Digital Health Literacy Access and Skills

 

Image credit: Pexels, Telehealth

By Lilian H. Hill, PhD

Health literacy and digital health literacy are related but distinct ideas. This blog post is part of our series on different forms of literacy in which we provide definitions of health literacy, digital health literacy, and eHealth literacy. 

Health Literacy

To understand digital health literacy, a definition of health literacy is needed. In Healthy People 2030 (2023), the U.S. Department of Health and Human Services (HHS) provided an updated definition of health literacy that has two components: personal health literacy and organizational health literacy:

• Personal health literacy is the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.
• Organizational health literacy is the degree to which organizations equitably enable individuals to find, understand, and use information and services to inform health-related decisions and actions for themselves and others. (para. 3)

Begun in 1980 and occurring decennially, the Healthy People initiative sets priority areas to improve population health, provides implementation tools, and tracks progress. This updated definition acknowledges the responsibilities of health providers and systems to communicate effectively with patients of varying identities, language skills, and literacy levels. Older definitions only included reference to personal health literacy skills, burdening patients. 

Digital Health Literacy

Digital health literacy refers to accessing health information online and navigating and using digital or electronic health information and patient resources. It includes electronic patient portals, technology for telehealth visits, and using computers and mobile devices to access medical information and interact with healthcare teams.

The World Health Organization defines electronic health (eHealth) services as the cost-effective and secure use of information communication technologies to support health. Examples include electronic communication between patients and providers, electronic medical records, patient portals, and digital personal health records. A category of eHealth is mobile health (mHealth), including phones, tablets, and computers to use applications (apps), wearable monitoring devices, and texting services. The Centers for Disease Control and Prevention (CDC) defines eHealth literacy as the ability to evaluate health information from electronic sources and apply the knowledge gained to addressing or solving a health problem (CDC).

Digital health literacy involves skills including: 

• Accessing and using online medical scheduling platforms to make appointments.
• Using and navigating electronic health records and patient portals.
• Receiving text message reminders from healthcare providers.
• Receiving digital health information instead of handouts (for example, information about medication instructions for medication adherence).
• Obtaining results of medical or diagnostic tests online.
• Searching for and evaluating online health information. (Rural Health Information Hub, n.d.).
• Comparing options and enrolling in a health insurance plan on a government website.
• Searching online for healthy recipes to prepare for a family member with health conditions such as hypertension or diabetes.

Unfortunately, these skills depend on computer and mobile device access, digital tools experience, and a robust broadband network. For example, people with limited income and live in remote rural areas need help accessing broadband. Estimates of people lacking access range between 21 to 162 million (Stauffer et al., 2020). The U.S. government announced investing over 40 billion dollars to extend broadband access to all Americans (The White House, 2023). Access depends on having a data plan with broadband access, yet 40% of low-income households are not subscribed to any data plans. Relying on limited cell phone data or public Wi-Fi spots has limitations, including interruptions and a lack of security and privacy (Sieck, 2021). 

Many healthcare organizations have invested heavily in digital resources to support patient healthcare. Research indicates these tools “can foster greater patient engagement, better support for patients outside of the clinic visit, and can improve health outcomes” (Sieck, 2021, p. 1).

Digital health literacy has become so important to healthcare that it is now included as one of the social determinants of health, the conditions in the environments where people live, learn, work, and play that influence human health, functioning, and quality of life (Sieck et al., 2021). Other elements include: 

• safe housing, transportation, and neighborhoods;
• racism, discrimination, and violence;
• education, job opportunities, and income;
• access to nutritious foods and physical activity opportunities;
• polluted air and water; and 
• language and literacy skills (USHHS, 2023). 

As clinical care delivery is quickly being integrated with digital technologies, Sieck et al. (2021) recommend that healthcare organizations adopt digital inclusive strategies, including assessing patient literacy and access and partnering with community organizations to facilitate digital skills training and connectivity. 

