Defining and measuring health literacy: how can we profit from other literacy domains?

When the antecedents of health-promoting behavior are explored, the concept of health literacy is deemed a factor of major influence. Originally defined as reading, writing and numeracy skills in the health domain, health literacy is now considered a multidimensional concept. The ongoing discussion on health literacy reveals that no agreement exists about which dimensions to include in the concept. To contribute to the development of a consistent and parsimonious concept of health literacy, we conducted a critical review of concepts in other literacy domains. Our review was guided by two research questions: (i) Which dimensions are included in the concepts of other literacy domains? (ii) How can health literacy research profit from other literacy domains? Based on articles collected from PubMed, PsycINFO, Communication & Mass Media Complete, CINAHL, SAGE Full-Text Collection, Cochrane Library and Google Scholar as well as selected monographs and editions, we identified seven distinct dimensions. Some of the dimensions recur across all reviewed literacy domains and first attempts have been made to operationalize the dimensions. Expanding upon these dimensions, the paper discusses how they can prove useful for elaborating a consistent and parsimonious concept of health literacy and foster the development of a more holistic measure.     

Putting the Pieces Together: An Integrated Model of Program Implementation

Considerable evidence indicates that variability in implementation of prevention programs is related to the outcomes achieved by these programs. However, while implementation has been conceptualized as a multidimensional construct, few studies examine more than a single dimension, and no theoretical framework exists to guide research on the effects of implementation. We seek to address this need by proposing a theoretical model of the relations between the dimensions of implementation and outcomes of prevention programs that can serve to guide future implementation research. In this article, we focus on four dimensions of implementation, which we conceptualize as behaviors of program facilitators (fidelity, quality of delivery, and adaptation) and behaviors of participants (responsiveness) and present the evidence supporting these as predictors of program outcomes. We then propose a theoretical model by which facilitator and participant dimensions of implementation influence participant outcomes. Finally, we provide recommendations and directions for future implementation research.     

Demonstration of replicable dimensions of health behaviors

Health behaviors are known to be multidimensional, but the precise number of dimensions involved and their behavioral content have not been clearly established. Using convergence of factor analyses of 40 health behaviors across two samples as the criterion for identifying both the number and content of health behavior dimensions, the present study showed that individual differences in health behavior can be conceptualized in terms of a hierarchical model. At the most general level, health behaviors formed two broad categories or dimensions, preventive behavior and risk taking behavior. Preventive behavior included two empirically distinct subsets of behaviors, wellness maintenance behaviors and accident control behaviors. Risk taking behavior included subsets comprised of traffic-related risk taking and risk taking through exposure to hazardous substances. This hierarchical model is consistent with important theoretical distinctions in health behavior research, can accommodate the findings of prior studies, and should provide a useful framework for formulating research questions regarding antecedents and consequences of individual differences in health behaviors. Brief scales are proposed for use as reference measures in future studies of health behaviors.     

Sociological refigurations of patient safety; ontologies of improvement and ‘acting with’ quality collaboratives in healthcare

The increasing focus on patient safety in the field of health policy is accompanied by research programs that articulate the role of the social sciences as one of contributing to enhancing safety in healthcare. Through these programs, new approaches to studying safety are facing a narrow definition of ‘usefulness’ in which researchers are to discover the factors that support or hamper the implementation of existing policy agendas. This is unfortunate since such claims for useful involvement in predefined policy agendas may undo one of the strongest assets of good social science research: the capacity to complexify the taken-for-granted conceptualizations of the object of study. As an alternative to this definition of ‘usefulness’, this article proposes a focus on multiple ontologies in the making when studying patient safety. Through such a focus, the role of social scientists becomes the involvement in refiguring the problem space of patient safety, the relations between research subjects and objects, and the existing policy agendas. This role gives medical sociologists the opportunity to focus on the question of which practices of ‘effective care’ are being enacted through different approaches for dealing with patient safety and what their consequences are for the care practices under study.     

School differences in pupil smoking: a consequence of a trade-off between health and education agendas?

