NNLM Health Literacy Framework

The NNLM Health Literacy Framework is a reference tool that we use to understand the key factors that influence individual and organizational ability to access, understand, and use health information.

The NNLM All of Us Program Center (NAPC) develops and distributes a robust portfolio of community-based programs and services focusing on five key areas: health literacy, digital literacy, community science, diversity in biomedical research, and precision medicine.

Regarding our work around health literacy, NAPC aims to ensure that the programs and services we develop align with current health literacy best practices and reflect key factors that contribute to health literacy. NAPC funded Communicate Health, to develop a health literacy framework as a reference tool for NNLM to understand the key factors that influence individual and organizational ability to access, understand, and use health information. Currently we use this framework to identify topics for new trainings and programs that will support health literacy.

Overview of the Framework

This framework names the key factors that influence an individual’s health literacy — or an individual’s ability to access, understand, and use health information.¹ There are many factors that can influence a person’s health literacy and a variety of ways those factors interact or overlap.

To make sense of those components, we drew inspiration from the socioecological model, a conceptual model that states that “health is affected by the interaction between characteristics of the individual, the community, and the environment.”² In other words, a complex range of influences and interactions affect — and are affected by — individuals’ health. The same is true for individuals’ health literacy. This framework focuses on how these interactions collectively influence health literacy.

Since all tenets of health literacy (accessing, understanding, and using health information) are closely connected, we included them all in the framework. But our emphasis is on factors and interactions (with information, people, organizations, and contexts) that facilitate or hinder understanding, as NNLM has the most influence in that space.

Structure of the Framework

The framework has 3 rings, which represent 3 levels of influence: Individual (consumer) and Information (inner ring) Professionals and Organizations (middle ring) Social and Cultural Determinants of Health (outer ring) The framework also has 2 types of arrows. They represent: The tenets of health literacy, which run through the entire framework Interactions between people and/or organizations

The Individual (consumer) and Information ring is the center of the framework — individual consumers need to access, understand, and use health information. How individuals interact — or don’t interact — with health information impacts health outcomes, and this maps directly to NNLM’s mission. The other rings in the framework influence how well individuals can access, understand, and use information.

The Professionals and Organizations ring represents 2 key players in the health literacy landscape — the intermediaries that can connect individuals to health information. Note that the roles that professionals and organizations play are similar (professionals ultimately make up organizations), but there are some distinctions. Since we know that professionals and organizations play a role in how consumers access, understand, and use information, this ring includes factors that map directly to the individual and information ring. For example, an individual’s listening skills interact with a professional’s oral communication skills and the communication norms at the professional’s organization.

The Social and Cultural Determinants of Health ring represents the broad social or cultural factors that can influence health literacy — like cultural norms that help or hinder the understandability and accessibility of health information. Other major social factors include governmental policies, structural racism and discrimination, and built environments and communities that help to create or maintain inequities in accessing or understanding information. The rings illustrate that there are interactions: Between factors on the same level (e.g., the knowledge and communication skills of professionals) Between factors on different levels (e.g., the self-efficacy of an individual and the tone of information they’re receiving) Across entire levels (e.g., between individuals and professionals as a whole) For more specifics of components within each ring, see the tables below under Breakdown of the Health Literacy Framework Factors.

Breakdown of the Health Literacy Framework Factors

This table lists the components that make up each factor in the framework.

Health literacy
Health literacy (arrow)	Accessing information Understanding information Using information
Information
Quality	Accuracy Adherence to clear communication best practices Readability Actionability
Language	Inclusivity Empathy
Format	Written Spoken Visual
Accessibility	Visibility (e.g., color contrast, text size) Website performance speed and responsiveness Navigability
Culture	Cultural relevance Diversity
Individual (consumer)
Skills	Listening Reading Numeracy News literacy Research literacy Visual literacy Problem-solving Reasoning Navigation Physical ability Digital literacy
Knowledge	Education Awareness of resources Memory Personal relevance or salience (prior experience) Familiarity with a topic (prior knowledge)
Psychological factors	Beliefs Attitudes Emotional state (i.e., stress, anger) Motivations Self-efficacy Mental health conditions (i.e., anxiety, depression)
Personal characteristics Note: Demographics have an association with health literacy but do not directly contribute to an individual’s skills. Though some populations are more likely to have limited health literacy skills because of factors like structural racism, their race, ethnicity, and other personal characteristics have no inherent effect on their health literacy skills. On the right is a sampling of personal characteristics found in the environmental scan associated with the development of this framework — but additional personal characteristics may be important to consider depending on the specific audience that’s receiving health information.	Language Age Culture Gender Geographic location Income Health status Education
Situational context	Health issues Life stressors
Professionals
Skills	Written communication Oral communication Visual communication Numeracy News literacy Research literacy Digital literacy Problem-solving Reasoning Interpersonal skills Empathy Cultural awareness
Knowledge	Education Awareness of resources Memory Personal relevance or salience (prior experience) Familiarity with a topic (prior knowledge)
Psychological factors	Beliefs Attitudes Emotional state (i.e., stress, anger) Motivations Bias
Organizations
Policies	Staff training Information quality standards Organizational requirements
Practices	Patient care models Accessibility Health care delivery systems Health information systems
Norms	Staff buy-in Company mission and values Leadership support
Societal and Cultural Determinants of Health
Government policies and laws	Federal policies and laws State and territorial policies and laws
Health care	Health insurance cost and coverage Hospital care models/patient care models Culturally competent care
Access	Access to health care providers/systems Access to internet Access to education Access to transportation
Culture and language	Community and cultural norms Beliefs and attitudes about health Available languages for information and interactions
Community	Social support Community-based resources Demographic makeup of community
Environment	Built environment, neighborhood and housing safety Environmental quality (e.g., air quality, water quality) Transportation infrastructure
Racism and discrimination	Racism Discrimination

References

[1] Squiers L, Peinado S, Berkman N, Boudewyns V, & McCormack L. The Health Literacy Skills Framework, Journal of Health Communication. 2012;17 sup3:30–54.

[2] Paasche-Orlow MK, Wolf MS. The causal pathways linking health literacy to health outcomes. Am J Health Behav. 2007 Sep-Oct; 31 Suppl 1:S19–26.

[3] Koh HK, Brach C, Harris LM, Parchman ML. A proposed “health literate care model” would constitute a systems approach to improving patients’ engagement in care. Health Aff (Millwood). 2013;32(2):357–367

[4] https://learn.healthliteracysolutions.org/products/october-19th-opening-plenary-working-together-to-support-health-literacy - tab-product_tab_handouts

[5] https://www.cdc.gov/healthliteracy/learn/index.html

[6] https://www.tandfonline.com/doi/full/10.1080/1059924X.2017.1358971