The Health Literacy Skills Framework

Figures & data

Figure 1  Framework for identifying constructs and their influence.

Table 1. Individual-level models of health literacy: A summary and comparison of key concepts from health literacy models, identifying the key concepts that have informed the development of the RTI Health Literacy Skills Conceptual Model (RTI HLSCM)

Framework Reference Model level Health literacy (HL): Dynamic/Static	How model defines health literacy	Key concepts included	Key contributions and strengths/limitations of model	Key concepts retained in RTI HLSCM
1. Baker (2006)  Individual-level modelDynamic	Presents Institute of Medicine's (IOM) and Healthy People's 2010 definition: “The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”States that this definition is static and presents framework that is dynamic (individual and health care encounter).Components of HL:▪ Print (ability to understand written health information).▪ Oral (ability to orally communicate about health).	Individual capacity (defined as reading fluency).Prior knowledge (includes vocabulary and conceptual knowledge of health and health care) affects capacity and health literacy.Potential mediators/moderators:culture and norms, barriers to change (new knowledge, positive attitudes, greater self-efficacy, behavior change).Outcomes: improved health outcomes.	Views underlying prior knowledge as a resource that affects HL, not as part of the definition.Strengths:▪ Identifies mediators/ moderators that may influence outcomes.▪ Emphasizes the role of prior knowledge and recognizes conceptual knowledge as well as vocabulary.Limitations:▪ Does not identify specific health outcomes.	▪ Prior knowledge.▪ Communication as component of HL.▪ Culture and social norms (from family, community, media, etc.) as factors that influence the relationship between health literacy and health outcomes.▪ Individual-level mediators: attitude, self-efficacy.
2 Lee, Arozullah, & Cho (2004)Individual-level modelDynamic	IOM definition: “the capacity of individuals to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”	Theoretical framework of how HL affects outcome—through intermediate factors: depicts “net” effects of HL and intermediate variables.Mechanisms or intermediate factors linking HL to health outcomes (considered intercorrelated):▪ Disease & self-care knowledge.▪ Health risk behavior.▪ Preventive care & physician visits.▪ Compliance with medications. Outcomes:▪ Health status.▪ Emergency care.▪ Hospitalization. Moderators/control variables:▪ SES.▪ Gender.▪ Ethnicity.▪ Health insurance coverage.▪ Disease severity.▪ Income discrepancy. Ethnic composition of community	Strengths:Presents testable relationships based on framework.Limitations:▪ Does not directly consider individual's motivation, self-efficacy, or attitude.▪ Does not consider provider-level, system-level, or societal-level factors.▪ While acknowledging its importance, does not include social support as a potential mediator of the relationship between HL and health outcomes.	Differences between Lee et al. framework and RTI framework:Lee: knowledge of health and disease is a mediator between HL on health outcomes;RTI: knowledge contributes to one's HL level and is a result of applying HL skills to stimuli.Health outcomes also influence control variables.Describes environmental variables as influencing health literacy skills development, mediators, and health outcomes.
3. Mancuso (2008) Individual-level modelDynamic	Reviews and critiques various definitions of HL but does not totally adopt any.	Six dimensions of competence that are antecedents of HL:1. Operational.2. Interactive.3. Autonomous.4. Informational.5. Contextual.6. Cultural.Attributes of HL:▪ Capacity: individual skills in information processing, oral language, social skills, and others.▪ Comprehension: understanding information.▪ Communication: reading, writing, speaking, understanding, listening, and observing.Consequences of poor HL: increased costs, less knowledge of diseases and treatments, fewer self-management skills, poorer compliance, more errors, poor ability to negotiate and access the health care system, poorer health outcomes.	Uses concept/dimensional analysis to conceptualize the antecedents, attributes, and consequences of HL. Positions HL within the context of individual and society and identifies the interaction between the six competencies and the three attributes.Limitations: does not identify the pathway between antecedents/attributes and outcomes; does not distinguish between long term and short term outcomes; does not identify potential mediators between HL and health outcomes.	▪ Communication as a component of health literacy.
4. Manganello (2008)Individual-level modelStatic	Refers to IOM definition: “the capacity of individuals to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”Framework specifies skills related to HL:Levels from Nutbeam (2000):▪ Functional.▪ Interactive.▪ Critical.Adds:▪ Media literacy.	Conceptual framework of adolescent HL.Individual traits (affect HL):▪ Age, race, gender, language, culture, education.▪ Social skills.▪ Cognitive skills.▪ Physical abilities.▪ Media use.HL (affect health outcomes):▪ Functional.▪ Interactive.▪ Critical.▪ Media literacy.Mediators:▪ Family and peer influences.▪ Mass media.▪ Education system.▪ Health system.Health outcomes▪ Health behavior.▪ Health costs.▪ Health-service use.	Strengths:▪ Considers HL based on the ecological model: incorporates both individual and environmental influences on HL and health outcomes.▪ Explains relationship between HL and health outcomes in specific subpopulation (adolescents), and recognizes that the structure of a framework explaining the relationship may vary by population.Limitations:▪ Does not address motivation, physician-patient interaction, and other psychological considerations.	Individual traits:▪ Culture.▪ Cognitive skills.▪ Physical abilities. Mediators:▪ Family.▪ Mass media.▪ Health care system.The influence of societal-level variables on all sections of the model.