Current policy documents stress that raising standards in education and health are inextricably linked, with schools identified as well placed to advance both agendas. This paper considers these assumptions in the light of data derived from 27 staff interviews conducted in two secondary schools. These schools served relatively disadvantaged communities, but differed in their pupil smoking rates with one school being 'high-smoking', the other 'low-smoking'. It explores whether this difference reflects the differential emphasis placed by each school on education or health. Analysis reveals that the 'low-smoking' school subscribes to holistic values and operates according to a child-centred bottom-up philosophy offering a differentiated programme of pupil support contingent on needs. In contrast, the 'high-smoking' school maintains a narrow focus on educational outcomes, and its high expectations are viewed as running counter to those held by pupils and parents. The contrasting school philosophies bring different unintended consequences. The holistic focus of the low-smoking school is associated with tempered educational expectations, thus conflicting with recommendations in education policies. The singular education focus of the high-smoking school leaves little room for a health agenda, and can overlook and disenfranchise the educationally disinclined. The school systems' impact on pupil engagement may explain their different smoking rates.     

Patterns of information transfer in health education: a bibliometric analysis of the research literature

The purpose of this study is to examine the extent to which health education has become a distinctly separate field of inquiry as evidenced by the patterns of information transfer in the health education research literature. Bibliometric analysis is used to determine: (1) if health education has an identifiable core of journals, (2) the extent to which health education research is derivative of research from other disciplines and (3) the extent to which research from other disciplines draws upon research published in health education journals. The results suggest that there is an identifiable core of journals that serve to characterize health education as a distinct field of inquiry. However, health education research is found to be more derivative of research from other fields than are the other comparative fields in the sample. Moreover, researchers in other disciplines use health education research less than half as often as health education uses its own research. Differences in citing patterns in journals dedicated to health education and by researchers publishing on health education topics in research journals of other areas seem to indicate that health education research is not one unified undertaking.     

Regional assemblage and the spatial reorganisation of health and care: the case of devolution in Greater Manchester,England

In this paper, we examine how space is integral to the practices and politics of restructuring health and care systems and services and specifically how ideas of assemblage can help understand the remaking of a region. We illustrate our arguments by focusing on health and social care devolution in Greater Manchester, England. Emphasising the open‐ended political construction of the region, we consider the work of assembling different actors, organisations, policies and resources into a new territorial formation that provisionally holds together without becoming a fixed totality. We highlight how the governing of health and care is shaped through the interplay of local, regional and national actors and organisations coexisting, jostling and forging uneasy alliances. Our goal is to show that national agendas continued to be firmly embedded within the regional project, not least the politics of austerity. Yet through keeping the region together as if it was an integrated whole and by drawing upon new global policy networks, regional actors strategically reworked national agendas in attempts to leverage and compete for new resources and powers. We set out a research agenda that foregrounds how the political reorganisation of health and care is negotiated and contested across multiple spatial dimensions simultaneously.     

TRADITIONALISM AND ITS RELATIONSHIP TO DISEASE RISK AND PROTECTIVE BEHAVIORS OF WOMEN LIVING ON THE HOPI RESERVATION

The fundamental aim of this study was to identify factors crucial for the development of effective cancer prevention programs for American Indian (AI) populations. Toward that end, we developed an instrument to assess the influence of traditionalism on health risks such as smoking, consumption, and obesity. A population-based survey was conducted among 559 randomly selected women living on the Hopi reservation aged 18 years and older, from July through December 1993. To construct a traditionalism score, we conducted focus groups in the community. A multidimensional approach was adopted by assessing three dimensions of native culture: language usage; cultural participation, or participation in such activities as Hopi ceremonies; and percentage of life spent off-reservation. A mean score of the three dimensions was computed for each respondent. High levels of traditionalism were significantly associated with disease protective behaviors, such as practicing traditional Hopi activities to keep healthy (OR = 3.07), and significantly inversely associated with disease risk factors such as smoking (OR = 0.26) and obesity (OR = 0.60) independent of age, marital status, and education. As these data provide a strong rationale for the promotion of traditions in public health programs aimed at decreasing rates of chronic disease among AI women, we conclude this paper with a discussion of the importance of traditionalism and how it might be accurately assessed.     

