Literacies

VOLUME 19 ISSUE 2

The International Journal of

Literacies

thelearner.com

The International Journal of Literacies ………………………………… The Learner Collection VOLUME 19 ISSUE 2 2012

Critical Reading in Health Literacy Kerry Renwick, Victoria University, Australia There is a growing body of literature (Zarcadoolas et al 2005; Kickbusch 2009; Nutbeam, D. 2009) that considers ‘health literacy’ as an essential aspect of both prevention and treatment of illness and disease. Health literacy is predominately presented as being about functional and operational literacy, that is to read, understand and act. The challenge in this is that much of what is conveyed requires understandings of biology and chemistry as well as medical and scientific terminology. Additionally where health illiteracy is identified it is perceived from a deficiency paradigm and therefore a ‘failure’ within the individual rather than consider the creation of ill health through disempowerment and disadvantage that arises out of age, gender, class and indigenity. While health promotion requires knowledge and functionality, critical health literacy needs to include individual and community engagement in health. Luke and Freebody (1999) have contended that there is a need to view literacy as a social construction and because of emerging and changing social and cultural conditions, it is necessary to engage in continual critique and reformulation of new possibilities for literate practice. Health is also presented as a social concept within the context of the Ottawa Charter (1986) and thus consideration as health literacy as social construct is required. This paper therefore argues that any effort to consider and develop health literacy also requires critique and reformulation for health promotion practice. Using Luke and Freebody’s (1990) four resources model of reading this paper will explore ways to consider health literacy as critical action. The model is a way for educators and students to manage the plethora of health and wellbeing data while creating meaningful connections and lifelong competencies. Keyword: Health literacy; Health promotion; Health education; Health Promoting Schools

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he World Health Organisation’s (WHO) goal of health for all (1986) is based on the idea that health is a human right and a resource that contributes to both quality and length of life. However health of individuals and communities is neither a static concept nor a universally shared experience. Health of communities varies with age, position, income, gender, Indignity, geography, and many other aspects of life and living. Health is both a social and political process and as such consideration of not only how but also where health is created is a critical aspect of health promotion and education. In 1986 in Ottawa Canada at a conference of health professionals, the idea that health was more than medicine, and that individuals, as social actors and their communities with or without sufficient resources for health also needed recognition and consideration. These understandings led to the development of the New Public Health encapsulated in the Ottawa Charter and a position that health promotion was a process of enabling people as individuals and communities to assert control over what determines health within their social and geographic local with intent to improve health. In calling for Health for All the Ottawa Charter (WHO 1986) articulates health as a resource for everyday life and as a human right. By identifying health as a social construct rather than a biomedical one there is consideration of how health is located outside medical systems and governance. Further Daniels et al (1999) argue that by investing responsibility for health solely with scientific medicine it actually hides socioeconomic inequality as a source of inequity and therefore becomes a barrier to health for all. In response to this the Ottawa Charter identifies nine fundamental conditions and resources for health: peace, shelter, education, food, income, a stable eco-system, sustainable resources, social justice, and equity. The creation of health is identified in a different way to that of the biomedical model from the dysfunctional body as machine paradigm and a behaviour change focus to one that considers the causes of health inequity and prevention of lifestyle-related disease. This position aligns with Anderson’s (1999) democratic equality that “guarantees all law-abiding citizens effective access to the social conditions of their freedom at all times” (p 289).