5. Nutbeam (2000) Individual-level model, but identifies social and political goalsDynamic: HL can be improved through educational programs	World Health Organization's definition (Nutbeam, 1998): “The personal, cognitive and social skills which determine the ability of individuals to gain access to, understand, and use information to promote and maintain good health.”	Identifies 3 progressive levels of HL (from Freebody & Luke, 1990):1. Basic/Functional: sufficient basic skills in reading and writing to be able to function effectively in everyday situations. Interventions should focus on the educational goal of communicating information.2. Communicative/Interactive: more advanced cognitive, literacy, and social skills used to actively participate in everyday activities, to extract information and derive meaning from different forms of communication, and to apply new information to changing circumstances. Interventions should focus on the educational goal of developing personal skills.3. Critical literacy: more advanced cognitive skills which, together with social skills, can be applied to critically analyze information, and to use this information to exert greater control over life events and situations. Interventions should focus on the educational goal of personal and community empowerment.Outcome model categorization (model includes measures for each category):Health promotion actions: education, social mobilization, advocacyHealth promotion outcomes (intervention impact measures): health literacy, social action and influence, healthy public policy and organizational practiceIntermediate health outcomes (modifiable determinant of health): healthy lifestyle, effective health services, healthy environmentHealth and social outcomes	Strengths:▪ Creates a multidimensional conceptualization of HL, goes beyond functional literacy to Integrate concepts of interactive and critical literacy into HL.▪ Places health education and communication into the wider context of health promotion, and highlights HL as a key outcome from health education.▪ Recognizes how social context and environment influence health behaviors, which in turn, affect health outcomes.▪ Identifies both individual and community/social benefit outcomes from each of the three HL levels.Limitations:▪ Does not cleanly and separately distinguish concepts of knowledge, skills, motivation, and access (empowerment).▪ Limited consideration of other individual-level factors.	▪ Influence of environmental factors on health outcomes.▪ Health behaviors related to lifestyle, but considered an outcome rather than a mediator in RTI's framework.▪ Morbidity and mortality as health outcomes.
6. Paasche-Orlow & Wolf (2007)Individual-level model and identifies system-level factorsStatic in model, but authors discuss HL as dynamic (changes over time, depends on context: complexity of tasks, attributes of health care system)	IOM definition but adds the emphasis that HL must be examined in the context of the specific tasks that need to be accomplished (context specific.)	Influences on individual's HL: sociodemographic variables (race, ethnicity, education, age, occupation, employment, income, social support, culture, language), capabilities (vision, hearing, verbal ability, memory, reasoning).Mediator/moderators presented as falling into three domains:▪ Access and utilization of health care (patient factors including navigation skills, self-efficacy, perceived barriers & system factors (complexity, acute care orientation, tiered delivery model).▪ Provider-patient interaction (patient factors including knowledge, beliefs, participation in decision making & provider factors including communication skills, teaching ability, time, and patient-centered care).▪ Self care (patient factors including motivation, problem solving, self-efficacy, knowledge/skills, & extrinsic factors (support technologies, mass media, health education, resources).Health outcome: no specific outcomes specified	Considers not only patient-level characteristics, but also characteristics of the health care system as component-cause mechanisms of the relationship between HL and health outcomes.Strengths:▪ Causal model focusing on pathways between HL and health outcomes.▪ Presents factors that could explain the association between HL and health outcomes.Limitations:▪ Model does not address inappropriate use of services such as overuse of the emergency room, level of patient activation, patient health behaviors.▪ Framework is unidirectional.	▪ Sociodemographic variables.▪ Individual capabilities.▪ Navigation skills (but included as a component of HL skills in RTI framework, rather than a mediator of relationship between HL and health outcomes).▪ Mediators of the relationship between HL and health outcomes:– Individual/ patient mediators (motivation, self-efficacy).– Health care provider.– Health care system. – Media.
7. Rootman et al. (2002)Individual-level modelStatic (focus is generally on literacy)	No definition offered.	Conceptual model.Actions (including policy, community development) and determinants (living & working conditions, socioeconomic status, education, personal assets) affect literacy.Literacy:▪ General literacy (reading ability, numeracy, judgment, critical thinking, interpretation of evidence, communication, and negotiation skills).▪ Health literacy (knowledge of health, ability to seek health info, ability to interpret health info, knowledge and ability to seek health care, ability to understand and give consent, and ability to understand “risk.”▪ Other literacy (political, economic, etc.).Effects of Literacy:▪ Direct: medication use, compliance, etc. → health status → quality of life.▪ Indirect: use of services, lifestyles, income, safety practices, work environment, access to health info, stress level → health status → quality of life.	Strength: comprehensively and separately considers literacy and HL skills, but includes them both in their model.	Health information-seeking as a HL skill.