Traditionalism and its relationship to disease risk and protective behaviors of women living on the Hopi reservation

The fundamental aim of this study was to identify factors crucial for the development of effective cancer prevention programs for American Indian (AI) populations. Toward that end, we developed an instrument to assess the influence of traditionalism on health risks such as smoking, consumption, and obesity. A population-based survey was conducted among 559 randomly selected women living on the Hopi reservation aged 18 years and older, from July through December 1993. To construct a traditionalism score, we conducted focus groups in the community. A multidimensional approach was adopted by assessing three dimensions of native culture: language usage; cultural participation, or participation in such activities as Hopi ceremonies; and percentage of life spent off-reservation. A mean score of the three dimensions was computed for each respondent. High levels of traditionalism were significantly associated with disease protective behaviors, such as practicing traditional Hopi activities to keep healthy (OR = 3.07), and significantly inversely associated with disease risk factors such as smoking (OR = 0.26) and obesity (OR = 0.60) independent of age, marital status, and education. As these data provide a strong rationale for the promotion of traditions in public health programs aimed at decreasing rates of chronic disease among AI women, we conclude this paper with a discussion of the importance of traditionalism and how it might be accurately assessed.     

Sociological refigurations of patient safety; ontologies of improvement and ‘acting with’ quality collaboratives in healthcare

The increasing focus on patient safety in the field of health policy is accompanied by research programs that articulate the role of the social sciences as one of contributing to enhancing safety in healthcare. Through these programs, new approaches to studying safety are facing a narrow definition of ‘usefulness’ in which researchers are to discover the factors that support or hamper the implementation of existing policy agendas. This is unfortunate since such claims for useful involvement in predefined policy agendas may undo one of the strongest assets of good social science research: the capacity to complexify the taken-for-granted conceptualizations of the object of study. As an alternative to this definition of ‘usefulness’, this article proposes a focus on multiple ontologies in the making when studying patient safety. Through such a focus, the role of social scientists becomes the involvement in refiguring the problem space of patient safety, the relations between research subjects and objects, and the existing policy agendas. This role gives medical sociologists the opportunity to focus on the question of which practices of ‘effective care’ are being enacted through different approaches for dealing with patient safety and what their consequences are for the care practices under study.In order to explore these questions, this article draws on empirical material from an ongoing evaluation of a large quality improvement collaborative for the care sectors in the Netherlands. It addresses how issues like ‘effectiveness’ and ‘client participation’ are at present articulated in this collaborative and shows that alternative figurations of these notions dissolve many ‘implementation problems’ presently experienced. Further it analyzes how such a focus of medical sociology on multiple ontologies engenders new potential for exploring particular spaces for ‘acting with’ quality improvement agents.     

Sexuality education: our current status, and an agenda for 2010

Three articles are presented that record changes in American public schools sexuality education during the last decade of the 20th century. These articles include "Adolescent Views," which reports major shifts in the prevalence and content of school-based reproductive health education over 1988-95. Instruction is focused on HIV/AIDS prevention, contraceptive education, how to say no to sex, and condoms. In "Changing Emphases," teachers of grades 7-12 testify to a marked shift from a more balanced treatment of abstinence and protection in 1988 to a heavier reliance on abstinence in 1999. The last article, "Grades 5-6," shows that sexuality education is much less common at these grade levels than in grades 7-12. Where programs exist, they mainly cover such topics as puberty, HIV/AIDS, sexuality, sexually transmitted diseases, sexual abuse, and abstinence, while the discussion of contraceptive methods is relatively rare. Views presented in these articles will help formulate research and advocacy agendas for 2010.     