References

• Improving Digital Health Literacy. Rural Health Information Hub. Retrieved from https://www.ruralhealthinfo.org/toolkits/health-literacy/2/digital-literacy 
• USHHS (2023, July 26). Healthy People 2030. Retrieved from https://health.gov/our-work/national-health-initiatives/healthy-people/healthy-people-2030 
• Sieck, C. J., Sheon, Amy, Ancker, J. S., Castek, J., Callahan, B. & Siefer, A. (2021). Digital inclusion as a social determinant of health. npj Digital Medicine 4, 52.; https://doi.org/10.1038/s41746-021-00413-8 
• Stauffer, A., de Wit, K., Read, A., & Kitson, D. ((2020). How States Are expanding broadband access: New research identifies tactics for connecting unserved communities. Pew Charitable Trust. Retrieved from https://www.pewtrusts.org/-/media/assets/2020/03/broadband_report0320_final.pdf 
• U.S. White House (2023, February 26). Biden-⁠Harris Administration Announces Over $40 Billion to Connect Everyone in America to Affordable, Reliable, High-Speed Internet. Retrieved from https://www.whitehouse.gov/briefing-room/statements-releases/2023/06/26/fact-sheet-biden-harris-administration-announces-over-40-billion-to-connect-everyone-in-america-to-affordable-reliable-high-speed-internet/ 

Cultural Competence, Cultural Humility, and Intercultural Literacy

Image credit: Lillian H. Hill

By Lilian H. Hill, PhD

The multiplicity of terms related to effective intercultural interactions confirms the need for theory development and educational initiatives to develop people’s skills. Terms that have been used include cultural competence, cultural humility, intercultural literacy, cross-cultural and multicultural interaction, cultural literacy, intercultural competence, and global competence (Schliakhovchuk, 2021). This article examines three related concepts: cultural competence, cultural humility, and intercultural literacy.

Cultural Competence

Cultural competence is defined as the ability to understand one’s own cultural identity, understand and respect the cultural identities of others, and seek to understand how the various cultural realities may differ and intersect to form relationships of mutual respect, dignity, and service to others (Lekas, 2020). Within professional settings, cultural competence involves congruent attitudes, behaviors, and policies that serve intercultural interactions (Arredondo, 2013). To be culturally competent, a person must possess an internal desire to understand the various cultural beliefs and values of others, consider how these values affect life decisions, actions, and goals, and be able to integrate these into interpersonal relationships. For example, the picture above shows several people learning about the Japanese tea ceremony. The term has been used in adult education, teacher preparation, elementary and secondary education, higher education, counseling and psychology, social work, healthcare, and business.

Cultural competence is a large construct with knowledge, skill, behavioral, and attitudinal aspects. Cross et al. (1989) laid the basis for a cultural competence continuum, moving from cultural destructiveness through incapacity, blindness, pre-competence, competence, and cultural proficiency.  

Figure 1: Continuum of Cultural Competence (Cross et al.,1989)

The premise of this continuum is that individuals and organizations reflect various levels of awareness, knowledge, and skills vis-à-vis their relationship with cultural variables.  

Many of the earlier articles on cultural competence appeared to take an essentialist view of culture in which it becomes a list of characteristics to be memorized rather than a dynamic process of complex interactions (Gray & Thomas, 2006). This is illustrated by resources that, reminiscent of a cookbook, provide a cultural overview of specific groups and describe their behaviors and practices with recommendations for appropriate ways of interacting with them (see for example, see Salimbene, 2000). These resources made no allowance for differences within cultural groups. While people espousing cultural competence may have good intentions, the danger is that it can reduce people to a stereotype. Cultural competence also treats cultures as static and fails to recognize the multiplicity of identities a single individual may have. However, some voices challenge the orthodoxy of the cultural competence view rooted in cultural differences. Wear (2003) suggests educators should examine how culture is conceived. She uses Giroux's (2000) concept of "insurgent multiculturalism" which looks beyond the focus on subordinate groups' deficits, to examine the historic, semiotic, and institutional roots of racism. Over the years, a model of the higher levels of "proficiency" has emerged that acknowledges a greater recognition of societal inequities (National Center for Cultural Competence, 2007).