8. Schillenger (2001)	“Functional” HL: measure of a person's capacity to function in the health care setting as determined by literacy (comprehension of written health care materials) and numeracy (ability to understand and act on numerical health care instructions).Person may also have difficulties processing oral communication.	Framework for association between functional HL and chronic disease outcomes.Being a patient with low functional HL is related to:Ineffective visit-based clinician-patient communication:▪ Poor understanding of disease process.▪ Poor recall/comprehension of advice and instructions.▪ Passive communication.▪ Nondisclosure of functional HL problem.▪ Unorthodox health beliefsAndIneffective home-based monitoring and disease management support:▪ Poor adherence.▪ Inadequate self-care.▪ Poor self-management.▪ Poor problem-solving skills.▪ Low self-efficacy.Outcomes:▪ Worse clinical outcomes.▪ Worse functional outcomes.▪ Higher utilization of services.	Model conceptualizes how worse outcomes among those with chronic diseases are because of visit-based and/or home-based care mediators such as self-efficacy, lack of comprehension or ability to perform self-care, or inability to correctly interpret or act on results.Limitations:▪ Does not consider social support.▪ Does not integrate into health outcomes model, health system, or physician/provider factors. The latter are included in a separate model.	▪ Key role of patient-provider communication in model, but included as an outcome in RTI framework, rather than as a mediator. ▪ Self-efficacy as a mediator of the relationship between health literacy and health outcomes.
9. Sørensen et al. (2012)Model incorporates individual- and population-level componentsDynamic	Health literacy is linked to literacy and entails people's knowledge, motivation and competences to access, understand, appraise, and apply health information in order to make judgments and take decisions in everyday life concerning healthcare, disease prevention and health promotion to maintain or improve quality of life during the life course.	Antecedents of health literacy include societal, environmental, situational, and personal determinants.Dimensions of health literacy include the abilities to access, understand, appraise, and apply health information, which are affected by knowledge, competence, and motivation. These competencies allow for the navigation of three health-related domains: the healthcare setting, disease prevention, and community health promotion efforts.The consequences of health literacy, defined at the population level, include health service use and health costs, health behavior and health outcomes, participation and empowerment, as well as equity and sustainability.	Strengths:▪ Offers a conceptual model based on a comprehensive review of existing models of health literacy▪ Provides a broad perspective of health literacy across health-related domainsLimitations:▪ Does not specify pathways at the individual level▪ Does not consider ecological or environmental influences on the health literacy process▪ Does not include individual-level mediators of the effects of health literacy on health-related outcomes	▪ The use and application of health literacy skills across a range of health contexts▪ The influence of situational and individual determinants on the development and use of health literacy skills
10. von Wagner, Steptoe, Wolf, & Wardle (2008)Individual-level modelDynamic	Presents IOM and Healthy People 2010 definition”: “The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions”Authors’ definition: HL is a combination of cognitive skills, knowledge, and experience attained throughout the life span. The relationship between HL and health action is mediated by at least 2 processes: motivation based and skill based.	Theoretical basis for model: Unlikely that HL has direct effects on most health outcomes; likely to depend on a range of mediating factors, called health actions (actions to promote health, prevent disease, comply with diagnosis and treatment)Uses constructs from social cognition models of health to integrate HL into a wider framework of health actions.Epidemiological or structural determinants (of reading and math skills and resulting HL):▪ Individual influences: Cognitive abilities, Age-related cognitive decline; and Knowledge▪ External influences: Environmental influences; Formal educational opportunities; Experiential learningSociocognitive or psychological determinants (mediators of HL, including motivational constructs that affect the performance of health outcomes):▪ Motivational phase: knowledge and understanding; affecting beliefs and attitudes.▪ System factors: health care costs; accessibility of health information.▪ Volitional phase or action control: implementation skills, including task-specific skills.Actions based on sociocognitive or psychological determinants:▪ Access and use of health care.▪ Patient-provider interaction.▪ Management of health and illness.	▪ Presents theory for role of HL on health outcomes based on social cognition models of processing.▪ Builds on framework by Paasche-Orlow & Wolf (2007), adding additional explanation.▪ Framework described as having been tested retrospectively (i.e., applied to earlier studies), but not prospectively.▪ Applied to shared decision-making (consent comprehension), access, and use of primary prevention services (recommendations for screening) and adherence to mediation (management of chronic disease).Limitations:▪ Does not include cultural or media influences.	▪ Quality of the patient-provider interaction as an outcome.▪ Knowledge as a moderator of health literacy skills.▪ Psychological determinants, such as beliefs, attitudes, knowledge and decision making as mediators.