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A decade later the principles of the Ottawa Charter were re-affirmed in the Jakarta Declaration (1997) together with the learnings over the intervening time that places of social interaction were important sites for specific and therefore, locally relevant health promotion. The recognition of the value of the settings in which people live, work and play was seen as crucial for building capacity for health and wellbeing and these included health promoting cities, health promoting hospitals and health promoting schools. Once specific settings were identified it became possible to begin consideration of both circumstances and possibilities for health promotion. For example, the Australian Health Promoting School model uses a framework for developing a setting for health promotion based on three areas of action. These areas encompass consideration of not only the children and adolescents that attend the school as a learning environment but also the staff – teaching, administration and support; parents and carers in the wider school community; and government and non-government health services (AHPSA). Each of these areas of action enable the identification of not only resources and actions that are health promoting within each school and its local community but also advocates for equity as a specific philosophy. By identifying personal capabilities for any person to be active as a citizen in a civil and inextricably just society Anderson (1999) claims the state of being human as crucial. She defines being human in three ways: “as a human being, as a participant in a system of cooperative production, and as a citizen of a democratic state” (p 317). The Jakarta Declaration (1997) also puts forward participation and engagement of individuals and communities in health promotion arguing that people are at the centre of such activity. In describing what it is to be citizen in a just society, Anderson’s human being is required to take action, specifically in this case about their health, including being involved in decision making processes. However for participation to be possible people need opportunity to become health literate and have access to health education. Achievement of effective participation and empowerment of people and communities requires access to education and information (Nutbeam 1998). This paper considers the development of health literacy as a resource for health. It argues that any consideration about and development of health literacy requires critique and reformulation for health promotion practice. In moving from considerations of (health) literacy as being more than functional this paper presents Luke and Freebody’s (1990) four resources model of reading to consider health literacy as critical action and as a model for educators and students to manage the plethora of health and wellbeing data while creating meaningful connections and lifelong competencies.

Health Literacy The development of the concept of health literacy has had broad implications in the field of health promotion (Nutbeam 2000). While functional literacy skills to read and understand medical/health information are necessary they are not sufficient in themselves to develop health in individuals and communities. Rather health literacy is vital to empowerment in that it “implies the achievement of a level of confidence to take action to improve personal and community health” (Nutbeam 1998, p357). Developing a person’s capacity health literacy requires more than reading of text and symbols in a pre-determined regime of health care. The World Health Organisation’s definition of health literacy provides for more than operational literacy designating that: “Health literacy represents the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health” (Nutbeam 2000, p264). Subsequently health literacy has been considered as a means for not only acquiring knowledge but also as a resource for engaging in health at a personal and community level. It

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therefore requires individuals to be active about health literacy where such activity is an act of democratic engagement. Nutbeam (2009) observes that literacy is both content and context specific. Health promotion and education curriculum offered in Australian schools has become a plethora of health issues that have been judged internally and externally, as being critical areas of learning for young people. And while there has been some recognition of a cognitive and constructivist approach to content, the concepts and information needs to be pitched at an appropriate level of understanding; and the focus being on delivering health-related knowledge about is what Jensen (2000) calls knowledge about effects. Health literacy that is knowledge about effects can be as varied as reading food labels, reading and completing medical forms to construction of health identities. Contexts for literacy are varied and can include a range of settings such as schools or hospitals, or situating the health literacy across a continuum of prevention and rehabilitation. When done in ways that connect with the individual and life experience there is opportunity to build the additional knowledges identified by Jensen (2000): knowledge about root causes; knowledge about change strategies; and knowledge about alternatives and visions. Consequently it can be seen how the contexts for health literacy have an impact on not only what health content is to be considered but also the ways in which the content is both specific and germane. Schools as a context for health literacy will predominately focus on prevention, for example where food and nutrition education could consider what foods are eaten by the families in my class/group/year level and why; and how the shelving and food positioning in the local supermarket is done in particular ways to maximise marketing and impulse buying. Hospitals may provide information about prevention and certainly provide rehabilitation programs. A person recovering from a heart attack in a rehabilitation program may consider the foods eaten by the family as contributing factors in the event and therefore how they might be eliminated or modified in the diet; and increasing their understandings about motivations for eating particular foods and when, and how to read food labels leading to different food choices at the point of sale.

Developing (Health) Literacy Understandings about literacy have increasingly come to recognise that it is more than being competent with the written word through functional reading and writing of text – if it were ever just that. The New London Group (1996) have posited that traditional literacy pedagogy is narrow and overly concerned with traditional literacy pedagogy, a view of literacy concerned with “formalised, monolingual, monoculture, and rule-governed forms of language” (p 61). The socio-cultural nature of language and literacy together with rapid change through technology has enabled an increased appreciation of how language is used in different ways and circumstances and that literacy involves a complexity of coding and decoding the written, visual and audio within varied contexts. Thus literacy can be seen as having numerous forms “that vary across time and communities – that literacy is a social practice, rather than a set of reading and writing skills to be acquired” (Cervetti et al 2006, p381). To make use of language not only requires a person to be able to use it but they are also involved in active production and transformation of language (Pahl and Rowsell 2005). Literacy pedagogy can no longer be perceived as a linear process rather that it makes use of a plurality of literacies that are in constant states of change. Such pluralities enable identification of multiple literacies and, according to Unsworth (2001) includes visual literacies; curriculum literacies; cyberliteracies and critical literacies. It is possible to see how perspectives of health literacy have taken similar trajectories. Health literacy is an increasing area of interest for health professionals considering efficacy in health care. This growing body of literature views health literacy in purely functional terms as it tries to understand how to ensure patient compliance with medical/therapeutic regimes (McCray 2005; Zarcadoolas et al 2005). Within this context health literacy is defined as “the ability to read,

