The Centers for Disease Control and Prevention defines health literacy as “the degree to which an individual has the capacity to obtain, communicate, process and understand basic health information and services to make appropriate health decisions.”
Initial research suggests that individuals with lower health literacy have poorer health outcomes, including higher rates of hospitalization, poorer overall health status and higher mortality. Yet interventions designed to improve health literacy have shown only mixed results such that reviewers have determined that there is insufficient evidence supporting these health literacy interventions.
Why?
While the definition of health literacy is broad, a closer look at how the term is operationalized and how interventions are designed reveals a more narrow focus on the communication and understanding of concrete health information. Improving people’s knowledge of disease is important, as it is logical to assume that an increased knowledge of disease and understanding of the connection between health behavior and well-being would result in healthier decisions.
But it could be argued that to have true health literacy, we cannot focus exclusively on information and logic. We must understand that for most of us, health decisions involve a substantial emotional component, in which our fear, sadness and other emotional states influence our decisions.
That brings us to the most important piece of information upon which we need to be “literate”: Most preventive health behaviors make us feel worse before we get better.
Consider the experience of any health behavior. Getting to medical appointments is often tedious and time consuming. Taking medication often is accompanied by significant side effects. Many treatment regimens involve denying ourselves enjoyable things.
It’s unlikely that at this point that people do not understand that eating less and exercising more would improve weight management. And yet it is arguable that one of the main reasons that these simple behaviors are so difficult is that they don’t feel good at first. To be sure, there’s little information that we can provide to help a person cope with the fact that a doughnut tastes better than a carrot.
For years, self-regulation models of illness cognition have purported that people manage their illness on both concrete representations of their illness (e.g., what is diabetes and what do I need to do to manage it?) as well as their emotional reactions to a disease (e.g., I’m afraid of not being able to attend family events where food is served).
Further, self-regulation models suggest that health goals for different issues may actually interfere with one another. And for people who struggle with multiple issues, the emotional component of health regulation can be even more tricky. For example, consider someone struggling with both diabetes and depression. Treatment for diabetes may involve restricting food and limiting engagement with risky social events (e.g., barbecues), whereas treatment for depression would encourage attendance at these types of social events.
Research suggests the impact of emotions on health behavior and that poorly managed mood can have a negative impact on health behaviors. For example, a meta-analysis of 12 studies found that depressed patients were three times more likely to be noncompliant with medical treatment as compared with non-depressed patients. Further, studies of schizophrenics show that side effects and stigma are two of the most common reasons given for discontinuing medication.
Furthermore, how we feel about our doctors influences our health behavior. Evidence suggests that emotion-based factors such as trust in a doctor predicts adherence. One study of 370 primary care patients found that trust in one’s doctor predicted compliance with medication regimens as early as four days after initial consultation. Another longitudinal study of 200 primary care patients followed over 12 months found at follow-up that those who trusted their doctors were significantly more likely to be trying to lose weight, as compared with those who did not trust their doctors.
So what can be done?
First and foremost, public health initiatives must address the emotional issues of health literacy. The goal would be that the emotion-focused interventions would accompany information. One example would be educating people about the possible stresses, hassles and negative emotions that may accompany particular medical issues and treatments that may arise for patients and their families. This may also include information on evidence-based treatments for mental health issues that may arise.
Second, we must educate people on the mindset and personal qualities necessary in order to tackle the often long and arduous task of managing one’s health. Conscientiousness, or the ability to strive for goals in a planful way while managing distress and exerting impulse control, has long been shown to predict longevity across the lifespan.
Part of the reason is that more conscientious people engage in healthier behavior. A meta-analysis of 194 studies shows that more conscientious people are more likely to engage in healthy behaviors, such as exercise, and avoid risky behavior, such as smoking. While there is debate as to whether targeting conscientiousness is effective on a public-health level, considering the potency of this personality trait in predicting outcomes, it appears certainly worthy of further exploration.
On a related note, having a sense of purpose is associated with increased longevity. One possible reason is that when one has a sense of purpose, he or she is more able to manage the emotional strain of certain health behaviors in the service of a higher goal. For example, an individual may be more willing to engage in difficult chemotherapy in order to be alive for one’s children or grandchildren.
Helping guide people to find and understand their motivating factors in engaging in health behaviors may be useful on a public-health level. Motivational interviewing, which helps people identify reasons for engaging in a particular health behavior, has been shown to be efficacious in a range of areas, such as smoking cessation.
Studies examining how to disseminate this technique on a public-health level could prove valuable.
Health literacy is a multidimensional concept comprising many factors. If we fail to help people understand the complex and powerful emotional factors that may influence health behaviors, and to help people cope with the difficult experience associated with many medical regimens, we are missing a crucial opportunity to improve public health.
Photo credit: Mathew Schwartz.
An earlier version of this article originally appeared in Huffington Post on July 10, 2015.