Critiques of Cultural Competence 

A critique of cultural competence is that cultural competence initiatives can stereotype and further marginalize people by assigning culture to people based on visible characteristics. Simplistic views of culture result in over-generalized representations of cultural identities and practices (Singer et al., 2015). Lekas et al. (2020) commented that:

Culture is not stagnant, but a changing system of beliefs and values shaped by our interactions with one another, institutions, media, and technology, and by the socioeconomic determinants of our lives. Yet, the claim that one can become competent in any culture suggests that there is a core set of beliefs and values that remain unchanged and that are shared by all the members of a specific group. This static and totalizing view of culture that connotes a set of immutable ideas embraced by all members of a social group generates a social stereotype. (p. 1)

Given the long-standing diversity of the U.S., it is arrogant and condescending to assume that a single person, institution, or system can become culturally competent in an all-inclusive manner. Everyone has their own intentional and unintentional racist, sexist, classist, and other biases, whether personally acknowledged or suppressed. Despite these biases, “the idea of cultural competency gives us a false sense of exemption from these human flaws in perception” that cause us to mistreat others (Cooks-Campbell, 2022, para. 22). Ignoring diversity does not adequately address people’s multiple identities or individuals whose identity is not immediately visible. 

Cultural Humility

Based on the flaws of cultural competence, some suggest that cultural humility should replace the term as a goal (Lekas, 2020; Tervalon & Murray-Garcia, 1998). Cultural humility is an approach to sociocultural differences that emphasizes intersectionality and understanding one’s implicit biases. This approach cultivates self-awareness and self-reflection, bringing a respectful willingness to learn to interpersonal interactions and attention to power dynamics. Reflecting upon one's culture is often a first step in becoming more aware of one's relationship with those culturally different from oneself (National Center for Cultural Competence, 2007). Self-reflection can be employed to identify how white privilege reinforces and maintains institutionalized racism (Lekas et al., 2020; Tyson, 2007). 

Intercultural Literacy

Intercultural literacy builds on the ideas of cultural competence but, much like cultural humility, adds concepts of critical reflection and self-examination. It also includes responsibility for contributing to constructive change within one’s culture. An interculturally literate person can draw on their background experience to comprehend a second culture, including its symbols and communications. Intercultural literacy requires analyzing dominant cultures as they interact with other cultures in global or cross-cultural partnerships. Intercultural literacy is “the competencies, understandings, attitudes, language proficiencies, participation, and identities necessary for effective cross-cultural engagement” (Heyward, 2002, p. 9). Yelich Biniecki and Stojanović (2023) note that cross-cultural interactions have become a daily experience for people and advocate that in “today’s internationalized work and education environments, developing the competencies, attitudes, and understandings to support cross-cultural encounters should be a priority” (p. 4). Preparation for internationalization is a goal of many higher education institutions (Yelich Biniecki & Stojanović, 2023) and businesses (Shliakhovchuk, 2021). Cross-cultural interactions are now the norm in a world with increased international interconnectedness, advanced communication technologies, frequent travel and migration, scholar and student exchanges, and displacement of populations due to conflict and devastation of natural environments (Schliakhovchuk, 2021). The current labor market requires workers with advanced skills, including soft skills that include communication, collaboration, and teamwork, all requiring the ability to work with others. 

Comparison of Related Concepts

Schliakhovchuk (2021) noted that discussion of international or global interactions emerged in the 1970s. Cultural competence was discussed as early as 1980, with cultural humility following soon after. Cultural literacy was described as early as the late 1980s, and, in the 21st century has become synonymous with “intercultural competence, intercultural literacy, CQ/cultural intelligence, or cultural mindfulness” (p. 234). The health professions intensively discussed cultural competence, and many training opportunities were offered. Over time, the reputation of cultural competence has waned because it assumes an impersonal, objective, and hypothetically superior person who is proficient in dealing with others. In contrast, intercultural literacy assumes more equality and parity among people involved in any intercultural relationship. Not only that, but intercultural literacy allows for self-examination, critical reflection, personal and cultural change, and the possibility of transformative learning.