Birth outcomes among urban African-American women: a multilevel analysis of the role of racial residential segregation

Residential segregation is a common aspect of the urban experiences of African-Americans in the United States (US), yet few studies have considered how segregation might influence perinatal health. Here, we develop a conceptual model of relationships between segregation and birth outcomes and test the implications of the model in a sample of 434,376 singleton births to African-American women living in 225 US Metropolitan Statistical Areas (MSAs). Data from the National Center for Health Statistics 2002 birth files were linked to data from the 2000 US Census and two distinct measures of segregation: an index of isolation (the probability that an African-American resident will encounter another African-American resident in any random neighborhood encounter) and an index of clustering (the extent to which African-Americans live in contiguous neighborhoods). Using multilevel regression models, controlling for individual- and MSA-level socioeconomic status and other covariates, we found higher isolation was associated with lower birthweight, higher rates of prematurity and higher rates of fetal growth restriction. In contrast, higher clustering was associated with more optimal outcomes. We propose that isolation reflects factors associated with segregation that are deleterious to health including poor neighborhood quality, persistent discrimination and the intra-group diffusion of harmful health behaviors. Associations with clustering may reflect factors associated with segregation that are health-promoting such as African-American political power empowerment, social support and cohesion. Declines in isolation could represent positive steps toward improving birth outcomes among African-American infants while aspects of racial contiguity appear to be mitigating or indeed beneficial. Segregation is a complex multidimensional construct with both deleterious and protective influences on birth outcomes, depending on the dimensions under consideration. Further research to understand racial/ethnic and economic health disparities could benefit from a focus on the contributory role of neighborhood attributes associated with the dimensions segregation and other social geographies.     

A focus on pleasure? Desire and disgust in group work with young men

There are a number of persuasive arguments as to why sexual pleasure should be included in sexual health work with young people, including the suggestion that this would provide young people with accounts of gender and sexuality that are more critical and holistic than those presented in the popular media, pornography and current sex education curricula. This paper considers the possibilities for engaging young men in critical group work about sexual pleasure in research and education contexts, drawing on a mixed-methods study of young people's understandings and experiences of ‘good sex’. The paper provides a reflexive account of one focus group conducted with a group of heterosexual young men and two youth educators. It explores some of the challenges to building relationships with young men and creating ‘safe spaces’ in which to engage in critical sexuality education in socially unequal contexts. In this case study, adult-led discussion elicits rebellious, ‘hyper-masculine’ performances that close down opportunities for critical or reflective discussion. Although there are some opportunities for critical work that move beyond limited public health or school-based sex education agendas, there is also space for collusion and the reinforcement of oppressive social norms. The paper concludes by imagining possibilities for future research and practice.     

Integration of borders: health in the national development policy context

In recent decades, Brazil's borders with other South American countries have been associated with a negative agenda. Public intervention has aimed almost exclusively at guaranteeing national security through a variety of restrictions. In the current century, with a slow but steady shift in the geopolitical paradigm, integration among South American nations has become a priority. Border regions have now become a strategic area for South American integration and appear as such on the member countries' development agendas. Within this new context, the current study aims to contribute to the connection between the regional health and development agendas, with a focus on border regions, taking a dual approach, by analyzing the development agenda vis-à-vis the field of health and providing clues on how health actions can contribute to a more general perspective of development and integration.     

Desperately seeking reductions in health inequalities: perspectives of UK researchers on past,present and future directions in health inequalities research

Following government commitments to reducing health inequalities from 1997 onwards, the UK has been recognised as a global leader in health inequalities research and policy. Yet health inequalities have continued to widen by most measures, prompting calls for new research agendas and advocacy to facilitate greater public support for the upstream policies that evidence suggests are required. However, there is currently no agreement as to what new research might involve or precisely what public health egalitarians ought to be advocating. This article presents an analysis of discussions among 52 researchers to consider the feasibility that research‐informed advocacy around particular solutions to health inequalities may emerge in the UK. The data indicate there is a consensus that more should be been done to learn from post‐1997 efforts to reduce health inequalities, and an obvious desire to provide clearer policy guidance in future. However, discussions as to where researchers should now focus their efforts and with whom researchers ought to be engaging reveal three distinct ways of approaching health inequalities, each of which has its own epistemological foundations. Such differences imply that a consensus on reducing health inequalities is unlikely to materialise. Instead, progress seems most likely if all three approaches are simultaneously enabled.     

