The Evolving Field of Health Literacy Research

We are quite pleased to present the current special issue on Health Literacy of the Journal of Health Communication. We hope readers will see this issue as a marker of the Journal's long-term interest and commitment to health literacy research and as an exhibit of the rapidly evolving field of health literacy. This issue presents findings from the first Health Literacy Annual Research Conference (HARC) which took place in October 2009 at the National Academy of Sciences Building, Washington, DC. HARC is an interdisciplinary meeting for investigators dedicated to health literacy research. Our aim is to attract a full range of investigators engaged in health literacy research including those involved in a broad array of public health, health services, epidemiology, translational, and interventional research activities. Establishing an interdisciplinary research home for health literacy investigators can accelerate: (1) professional development, (2) advancement of the science of health literacy research, and (3) promotion of interdisciplinary research.

The HARC conference took place over 2 full days in October 2009 and highlighted areas of important research advancement as well as key lacunae in the field. A keynote address by David Baker, MD, MPH examined the role health literacy in patient education, and a keynote address by Anne Beal, MD, MPH, focused on the role of health literacy in health disparities. The conference also included four panels of invited speakers dealing with: (1) measurement; (2) health literacy and verbal interactions; (3) health information technology interventions; and (4) organizational assessment and change. Current gaps in the research were examined by invited speakers and in breakout sessions relating to public health approaches to health literacy, health disparities and health literacy, and health information technology. An additional 62 posters and 12 oral abstracts were presented, making this clearly the largest set of Health Literacy research presentations in any single meeting to date. The meeting was attended by an interdisciplinary array of investigators representing the strong majority of health literacy investigators in the United States.

HARC II will take place October 18–19, 2010, in Bethesda, Maryland (http://www.bumc.bu.edu/healthliteracyconference/).

While many important unanswered questions loom, the articles in this issue highlight the blossoming nature of health literacy research. In her commentary, Health Literacy: The Second Decade for Distinction, Parker chronicles the major landmarks of the last decade. A Pubmed exercise tells a similar story. Using the Health Literacy topic specific query under the Pubmed tools tab (see: http://www.nlm.nih.gov/services/health_literacy.html) reveals the tremendous growth of research in this field: in the 5 years between 1986 and 1990 there are 129 references in Pubmed; in the years 1991 to 1995 this search yields 306 references; between 1996 and 2000 there are 307 references; from 2001 to 2005 there are 602 references from this search; and in the current interval, between 2006 and 6/6/2010, there are already 1576 references returned by this search (see Figure 1). As striking as this may seem, it is also important to note that this collection of references is dominated by observational research, indeed, fewer than 8% of these citations are tagged as trials.

Figure 1 Health literacy citations in Pubmed. Lighter bars represent all citations identified by Health Literacy topic specific query. Darker bars represent the subset of these citations identified as trials, clinical trials, or randomized controlled trials.

An ongoing research area in the field relates to health literacy measurement. McCormack et al. presents pilot data from a new skills-based instrument, Yost and colleagues present data on the acceptability of a talking touchscreen assessment tool, and Gazmararian et al. describes a tool developed to assess the health literacy environment of health plans (McCormack et al.; Yost et al.; Gazmararian et al.). All such efforts inherently reflect underlying definitional issues, which are also the focus of a Commentary by Berkman et al.

This special issue also provides evidence about health literacy in an array of contexts including advanced care planning (Sudore et al.), informed consent for research among Spanish speakers (Cortés et al.), two articles about cancer screening (Wilson et al. and Mazor et al.), and the relationship between health literacy and the quality of communication in health care organizations (Wynia et al.). Self-efficacy is shown to link literacy and numeracy in glycemic control (Osborn et al.) and a new instrument of patient self-efficacy regarding communication with clinical encounters (Clayman et al.). Despite evidence of a large ‘digital divide’ by level of health literacy in accessing and using a patient-portal (Sarkar et al.), it appears that such barriers are surmountable, as Bickmore et al. present evidence from two trials of an ‘embodied conversational agent’ technology interface that is usable by people with limited literacy (Bickmore et al.).

We have also included a Commentary on the role of health literacy research for the elimination of health disparities (Paasche-Orlow & Wolf) and a Commentary that situates the field of health literacy within a public health paradigm (Baur). In addition, we have included an international policy paper that summarizes the health literacy objectives of the United Nations Millennium Development Goals (UN Economic and Social Council [ECOSOC]).

Taken together, the special issue reflects the important role that health literacy plays in many aspects of health communication. The Department of Health and Human Services recently outlined a National Action Plan to Improve Health Literacy (http://www.health.gov/communication/HLActionPlan/). Clearly, improving health literacy is a widespread goal. However, it is a means to end. Ultimately, improved health literacy can lead to clearer communication, better informed decisions, and the delivery of quality health care services. To achieve these objectives, we need to continue to study how to measure health literacy, which interventions can improve health literacy levels, and the relationships between health literacy and health outcomes.

The Health Literacy Annual Research Conference (HARC) meeting was coordinated with the assistance of Rose Martinez on behalf of the Institute of Medicine Roundtable on Health Literacy and sponsored by a grant from the National Center on Minority Health and Health Disparities (NCMHD), Project Officer––Robert Netty, with additional significant support from the Agency for Healthcare Research and Quality (AHRQ), Project Officer—Cindy Brach. Additional coordination and support was provided by Helen Meissner, of the Office of Behavioral and Social Sciences Research (OBSSR) as well as the National Institute of Biomedical Imaging & Bioengineering (NIBIB), Project Officer—John Haller, and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Project Officer—Lynne Haverkos. Principal Investigator Michael Paasche-Orlow, 1 R13 MD003392. This Special Issue was supported by generous funding from RTI International, the Health Literacy and Learning Program, Division of General Internal Medicine, Feinberg School of Medicine at Northwestern University, the George Washington University Center for Global Health, and the Section of General Internal Medicine, Boston University School of Medicine.