References

• Arredondo, E. (2013). Cultural competence. In M. D. Gellman, M. D. & J. R. Turner (Eds.), Encyclopedia of Behavioral Medicine. Springer. doi.org/10.1007/978-1-4419-1005-9_172
• Brandt, D., & Clinton, K. (2002). Limits of the local: Expanding perspectives on literacy as a social practice. Journal of Literacy Practice, 34(3), 337-356
• Cooks-Campbell, A. (2022, February 14). How cultural humility and cultural competence impact belonging. Retrieved from https://www.betterup.com/blog/cultural-humility-vs-cultural-competence
• Cross, T., Bazron, B., Dennis, K., & Isaacs, M. (1989). Towards a culturally competent system of care (Vol. 1). Washington, DC: Georgetown University Child Development Center, CASSP Technical Assistance Center.
• Giroux H. (2000). Insurgent multiculturalism and the promise of pedagogy. In E. M. Duarte & S. Smith (Eds.), Foundational Perspectives in Multicultural Education (pp. 195-212). Longman.
• Gray, P. D., & Thomas, D. J. (2006). Critical reflections on culture in nursing. Journal of Cultural Diversity, 132(2), 76-82. 
• Hayes, E., & Colin III, S. A. J. (1994). Racism and sexism in the United States: Fundamental issues. In E. Hayes & S. A. J. Colin III (Eds.), Confronting racism and sexism. New Directions for Adult and Continuing Education, No. 61 (pp. 5-16). Jossey-Bass.
• Heyward, M. (2002). From international to intercultural: Redefining the international school for a globalized world. Journal of Research in International Education, 1(1), 9−32. https://doi.org/10.1177/147524090211002
• Imel, S. (1998). Promoting intercultural understanding: Trends and Issues. Center on Education and Training for Employment. (ERIC Document Reproduction Service No. ED424451.
• Lekas, H. M., Pahl, K., & Fuller Lewis, C. (2020). Rethinking cultural competence: Shifting to cultural humility. Health Services Insights, 13, 1-4. doi: 10.1177/1178632920970580
• National Center for Cultural Competence. Georgetown University Center for Child and Human Development. Retrieved February 22, 2008 from http://www11.georgetown.edu/research/gucchd/nccc/
• Salimbene (2000). What language does your patient hurt in? A practical guide to culturally competent patient care. EMC Paradigm. 
• Shliakhovchuk, E. After cultural literacy: new models of intercultural competency for life and work in a VUCA world. Educational Review, 73(2), 229-250 doi:10.1080/00131911.2019.1566211
• Tervalon, M., & Murray-Garcia, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117-125. doi: 10.1353/hpu.2010.0233
• Tyson, S. Y. (2007). Can cultural competence be achieved without attending to white racism? Issues in Mental Health Nursing, 28: 1341-1344.
• U. S. Department of Health and Human Services, Office of Minority Health. National Standards for culturally and linguistically appropriate services for healthcare. Retrieved from http://www.omhrc.gov/assets/pdf/checked/finalreport.pdf
• Wang, W. (2007). Cultural competence of international humanitarian workers. Adult Education Quarterly, 57, 187-204.
• Wear D. (2003). Insurgent multiculturalism: rethinking how and why we teach culture in medical education. Academic Medicine, 78(6), 549-54. doi: 10.1097/00001888-200306000-00002
• Yelich Biniecki, S., & Stojanović, M. (2023). Fostering internationalization in adult education graduate programs in the United States: Opportunities for growth. Educational Considerations, 49(2). https://doi.org/10.4148/0146-9282.2364