Figure 2  The health literacy skills conceptual framework. (Color figure available online.).

Baker , D. W. ( 2006 ). The meaning and measure of health literacy . Journal of General Internal Medicine , 21 , 878 – 883 .

 PubMed Web of Science ®Google Scholar

Lee , S. , Arozullah , A. , & Cho , Y. ( 2004 ). Health literacy, social support, and health: A research agenda . Social Science and Medicine , 58 , 1309 – 1321 .

 PubMed Web of Science ®Google Scholar

Mancuso , J. M. ( 2008 ). Health literacy: A concept/dimensional analysis . Nursing and Health Sciences , 10 , 248 – 255 .

 PubMed Web of Science ®Google Scholar

Manganello , J. A. ( 2008 ). Health literacy and adolescents: A framework and agenda for future research . Health Education Research , 23 , 840 – 847 .

 PubMed Web of Science ®Google Scholar

Nutbeam , D. ( 2000 ). Health literacy as a public health goal: A challenge for contemporary health education and communication strategies into the 21st century . Health Promotion International , 15 , 259 – 267 .

 Web of Science ®Google Scholar

Paasche-Orlow , M. K. , & Wolf , M. S. ( 2007 ). The causal pathways linking health literacy to health outcomes . American Journal of Health Behavior , 31 ( Suppl. 1. ), S19 – S26 .

 PubMed Web of Science ®Google Scholar

Rootman , I. , Gordon-El-Bihbety , D. , Frankish , J. , Hemming , H. , Kaszap , M. , Langille , L. , Quantz , D. , & Ronson , B. ( 2002 ). National literacy and health research program needs assessment and environmental scan. Ottawa, ON: Canadian Public Health Association. Retrieved from http://www.cpha.ca/uploads/portals/h-l/needs_e.pdf

 Google Scholar

Sørensen , K. , Van den Broucke , S. , Fullam , J. , Doyle , G. , Pelikan , J. , Slonska , Z. , & Brand , H. ( 2012 ). Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health, 12: 80. Retrieved from http://www.biomedcentral.com/1471-2458/12/80

 Google Scholar