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understand, and act on health care information” (The Centre for Health Care Strategies Inc 2000 cited in Kickbusch 2001) and “the ability to perform basic reading and numerical tasks required to function in the health care environment” (AMA 1999, p 553). Using the New London Group’s critique of traditional literacy it is possible to see how much of the research on health literacy is positioned in similar ways. The use of text is formalised through the use of medical terminology; using scientific concepts that are essentially monolingual; within a monoculture that is the health system; and makes use of rule-governed forms of language that have meaning for health professionals. Responses to this interpretation of health literacy can therefore be seen in: • the development of diagnostic tools (Andrus and Roth 2002; McCray 2005; Schwartzberg, et al 2005); • the focus on rewriting medical communication to make them more accessible - i.e. utilise plain English or everyday language (Andrus and Roth 2002; Ratzan 2001; Zarcadoolas et al 2005); and • acknowledgement that low (health) literacy is closely associated with low socioeconomic circumstances (Nutbeam 2008; WHO 2007; Ratzan 2001). Developing health literacy has therefore become a focus for health professionals because of its implication in the treatment and management of illness and challenges for patients navigating through health care settings. The narrow definition of health literacy as purely functional, sets up a deficiency perspective so that health literacy is perceived as a strong predictor of health status compared to socio-economic status (SES), status, age, ethnic background (Speros 2005). Health care professionals end up finding what they were looking for – that the lay population does not ‘read health’ to the same standard as health professionals. As with literacy, health literacy is not purely functional and a range of ‘component’ or ‘composite’ literacies have been identified including: fundamental literacy; information literacy; media literacy; computer literacy; interactive health literacy; science/scientific literacy, civic literacy; and cultural literacy (Nutbeam 2000; Zarcadoolas et al 2005; and Norman et al 2006). Kickbusch (2009) suggests that health literacy is a “challenge of access” and “is about rights, access and transparency” (p132) in an inequitable world. Low levels of health literacy have been linked to negative impacts on an individual’s health outcomes and the health care system as a whole. The identified impacts of low health literacy for patients included poor understandings of their disease; to be less likely to adhere to prescribed treatment regime; not to make use of preventative services; and to experience more frequent hospital admissions. Within the health care system low levels of health literacy have been associated with increased morbidity and medical costs and inefficient use of health care services (Cotugna and Vickery 2003; Scudder 2006; Parker et al 2008; Pleasant and Kurvilla 2008; Muir and Lee 2010). Wilkinson (2005) contends health status is closely linked to socioeconomic status and it appears that health differences in populations arise out of the social environment and that more egalitarian societies tend to be healthier. Acknowledging this perspective Sparks (2011) defines health literacy as an underpinning aspect of health promotion and argues that it is a component of health promotion systems that it supports other health promotion activities including addressing social determinants of health and sustainability. To make a difference particularly for social justice the pedagogy of health literacy must have a critical edge. In writing about literacy Freebody and Luke (1999) contend that a experience or artefact demonstrating a ’failure’ of “literacy isn’t about individual deficits – it’s about access and apprenticeship into institutions and resources, discourses and texts” (p5). Rather than (potentially) blaming the individual/victim it is important to consider the ways in which low or poor levels of health literacy is not in itself the cause of illness – of chronic or preventable lifestyle related illness but perhaps another aspect of disadvantage and psychosocial risk factors that contribute to inequity.

