The Ever-Evolving Nature of Health Literacy in Organizations: A Commentary on the 2021 JPHMP Article "Updating Health Literacy for Healthy People 2030".

Healthy People is a data-driven policy framework that public health managers and practitioners use to guide their work (eg, collaborations, logic models).1 In 2021, JPHMP published the article by Santana et al, titled “Updating Health Literacy for Healthy People 2030: Defining Its Importance for a New Decade in Public Health.”2 Their article informs public health managers and practitioners that, henceforth with Healthy People 2030, 2 definitions of health literacy—that is, individual and organizational—will be used to appraise how well health promotion efforts align with the framework's objectives.3 Santana et al relay that organizational health literacy is defined as “the degree to which organizations equitably enable individuals to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.”2(pS259) This formal definition of organizational health literacy is new to the framework, though efforts to promote something to its effect have been around for some time (eg, training manuals and workshops teaching health care providers how to be clear and effective in their communication with patients).4

Each author of this commentary, for some time, has felt if organizational barriers remain unaddressed, efforts to improve community health will be severely constrained if not immobilized. We are not alone in this maxim, given the wide adoption of a social ecological perspective by many professions that contribute to health promotion.5,6 We wrote this commentary to the article by Santana et al to elicit further contemplation among health care managers and practitioners on the significance of the organizational health literacy definition added to the Healthy People framework. Two research-based perspectives on health literacy were used to develop our commentary: one focused on patient skills and behaviors, and one focused on health care administration (ie, broadly defined as organizational entities involved in health promotion).

Health literacy concerns the degree to which individuals obtain, understand, and use basic health information and services to make decisions to manage or improve their own or other's health.2,7 Health literacy is a process that involves cognitive and social skills rooted in the cultural awareness of an individual's environment.8 There are fundamental components to health literacy that include an individual's ability to (1) be self-aware and possess knowledge of different aspects of health and health care systems; (2) find, understand, and use health information; and (3) confidently maintain health through self-management strategies and interactions with health care systems.9 The concept of health literacy continuously evolves with time, context, and various health needs.8 Overall, higher levels of health literacy are associated with lower levels of hospitalization, higher rates of health screening, and higher levels of health status and quality of life.10 In part, these associations are a result of healthful behavior changes achieved through health literacy interventions, including increased physical activity, decreased smoking, and improved diet.10,11 However, the predominant focus in practice settings concerning health literacy promotion has been on individual changes, rather than environments.

For some time now, calls have been made to expand health literacy scholarship and policy discussion to include environments that clients and the public navigate. A progress report for Healthy People 2010 contained the following commentary:

Healthcare and public health delivery systems are complicated bureaucracies.... Even highly motivated and educated individuals may find the systems too complicated to understand.... Consequently, assessments of individuals' health literacy skill may actually reflect system complexity rather than individual skill level.2(pS259)

Since these cautionary words, health literacy research has expanded to include appraisals of organizational capacity to deliver literacy-sensitive care, specifically by providing materials/services that individuals with low health literacy would understand, learn from, and feel empowered by.12 Using literacy-sensitive materials and techniques to foster understanding, similar gains in health knowledge and health behavior are observed regardless of health literacy level.13–16 Yet, within practice, health materials and services remain as major barriers to quality care and the adoption of preventive health behaviors.17–20 Persistent issues include health materials with low readability, contradictory information, and unclear visual media.21–23

Although physicians may have their own method in how they council patients, there are many actors involved in health communication (eg, the design of signage, forms, Web sites).24 Numerous tools have been developed to aid the many actors involved in delivering health care so that the information they produce would support health literacy among patients and the public.4 However, these tools seem seldom used. While part of it may be due to their complexity,25 another driver may be low awareness among providers on what factors affect health literacy.26 Several reports have shown providers overestimate their ability to convey information clearly, contributing to patient confusion and decreased confidence to manage their health or make informed decisions.21,26–28 Others have shown teams are not on the same page in designing patient education material or other services, such as adding contradictory information or details that increase reading difficulty.29,30 Thus, the organizational health literacy definition added to the Healthy People framework is promising to see.2

Santana et al2 report that adding an organizational definition for health literacy had a plurality of public and expert support. This should not be surprising. Since at least 1989, when the US National Cancer Institute published its landmark resource guide, Making Health Communication Programs Work: A Planner's Guide, the onus of health literacy promotion has been with organizations.4 Numerous state and federal laws exist mandating health care sites to use plain language communication and language services.31 In 2006, Paasche-Orlow et al32 summarized action steps that may be taken to become a health literate organization. Others have followed suit, including testing and studying the adoption of the Universal Precaution approach.33 Preliminary work has extended this line of research into the study of patient portal systems.28

While organizations may seek to empower clients to meet personal health needs and aid them in doing so, their policies or norms often undermine their efforts.16,34 As Neuhauser et al35 stated, more than 800 research studies had found health material by medical and public health groups were too hard to be easily read by lay adults. In their own study, they found emergency preparedness materials disseminated by public health departments and others exceeded the suggested sixth-grade reading level. Schur et al36 found that while many local public health departments had in place strategies to meet the needs of culturally and linguistically diverse populations, only one-third had tested the readability of their materials. Wide adoption of the definition for organizational health literacy could encourage public health professionals to examine not only their own organization's policies37 but also their approach to community-engaged partnerships.26

Concluding Thoughts

Santana et al concluded their article with a list of action steps. Among them was to “[engage] public and private partners in the work of increasing both personal and organizational health literacy.”2(pS262) The expanded view of health literacy promotion to include organizations gives incentive to measure progress at 2 levels: individual and organizational.2 Santana et al, in their article, encouraged action-based research be used, whereby public health professionals engage in partnerships that promote organizational health literacy and track how it develops.38 Work in this area has already begun.39 Clearly, this action-based research should extend beyond health care organizations.4,40,41 Toward that end, and in the form of a JPHMP Direct post, we offer a policy template for promoting organizational health literacy that was developed using the Health in All Policies framework.42,43