Health literacy for improved health outcomes: effective capital in the marketplace.

Improving consumers' health literacy addresses many of the rising problems in healthcare. We empirically support a reconceptualization of health literacy as a social and cultural practice through which adults leverage a range of skills as well as social networks to meet their needs. Pierre Bourdieu's "theory of practice" guides this reconceptualization and facilitates articulation of the array of strategies used in the complex healthcare marketplace. We focus on the low literate consumers' alternative forms of capital and the providers' recognition and support. The findings, from an emergent research design consisting of depth interviews with low literate consumers and healthcare providers, suggest a critical, reflective approach that enhances health literacy, empowers consumers to become partners in their own healthcare programs, and improves health outcomes.

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Low health literacy is one of the most pressing problems in public healthcare. Particularly, the lack of functional literacy in the health arena creates inefficient utilization of services, driving up healthcare costs (Kusuma et al. 2008). Consumers are overwhelmed by healthcare-related communications written well above their reading abilities (Davis et al. 1993). More than one-third of the U.S. population experience difficulties completing healthcare-related tasks such as utilizing charts, interpreting an over-the-counter (OTC) drug label, or following prescription instructions (Sondik 2007). Low and marginal literacy is related to the misunderstanding of prescription medication labels which, in turn, contributes to the more than $177.4 billion in annual costs attributed to medication noncompliance (Ernst and Grizzle 2001). In addition, low health literacy levels translate into limited access to health information, suboptimal preventive care, and ineffective decision making about treatments (Shore 2001). Low health literacy harms consumers, perpetuates the existence of preventable diseases, creates large disparities in healthcare services, and drives up healthcare costs (IOM 2004).

In this study, we develop and empirically support a sociocultural conceptualization of health literacy. Findings from our interpretive study illuminate the range of skills and social networks that consumers leverage to fulfill their needs in a healthcare marketplace. We further flesh out strategies that empower consumers to take responsibility of their healthcare decisions. We begin by delineating the relationship between traditional and health literacies.

PERSPECTIVES ON HEALTH LITERACY

Current Definitions and Measures of Health Literacy

A widely accepted definition of health literacy is the "degree to which individuals have the capacity to obtain, process, and understand basic health information and services to make appropriate health decisions" (Ratzan and Parker 2000). In accord with this definition, most often health literacy is measured using the Test of Functional Health Literacy in Adults (TOFHLA; e.g., Baker, Parker, and Clark 1998) and the Rapid Estimate of Adult Literacy in Medicine (REALM; e.g., Davis et al. 1993). TOFHLA consists of sixty-seven numeracy and reading comprehension questions, assessing one's health literacy level as inadequate, marginal, or adequate (IOM 2004). The REALM requires individuals to read and pronounce various medical terms and conditions in a three- to five-minute timeframe. Mispronunciations are counted as incorrect and the number of correct pronunciations forms the basis of this assessment (IOM 2004). Both these scales receive frequent criticism for being limited to reading comprehension rather than purposefully using health information (DHHS 2007).