The concept of health literacy evolved from a history of defining, redefining, and quantifying the functional literacy needs of the adult population. Along with these changes has come the recognition that sophisticated literacy skills are increasingly needed to function in society and that low literacy may have an effect on health and health care. We present a brief history of literacy in the United States, followed by a discussion of the origins and conceptualization of health literacy. Increased attention to this important issue suggests the need to review existing definitions of the term "health literacy," because despite the growing interest in this field, one question that persists is, "What is health literacy?"

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This article aimed to provide a descriptive review of the psychometric properties and conceptual dimensions of published health literacy measurement tools. PsycINFO and PubMed search from 1999 through 2013, review of the grey literature, and an environmental scan was conducted to identify health literacy measurement tools. For each tool, we evaluated the conceptual dimensions assessed, test parameters, and psychometric properties. Of the 51 tools identified, 26 measured general health literacy, and 15 were disease or content specific, and 10 aimed at specific populations. Most tools are performance based, require in-person administration, and are exclusively available in a pencil and paper testing mode. The tools assess 0 (proxy measure) to 9 of the 11 defined dimensions of health literacy. Reported administration times vary, from less than 1 to 60 minutes. Validation procedures for most of the tools are limited by inadequate power to ensure reliability across subgroups (i.e., race, age, ethnicity, and gender). The health literacy measurement tools currently available generally represent a narrow set of conceptual dimensions with limited modes of administration. Most of the tools lack information on key psychometric properties. Significant work is needed to establish important aspects of the construct, convergent, and predictive validity for many tools. As researchers develop new measures, inclusion of a full range of conceptual dimensions of health literacy, more representative sampling for testing, and additional modes of administration will allow a more refined and flexible approach to research in this field.

Health literacy is on the public health agenda. The goal to "improve the health literacy of the population" was included as an objective in Healthy People 2010 and 2020 Objectives. In 2004, the Institute of Medicine released Health Literacy: A Prescription to End Confusion, which recommended that "the Department of Health and Human Services and other government and private funders should support research leading to the development of causal models explaining the relationship among health literacy, the education system, the health system, and relevant social and cultural systems" (Nielsen-Bohlman, Panzer & Kindig, 2004, p. 55). The U.S. Department of Health and Human Services' 2010 National Action Plan to Improve Health Literacy reinforces the need for conceptual advances in the field by calling for the development and implementation of health literacy Health Literacy Skills Framework 31interventions on the basis of theories and models, drawing from such related disciplines as communication, education, cognitive science, and medical sociology (p. 44).Pleasant, McKinney, and Rickard (2011) indicated that there is a lack of true theoretical frameworks that explain health literacy. Theory should be the foundation for developing reliable and valid measures of health literacy, which will allow the field to better study and understand the role of health literacy in health behavior change. This lack of theory has caused researchers to define health literacy in many different ways (Peerson & Saunders, 2009) and, thus, studies vary significantly depending on the definition and measures used (DeWalt, Berkman, Sheridan, Lohr, & Pignone, 2004;Peerson & Saunders, 2009;Pignone, DeWalt, Sheridan, Berkman, & Lohr, 2005).The absence of a common definition and understanding of health literacy may have slowed the field's progress in developing measures and conducting solid methodological research. There are a variety of models and frameworks that describe factors associated with health literacy skills (Baker, 2006;Mancuso, 2008;Nutbeam, 2000;Paasche-Orlow & Wolf, 2007;von Wagner, Steptoe, Wolf & Wardle, 2009). A comprehensive health literacy theory or framework may spur more professional discussions to help lay the foundation for a new era of theory-driven research.The majority of these frameworks illustrate the effects that health literacy has on health-related outcomes (Lee, Arozullah, & Cho, 2004;Manganello, 2008;Nutbeam, 2000;Paasche-Orlow & Wolf, 2007;Rootman et al., 2002; Schillenger, 2001;von Wagner et al., 2009). However, few illustrate the full continuum of relations among predictors, moderators, mediators, and outcomes of health literacy all in one theory or framework (Pleasant, 2011). PurposeThe purpose of this article is to introduce a framework for conceptualizing health literacy that builds on existing theoretical frameworks. We undertake three activities in the article:1. First, we review and synthesize the several existing theoretical frameworks for health literacy and describe their strengths and weaknesses. 2. Se...

Engaging individuals with cancer in decision making about their treatments has received increased attention; shared decision making (SDM) has become a hallmark of patient-centered care. Although physicians indicate substantial interest in SDM, implementing SDM in cancer care is often complex; high levels of uncertainty may exist, and health care providers must help patients understand the potential risks versus benefits of different treatment options. However, patients who are more engaged in their health care decision making are more likely to experience confidence in and satisfaction with treatment decisions and increased trust in their providers. To implement SDM in oncology practice, physicians and other health care providers need to understand the components of SDM and the approaches to supporting and facilitating this process as part of cancer care. This review summarizes recent information regarding patient and physician factors that influence SDM for cancer care, outcomes resulting from successful SDM, and strategies for implementing SDM in oncology practice. We present a conceptual model illustrating the components of SDM in cancer care and provide recommendations for facilitating SDM in oncology practice.