health literacy as not simply a function of basic literacy skills, but as “dependent on individual and system factors, including communication skills of lay persons and professionals, lay and professional knowledge of health topics, culture, the demands of the healthcare and public health systems, and the demands of the situation/context” (http://www.health.gov/communication/literacy/quickguide/factsbasic.htm). “Health literacy varies by context and setting and is not necessarily related to years of education or general reading ability,” according to the National Network of Libraries of Medicine (http://nnlm.gov/outreach/consumer/hlthlit.html). The Institute of Medicine (IOM) states that, “Even well-educated people with strong reading and writing skills may have trouble comprehending a medical form or doctor’s instructions regarding a drug or procedure” (2004). Thus, the literature review supports an increasing recognition of the importance of context and setting when assessing health literacy. The project team adopted a slightly modified version of the Ratzan and Parker (2000) definition.

Conceptual Framework and Skills-Based Approach to Measurement

The next step in the project was to develop a conceptual framework (see Figure 3-1). As Pleasant said earlier, a conceptual framework is critical as a foundation of measurement. An important component of this framework is the feedback loop from health-related outcomes back into skills; people learn from their experiences, and that affects their skills for the future.

There is an increasing call in health care for consumer activation, consumer empowerment, and consumer involvement. Under these circumstances a skills-based approach to measuring health literacy is warranted. Therefore, the approach under development will include assessments of people’s ability to use different types of health information to make informed decisions as well as the skills needed across the life course in periods of health and periods of illness. Issues addressed range from disease prevention to treatment and self-management. The assessment will be based on the U.S. health care system, which means that the measurement process reflects current health insurance issues and care provided in public and private systems. One challenge in creating a skills-based approach in which data are collected via a computer is keeping up with technological advancements and changes in health-related materials that are used in the measurement process.

The measures will cover several health literacy domains, including print (both prose and document), numeracy skills, communication (including listening, speaking, and negotiating), and information seeking or navigation. A hierarchical approach was taken to determine the measures. First the skill or task was identified. Second, stimuli that enabled



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