Health and mortality of the elderly: the grade of membership method, classification and determination.

With the aging of society, issues concerning the reform of the Dutch health care system are ranked high on the political agenda. Sensible reforms of the health care system for the elderly require a thorough understanding of the health status of the old and of its dynamics preceding death. The health status of the elderly is intrinsically a multidimensional and dynamic concept and a rich set of indicators is needed to capture this concept in its full extent. This feature of health requires techniques to reduce dimensionality as, in general, it is difficult to simultaneously handle all indicators in any economic analysis. In the first part of this paper we focus on methods that comprise these multidimensional measures into a limited number of indices. The Grade of Membership (GoM) approach introduced by Manton and Woodbury (Methods of Information in Medicine 1982; 21) is specifically designed to characterize the complex concept of health. The method simultaneously identifies all dimensions of the concept of interest and the degrees to which an individual belongs to each of these types (i.e. grades of membership). We apply the method to a set of 21 indicators from a rich database of the Longitudinal Aging Study Amsterdam (LASA). The individual degrees of involvement in the different health dimensions obtained from this method are used in subsequent analyses of health and mortality.     

Entitlements to health care: Why is there a preference for private facilities among poorer residents of Chennai,India?

This paper examines access to health care by poorer residents in Chennai, India. It reveals constraining and enabling conditions for impoverished users seeking treatment. We explore patterns of health-seeking behaviour through the reasoning of residents themselves as well as stakeholders involved in providing care for these users. Particular attention is paid to the needy residents' preference for private health care providers despite the costs involved and that free public facilities are available. We address this issue by combining Sen's entitlement approach with Penchansky and Thomas' work on access to health care. Based on data gathered in a qualitative field-based research design including interviews with 14 residents and 58 stakeholders involved in caring for poor people, we argue that the availability of health care facilities within walking distance is a necessary but not sufficient precondition for satisfactory access. Rather, we demonstrate the influence of 'entitlements to health care' which allow poor households that are endowed with resources such as income, knowledge and social networks to realise access. The narratives we present reveal not only experiences of health care, but also feelings about its utilisation. The latter, we contend, are crucial in determining choice of health care facilities. This finding suggests that analyses of affordability and physical access to health care in less developed countries should include a focus on emotional dimensions of utilisation. In other words, there is a need to consider not only effective access to health care, but also affective dimensions of treatment for poorer citizens.     

A new era for health services research?

The suggestion that health services research is now on the threshold of a new era of importance is a commonplace theme in selected forums. Concern over escalating costs and quality assurance in the health care industry have inspired government, business, insurers, and health care organizations to search for answers in health services research. Those who expect a new era of assessment and accountability will be disappointed, however, if certain key conditions, such as financial resources, multidisciplinary cooperation, significant new training programs, and unified action on national and state public interest research agendas, are not satisfied.     

Diffusion of Cancer Education into Schools

Though implementing health education in schools has numerous advantages, many barriers impede adoption of effective curricula. Diffusion theory provides a framework for understanding why some school systems do not implement comprehensive, sequential, and behaviorally oriented curricula. Reasons for failure to provide optimal health education include competition for time, unawareness of resources and research results, political considerations, long-range planning difficulties, lack of teacher training, lack of testing, other academic priorities, uncertainty about responsibility for health education, and costs. Health educators can overcome such difficulties by working within existing curricular agendas, political interests, and budgets, and by organizing interventions through school health councils, while recognizing local programs, conditions, and resources.     

Methodological problems associated with practice-close research

Within the health professions, it is not uncommon to investigate problems in one's field of practice, but researchers who study their own field are bound to encounter both ethical and methodological problems. In this article, the authors focus on some of the challenges in what they have chosen to call practice-close research. They focus on two issues within this area: the researcher's ability to explicate his or her preconceptions and the researcher's interaction with the participants in the study. It is difficult to treat these dimensions separately, as they border on and will influence each other. The discussion in the article of methodological challenges of practice-close research is based on experiences gleaned from a study in which the first author investigated her own practice.