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Developing Health Literacy Critically Wilkinson (2005) suggests small differences in inequality matter – to health, levels of violent crime in communities, the nature of social interrelations and therefore quality of life. Daniels et al (1999) suggests “that there are plausible and identifiable pathways through which social inequalities produce inequalities in health” (p223) and identify how the reduction of support and resourcing of social goods like education effects opportunities in life and subsequently determinants of health. Understandings about possibilities health for all is informed by Anderson’s (1999) ‘democratic equality’ and arises out of inherently just communities and deployment of social resources equitably to positively influence for the fundamental conditions and resources for health. The focus of most of the literature on health literacy is on adults with minimal consideration of adolescents and children. The value in considering health literacy for children and adolescents is not about enabling medicalised consumerism rather developing levels of literacy that facilitate the individual’s ability to follow designated regimes while also considering if the regime makes sense under varied socioeconomic and political circumstances around current and unforseen or yet to be experienced health status. This is reflected in Jensen’s (2000) view of health education that draws on a democratic rather than a moralistic paradigm which requires an ‘actionorientation’ perspective where knowledge is actively integrated and critiqued. It recognises schools as spaces where situated social practices are experienced, reinforced and challenged; as well as the ways in which children and adolescents experience schooling contributes to future wellbeing – theirs and that of their community. The school as a setting is predominately about primary health promotion where the intent is to decrease the number of new cases i.e. incidence (Gill 1997) and therefore the prevention of health problems before they have developed (Bunton et al 2000). Here the biomedical perception that educational epistemology is solely behaviouralist that generates behaviour modification/change and generation of ‘healthy’ habits is the goal. In Dewey’s (1944) development of habits he argues that they are more than just behaviour, rather that habits form because we understand the situations in which the habits operate, forming an inclination or an intellectual predisposition ⎯ offers a strong argument for the development of the settings approach to health promotion, given that a key aspect is the recognition that the major determinants of health are social; and that a community is able to create a healthier environment because its members gain the knowledge and skills to do so (Burgher et al 1999). According to Luke (2000) when literacy teachers work with their students it “is not about enhancing their ‘individual growth’, ‘personal voice’, or ‘skill development’. It is principally about building access to literate practices and discourse resources, about setting the enabling pedagogic conditions for students to use their existing and new discourses for social exchange” (p449). Health education pedagogy has traditionally been the transmission of knowledge about health with the intent of changing student’s behaviour (Renwick 2006) and has been promulgated as being individualistic and has been critiqued as using “highly prescriptive, rigid and often ideologically based approaches” (Roche et al 1997, p 1208). The health promotion movement began with a social view of health grounded on the principle of equity (Tones 1996 ) therefore schools as a setting for health promotion, are required to operate within a framework of inclusivity and use a pedagogy that supports social relations and respect. Pedagogy that uses critical literacy provides a possibility for rethinking the ways in which texts are both read and understood and as Luke (2000) states “involves a theoretical and practical ‘attitude’ towards texts and the social world, and a commitment to the use of textual practices for social analysis and transformation” (p454). Equally any pedagogy for health literacy requires a critical perspective ‘attitude’ to health/medical texts enables consideration not only ‘What information is needed or available to whom and when?’ but also ‘Whose information is it and

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what are possible meanings for the individual?’ as well as ‘How realistic is it within the individual’s daily life and community?’ and ‘What other options exist or should exist?’ The development of an approach to critical literacy by Freebody and Luke (1990) identified four sets of requisite social practices. These practices provide a basis for literacy that acknowledges the breath of social activity that involves literacy; the use of a range of practices to create meaning in and through their reading and writing; and that texts are valued laden both in what is said and what isn’t. While originally developed and used in Australian schools as an approach to early reading this approach to critical literacy also provides insight into how critical health literacy might be developed. • Code Breaker – This requires the reader to decode systems of written and spoken languages and visual images. While this requires a level of functional literacy, understanding about the way health messages are constructed is also necessary. In Australia, skin cancer programs are well entrenched in primary schools and many will be explicitly signed as being “Sun Smart” (SunSmart) Some children arrive at school with explicit understandings about wearing hats and applying sun screen and therefore are in a better position to operate within the expectations of the school. For all children these expectations become a lived everyday experience with clear understandings about the meaning of “no Hat no Play”. • Meaning Maker – For readers to build and construct meaning from texts they draw on what Gee (2011) calls “situated meanings”. The reader draws on their engagement of the range of cultures they experience – family, ethnicity, popular, emergent, etc. to make meaning about the text. As a result the reader has to navigate how texts vary and take on different meanings in specific locals. Most food selection models present images of food with minimal preparation and as ‘whole’ entities therefore should a child believe that they need to eat an entire raw fish or a head of lettuce? A dietary guideline that states ‘eat a variety of foods’ has a particular interpretation of what variety means. Within some social contexts this can be interpreted as a different type of fast food each night. And what might be the priorities if a child lives with food insecurity 1 or if the foods identified do not match with the culture and cuisine at home? • Text User – Readers using texts effectively requires more than comprehension responses. A range of texts exist in the reader’s everyday for varied cultural and social functions and requires a response or action from the reader. Students who have a sense of connectedness 2 to their school and the conditions for learning are more likely to experience schooling in a way that contributes to their wellbeing (Water et al 2009). The daily schooling experience supports students to sense of belonging by providing opportunity for them to engage and participate competently; to inter-relate with peers and adults in socially appropriate ways; and to take risks (safely) and autonomously. • Text Analyst – When readers analyse, critique and ‘second-guess’ texts they consider what informs and ‘sits’ behind the text. Considerations would include the

