Public Heath Literacy: A Modifiable Social Determinant
By S. Todd Stolp MD
Clinicians and public health practitioners alike have lamented shortcomings in public health literacy that have contributed to poor outcomes from the COVID-19 pandemic.[1] Of course, the primary institutional solution for any weakness in literacy, including health literacy, is our educational system. Yet collaboration between clinical and public health experts and their colleagues in the educational sector to improve public health education curriculum across the country is lacking.
Public Health Literacy Defined
The definition of “health literacy” and “public health literacy” has evolved. In 2009, Freedman et al proposed to divide “health literacy” into “individual-level health literacy”- a concept which continues to be developed in the recently updated Healthy People 2030 definition – and “public health literacy.”[2] The definition of “public health literacy” as proposed by Freedman et al is “the degree to which individuals and groups can obtain, process, understand, evaluate, and act upon information needed to make public health decisions that benefit the community.”
This notion of “public health literacy” is acutely relevant to an effective public health system, partly because rigorous public health literacy strengthens the partnership between a community and local public health professionals and partly because public understanding of population health vocabulary facilitates communication. But the benefits of public health literacy go much further. A focused effort to improve school health education curriculum to advance public health literacy is exactly the prescription this country needs.
U.S. National Health Education Standards
In 2022, two different coalitions of health educators, the National Consensus for School Health Education[3] (NCSHE) and SHAPE America,[4] worked on disseminating two competing versions of new U.S. National Health Education Standards (NHES). A modern revision of the 2007 NHES poses an enormous opportunity to address shortcomings in public health literacy. In the wake of the COVID-19 pandemic and other ongoing public health challenges, updated public health education curriculum in K – 12th grades should include renewed focus on public health principles, epidemiological knowledge, statistical proficiency and must integrate public health education with other cross-cutting STEM subject matter. Clinicians and public health professionals who have worked with the public, both behind the closed doors of clinics and in the national media over the course of the COVID pandemic to convey public health messages, have been underutilized in the development of the new NHES. In addition, the release of two different versions of updated national standards is likely to create inconsistent implementation and confusion among state departments of education and those who are developing new health education curricula. A more collaborative effort is needed.
What Can Improved Public Health Literacy Accomplish?
Of course, barriers other than low health literacy, such as lack of access to healthcare and insufficient financial resources, present obstacles to health-seeking behavior that cannot be mitigated by health education. The 2020 National Academy report, Encouraging Adoption of Protective Behaviors to Mitigate the Spread of COVID-19: Strategies for Behavior Change,[5] cautions that “(t)here is not strong evidence that explaining the science of disease can directly change behavior.” But this cautionary statement ignores overwhelming evidence that a foundational understanding of the science of disease enables timely access to services, facilitates rewards for health-promoting behaviors and avoids unnecessary costs and unproven treatments.[6] The success of historical campaigns like tobacco control were propelled by limiting access to tobacco and shifting costs of tobacco-related disease to tobacco consumers and industries, but these efforts were built on an understanding of tobacco-related disease and political will, all of which were facilitated by public health literacy. Campaigns now underway to curb firearm violence have been hobbled by limited access to public health research, but new studies will now hopefully see new strategies emerge. While it is not a panacea against future public health challenges, improved public health literacy is a critical catalyst for interventions encouraged by the National Academy report, like access to services, rewards for health promoting behaviors and financial incentives, to be effective.
In fact, an overwhelming amount of research supports the need for a foundational understanding of health science as a cornerstone for public health, for resilience to both public health emergencies and chronic diseases. Following the Dobbs Decision in 2022, education has been shown to facilitate access to contraception for those with limited options.[7] Lower health literacy scores on the Rapid Estimate of Adult Literacy in Medicine–Short Form (REALM-SF) have correlated with a variety of adverse maternal and neonatal outcomes.[8] The American Heart Association position statement Health Literacy and Cardiovascular Disease: Fundamental Relevance to Primary and Secondary Prevention provides comprehensive support for health literacy in battling the country’s most common cause of death.8 The U.S. Surgeon General’s 2021 advisory, Confronting Health Misinformation, includes the recommendation that educators should implement “…health literacy programs….across all educational settings, including elementary, secondary, post-secondary and community settings.”[9]
Public Health Literacy and Health Equity
It is easy to feel powerless when public health workers are confronted with gaping health disparities rooted in a tangle of social, geographic, racial, ethnic and economic realities. However, one tool available to us living in a country that has not yet embraced universal health care, is a system that promises universal education. Advancing public health literacy through nationwide standards in health education is a tangible way to address health disparities, insofar as our schools are satisfactorily funded to meet those standards.
The Need for Partnership
Relying upon the expertise of specialists in the field of education is, of course, critical to the development of an effective update and implementation of public health literacy educational standards. Employing developmentally appropriate and evidence-based teaching methods in accordance with frameworks that build upon cross-cutting lessons in other STEM subject matter is vital. However, it is equally important that curriculum include insights that are foundational to public health principles. Examples might include demonstrations reflecting the additive or exponential effects of disease prevention measures taken within a population during an outbreak, or simultaneous lessons illustrating natural selection principles in action when antibiotic resistance emerges in a community. Insights that distinguish normal grief from clinical depression can be gained from studies of literature and parallels between physical and mental disabilities, thereby helping to destigmatize mental health care.
