Takemi Program in International Health
The Takemi Program in International Health seeks to improve health and health systems around the world by welcoming mid-career health professionals and scholars to the Harvard T. H. Chan School of Public Health to conduct path breaking research and develop their leadership skills.
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Boston, MA 021151, USA
Health Literacy Studies
Health literacy plays a central role in health outcomes, equity, and access to care. It reflects the dynamic interaction between individual skills, communication practices, materials and tasks, and institutional environments. Research and practice in this field have consistently shown that health literacy is not only about the abilities of individuals, but also about the demands and complexities embedded in health information, services, and systems.
Health literacy is commonly understood as the degree to which individuals can access, understand, appraise, and apply information to make decisions about their health. However, contemporary research emphasizes that health literacy is not solely an individual attribute; it is shaped by the clarity of communication, the accessibility of health systems, and the broader social and institutional context in which health activities take place.
This section brings together a broad array of research findings, conceptual frameworks, practical tools, policy developments, and teaching resources aimed at strengthening health literacy across populations. It provides foundational knowledge for academics, health professionals, researchers, and policymakers interested in addressing the barriers that hinder equitable health communication and outcomes.
The resources and frameworks compiled here originate from the pioneering work conducted by the Health Literacy Studies research team at the Harvard T.H. Chan School of Public Health under the leadership of Dr. Rima Rudd. Developed in the 1990s, this was the first academic initiative to systematically gather health literacy research findings, policy developments, educational materials, and assessment tools. Since then, health literacy has gained global recognition as a key determinant in health disparities and an essential component of public health strategy.
Today, these materials and contributions continue to evolve. Building on the foundations established by Dr. Rudd, dissemination efforts have expanded through partnerships with the Horowitz Center for Health Literacy at the University of Maryland and the Takemi Program in International Health at Harvard. Dr. Aya Goto, Professor of Practice and Director of the Takemi Program, plays a leading role in preserving, updating, and expanding the original Health Literacy Studies materials. Her work extends the reach of health literacy research and training into international contexts, emphasizing practical application through workshops, educational initiatives, and community-based program.
Understanding Health Literacy
What is Health Literacy?
Health literacy is commonly defined as the degree to which individuals can access, understand, appraise, and apply health information to make informed decisions. Early definitions, such as Don Nutbeam’s work for the WHO Health Promotion Glossary (1998), positioned health literacy as an evolving construct, emphasizing that it cannot be reduced to individual skill levels alone.
Contemporary perspectives highlight that health literacy depends on multiple factors:
- The skills of individuals (reading, writing, speaking, listening, numeracy, problem solving)
- The clarity of communication from professionals
- The complexity of texts and data presentations
- The difficulty of tasks individuals must perform
- The environment in which health interactions occur
Thus, health literacy is not solely a patient’s characteristic, but an outcome shaped by communication practices, institutional settings, and societal structures. A true understanding requires assessing all sides of the literacy exchange: individual capacities, demands of texts and tasks, and institutional facilitators or barriers.
For an extended discussion, see Rima Rudd’s article: “Health Literacy Insights and Issues” in Health Literacy: New Directions in Research, Theory, and Practice (2017)
Deconstructing Health Activities
Health activities often involve clusters of texts, tools, and tasks rather than single actions. For example, “taking medication” includes reading prescriptions, understanding labels, signing consent forms, constructing reminders, and interpreting instructions amidst daily life distractions.
Literacy research shows that we cannot measure a person’s reading or comprehension skills without also analyzing:
- The complexity of the texts involved
- The clarity of spoken communication
- The difficulty of the tasks
- The design of supporting tools
Deconstructing health activities enables a deeper understanding of where barriers to comprehension and action arise and guides the design of more effective communication strategies.
Explore examples of deconstruction in the Chart of Health Literacy Related Activities, Materials, and Tasks.
Research Findings
Early large-scale literacy surveys revealed significant gaps between adults’ literacy skills and the demands placed on them by everyday materials, including those used in healthcare. These findings helped frame literacy as a public health issue.
Program for the International Assessment of Adult Competencies (PIAAC) Findings
- OECD Skills Outlook 2013: First Results from the Survey of Adult Skills
- Literacy, Numeracy, and Problem Solving in Technology-Rich Environments Among U.S. Adults: Results from the Program for the International Assessment of Adult Competencies 2012
National Assessment of Adult Literacy (NAAL) Findings
Adult Literacy and Life Skills Survey (ALLS) Findings
International Adult Literacy Survey (IALS) Findings
- Literacy in the InforIALS covermation Age: Final Report of the International Adult Literacy Survey (IALS)
- The Twin Challenges of Mediocrity and Inequality: Literacy in the U.S. from an International Perspective
National Adult Literacy Survey (NALS) Findings
Focused studies on health literacy have adapted methodologies from general literacy surveys to better capture the specific demands of health-related communication.
Several reviews have synthesized the growing body of evidence regarding the consequences of limited health literacy and the effectiveness of interventions.
These include:
- Health Literacy in The “Oral Exchange”: An Important Element of Patient–Provider Communication by S. Nouri, R. Rudd. Patient Education & Counseling, Volume 98(5); (2015).
- Health Literacy Interventions and Outcomes: An Updated Systematic Review by N. Berkman et al. Rockville (MD): Agency for Healthcare Research and Quality (US). Report No.: 11-E006; (2011).
- Health Literacy: An Updated Review of the Medical and Public Health Literature by R. Rudd with J. Epstein Anderson, S. Oppenheimer, C. Nath. Annual Review of Adult Learning and Literacy, Volume 7; (2007).
- Understanding Health Literacy and its Barriers by M. Zorn, M. Allen, A. Horowitz. Library of Medicine; (2004).