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The World Food Summit of 1996 defined food security as existing “when all people at all times have access to sufficient, safe, nutritious food to maintain a healthy and active life” (Food and Agriculture Organization, "Rome Declaration on World Food Security," World Health Organisation, http://www.fao.org/docrep/003/w3613e/w3613e00.htm.) 2 Student connectedness can be defined in various ways but essentially considers the extent to which students feel like they are part of the school because it supports them both academically because teachers provide feedback about the regard they have for them and their progress; and though a supportive environment where students feels that others like them, and that considers discipline in fair a way and the social-cultural context of the wider community (Libbey 2004; Waters et al 2009).

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type of person writing such a text and what might be their historical context; and who is the intended reader of the text and what is the writer/text asking of them? Clothing sales catalogues can be used as a resource to integrate construction of gendered images and identity. Readers get to respond to what is portrayed as being ‘typically’ female and male – types of clothing, colours, images used, and the possible types of activities while wearing such clothing. Who is determining what is presented as female and male; and what do they get out of it? These social practices are in and of themselves. They are not sufficient to claim that critical health literacy is “done”. The four sets of social practice for critical literacy put forward by Freebody and Luke (1990) are not intended to be formulistic although their application does enable children and adolescents to consider any health issue but to be able to do so with situated meaning. In this sense students assess health issues, consider how they play out within their world and therefore generate a meaningful response rather than predetermined behaviour change. The potential for critical health literacy in schools to generate attitudes to support health promotion activities by individuals and in groups is substantial. But to do so requires the crafting of meaningful learning experiences around informed reflective practice (Renwick 2006). If, as Luke argues (2000), critical literacy is an attitude about how literacies and the social world are perceived then this ontological positioning requires an action oriented approach to health education in schools.

Conclusion Democratic equality as described by Anderson (1999) espouses relationships between and amongst people rather than focusing on patterns of distribution for resources and goods. In doing so, social norms and differences in socio-economic circumstances and the ways in which they contribute to and determine inequality so differences in health are revealed. Such equality is not given nor is it a passive state instead it requires active engagement using competencies such as critical literacy. Critical health literacies should enable students, teachers and others in the school community to be able to not only deal with situations in the school’s domain, but to also see possibilities for other domains experienced throughout life. Thus, the notion of democracy put forward by Dewey (1938) requires that there is access to a range of sources of (health) knowledge (Willinsky 2002) and is consequently relevant to health (literacy) within the community context (Renwick 2006). Like literacy, health is socially constructed and both need to be appraised and reinvented in response to social change (Freebody and Luke 1999). Skills related to critical (health) literacy provide possibilities for individuals to be able to respond to a range of initiatives and circumstances in ways that make sense within their life experiences and communities and can contribute to both personal and social wellbeing.

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ABOUT THE AUTHOR Dr. Kerry Renwick: Kerry has extensive experience working in both school and community based health education and vocational education. Kerry is a past president of the Health Education Association of Victoria with experience working in public health nutrition. Her Ph.D., topic was a critical analysis of health promoting schools in Australia.

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