated and socially complex understandings of HL forwarded by community literacy scholars and practitioners.

Physicians Scott C. Ratzan and Ruth M. Parker defined HL in 2000 as "the degree to which individuals have the capacity to obtain, process, and understand the basic...

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