Critical thinking skills must also continue to be a focus of updated health education material. There is evidence that automated dissemination of messages during the COVID pandemic has been disproportionately used to spread misinformation compared with its use to disseminate accurate and reliable public health information.[10] While assessing resource reliability was already a recognized focus of the previous 2007 National Health Education Standards, recent elegant work conducted by public health researchers during the COVID-19 pandemic to understand effective countermeasures to mis- and disinformation campaigns has added to the evidence-base for mitigations that should be included in new educational material.[11]
We Must Not Let SDOH Become a Cliché
Which brings us to the familiar topic of the Social Determinants of Health (SDOH). There is real risk that “SDOH” will become nothing more than a cliché unless clinical and public health professionals provide the service of translating science into action. APHA testimony to Congress in 2021 on the topic of “Vaccine Hesitancy” addressed the need for clinicians and public health communities to provide information to the public, but the need to partner with educators to build primary prevention before the advent of the next public health threat was not prioritized. Numerous published essays have encouraged a new paradigm for healthcare and public health without mention of the critical role of education and public health literacy in primary prevention.[12] In a brief evaluation report of the CDC initiative, Improving the Social Determinants of Health – Getting Further Faster, support for education was mentioned only in the context of “outdoor education” or as a secondary prevention strategy, but not as primary prevention.
Shortfalls in the U.S. healthcare workforce are expected to worsen according to projections.[13] One way to increase interest in a possible future career in healthcare or public health is to increase exposure to the opportunities and the attractive features of those occupations. By expanding student exposure to epidemiologic investigations and the “Sherlock Holmes” challenges intrinsic to public health work, early curiosities can be cultivated into career trajectories to fill vacancies in the future workforce.
Calls to energize government and private institutions to fund and devote expertise to address public health literacy as one of the few social determinants that can be modified have been meager.[14] While “education” has been raised as a potential mitigation, tangible efforts to coordinate with private educational coalitions and government departments have not been center stage. With the 2022 release of newly proposed National Health Education Standards, it is still not too late to roll up our sleeves.
[1] The Lancet Public Health Editorial, Education: a neglected social determinant of health; Vol. 5, Issue 7 2020; e361 https://doi.org/10.1016/S2468-2667(20)30144-4
[2] Freedman D, Bess K, Tucker H et al Public Health Literacy Defined, Am J Prev Med 2009;36(5):446–451) https://pubmed.ncbi.nlm.nih.gov/19362698/
[3] National Consensus for School Health, Accessed January 31, 2023 https://www.schoolhealtheducation.org/
[4] SHAPE America, Society of Health and Physical Educators, Accessed January 31, 2023 https://www.shapeamerica.org/standards/health/
[5] National Academies of Sciences, Engineering, and Medicine. 2020. Encouraging Adoption of Protective Behaviors to Mitigate the Spread of COVID-19: Strategies for Behavior Change. Washington, DC: The National Academies Press. https://doi.org/10.17226/25881
[6] Magnani et al, Health Literacy and Cardiovascular Disease: Fundamental Relevance to Primary and Secondary Prevention: A Scientific Statement From the American Heart Association, Circulation. 2018;138:e48–e74. https://doi.org/10.1161/CIR.0000000000000579
[7] Nelson H, Cantor A, Jungbauer R et al Effectiveness and Harms of Contraceptive Counseling and Provision Interventions for Women Annals of Int Med, May 24, 2022 https://doi.org/10.7326/M21-4380
[8] Yee L, Silver R, Haas D et al Association of Health Literacy Among Nulliparous Individuals and Maternal and Neonatal Outcomes, JAMA Network Open. 2021;4(9):e2122576. https://doi.org/10.1001/jamanetworkopen.2021.22576
[9] Murthy, V, Surgeon General of the United States, Confronting Health Misinformation: The U.S. Surgeon General’s Advisory on Building a Healthy Information Environment, June 24, 2021 https://www.hhs.gov/sites/default/files/surgeon-general-misinformation-advisory.pdf
[10] Ayers et al, Spread of Misinformation About Face Masks and COVID-19 by Automated Software on Facebook JAMA Internal Medicine; June 7, 2021 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2780748
[11] Vraga EK, Bode L. Addressing COVID-19 misinformation on social media preemptively and responsively. Emerg Infect Dis. 2021 February 2021 [January 4, 2021]. https://doi.org/10.3201/eid2702.203139
[12] Jonas, W and Adibe, B An Integrated Framework for Achieving National Health Goals, JAMA Health Forum. May 20, 2022;3(5):e221109. https://doi.org/10.1001/jamahealthforum.2022.1109
[13] Buntin, M Projecting the Health Care Workforce Needed in the US, JAMA Health Forum. 2022;3(8):e222430. https://doi.org/10.1001/jamahealthforum.2022.2430
[14] Butler, S What is the Outlook for Addressing Social Determinants of Health? JAMA Health Forum, 2021;2(9):e213639. https://doi.org/10.1001/jamahealthforum.2021.3639