Health Literacy: A Review of the Medical and Public Health Literature by R. Rudd, B. Moeykens, T. Colton. Annual Review of Adult Learning and Literacy, Volume 1; (2000).
Strategies
and Tools
Health Literacy is best understood as an exchange: such as one between a reader and a text or posting, a listener and a speaker, a viewer and a designer… and always takes place in a context such as a home or workplace, a medical office, a lecture hall, a community agency, or within a public health or healthcare institution. The difficulty of the text, the clarity of the speaker, the comfort of the setting – are all key components of health literacy. One cannot measure a person’s skills without considering the attributes or characteristics of the ‘other side’ of the exchange. These characteristics will support or inhibit the exchange inherent in health literacy. The atmosphere, practices, directions, materials, procedures, norms, regulations of an institution … will all influence a person’s ability to access, comprehend, and use information, advice, and services. Institutional norms, practices, policies, and regulations will also support or inhibit a professional’s ability to appropriately engage with visitors, patients, and clients.
Assessing the ‘health literacy environment’ of health and health care institutions is a key step in identifying and understanding facilitating factors and barriers to health information, care, and services. Below are resources that will assist you.
- HLE 2: The Health Literacy Environment of Hospitals and Health Centers
- The Health Literacy Environment Activity Packet: First Impressions and A Walking Interview
- The Health Literacy Environment of Hospitals and Health Centers – Partners for Action: Making Your Healthcare Facility Literacy-Friendly
- AHRQ Health Literacy Universal Precautions Toolkit
- Health Litehealth literacy review a guideracy Review: A Guide, New Zealand Ministry of Health, 2015
- How Can Health Care Organizations Become More Health Literate? – Workshop Summary
- Ten Attributes of Health Literate Health Care Oranizations
- What did the Doctor Say?: Improving Health Literacy to Protect Patient Safety
Learn More
- Horowitz A, Maybury C, Kleinman D, Radice S, Wang M, Child W, Rudd R. (2014). Health Literacy Environmental Scans of Community-Based Dental Clinics in Maryland. American Journal of Public Health, 104(8): e85-e93.
- Groene O, Rudd RE. (2011). Results of a feasibility study to assess the health literacy environment: Navigation, written and oral communication in ten hospitals in Catalonia, Spain. Journal of Communication in Healthcare, 4: 227-237.
- Rudd R. (2005). Navigating Hospitals: Literacy Barriers. Literacy Harvest, 11(1): 19-24.
- Rudd R, Renzulli D, Pereira A, Daltroy L. (2005). Literacy Demands in Health Care Settings: The Patient Perspective. Understanding Health Literacy: Implications for Medicine and Public Health.
As we develop health materials for the general public – on paper, in postings or online – we need to eliminate as many barriers to comprehension and use as possible.
The Challenge for Writers
Health literacy insights tell us to pay attention to a wide variety of text characteristics that ease or inhibit reading. Materials assessment tools offer insights for the development of materials and can be used a a check list by writers. Health texts are generally action oriented and so writers also need to consider what it is they expect readers to do as a result of engaging with their text. Will the text make it easy for people to take action?
Consider the Reader
Reading is a complicated task. The components of reading include the following:
- Alphabetics: the process of using letters in an alphabet to represent sounds in the spoken word. Needed skills include knowledge of basic sounds [phonemes] and an understanding of the relationship between these sounds and letters [phonics].
- Fluency: ability to read with speed and ease – akin to the rhythm of speech.
- Vocabulary: knowledge of the meaning of a word. Understanding less common words requires background knowledge. It is important to remember that jargon is really a secret language among people in a particular group.
- Reading comprehension: a construction process. This process involves all the elements of a reading process to derive meaning from text.
- Beginning readers are developing skills in sounding out words. They learn to link sound to meaning. Over time, they learn about linked words in short sentences. They often read one word at a time [slowing the process] and may skip over unfamiliar words. New readers may tire easily. As a result, new readers often focus on individual words and have difficulty focusing on the meaning of a sentence. Intermediate readers are building background knowledge and vocabulary. At the same time, they are improving word recognition and fluency. They are learning to derive meaning from text and to make inferences. Advanced readers read with speed and ease. They understand the context and can make inferences. They are using the written word and applying literacy skills to a variety of academic and mundane tasks.
Useful Handouts
Participatory Materials Development
Participatory materials development processes support democratization of knowledge because such efforts engage members of the intended audience as co-creators. Participatory processes or co-design are of particular value to health literacy because the resulting product incorporates the voice, language, image, issues, and perspective of the community for whom and by whom the materials are designed. Educational materials written and designed by members of the intended audience can be powerful tools for sharing information and spurring action. Furthermore, materials produced through a participatory process highlight the community based authors as critical thinkers who can inspire others. Click here for Rudd RE and Comings JP (1994). Learner developed materials: an empowering product, Health Education Quarterly, 21(3): 313-327. This article also highlights the important health literacy theme of dignified dialogues.
Photonovels
Photonovels look like comic books but use photographs rather than drawings. They are popular entertainment media in many Latin American countries. The development of photonovels is now quite easy because of digital cameras and readily available computer programs for layout and design. Participatory processes involve members of the community or ‘intended audience’ as storytellers, writers, set designers, actors, photographers, promoters, disseminators, and evaluators. These photonovels produced long before the readily available digital cameras and computer assisted layout serve as examples:
- Examples [PDF Documents]
- Workers Take Action
- A Working Neighborhood
- Un Intruso En Mi Patio…
Photovoice
Caroline Wang and colleagues developed another very innovative participatory approach called Photovoice. Community people took pictures of aspects of their lives and used their photos and stories to advocate for change. Please link to the website www.photovoice.org for a full introduction, references, and examples.